II. Forging a people-centred approach to private healthcare: integrating social accountability and regulation in a rights-based framework
In order to tackle the widespread problems faced by ordinary people concerning private health care, there is need for health system initiatives, combined with large scale social action. Building effective regulatory frameworks must go hand in hand with developing a climate of social accountability and patients rights. We must recognise that current weak regulation, or gaps in regulation of the private medical sector in many LMICs is linked with minimal political will to regulate this sector, since the private healthcare industry often has significant financial and political clout. Weak political will may also be linked with lack of expression of popular demand for accountability of the private medical sector, even though there may be widespread yet diffuse discontent in the population about practices of the private sector.
Nevertheless there is a strong case in favour of effective regulation of private healthcare providers, with components of social accountability.
Key arguments supporting the need for such regulation include:
The Human rights argument: In context of frequent violation of Patients rights in private health care facilities, it is worth reiterating that responsibility of the state regarding promotion of Human rights includes protection of citizens from rights violations by third parties. The UN CESCR General Comment 14 on the Right to Health brings forth the indisputable role of the Human rights framework in dealing with the private health sector. It must be emphasised that Patients Rights are Human Rights – and hence effective regulation of private healthcare providers must be ensured by the state, especially to guarantee protection of Patients rights.
The Public funding argument: In many LMICs, the private medical sector including ‘charitable’ hospitals have received significant public subsidy in various forms. This may include subsidised land in urban locations, and inflow of highly trained doctors from publicly funded medical colleges, which may be a continuous and massive subsidy from public systems to the private medical sector. Further, many governments have initiated large scale publicly funded health insurance schemes and ‘Public-Private Partnerships’, wherein significant public funds are made available to private providers.
Given such historical as well as ongoing flow of public subsidies and finances to the private medical sector, the need for concomitant public accountability systems cannot be denied. It is logical that all services which have been supported through public funds in any form (which would include the entire private medical sector), must also be held publicly accountable, through a framework of effective regulation and rights.
The Market failure argument: Health care is a sector which is notoriously prone to ‘market failure’, due to massive asymmetry of knowledge and power between healthcare providers and patients, as well as the unique vulnerability of patients. In an unregulated ‘free’ market, unfortunately doctors and hospitals are often free to exploit patients by over-treating, over-investigating, over-operating and over-charging them. The globalised pharmaceutical industry and medical technology industries with booming technological advancements are continuously introducing new drug molecules and technologies. These massive industries tempt doctors with graft and incentives, further distorting the situation to the detriment of patients. Given this context, the only logical antidote to market failure, to correct the major imbalance between health care providers and patients, is effective public regulation with social accountability, which could ensure that the interests of patients and citizens are placed at the centre of the health care system.
Regulation must be accountability writ large
Until now, regulation of the private medical sector has often been looked upon as a bureaucratic function of the state, largely divorced from issues of patients rights, and accountability of private hospitals to patients and citizens who use health services. However if we agree that regulation is a form of social accountability writ large, then regulators must be accountable to citizens, and citizens concerns must be strongly reflected in the regulatory framework. Otherwise regulatory bodies may be captured by elites, or regulation may remain minimal, or may become an additional channel for corruption.
Given this context, we propose that demand for protection of Patients rights could be an important fulcrum for social mobilisation related to regulation and social accountability of the private medical sector. Social mobilisation around demands like protection of Patients rights, and regulation of private hospitals to ensure affordability and quality of care, could be a central strategy of the health movement and civil society organisations. Along with this there is also need for working within the medical profession, and developing a voice for social responsiveness from sections of doctors interested in ethical, rational care, who may be concerned about the negative impacts of gross commercialisation on their profession.