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 50th 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 6th
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.