Initially there were murmurs followed by hush-hush meetings of a select few. Lately, some reports have appeared in print about allowing private practice to full-time doctors in government hospitals in Maharashtra. (1) Although the report mentions that civic hospitals have not been included in this plan, it is only a matter of time before the 'bait' is extended to all.

The winds of liberalisation and privatisation seems seem to be blowing the wrong way as far as public hospitals are concerned. These are the only places where the poor can still seek excellent health care at no or minimum cost.

Until not very long ago, these hospitals were managed by honorary doctors in addition to full-time ones. On the recommendations of the Medical Council of India, the honorary system was gradually phased out since it was felt that medical teachers should spend longer hours in the hospitals in order to give effective patient care as well as higher teaching standards. Why did a lobby appear all of a sudden favour of private practice being allowed to full time doctors in municipal and government hospitals? Does this means that honorary doctors' appointments were stopped so that full-time doctors could have the best of both worlds?

Health care is a government's job
There is an urgent need to implement a rational national policy on health. This is perhaps one public sector that needs protection in the present climate of reforms and privatisation of sick public sector units. In matters related to the health and medical care of the people, in any civilised society with a sense of social justice, the responsibility must be that of the government and not relegated to the private sector.

Technology-and profit-driven private health care has become dominant in the last decade and has been reflected in the falling standards of health care in government - run hospitals. Government cannot be allowed to abrogate their responsibility and seek an easy way out by privatising government hospitals or by permitting government doctors private practice. A large segment of our population is still poor and cannot afford the expensive medical treatment offered at these high-tech hospitals. Health care still needs to be a national enterprise and the public sector needs to be regulated. Even in the West, cost containment has become a relevant issue, due to high-tech medical care. In the US, the Clinton health reforms were meant to regulate health care costs which had been growing unchecked.

Need for a national policy
It is rather strange that there is no comprehensive national policy on the question of whether or not doctors working in government hospitals should be permitted private practice. There are different rules in different states, and nobody is willing to learn from the experience of others. Rajasthan, Madhya Pradesh and UP are among those who have stopped private practice. West Bengal and Kerala have banned private practice to government doctors while Karnataka, which allows private practice to government doctors, has a dismal record of health care standards in government hospitals, as most of the time doctors are busy with private patients. The J&K government has a record of vacillating, allowing, disallowing and permitting the privilege once more. Maharashtra is willing to start it.

Poor patients have to shell out hefty sums to get attention in government hospitals or else seek care in private hospitals and nursing homes. This only underscores the need for a uniform and comprehensive policy at the national level, not leaving the decisions to the whims and fancies of the ruling parties with their overactive lobbylists.

It is amazing that the state government and other authorities seem to be more than willing to listen to the pro-practice lobby when they should really be worried about maintaining standards of health care and making it affordable and accessible in public hospitals. There can be little doubt that if private practice is allowed to the doctors working in public hospitals, corrupt practices which already exist to some extent will become rampant. Checking the misuse of hospital facilities like out -of-turn admission and surgeries of private patients in free municipal and government hospitals will be an uphill task even if carried out with the best of intentions. How are the poor and under privileged going to complain about the neglect that they would suffer from such a system? And to whom ? Besides, medical students, both undergraduate and postgraduate, will learn these malpractices early during their training period, at a stage when senior consultants are the role models whom these young people try to emulate. As such the medical profession which was considered noble at one time now stands exposed to charges of neglect, corruption and commercialisation.

It is further surprising that medical teachers should complain of the wide disparity between their incomes and those of their colleagues in private practice. They were all aware of these disparities when they accepted these responsibilities. And when compared to employees of other government organisation, full - time doctors should not complain of a raw deal.

This is not to suggest that the government should not improve the working conditions of doctors as well as provide facilities and perks for decent living standards. The Fifth Pay Commission's recommendations should address at least some of the financial issues and medical teachers should ask for a better deal, as is granted to central university teachers in Delhi and elsewhere. At the same time the government must admit that at least some doctors leave public hospitals because of poor working conditions, just as some leave to make more money. The government therefore needs to think of ways it can retain dedicated and skilled doctors, who had opted to work in public hospitals with a certain commitment, and not take the easy way out of allowing private practice. This cure may be worse than the disease for it will directly affect a pillar of the otherwise beleaguered public health system, Private practice if allowed, will erode and collapse the system.

There are other important issues to be considered. If full-time doctors are allowed private practice there is no reason why government employees of other public and private organisations should not ask fro similar benefits and compensations. It shouldn't be long before nurses, engineers, administrative staff, airline pilots, railway motorman, best drivers and conductors, policemen, and more ask for similar privileges. We may have bureaucrats and ministers working part-time while they hold more lucrative private assignments outside. One can even imagine supreme court judges and the chief justice of India asking for similar privileges because some lawyers have fabulous professional incomes in their private practice.

Alternatives exist
Instead of taking the 'soft option' of allowing private practice, the authorities must strengthen the present system with better housing facilities, easy and soft loans for procuring flats and cars, revamping recruitment policies to fill vacant positions in government and civic hospitals - all of which will help retain talent. Efficiency should become the keyword in all activities involved in running hospitals so as to avoid the frustrations of medical staff with non-working equipment and uncommited paramedical and labour staff. The procedures should be curtailed and it should be ensured by the authorities that only medicines and equipment of standard qualities are made available. An efficient and committed administration workingcloselywith dedicated staff can make public hospitals excellent centres of health care. Those with talent and dedication will stay while those interested in making more money will leave at the cost of job satisfaction. Industrial houses and financial institutions could contribute significantly towards improving hospital facilities just like they do in private hospitals with suitable donations and appropriate acknowledgement. Similarly, eminent people with professional management experience should be invited to participate in hospital management. There is no doubt that doctors will be attracted to work in congenial conditions and at the same time have the satisfaction servicing the poor and underprivileged - an aim with which many of us chose the medical profession.

Reference
Aguiar-Deshpande S. Private practice bait for government docs. Express Newsline April 29,1998.

Dr Ratna Magotra,Professor and Head of the Department of Cardiovascular Surgery, KEM Hospital, Parel, Mumbai 400 012.