Indian healthcare system is plagued with numerous problems and too many laws. The solution is to ensure that regulation is streamlined and proper viz. Clinical Establishment Act
It is said that "health is wealth"; but in India, health is getting increasingly unaffordable. Is there some solution to making health more accessible and affordable not only to the middle class but also the masses? Before we look at the possible solution, we need to understand a few facts and problems.
Statistical background (Source - National Health Profile 2010-11)
# The doctor population in India is 1:1,500 when compared to an estimated 1:1,000 in China and 1:350 in the United States (USA). In urban India, the ratio is estimated at around 1:500 while rural India it is at around 1:2,500
# There are about 9.2 lakh allopathic doctors in India and surprisingly about 7.5 lakh doctors practicing 'alternate' medicine (i.e. AYUSH, comprising of Ayurveda, Yoga, Unani, Siddha and Homeopathy), primarily in the rural sector
# There are about 500 AYUSH colleges with 30,000 doctors graduating annually
# There are 355 MCI-recognised (Medical Council of India) medical colleges in India, with a total annual intake of about 40,000 doctors for an MBBS degree. Roughly half the colleges are in the private sector, which has seen a growth of 900% between 1970 and 2004. About 22,000 dentists graduate every year.
# There are also over 2,000 nursing institutes registered with Indian Nursing Council, with over 80,000 nurses graduating every year
# The Pharmacy Council of India has approved over 600 colleges, with about 36,000 students graduating in pharmacy, every year
# India has about 12,760 allopathic government hospitals, with a bed capacity of 5.76 lakh (Source - Ministry of Statistics and Programme Implementation, 2010). However, India has less than 1 bed per 1,000 population compared to a ratio of 3 for China and 3.1 for USA
# There are 23,887 primary health care centres in India
Prime problems faced by India's healthcare system
In April 2010, the President of MCI and his two associates were arrested by the Central Bureau of Investigation (CBI) while accepting a bribe of Rs2 crore to grant license to a medical college in Punjab. MCI's main duty also includes registration of doctors and maintaining the Indian Medical Register.
But there is no comprehensive 'Hospitals registry' established in India, containing data of detailed healthcare facilities. And surprisingly, no standard or norms exist for clinical processes that need to be followed by the hospitals across India.
A typical hospital needs to comply with several acts such as law related to governing the commissioning of hospital, law governing storage/ sale of drugs and safe medication. For example, all allied acts (like Biomedical Waste Management Rules or BNHA etc) could have been merged with only one regulatory Act. Consider the following which comes under different ministries:
# The Quality Council of India (and its NAHB) is under Ministry of Commerce and Industry.
# The IPHS and Clinical Establishment Act comes under Ministry of Health and Family Welfare.
# The Medical Insurance (IRDA) is under Ministry of Finance.
# BIS (Bureau of Indian Standards) and Consumer Protection Act are under Ministry of Consumer Affairs, Food and Public Distribution.
# Medical Council of India is another governing body.
This confusion could have been eliminated by bringing all medical industry related matters under one central government regulatory authority, but this effort has been stalled by possible vested interests.
Introduced in the Rajya Sabha in December 2011, the NCHRH (The National Commission for Human Resources for Health) Bill, aimed at regulating professional councils such as Medical Council of India, Dental Council of India, Pharmacy Council of India and Indian Nursing Council and provide for mechanism for the regulation of standards of health education throughout the country to ensure adequate availability of human resources in all the states.
Unfortunately, the Parliamentary Standing Committee on Health and Family Welfare submitted its report to Rajya Sabha recommending strengthening councils like the MCI and DCI with sufficient safeguards instead of creating an over-arching regulatory body. The committee also agreed with the viewpoint of the states that the composition of the Commission gives no representation to them.
# 'Capitation fees' has made it difficult for genuine students to pursue the medical profession and could also be a cause for 'medical inflation'
# There is a shortage of teaching staff in government hospitals due to a pay differential compared to private institutes
# There is no common nationwide entrance exam like JEE or CAT, for admission into MBBS
# Referrals or commissions between doctors and pharmaceutical companies or hospitals needs to be regulated
# Lack of sanitation and proper hygiene is one of the root causes for illnesses to spread and the healthcare system is unaffordable for many
Is there a solution?
