'Healthcare is not an industry.'
'The government is only encouraging insurance as they are not able to provide healthcare to people.'
'Opening new medical colleges is not what is needed.'
'You have to invest in public sector hospitals.'
'You cannot hand over healthcare to the private industry.'
The brutal rape and murder of a 31-year-old lady doctor at the R G Kar Medical College and Hospital in Kolkata on August 9, 2024 shocked the nation.
The tragedy is that this attack on a doctor is not an isolated incident.
Why is it that doctors have become a target of people's ire?
"What happened at the medical college in Kolkata was not an isolated incident," says Dr R V Ashokan, national president of the Indian Medical Association. "The situation right now is such that incidents like this will continue to happen throughout the country."
"Here, if you want to see a doctor, you can meet him immediately unlike in the UK, US, Australia, Canada or New Zealand... Healthcare shouldn't be in the hands of the private industry," Dr Ashokan tells Rediff.com's Shobha Warrier.
In your post on X, you wrote that what happened at the RG Kar Hospital brought out the rot that has set in the country's medical colleges.
Has this rot been there for quite some time, or it happened in the last couple of decades? Where exactly is the rot?
The rot doesn't happen in one day. The rot is there in all dimensions of medical education.
Right from the way of selection, with NEET came in as the entrance examination, the stress starts for the children.
Before that, privatisation of medical education happened. Today, we have more medical colleges in the private sector than in the public sector.
When I grew up, medical colleges were the last word in medicine. For example, medical colleges like the Trivandrum Medical College or the Madras Medical College were the final word in treatment.
Today, they are not. Today, the place has been taken by hospitals like Apollo or Max.
Somewhere we lost it. The government medical colleges themselves lost their prominence.
It is a long story of how we messed up our healthcare system.
How much is privatisation of healthcare the reason for the rot?
It begins there. It begins with the government handing over the healthcare needs of the people to private hands.
Maybe they were not able to prioritise or unable to take care of the needs of the people.
About 3.9% of the GDP is the country's total expenditure on healthcare, and out of which the government's contribution is 1.1% which is around Rs.3.85 lakh crores.
It is 2.8% from the private sector.
It means the spending from the private sector is two times more than the public sector.
If this is the real picture, where is the hand of the government in healthcare?
The fall of our medical colleges, followed by the fall of the medical education, started with privatisation. It has become a farce now.
Also the load on the children doing post-graduation is immense now.
Two things happened. Creations of new posts almost stopped. There is no recruitment anywhere of medical officers.
The number of medical officers has never increased in comparison to the increase in the population.
By not filling up the posts, the load falls on the post graduate students who come to the medical colleges to learn.
The health system has become hollow from inside.
Even if there are appointments in the health system, they are ad hoc.
There is a system called the National Health Mission which is a parallel arrangement to bypass the establishment.
It gets Rs 36,000 crores (Rs 360 billion) to hire doctor, nurses etc for a very low fees for a short duration of 8 months, 9 months, etc.
You need to have people in the system who are proud of being government doctors.
What will be the sense of belonging for a temporary doctor?
So, the rot is due to lack of investment and handing healthcare to the private industry and handing over the medical education to the private sector.
It is said that post graduate medical students are made to work almost 100 hours a week which is inhuman.
How can a human being be alert after so many hours of work especially when they are dealing with people?
I call this exploitation. They are basically post graduate students who are dependent on senior professors. They have no voice or choice as they need to face the professors in the examinations.
Unfortunately, the entire burden of the patient care has fallen on these children. They are running the medical colleges.
Otherwise, how can just a strike by the post graduate students (in Kolkata) paralyse the medical system?
Is the number of doctors per people in India which is said to be close to 1:1000, low?
In Kerala, it is 1:400 and in Tamil Nadu, it is even less. In the entire south, it is 1:500.
In Parliament, the minister said that for the whole of India, it is 1:835.
So, we have long surpassed the number of doctors which is required.
Because there is so much of unemployment among MBBS doctors, there is this mad frenzy to do post-graduation.
Every MBBS graduate feels worthless unless they have a specialisation.
Every year, 110,000 students pass the MBBS, but there are only 65,000 post graduate seats. So, every year, 45,000 MBBS graduates don't get admission for post-graduation.
Imagine they give at least three attempts before either giving it up or doing something else. Then you calculate the number of MBBS graduates who remain in the coaching centres!
So, 150,000 students spend their time in the coaching centres because they have nowhere to go.
The government is not recruiting, and you cannot just open a clinic with just an MBBS degree. So, these children pick up night jobs for daily wages.
I would say, the number of doctors per people is not low. In fact, there is an over production of doctors, and public service recruitment is not happening anywhere.
Only if the government invests in healthcare, more jobs will be created.
