IIMB expert brings into sharp focus the need to have a regulator body to check corruption and malpractice in the healthcare sector
The recent Global Ethics Forum 2014 on 'Equality in an Unequal World', hosted by the Centre for Corporate Governance & Citizenship and Indian Institute of Management Bangalore from January 03-05, 2014 discussed gender equality at one of the panel discussions.
The panel, moderated by Professor Vasanthi Srinivasan, comprised Gita Sen, expert on gender and development, IIMB; Sucharita Eashwar, Executive Director India, WE Connect International; Le Ping, Deputy Director, Research Institute of Globalization and China's Modernization, UIBE, China; and Afua Ansre, UN Women Africa.
Dr. Gita Sen, who has worked for 35 years, nationally and internationally, on population policies, reproductive and sexual health, gender equality and women's human rights, brought into sharp focus the connection between gender equality and health.
She opened the panel discussion with a reference to the Gender Gap Report by the World Economic Forum that ranks India 101 out of 136 countries on gender equality. "In India, we have traditionally failed in making and implementing human development policies for girls and women, be it in healthcare or education. Half of our work force is under-utilized. This is a failure of policy, not history," she declared, drawing attention to the fact that India is the lowest ranked nation among BRICS in the Gender Gap Report.
In this interview with Kavitha Kumar, she emphasizes the need for India to have a strong regulatory body that is responsible for public health.
Public Health is clearly not a priority in this country. For a country of over a billion people, we do a terrible job of ensuring safety and effective services in public health. What should be done to fix the regulatory mess?
When we say that public health is not a priority in this country, one of the clear indicators is that, as a country, although we spend around 5 per cent of our GDP on health, only about 1 per cent of GDP comes from the government. In most countries that do a decent job in health policy, around 50-60% of health spending is by government, where they consider public health as public good. You cannot deal with malaria, tuberculosis, HIV etc. with a public spending of 1 per cent.
Particularly, in last couple of decades, after the economic reforms, health was not a priority. We were busy becoming a super power. Public expenditures on health stagnated for a while. This shows in other outcomes as health status and indicators. By early 2000s, there was a big increase in inequality access to healthcare. During the 1990s the Government decided, because there was a dearth of medical care experts (doctors and nurses) in the public sector, to open up healthcare to the private sector. The idea of inviting corporates to both healthcare and health education (privatization) was intended to fill the gaps. The problem was there was no regulatory mechanism for the health system to cope effectively with the fallouts of this privatization. That gave rise to a serious set of issues. The problem is that there is information asymmetry in the health sector. Unless one has systems for regulating (kind of services provided, the way the care is given etc.), there will be malpractice and ethical problems, with no forum for redressal. The failure of (having) a regulatory body encourages malpractices in each and every stratum. This encourages health practitioners to close ranks, in case of wrong diagnosis.
While it is acceptable for us to have a qualified and extremely competent Governor of the Reserve Bank of India, an institution that oversees monetary policy, why not for an institution that is responsible for public health? Is public health not half as important as fiscal health?
See, we also have SEBI. SEBI's classic regulatory architecture is proactive. In business, it is encouraged but when it comes to health policy, there is huge objection to have a regulatory body. In SEBI, regulation is about managing competition among the corporates themselves. But in the medical field, regulation is managing the relationship between providers and receivers of care. Therefore it has become very difficult to put a regulatory architecture in place in India. There's the Drug Controller's office but these offices are often a hot bed of corruption. There is the Clinical Establishment Act, which is in process still. All is does is seek to identify and registering clinical establishments and even this is slow to move; very little real regulation as yet.
I was a member of the High-Level Expert Group, the HLEG as it was known, appointed by the Planning Commission to recommend how to move the country towards universal health coverage. We had suggested among other things a whole well-integrated regulatory architecture for health that built on the best of regulatory frameworks that are in place (in terms of standards, norms, technology). Countries like Brazil and Thailand have been able to put regulations in place for the health sector. From the point of view of patients, we need a mechanism where patients can register complaints and/or redress their grievances.
