Public Health Systems

For any society to grow and prosper an essential requirement is that its citizens remain healthy. Good health is not only a blessing but is essential both for living life to its fullest as well as productively. Public Health Systems is to do with how health care could be organised and managed towards this end, and is a specialized field of management. Of course, involvement of doctors and medical professionals would bring in domain knowledge and expertise which would be essential for a functional and equitable Public Health System to evolve.

The US model of health care is much talked about and we in India seem to be so enamoured by it that we are bent on aping it without really understanding it, as there is much in it which is truly disappointing.

The Nobel Prize winning economist Prof Stiglitz has commented in one of his essays (Ebola & Inequality, The Great Divide),“America’s largely private health care system is failing. ... True, at the top end, the US has some of the world’s leading hospitals, research universities, and advanced medical centers. But, though the US spends more per capita and as a percentage of its GDP on medical care than any other country, its health outcomes are truly disappointing. ... American male life expectancy at birth is the worst of 17 high-income countries – almost four years shorter than that in Switzerland, Australia, and Japan. And it is the second worst for women, more than five years below life expectancy in Japan. ... Other health metrics are equally disappointing, with data indicating poorer health outcomes for Americans throughout their lives. ... Good health is a blessing. But how countries structure their health care system – and their society – makes a huge difference in terms of outcomes.” 

This aspect of the dysfunctionality of the US Health System has also been commented upon by Dreze & Sen in their book, An Uncertain Glory. In their words, “The US health care system is one of the most costly and ineffective in the industrialised world: per capital health expenditure is more than twice as high in Europe, but health outcomes are poorer with, for instance, the US ranking 50^th in the world in terms of life expectancy". 

These viewpoints prompts us to examine some aspects that are desirable in designing an efficient and effective public health care system by incorporating elements of current thoughts in management theory and economics.  First, since health-care professionals require long and high levels of training, there is and would always remain high levels of asymmetric information between doctors and patients. That is, doctors have much more information available with them on the patient’s health and the possible future course of action than the patient has about herself. To remedy this, doctors have been given the responsibility to fully inform the patient of the treatment protocol before starting any treatment. This sounds very nice in theory, but is practically impossible to follow. A case of wishful thinking which is bad thinking as it leads to little wish fulfilment. In treating any patient, there are various possible therapeutic options between surgery, medication, life-style changes, radiation, or doing nothing at all. Even the specific medication can vary. Doctors decide on the required investigations and most appropriate treatment regime based on age, medical and socio-economic condition, co-morbidities, previous drug regime, possible follow-up treatments which would be required etc. etc. It is impossible both for the doctor to explain all this succinctly to patients given their heavy work-load as well as for patients to understand it given their limited knowledge of the nuances of medical treatment.  In deciding on the treatment protocol doctors bring in years and decades spent on their education and training – which as is well known is time taking and strenuous.

Second, to ensure doctors prescribe the most cost-effective and suitable treatment, they need to have the right incentives. Due to high levels of asymmetric information the scope for perverse incentives is very high. What that means in plain English is that doctors, like any other human being, will have an incentive to prescribe expensive procedures if it benefits them personally, given a chance to do so. As is well known, in corporate hospitals there is a well laid out practice of laying revenue targets for all consultants. It therefore very naturally directs them to prescribe all kinds of diagnostic investigations and the most elaborate treatments so as to inflate earnings.

Any stable, equitable, widely available, self-sustaining health care programme has to explicitly take these two factors into account. 

Some very specific instances how this plays out in real life come to mind, both good and bad. In one case, I was having high fever and was worried since I had some travel plans. I therefore went and met a doctor - a GP. He examined me and pronounced, “I can see no evidence of any kind of bacterial infection. In all probability, you have some kind of virus infection. Go home and take rest. If the fever does not go down on its own in three days, come back. If it goes above 100° F, take a paracetamol.

In another case, my brother had been diagnosed with some very serious kidney ailment and it set off a long chain of visits to various doctors. At every stop, it was standard for the doctor to prescribe two things – a blood test to check urea and creatinine levels and an ultra sound report of the kidney. Mind you a fresh one for each doctor we visited. There seemed to be no end of it and there was no resolution in sight. Finally, based on suggestions with friends we made a trip from Patna to Chandigarh to meet a specialist. Over 15 minutes this doctor discussed his issues with my brother and then proceeded to physically examine him over the next 10 minutes. Then he announced his verdict and prescribed a line of treatment. We were a little aghast and I bluttered out, “aren’t any tests required?” The doctor just smiled and replied, “I have seen all that was to be seen”. Later I came to know that this doctor had diagnosed the condition of the kidney by tapping the back and the levels of urea and creatinine by examining the eyes.

Now a couple of horrible experiences.

