III. Example of campaign experiences from India – developing a three pronged strategy
Documented personal experiences of patients, specific studies, and testimonies by ethical doctors have established that unnecessary procedures and medications, perverse system of kickbacks, super profiteering during hospital supply of stents, implants etc., and other malpractices are rampant in private hospitals in India. Every year more than 60 million people in India are pushed below the poverty line due to unaffordable health care expenditures. While regulation of private hospitals and legal protection of patients rights must be ensured to stop such medical malpractices, it has often been a challenge to develop effective campaigns around such ‘non-standard’ issues. However in Maharashtra state of India, over the last decade civil society organisations, health activists and health professionals have developed a range of interrelated strategies to build effective social mobilisation and advocacy around accountability of the private medical sector. The ‘three pronged strategy’ centred in Maharashtra state, India consisting of the following related approaches, is briefly described here as an example.
1) Mobilising citizens for protection of patient’s rights and regulation of private medical sector
The Maharashtra state chapter of People’s Health Movement (Jan Arogya Abhiyan) is a wide network of civil society organisations, health activists, doctors and public health professionals. This coalition has been mobilising people and advocating with decision makers for protection of patients rights and related regulation of private hospitals across the state, since over a decade. The recent most chain in this series of actions is the ‘Patients Voice, Citizens Initiative’ campaign. This campaign has reached out to tens of thousands of people from extremely diverse social backgrounds, by conducting a ‘mass poll’ on patients rights in different parts of Pune district in mid-June 2017. The objective is raising awareness and building social momentum for protection of patient’s rights, preventing exploitation of patients in large private hospitals including corporate hospitals, and improving the quality of care in public hospitals. This is linked with the demand to enact Maharashtra Clinical Establishment Act, including a charter of patient’s rights along with an effective grievance redressal mechanism.
During the first phase of the campaign, health activists approached ordinary people with a short polling slip, asking their opinion on three questions - Should the State Government regulate and standardize private hospitals to check commercialization? Should Government take concrete steps to improve quality of care in public hospitals? Should Government immediately enact legislation to protect patient’s rights? Activists asked over 21,000 people, each of them asked to give their ‘vote’, by taking the ballot papers and boxes to various residential societies, slums, villages, companies, colleges, self help groups etc., conducting the voting process at more than 80 places in the city and district. Respondents included government employees, doctors, nurses, IT professionals, unorganized sector workers, waste pickers, domestic maids, farmers, farm labourers, senior citizens, sex workers, autorickshaw drivers and teachers. People from across the social spectrum enthusiastically participated and voted, with the overwhelming majority of over 99% voters expressing their firm support for patients rights, regulation, standardization of private hospitals, along with improved quality of care in public hospitals. Now in the second phase of this campaign, it is planned to conduct such ‘polling’ in various other parts of the state, along with strongly communicating the results to media, legislators and decision makers.
2) Bringing together conscientious citizens and rational doctors to foster dialogue through ‘Citizen – Doctor Forums’
Citizen-Doctor Forums (CDF) have been formed in the cities of Mumbai and Pune of Maharashtra state.
CDF Mumbai is a growing joint platform of aware citizens and ethical doctors in Mumbai, to promote much-needed dialogue between society and medical community. It intends to strive for justice to the patients suffering from medical malpractices, and is publicly critical of the way in which Maharashtra Medical Council (MMC) is mishandling patients' grievances, requiring major reforms and ‘cleanup’ of MMC. CDF-Mumbai is striving to create public pressure on MMC while also providing support and advice to patients who face problems while accessing care in private hospitals. Pune Citizen Doctors Forum (PCDF) is formed by volunteer-citizens in Pune, from various professional and social backgrounds and like-minded doctors, to bridge the current trust deficit between patients and doctors who are trying to do ethical, rational practice and rebuild this trust. PCDF is preparing a data base of patient-friendly doctors from Pune city so as to offer a list of such doctors to patients in need, while creating a web based platform (www.medimitra.org) which can be used by patients to suggest names and provide feedback on doctors whom they have found to be patient-friendly. This information can be used by others patients who are looking for patient-friendly, rational, ethical doctors. PCDF also periodically organizes discussions among citizens and doctors on key topics related to health care, and is planning to publish with the help of involved doctors, standard educational material in lay language on rational care for common health problems.
3) Organising doctors to promote rational, ethical healthcare - Alliance of Doctors for Ethical Healthcare (ADEH) is an emerging national network of doctors in India committed to promoting ethical and rational health care, while challenging current malpractices within the medical profession. A few hundred doctors from various parts of India have so far joined ADEH, since they realised that there are several 'voices of conscience' among doctors within the sea of commercialisation, but these doctors are scattered and did not have a platform to raise their issues. These doctors who themselves practice in a rational and ethical manner, and are agitated about the increasing malpractices, have often faced their own survival struggles, due to 'resisting' the prevalent mal practices. ADEH has publicly intervened in the debate surrounding restructuring of Medical Council of India, and provided technically informed inputs to the National Pharmaceutical Pricing Authority (NPPA) of India towards fixing the ceiling price of coronary stents and other medical devices to make these affordable for common people. ADEH is now enlarging its reach to doctors through small meetings in various cities and by its website, and plans to organise a national convention on ethical healthcare in the near future.
Overall, these three approaches are being developed in a synergistic manner, with the objective of mobilising citizens, involving sensitive doctors, and facilitating dialogue towards improving the responsiveness and accountability of health care. While this is just one small example of possible strategies, in the coming period many such initiatives and experiences from different areas may be identified and shared through the thematic hub, to enable cross learning and refinement of approaches to ensure accountability of the private medical sector in various countries.