As there are vested interests at play, there is going to be stonewalling of any bid to introduce regulation. What is the solution?
Communities have to be part of the change. Both policies and community should work hand-in-hand to bring about the change. It is a political question. While the abysmal state of the country's health system sometimes drives one to despair, change can happen in the most unexpected ways. Look at the political revolution in New Delhi, and the victory of the Aam Aadmi Party (AAP). This points to the possibility of change even in the dire situations, and this offers a ray of hope.
There is plenty of talk about India as a hub of 'medical tourism' with feel-good stories handed out regularly to the media. The real issues in public healthcare often fail to get the time and space they deserve.
'Medical tourism' may help the corporate sector, but it will not solve the health problems of the country. In no country have there been real advances in public health without the strong and central role of the public sector (government). Private sector can pitch in effectively only when they agree to be regulated. Some elements of quality may be better in the private sector but medical service may not be better. What's worse, if more and more of formerly public hospitals are turning into private hospitals, where will ordinary people go? The poor cannot go to corporate hospitals. The high-tech hospitals are only for the insured. There are attempts by some state schemes as in Andhra Pradesh to expand the public health insurance offered by the Rashtriya Swasthya Bima Yojana (RSBY) to include care in corporate hospitals but these schemes are financially unviable as more and more research is showing.
You have worked in the area of women's health, particularly maternal healthcare. Would you please take us through the Fostering Knowledge Implementation Linkages Project (FKILP), an effort commissioned by the Karnataka government to strengthen the evidence base for public health?
The project began in 2011 in as a spin off from our work in Koppal district in north Karnataka, where we have been working on improving maternal health. Karnataka has first rate researchers and NGOs working at the ground-level. But there is no collective learning between the NGOs and the health department. Information exchange can help to transfer knowledge to policy. The FKIL project was started to help build a network of health researchers and the health department and create a forum. In the first year, we had three workshops, where the health department and researchers exchanged knowledge and experiences on a number of very practical subjects such as maternal anaemia. We discussed how the policies of the health department can be tracked, monitored and researched for correct assessment.
What are the main obstacles for countries trying to reduce maternal death? And why are some regions having more success than others? Is it just a question of investing more resources? Do culture and tradition have an impact on maternal death? Or is it about the status of women in society and their right to access sexual and reproductive health?
The status of women in society is just an element of the problem. It is how the health system prioritizes maternal health. According to the latest statistics, maternal mortality ratio has fallen below 200. It is a 5-6% per year decline. The Government's Janani Suraksha Yojana - a conditional cash transfer scheme - to get women to have institutional deliveries is claimed to have turned the tide. But, the big question for the health system is whether the institutional deliveries that are incentivized by the JSY are safe deliveries. Our research has been able to point specific needs to make that transition. And the research isn't telling us with certainty that this transition is happening.
If we bring in the private sector, they begin to skim the cream. They take all the easy cases and dump the difficult ones back on the public system. If one is paid by the case (in the model envisaged by the government when they rope in private players), why will any doctor handle a difficult case? At the end of the day, quality of medical service will become an issue. For management students, the focus it's not just on hospital management. It is management of a public system for provision of health. How do you ensure that HR is managed, how do you ensure that you do not create moral hazards in the system? The fundamental question from the regulation perspective for management students is to ensure smooth flow of services.
On an educational front, the Government is trying to reduce the duration of an MBBS course from five to three years. The idea is also to bring in more local people, as there are greater chances on them serving locals. Serving at home will be their priority and remote villages will then have primary healthcare personnel. The government is trying work on this, but the medical profession is preventing it from happening.
