Home
Current Issue
Past Issues
Support
About IJME
Apr-Jun2002-10(2)
LETTER FROM
KOLKATA
User charges in public
hospitals: money for nothing
On January 10, some opposition parties in West
Bengal called a bandh opposing the hike in fees for public hospitals and related
services. Charges for case papers and private rooms, had doubled, and those for
X-rays and other investigations had also been hiked. All public services up to
the sub-division level were asked to open an afternoon pay clinics. The morning
'free' OPD clinics will charge Rs 2 per patient for registration; the afternoon
clinics will charge fees which will be split between doctors, technicians and
the state coffers. (Recently, another government order reduces the 'hiked
charges' to an extent.) Though the announcement carried a rider that all
services would be 'free for the poor', the question is: how are the poor
identified? To avail of this facility, people would have to obtain a certificate
from a corporator, panchayat pradhan, MLA or MP. Need one say more?
There are varying opinions on the bandh's success,
but the government has put a hold on the hike in rates. The government charges
(after the rate hikes) Rs 1,200 for a CT scan. Outside, the charges are Rs
1,500. But everyone knows that private scan centres give referring doctors
commissions of 20 per cent, and still make a profit from the remaining Rs 1,200.
Which means the government is making a profit when charging for this test. This
is not cost recovery; this is profit.
Neither the proponents and opponents of rate hikes have raised the question of medical auditing, rational therapy, and the use of drugs. That is, what is going on in hospitals? Does paying more guarantee better care? No.
At the same time, if there is no hike, is what is
going on acceptable? Is there any monitoring of the investigations and drugs
being prescribed and/or used? Will there be a change if people pay more? If so,
that means if you get something free, you should not complain even if it is of
unacceptable quality.
The order for opening afternoon pay clinics have
not been officially revoked, but one hears that attendance is negligible. Now,
since the same doctors who run the morning OPD will attend the afternoon
clinics, will there be a qualitative change in care at the afternoon clinic?
Will payment ensure value for money? Will those who cannot pay be forced to take
inferior service? Will doctors talk softly to the afternoon
patients?
Another topic of debate here has been the spate of government 'policies' in health.
Look at the National Health Policy - a policy
without entitlement, which is no policy at all. Surely only an independent
government can formulate a policy. But our policies are dictated by donor
agencies. In the 1983 health policy, the government's statement/declaration was
to make general health services and personnel available to people. We promised
to implement the WHO's programme for Health for All through universal primary
health care - this means using appropriate technology and services compatible
with the country's needs and which the community. can afford. But that was only
a policy statement. Instead, in the last two decades, we have produced
specialists in a large way, and promoted high-technology medical
care.
A'new drug policy' was announced in February. But
India has never formulated a drug policy in the true sense - by the ministry of
health, assessing and responding to our health needs. These so-called drug
policies are industrial pricing policies written by the ministry of chemicals
and fertilisers. These are based on assessment only of market needs. If trash
has a demand, if useless, irrational drugs can bring profits, companies will
devote themselves to making them. There has never been an attempt to determine
an essential drug policy to decide how many drugs we need, keep only them and do
away with the rest; and the issue of entitlement for those who do not have
purchasing power has never been considered.
In India, it is said that there are 100,000
formulations. This is guesswork because there is no centralised registry of the
number of drug licenses issued as the licences are issued by different state
drug control authorities. As a result of our 'drug policy', people are duped by
doctors, and companies who use high pressure sales tactics to increase their
markets.
The 1986 Drug Policy called for the setting up of
two agencies: the National Drug Authority to examine the number of formulations
needed in our country, monitoring use of drugs by the prescribers, monitoring
promotional activities of the manufacturers, and quality of drugs circulating in
the market, etc. and the National Pharmaceutical Pricing Authority to look after
drug pricing to ensure adequate profit for the manufacturers. The latter was
formed overnight because that was in manufacturers' interests.
But almost two decades down, the National Drug
Authority is still not established. And the latest drug policy does not even
mention the National Drug Authority. It does not even talk about the prevalence
of irrational, dangerous or marginally useful formulations. In the so-called
Drug Policy, the question of entitlement is absent. Unless there is entitlement,
the poorest of the poor will never get and demand the drugs they need from
public hospitals and dispensaries. The number of drugs under price control has
steadily gone down over the years, from 432 to barely 32 under the new policy.
The argument has been that free competition between companies will push prices
down. That is possible only when drugs are sold as generics, when the buyer has
a choice. This may happen in the case of commodities other than drugs. Worldwide
experience shows that this has never happened in the case of drugs because drugs
are sold as brands, and these brands are prescribed by the doctor - the real
consumer does not/cannot make the choice as in the case of other commodities.
This is the reason that brand manes are promoted to the prescribers and not to
the consumers.
Kolkata
Correspondent