You mean, all the problems started with the government moving away from education and healthcare, and giving it to the private sector?
Exactly! That's why I say, what happened at the medical college in Kolkata was not an isolated incident.
The situation right now is such that incidents like this will continue to happen throughout the country.
Why blame Bengal? The situation is the same in every state. The situation is the same in every medical college. The situation is the same in every medical department.
It will not change by building more toilets and putting up CCTVs.
The violence is due to lack of investment in health.
On one side, the government institutions have lack of investment and human resources. On the other side, the private sector hospital industry is unaffordable.
So, where will people go for health care?
Do you think there is rage within the people because of this, and doctors have become soft targets?
Yes, doctors have become soft targets as they are close to the patient.
Doctors are the face of the health system, especially resident doctors and duty doctors manning the emergencies and casualties. Naturally they are the targets.
At the end of the day, the relevance of any doctor is only when there is a patient. A doctor gets the respect only because of the patient.
The whole profession is for the patient. So, doctors also cannot react in a way an ordinary man reacts in a street.
But they are also human beings...
That is why what happened in West Bengal is not dying down. And the reason is the rot in the healthcare system.
You should understand that what we see there is not the disease; it is only the symptom.
Would you say the disease is the neglect of the healthcare system?
Exactly. It is the neglect, lack of investment, not increasing human resources, and lack of providing care from the government side.
In Kerala and Tamil Nadu, the public sector is very strong, and it gives tough competition to the private sector.
Twenty years ago, two third of the deliveries were happening in the private sector in these two states. Today, two third of the deliveries happen in the public sector. This is what should be replicated everywhere.
Tamil Nadu leads the way in how primary health centres should be run. In selected primary centres, caesareans also happen, and they open 24 hours a day. In Kerala, they have two OPs (outpatients), one in the morning and one in the evening.
In both these states, medicine is supplied at home for diabetes and hypertension. Teams led by doctors go to houses and check blood glucose and blood pressure, and supply medicines for one month.
You feel violence against doctors will reduce then?
It has reduced in Kerala. The state also has an Act.
Yes, people do react because of high expectations.
Do you feel people get frustrated when the privileged in society get good medical treatment at private hospitals while they feel helpless?
Yes. The reasons are= lack of investment in medical infrastructure and human resources in the public sector, and letting loose this concept of 'for-profit' corporate healthcare.
In principle, it is not correct to bring in the for-profit industry in healthcare.
The for-profit hospitals are run by for-profit insurance agencies.
Take the case of the United States now. 15% of the GDP of the US goes to healthcare, but 20% of Americans do not get care.
Americans cannot go anywhere for care. At least, here we have government hospitals.
We have government hospitals, and the small and medium clinics and hospitals run by doctors.
Here, if you want to see a doctor, you can meet him immediately unlike in the UK, US, Australia, Canada or New Zealand.
But corporatisation of hospitals is happening in India now....
Not just corporatisation, the small and medium hospitals are closing. No new doctor opens a small hospital these days. It is a loss to society.
In Punalur (Kerala), I am the last person to open a hospital, and that was 40 years back!
Healthcare should belong to the profession. Healthcare is not an industry.
But today, it is an industry officially and it is regulated as an industry.
More and more doctors are becoming employees than practising their profession independently.
IMAGE: Dr R V Ashokan. Photograph: Kind courtesy Dr R V AshokanSo, what kind of future do you see for the healthcare system in India?
If this continues, we will become another United States.
The government is only encouraging insurance as they are not able to provide healthcare to people.
With all respect to the PMJAY (Pradhan Mantri Jan Arogya Yojna), its penetration or comprehensiveness is inadequate.
Opening new medical colleges is not what is needed.
You have to invest in primary care.
You have to invest in public sector hospitals.
You cannot hand over healthcare to the private industry.
You are also connecting healthcare to the insurance industry which is for-profit.
How can the system be cleansed?
In 2012, for the 12th 5-year plan, the high-level expert group headed by Dr Srinath Reddy wrote a very beautiful document.
The document recommended Universal healthcare which was, the basic health cover should be ensured by the government without any insurance, without any third party intervention, and it had to be between the patient and the government.
In ten years' time, the NITI Aayog says they cannot provide heath cover for everybody, and that for the 92 crore (920 million) people who don't have any health cover, they will hand them over to the private insurance industry.
What is needed is we have to reverse our direction policy-wise. The government has to be the main provider of healthcare and they should bring in more money to the table.
Now, only one part of the expenditure is from the government while two parts are by the private sector. This has to change.
60% of the healthcare expenditure should come from the government.
Healthcare shouldn't be in the hands of the private industry.
Unless that happens, we will be another United States. And this has to be stopped.
Feature Presentation: Ashish Narsale/Rediff.com