In the near future, human development is going to be the basis for growth. We are at a critical juncture because the burden of communicable infectious diseases is equal to non-communicable diseases (heart problems, diabetes, cardio-vascular illnesses). Non-communicable diseases are not limited to the better-off, which is scary. If a person contracts malaria or diarrhea, there are chances of the person dying sooner. But, a person suffering from a non-communicable disease requires long term care from the medical system.
This is where research should transfer into policy... how do we find an effective mechanism?
We have to be creative. Like the FKIL project, a simple idea can bring in change. Health awareness should spread to each and every nook and cranny of the country. And we have to be willing to bite the bullet on effectively regulating the health sector, both private and public.
More about Dr. Gita Sen
Dr. Gita Sen is a founder and member of the Executive Committee of Development Alternatives with Women for a New Era (DAWN). The United Nations System has sought out her expertise in a number of ways, including during intergovernmental processes, high-level events and as an advisor to policies and programmes. She was lead consultant for drafting UNFPA's India Country Population Assessment document for the 2003-2007period.
She currently serves on the Scientific and Technical Advisory Group of WHO's Department of Reproductive Health and Research, and is co-chair of PAHO's Technical Advisory Group on Gender Equality and Health.
In India, she has been a member of the Mission Steering Group for the National Rural Health Mission, and is on the Governing Board of the National Health Systems Resource Centre. She was a member of the High Level Expert Group on Universal Health Care set up by the Indian Planning Commission. She served on the Governing Boards of UNRISD and of the UN University. Her numerous book publications include among others Gender Equity in Health: the Shifting Frontiers of Evidence and Action (Routledge, 2010), Women's Empowerment and Demographic Processes- Moving Beyond Cairo (Oxford University Press/IUSSP, 2000), and Population Policies Reconsidered: Health, Empowerment and Rights (Harvard University Press, 1994).
She has received honorary doctorates from the University of East Anglia, the Karolinka Institute (Stockholm), the Open University (United Kingdom) and the University of Sussex, and will receive one from the University of Edinburgh in 2014. She was a recipient of the Volvo Environment Prize for her work on women, population and development.
IIMB expert brings into sharp focus the need to have a regulator body to check corruption and malpractice in the healthcare sector
The recent Global Ethics Forum 2014 on 'Equality in an Unequal World', hosted by the Centre for Corporate Governance & Citizenship and Indian Institute of Management Bangalore from January 03-05, 2014 discussed gender equality at one of the panel discussions.
The panel, moderated by Professor Vasanthi Srinivasan, comprised Gita Sen, expert on gender and development, IIMB; Sucharita Eashwar, Executive Director India, WE Connect International; Le Ping, Deputy Director, Research Institute of Globalization and China's Modernization, UIBE, China; and Afua Ansre, UN Women Africa.
Dr. Gita Sen, who has worked for 35 years, nationally and internationally, on population policies, reproductive and sexual health, gender equality and women's human rights, brought into sharp focus the connection between gender equality and health.
She opened the panel discussion with a reference to the Gender Gap Report by the World Economic Forum that ranks India 101 out of 136 countries on gender equality. "In India, we have traditionally failed in making and implementing human development policies for girls and women, be it in healthcare or education. Half of our work force is under-utilized. This is a failure of policy, not history," she declared, drawing attention to the fact that India is the lowest ranked nation among BRICS in the Gender Gap Report.
In this interview with Kavitha Kumar, she emphasizes the need for India to have a strong regulatory body that is responsible for public health.
Public Health is clearly not a priority in this country. For a country of over a billion people, we do a terrible job of ensuring safety and effective services in public health. What should be done to fix the regulatory mess?
When we say that public health is not a priority in this country, one of the clear indicators is that, as a country, although we spend around 5 per cent of our GDP on health, only about 1 per cent of GDP comes from the government. In most countries that do a decent job in health policy, around 50-60% of health spending is by government, where they consider public health as public good. You cannot deal with malaria, tuberculosis, HIV etc. with a public spending of 1 per cent.