In spite of NCHRH being stalled, there is still a glimmer of hope. The Clinical Establishments (Registration and Regulation) Act, 2010 (the Act) has been enacted by the Central Government to provide for registration and regulation of all clinical establishments in the country establishments from the public and private sectors, of all recognised systems of medicine including single doctor clinics (the only exception will be establishments run by the Armed forces), with a view to prescribing the minimum standards of facilities and services provided by them.
The Act has taken effect in some states namely, Arunachal Pradesh, Himachal Pradesh, Mizoram, Sikkim, and all Union Territories since 1st March, 2012. The states of Uttar Pradesh, Rajasthan, Bihar and Jharkhand have adopted the Act and are in the process of drafting/ finalising the state rules. The respective state councils would need to compile the data and send monthly updates to the National Register.
A National Council is formed under the Act, and has had three meetings so far. The National Council needs to be congratulated for discussing the right issues, though it is a little disappointing to note that its core responsibilities have not yet been fulfilled in the mandated time-bound manner.
As per Section 5 of the the Act, within two years of implementation of the Act, the esteemed National Council was to compile and publish a national register of all the clinical establishments in our country. Data from only three states has been listed on its website. It has been two years and the National Council must take urgent steps to speed up the process with the other states.
As per Sections 5 and 7 of the the Act, within two years of implementation of the Act, the National Council was to form minimum set of standards to ensure proper healthcare across India. Guidelines for only a few procedures have been posted on the website, and for others, as per the last minutes of meeting, a timeline of six months has been granted.
Unfortunately, there is no provision for accountability to ensure timely implementation.
The National Council under the Act should speed up the preparation of standard charges, at least for the 42 standard medical procedures, as discussed in their meetings dated 31 October 2012 and 23 June 2013. If this can be speeded up, it could easily be the most important contribution towards the health and wellbeing of millions of Indians, especially the uninsured. This can effectively address the discrepancy in rates charged to insured patients versus the non-insured.
Does the esteemed National Council have the mandate to register clinical establishments only if they adhere to points from Code of Ethics Regulations Act 2002 like prominent display of rate charts and disallowing (or regulating) referrals or commissions? If compliance of the above can be made mandatory in the registration process, it would help the consumers tremendously.
Disappointingly, a section of medical professionals has opposed such measures on the ground that it would unleash an 'Inspector Raj'. Indian Medical Association (IMA), says, "Provisions in the Clinical Establishment Act will increase the establishment cost of medical establishments and consequently the cost of treatment. According to the new Act, doctors will have to take a no-objection certificate from all neighbours living near the clinic. Also, doctors will have to issue a daily prescription audit, which is almost impossible. If a doctor does not register or fails to show necessary papers, he will be fined Rs5 lakh".
Actually, as per section 40 of the Act, the first fine is Rs10,000, the second fine is upto Rs50,000 and only the third fine is Rs5 lakh.
The National Council must undertake serious steps to educate the medical fraternity that the Act will go a long way in streamlining the healthcare sector and benefit not only the consumers but also the doctors.
(Gaurang Damani is an engineer and an eminent social and legal activist. He is also the founder of 'Karmayogi Pratisthan', an NGO that builds awareness and empowers people about how to deal with everyday problems. He is also the publisher of a website called DieHardIndian, an exhaustive repository of information for the Indian citizen.
During the September quarter LIC Housing Finance’s net profit grew 28% to Rs310.07 crore as its net interest income-NII rose to Rs453 crore from Rs354 crore
LIC Housing Finance Ltd (LICHFL), one of the largest housing finance company in India promoted by Life Insurance Corporation (LIC) of India, in its September quarter recorded growth of 28% in net profit to Rs310.07 crore compared with Rs243.06 crore in the same period last year. While its revenues grew 22%to Rs2,247 crore from Rs1,840 crore during the same period last year.
LICHFL’s net interest income for the September quarter reported a growth of 28% at Rs453 crore compared with Rs354 crore for the same period last year. Net interest margins stood at 2.22% compared with 2.10% in same period last year.
