While some states have managed to increase access to affordable healthcare, it remains below par when compared to other developing economies.
This is the second article in a two-part series analysing the asymmetric status of healthcare delivery across Indian states. Read the first part here.
Aiming to ensure the delivery of a minimum standard of services by clinical establishments across India, the central government enacted the Clinical Establishments (Registration and Regulation) Act in 2010. All types of clinical establishments, except those run by the armed forces, fall within the ambit of this Act. The need for such a legislative act was sparked off by wide variation in healthcare delivery across providers, resulting not only in compromised patient safety but also concerns about transparency and accountability in healthcare costs.
The Clinical Establishments Act seeks to ensure that the operative functioning of healthcare delivery systems in states is in compliance with prescribed, transparent guidelines and keep any form of regulatory malpractices in check (related to drug pricing, licensing provisions or procurement, for instance). This Act has been in effect in Arunachal Pradesh, Himachal Pradesh, Mizoram, Sikkim and all union territories except the National Capital Region of Delhi since March 1, 2012.
A closer look at the data on the number and type of clinical establishments across some of the above states clearly indicates a skewed distribution of healthcare providers.
Compared to the other states, Delhi has registered the maximum number of clinical establishments.
In the figure below, looking at the structural composition of the healthcare establishments in Delhi, there is a need for the state to expand government-funded diagnostic centres and nursing homes in proportion to the clinical centres available.
In terms of the total number of government clinical establishments like primary healthcare centres, sub-centres and district hospitals, states like Himachal Pradesh and a few northeastern states have done well in improving access to public healthcare facilities, particularly since the introduction of National Health Mission and National Rural Health Mission as centrally-funded schemes. Still, the delivery of standardised basic medical care services across states remain below par when compared with other developing economies like Thailand, China or Brazil.
Beyond the states listed that have introduced the Act, West Bengal introduced and passed its own legislation called the West Bengal Clinical Establishments (Registration, Regulation and Transparency) Act, 2017. This aims to streamline the procedures of registration of clinical establishments, medical licensing systems and accounting for criminal offences related to medical practice under a prescribed adjudicating, regulatory body called the West Bengal Clinical Establishment Regulatory Commission. One of the critical points raised by this Act relates to identifying criminal punishment for all doctors charged with medical negligence.
According to the newly enacted Bill, doctors or healthcare facilities may face criminal proceedings under Indian Penal Code, including a cancellation of their medical license, if found guilty of medical negligence. The Indian Medical Association (IMA) has raised strong objections to this clause. The IMA wants a single-window accountability for doctors to reduce the scope of harassment and no differentiation in treatment between the private sector and government-appointed doctors.
The implementation of the Act and its outcomes may qualify as a subject of greater scrutiny in the coming months. However, on a more systemic level, the very nature of regulating healthcare service raises two key issues, currently marring the healthcare delivery system in India (previously highlighted in this article). This pertains to the mandate and legality of government agencies – their capabilities and the feasibility of carrying out identified outlays or health goals.
As a case in point, the 2017 National Health Policy proposes the need for strengthening existing medical colleges and converting “district hospitals to new medical colleges to increase number of doctors and specialists, in States with large human resource deficits”. But there is no clarity on the financial feasibility of such a proposal. It is not sufficient to regulate the private sector; the public healthcare system needs to be revamped to serve as a substitute. Setting price ceilings and imposing punitive measures may serve as a disincentive to providers, thereby hampering delivery. This will only make matters worse, whereby neither is the public sector living up to the standard, nor is the private sector incentivised to deliver what it is capable of delivering.
Based on the available data, there remains a strong need by more states to recognise the Clinical Establishments Act with support of the Union government and put in additional financial resources in facilitating more nursing homes and diagnostic centres (in proportion to clinical centres); ensure monitoring of prescribed agency considerations for public health departments; and ensuring affordable healthcare in a transparent way.
It is vital for the Indian state to not only consider increasing clinical establishments in semi-urban and rural areas (where access is sparse), but also to ensure compliance of basic minimum standards of medical treatment by doctors in existing clinical establishments, which is essential for delivering quality medical care services to everyone. From a policy perspective, ensuring affordable healthcare access for mother-child care, reduction in out-of-pocket expenditure due to asymmetric distribution of healthcare services (via public and private healthcare centres), standardised medical training and monitoring of doctors (across states) and healthcare insurance (linked through an Aadhaar-registered scheme) require greater deliberation and focus by the Union government.
Ayona Bhattacharjee is assistant professor of economics at Jindal Global Business School, O.P. Global Jindal University and Deepanshu Mohan is assistant professor of economics at Jindal School of International Affairs, O.P. Global Jindal University.