Particularly, in last couple of decades, after the economic reforms, health was not a priority. We were busy becoming a super power. Public expenditures on health stagnated for a while. This shows in other outcomes as health status and indicators. By early 2000s, there was a big increase in inequality access to healthcare. During the 1990s the Government decided, because there was a dearth of medical care experts (doctors and nurses) in the public sector, to open up healthcare to the private sector. The idea of inviting corporates to both healthcare and health education (privatization) was intended to fill the gaps. The problem was there was no regulatory mechanism for the health system to cope effectively with the fallouts of this privatization. That gave rise to a serious set of issues. The problem is that there is information asymmetry in the health sector. Unless one has systems for regulating (kind of services provided, the way the care is given etc.), there will be malpractice and ethical problems, with no forum for redressal. The failure of (having) a regulatory body encourages malpractices in each and every stratum. This encourages health practitioners to close ranks, in case of wrong diagnosis.
While it is acceptable for us to have a qualified and extremely competent Governor of the Reserve Bank of India, an institution that oversees monetary policy, why not for an institution that is responsible for public health? Is public health not half as important as fiscal health?
See, we also have SEBI. SEBI's classic regulatory architecture is proactive. In business, it is encouraged but when it comes to health policy, there is huge objection to have a regulatory body. In SEBI, regulation is about managing competition among the corporates themselves. But in the medical field, regulation is managing the relationship between providers and receivers of care. Therefore it has become very difficult to put a regulatory architecture in place in India. There's the Drug Controller's office but these offices are often a hot bed of corruption. There is the Clinical Establishment Act, which is in process still. All is does is seek to identify and registering clinical establishments and even this is slow to move; very little real regulation as yet.
I was a member of the High-Level Expert Group, the HLEG as it was known, appointed by the Planning Commission to recommend how to move the country towards universal health coverage. We had suggested among other things a whole well-integrated regulatory architecture for health that built on the best of regulatory frameworks that are in place (in terms of standards, norms, technology). Countries like Brazil and Thailand have been able to put regulations in place for the health sector. From the point of view of patients, we need a mechanism where patients can register complaints and/or redress their grievances.
As there are vested interests at play, there is going to be stonewalling of any bid to introduce regulation. What is the solution?
Communities have to be part of the change. Both policies and community should work hand-in-hand to bring about the change. It is a political question. While the abysmal state of the country's health system sometimes drives one to despair, change can happen in the most unexpected ways. Look at the political revolution in New Delhi, and the victory of the Aam Aadmi Party (AAP). This points to the possibility of change even in the dire situations, and this offers a ray of hope.
There is plenty of talk about India as a hub of 'medical tourism' with feel-good stories handed out regularly to the media. The real issues in public healthcare often fail to get the time and space they deserve.
'Medical tourism' may help the corporate sector, but it will not solve the health problems of the country. In no country have there been real advances in public health without the strong and central role of the public sector (government). Private sector can pitch in effectively only when they agree to be regulated. Some elements of quality may be better in the private sector but medical service may not be better. What's worse, if more and more of formerly public hospitals are turning into private hospitals, where will ordinary people go? The poor cannot go to corporate hospitals. The high-tech hospitals are only for the insured. There are attempts by some state schemes as in Andhra Pradesh to expand the public health insurance offered by the Rashtriya Swasthya Bima Yojana (RSBY) to include care in corporate hospitals but these schemes are financially unviable as more and more research is showing.
You have worked in the area of women's health, particularly maternal healthcare. Would you please take us through the Fostering Knowledge Implementation Linkages Project (FKILP), an effort commissioned by the Karnataka government to strengthen the evidence base for public health?
The project began in 2011 in as a spin off from our work in Koppal district in north Karnataka, where we have been working on improving maternal health. Karnataka has first rate researchers and NGOs working at the ground-level. But there is no collective learning between the NGOs and the health department. Information exchange can help to transfer knowledge to policy. The FKIL project was started to help build a network of health researchers and the health department and create a forum. In the first year, we had three workshops, where the health department and researchers exchanged knowledge and experiences on a number of very practical subjects such as maternal anaemia. We discussed how the policies of the health department can be tracked, monitored and researched for correct assessment.