A very close friend of mine had been diagnosed with end stage liver cancer. As friends we discussed the situation, and then he asked me to be the executor of his “living will”. That is, he gave me the legal authority to take some decisions on his behalf in case he became incapable to doing so.  He was clear that he should not be put on life support and he gave me the written authority to take him off life support, if required. His logic was that his sons were young and might not be able to take this difficult decision. The inevitable happened. His condition took a turn for the worse and his sons rushed him to the hospital, and also called me. By the time I reached the hospital my friend had been put in the ICU and was being given all kinds of very expensive treatments. I approached one of the senior consultants in this hospital, who I personally knew very-well, and is a very fine human being, with the request that he be taken off life support. The response was most unexpected. I was informed that if the hospital did so, they may be charged with murder and as such would not and could not do it. I also came to realise that going the legal way to execute the living will was an extremely cumbersome and time taking process and practically impossible. I spent four days in extreme mental agony at having failed a friend in fulfilling a promise I had made. Over these four days, my friend was in complete vegetative state in the ICU. Thankfully he died on the fourth day. The hospital in the meanwhile ran up a bill of around Rs.5 lakhs and deigned to release the body only after the full payment had been made.

A relative had been ailing for quite some time (over 7 years) and I accompanied her on a visit to meet the consultant at a very reputed corporate hospital. After examining her, the doctor advised, that he suspected colon cancer, and to verify which she would have to be admitted for a couple of days. I asked this gentleman, given the patient’s existing condition would it be possible to give any kind of therapeutic treatment – surgery or chemo or radiation – if the diagnosis was confirmed. He was kind (and brave) enough to accept that there were practically no treatment options available in her condition. We brought her home and gave her all the love and care we could manage and she passed away peacefully at home three months later.

In medical circles, the rule of thumb is that any investigation or treatment should be prescribed, if and only if, it would result in helping the patient in any way. Something which is very conveniently forgotten in the corporate health care environment.

We, as a society swear on the glamours of corporate form of managing human organisation as being the most efficient and effective way of doing things. However, there is another vision of the corporation – one which is truly frightening.

In a film titled, The Corporation, the three Canadian co-creators, Mark Achbar, Joel Bakan and Jennifer Abbott, ask the question that, if a corporation is a person, what kind of person would it be?  The Economist in its edition dated 6^th May 2004 sums up the conclusions of the film in these words, “…the corporation is a psychopath. Like all psychopaths, the firm is singularly self-interested: its purpose is to create wealth for its shareholders. And, like all psychopaths, the firm is irresponsible, because it puts others at risk to satisfy its profit-maximising goal, harming employees and customers, and damaging the environment. The corporation manipulates everything. It is grandiose, always insisting that it is the best, or number one. It has no empathy, refuses to accept responsibility for its actions and feels no remorse. It relates to others only superficially, via make-believe versions of itself manufactured by public-relations consultants and marketing men. In short, if the metaphor of the firm as person is a valid one, then the corporation is clinically insane.”

Therefore, is there a better way to move forward!

I would like to take the help of some financial economists in trying to find a possible solution. Shleifer & Vishny argue in their paper, A Survey of Corporate Governance (The Journal of Finance, June 1997), that, “We have suggested that, in some situations, concentrated ownership may not be optimal because non-shareholder constituencies such as managers, employees, and consumers are left with too few rents, and too little incentive to make relationship-specific investments. In these situations, cooperative might be a more efficient ownership structure. …  This logic has been used to explain why health care, child care, and even retailing are sometimes best provided by cooperatives”. 

Privatised health care systems are a classic example of concentrated ownership with all stakeholder other than the promoters (who are generally top-notch consultants or private equity invetors), having little say in the functioning of system. The ones left out from having a say include junior doctors, nurses and other support staff, and of course the patient. Since large investments are required to set up and run these entities, they are left with no choice but to seek to generate large returns - by any and all means. Meanwhile, the bulk of the staff, ie all than the top consultants, have to put in long hours and much labour at low pay. In the process their prime objective - health care - is effectively bypassed.

One possibility which can and should be explored is to organise primary health care through cooperatives. Individual GPs can set up their own private clinics while being a member of a cooperative society. The coop could help out by maintaining quality standards, common clinic design standards, bulk procurement of consumables and durables, and arranging easier access to credit.  The coop brand name would also help in reassuring prospective patients of being offered certain minimum care standards.

Since the owner manager would have a large say in the functioning of individual clinics, the kind of pulls and pressures doctors face in working in corporate hospitals become much less. At the same time, they would have organised support from the cooperative of which they are a member which would help them set up and stabilise their clinics. Once the system of standalone clinics start functioning and become stabilised, larger secondary and tertiary care health care systems may be thought of as extensions of the same model.

Unfortunately, the way we have built up our cooperative system over the last century plus, they have become a cesspool of corruption. To bring out its true potential, re-orientation of the cooperative philosophy from a means of doing charity to a system of organising human endeavour would be required.  Changing the mindset would take much time and effort, but a start can be made - keeping the success of the milk cooperatives as an ideal.