During the quarter to end September, the company disbursed total loans of Rs5,947 crore when compared with Rs5,838 crore for the same period last year, a marginal growth of 2%.
Segment-wise the outstanding mortgage (loan asset) portfolio registered a growth of 20% as on September 30, 2013 at Rs83,216 crore as against Rs69,119 crore in same period last year.
The Individual loan portfolio stood at Rs80,704 crore from Rs66,458 crore recorded a growth of 21%.
Developer loan portfolio stood at Rs2,512 crore as on 30 September 2013 as against Rs2660 crore in same period last year. (Should we, include this or not? YES. Include)
LICHFL’s gross total gross non performing assets (GNPAs) including developer loans stood at 0.73% compared with 0.60% in same period last year. Similarly, its non performing assets (NPAs) stood at 0.44% as on 30 September 2013 from 0.28% last year.
At 11.40am Thursday, LICHFL was trading 3.8% higher at Rs223, on BSE, while the S&P BSE Sensex was marginally up at 21,052.
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Accidents happen all the time and are a combination of several factors. Yet, when it comes to fixing responsibility who is to blame?
This morning’s newspaper carried a story about a railway accident in which a woman lost her legs while trying to board a local train. Whenever Moneylifers read a story like this, they are reminded of Samir Zaveri, Mumbai’s hero. A man who stands the tallest of all... without legs!
Yet, an important, though unconfirmed, part of the story was that the woman was trying to board a running train. And herein lies the rub.
An accident is a combination of certain factors that, in isolation, would mean nothing and go unnoticed. But, when all the unpropitious stars are in alignment, or misalignment, tragedies occur. Who then is to blame? The moment something goes wrong, and if the person involved is dead, the usual PR responses are trotted out. Pilot’s mistake. Equipment malfunction. Human error. Sabotage.
This writer firmly believes in the adage that, if there is malady, there has to be a remedy. In the accident mentioned above, what would you decide if you were the judge?
Suppose the woman was about to board the train and it started. Would you try and call it her mistake? After all, there are no audible signals to indicate a start. All trains do not always halt for a specific period. Some platforms are so curved and the trains are so long that neither the guard nor the driver can see all the compartments. Travelling everyday and coming home safe is a gamble. Some win, some lose. It is a throw of the dice.
Unfortunately, people take their lives into their hands so many times a day. How would you decide cases like these? The courts, while sympathetic to cases of grave injury, do not pass orders without going into the merits of the case.
Let us, at this moment, digress a bit and consider the recent initiatives taken by the railways due to the efforts of activists and Moneylife. Ambulances have been kept ready at some stations. Most importantly, platforms have been raised. Yet a lot remains to be done.
Maybe the most important facet now facing us is the care that passengers themselves must take. There is no programme to teach them the basics. It does not take a rocket scientist to understand that trying to board a moving train or bus is dangerous. It requires less grey matter to understand not to travel on train rooftops or on the links between bogies. If an accident were to take place in these circumstances, what would you say?
You be the judge.
Cases of gross negligence, like rooftop travel, can bring no relief. In fact, if the perpetrators survive, they can, and should, and are being punished. Would you grant relief to persons, or kin of those persons, who are involved in accidents while crossing railway tracks in spite of foot over bridges? Would you allow compensation to those persons involved in accidents, often fatal, that occur when they are busy talking on their cell phones or listening to the radio?
You be the judge.
There is a recent new, deadly trend. Footboard travellers block half the door, what they call the ‘right side’, forcing passengers getting on and off to use only half the available space. That means the passengers get only half the time to board or alight. Accidents are, therefore, bound to happen. Who would you hold responsible?
To begin with, both, the authorities for not implementing the rule against travelling on the footboard, even when there is room to move inside, and the foot-boarders, for endangering life. And above all, all of us for lacking basic civic sense.
The fault lies with both, the pot and the kettle. Both need a good scrubbing.
Bapoo Malcolm is a practising lawyer in Mumbai. Please email your comments to [email protected] or [email protected]