What are the main obstacles for countries trying to reduce maternal death? And why are some regions having more success than others? Is it just a question of investing more resources? Do culture and tradition have an impact on maternal death? Or is it about the status of women in society and their right to access sexual and reproductive health?
The status of women in society is just an element of the problem. It is how the health system prioritizes maternal health. According to the latest statistics, maternal mortality ratio has fallen below 200. It is a 5-6% per year decline. The Government's Janani Suraksha Yojana - a conditional cash transfer scheme - to get women to have institutional deliveries is claimed to have turned the tide. But, the big question for the health system is whether the institutional deliveries that are incentivized by the JSY are safe deliveries. Our research has been able to point specific needs to make that transition. And the research isn't telling us with certainty that this transition is happening.
If we bring in the private sector, they begin to skim the cream. They take all the easy cases and dump the difficult ones back on the public system. If one is paid by the case (in the model envisaged by the government when they rope in private players), why will any doctor handle a difficult case? At the end of the day, quality of medical service will become an issue. For management students, the focus it's not just on hospital management. It is management of a public system for provision of health. How do you ensure that HR is managed, how do you ensure that you do not create moral hazards in the system? The fundamental question from the regulation perspective for management students is to ensure smooth flow of services.
On an educational front, the Government is trying to reduce the duration of an MBBS course from five to three years. The idea is also to bring in more local people, as there are greater chances on them serving locals. Serving at home will be their priority and remote villages will then have primary healthcare personnel. The government is trying work on this, but the medical profession is preventing it from happening.
In the near future, human development is going to be the basis for growth. We are at a critical juncture because the burden of communicable infectious diseases is equal to non-communicable diseases (heart problems, diabetes, cardio-vascular illnesses). Non-communicable diseases are not limited to the better-off, which is scary. If a person contracts malaria or diarrhea, there are chances of the person dying sooner. But, a person suffering from a non-communicable disease requires long term care from the medical system.
This is where research should transfer into policy... how do we find an effective mechanism?
We have to be creative. Like the FKIL project, a simple idea can bring in change. Health awareness should spread to each and every nook and cranny of the country. And we have to be willing to bite the bullet on effectively regulating the health sector, both private and public.
More about Dr. Gita Sen
Dr. Gita Sen is a founder and member of the Executive Committee of Development Alternatives with Women for a New Era (DAWN). The United Nations System has sought out her expertise in a number of ways, including during intergovernmental processes, high-level events and as an advisor to policies and programmes. She was lead consultant for drafting UNFPA's India Country Population Assessment document for the 2003-2007period.
She currently serves on the Scientific and Technical Advisory Group of WHO's Department of Reproductive Health and Research, and is co-chair of PAHO's Technical Advisory Group on Gender Equality and Health.
In India, she has been a member of the Mission Steering Group for the National Rural Health Mission, and is on the Governing Board of the National Health Systems Resource Centre. She was a member of the High Level Expert Group on Universal Health Care set up by the Indian Planning Commission. She served on the Governing Boards of UNRISD and of the UN University. Her numerous book publications include among others Gender Equity in Health: the Shifting Frontiers of Evidence and Action (Routledge, 2010), Women's Empowerment and Demographic Processes- Moving Beyond Cairo (Oxford University Press/IUSSP, 2000), and Population Policies Reconsidered: Health, Empowerment and Rights (Harvard University Press, 1994).
She has received honorary doctorates from the University of East Anglia, the Karolinka Institute (Stockholm), the Open University (United Kingdom) and the University of Sussex, and will receive one from the University of Edinburgh in 2014. She was a recipient of the Volvo Environment Prize for her work on women, population and development.