COPASAH Thematic Hub COPASAH Thematic Hub on Accountability of Private Medical Sector
This concept note provides an overview of theCOPASAH Thematic Hub on Accountability of Private Medical Sector, describing some background on the current private medical sector in LMICs with a focus on South Asia, followed by a brief conceptual framework for developing a social accountability approach to this sector, followed by an example of initiatives from India, concluding with a description of this emerging Thematic hub.
I. Private Medical Sector–‘All is not well’ with the unregulated giant
The private sector in healthcare, and privatization of health systems are becoming important issues today in the context of most LMICs (Low and Middle Income Countries). As pointed out in a recent Lancet series: ‘The private sector in health care is not going away. Indeed, it has a large and expanding part to play in the health systems of all low-income and middle-income nations’. There is also increasing concern regarding regulation of the private sector, in context of mixed systems comprising both public and private segments: ‘The task of those concerned with health should be to subject the private sector to scrutiny—description, analysis, and evaluation…; the evidence on which to make wise policy decisions concerning the private sector is often weak or absent. That situation must change’.
In this section we will take a brief review of the private segment of healthcare systems in several South Asian countries, followed by a quick look at the current status of regulation of this sector.
The Private medical sector in South Asia (Bangladesh, India, Nepal, Pakistan, Sri Lanka) The private health care sector is tremendously heterogeneous, ranging from independent informal and formal practitioners to small, medium and large hospitals, charitable hospitals and corporate hospital chains and diagnostic centres. While there are similarities among all the five countries as far as presence of a private sector goes, there are also significant differences among them with respect to the size, nature, and importance of the private sector, and the relationship between the private and public healthcare segments. A bird’s eye view indicates that in this region Sri Lanka has a much better resourced public sector, with a smaller private sector, and overall lower levels of commercialisation of healthcare. However, the private sector is reported to be a growing forceeven in Sri Lanka, due both to greater investment from private players.India hasa very large and dominant private sector ranging from large for-profit corporate entities in hospital and diagnostics, not-for-profit trust hospitals,smaller doctor owned hospitals and nursing homes, individual practitioners (qualified andunqualified), chemists, and traditional healers.Similarly, Bangladesh, Nepal and Pakistan have weak public health infrastructure and low levels of public spending, and a private
Horton, R. and Clarke, S. (2016) The Perils and Possibilities of the Private Health Sector. The Lancet 388: 540-1, Published OnlineJune 26, 2016, http://dx.doi.org/10.1016/, S0140-6736(16)30774-7  Same as in footnote 1. Govindaraj et al (2014) Healthcare in Sri Lanka: What can the private health sector offer? HNP Discussion Paper World Bank.
sector including for-profit andnot-for-profit hospitals,general practitioners (both qualified andunqualified), chemists, and diagnostic laboratories.The following section gives a very brief country-wise outline.
Sri Lankahas proportionally the smallest private medical sector among the group of South Asian countries, since the public sector accounted for 73% of the hospitals and 93% of bed capacity, while handling over 90% of the total patient admissions in 2014. Public-sector hospitals are engaged in both curative and preventive care, while the private sector focuses mainly on curative care. The quality of treatment and management of inpatient care was found to be better in the public sector despite being available at a lower cost. While the number of private hospitals has increased during 1999 to 2011, private hospital beds represented only 6% of the total hospital beds, consisting mainly of a few leading hospital chains and large number of small regional players. The top five private hospitals accounted for nearly half of the private-sector bed capacity in 2014. Medical tourism was reported to be a key growth driver, which is concentrated in the Western Province, while rising per capita income was also seen as increasing demand for private healthcare. This was accompanied by increase in the technologies available at private hospitals, and a shift in the private sector from smaller to larger facilities having over 100 beds.
In Nepalnearly two-thirds of healthcare delivery facilities are privately owned and operated. There are an estimated 3000 private healthcare enterprises in Nepal, of which around 70% are diagnostic clinics, and 26% are primary clinics, secondary and tertiary hospitals. The secondary and tertiary private sectors are better organised, and their growth was outpacing growth in the public sector. The number of private secondary hospitals has increased from around 69 in 1995 to 350 in 2015,with secondary and tertiary hospitals largely concentrated in Kathmandu and a few other urban centres like Pokhara. Significant foreign investments have been made since 2010, especially in private tertiary hospitals whileestablished business groups of Nepal,as well as groups of high net worth doctors have set up healthcare companies.
In Bangladesh private presence in secondary and tertiary level medical care has emerged over the last one and a half decade. As of November 2016 there were 14,337 registered private hospitals, clinics and diagnostic centres, while the total number of government hospitals under the DGHS was 610. Local businesses and entrepreneurs from the pharmaceutical and diagnostic care industries have expanded to set up multi-specialty hospitals. Bangladesh has a liberal FDI regime, with no limit for equity participation and repatriation of profits and income. In the late 2000s, Goldman Sachs identified Bangladesh and Pakistan
Sengupta, A., Mukhopadhyaya, I., Weerasinghe M.C., and Karki, A. (2016) The rise of private medicine in South Asia. British Medical Journal 2017;357:j1482 | doi: 10.1136/bmj.j1482 Rannan-Eliya, R.P. et al (2015) Quality of in-patient care in public and private hospitals in Sri Lanka. Health Policy and Planning 30: 146-158. Ranasinghe, N and Mudannayake, D (2015) Sri Lanka Private Sector Hospitals.Fitch Ratings NY. September 28. www.fitchratings.com Amarasinghe, S. et al (2015) Private Health Sector Review 2012. IHP Technical Reports Series Number 2, Institute for Health Policy, Colombo, Sri Lanka  A Report on Market Data for Private Sector Investments in Nepal Healthcare Sector, by Dolma Development Fund, UKAID and Intellecap, September 2014 Government of the People's Republic of Bangladesh (2017) Health Bulletin 2016. Management Information System, Directorate General of Health Services, Ministry of Health and Family Welfare.
among the eleven next big emerging markets (N 11), which was expected to have implications in healthcare arena, for healthcare financing and potential for private investment in infrastructure.
India has one of the largest private healthcare sectors in the world, and the private healthcare industry here is much more developed compared to the previous three countries, where it is in an emerging phase. The private healthcare sector in India is more established as well as diversified, and more influential in policy making. Available reports show that the private sector is dominant and providesabout 80% of outpatientservices and 60% of inpatient services. Further,privatefacilities are expanding to smaller towns andcities, with 48% of all private hospitalsand two thirds of corporate hospitals reported to be located insmaller cities.The most significant development is that there has beenorganized promotion of healthcare provision as a big business opportunity and the rise of the healthcare industry, projecting healthcare provision as a highly profitable economic venture. The healthcare sector in India has become an attractive area for private capital investment by global investment firms, private equity funds, and high-net-worth-individuals, and also by global financial institutions such as International Finance Corporation (IFC). Further there are several Indian multinational healthcare companies that have growing presence in neighbouring South Asian countries, as well as in the Gulf and in some African countries.
In Pakistan, health care is highly privatised, with public health expenditure as percentage of GDP falling from 0.72% in 2000-01, to just 0.42% in 2014-15. Private spending on healthcare was estimated to be 70%, out of which 98 % expense was borne by households. Private services include for-profit clinics, high-tech specialty hospitals, and not-for-profit clinics and hospitals that provided free or discounted care to the poor, pharmacists and laboratory technicians, nurses along with shopkeepers, unqualified practitioners, traditional healers. According to an IFC report (2011), an increasing number of trusts, NGOs and social welfare organizations had invested in not for profit health facilities, which were serving a very large cross section of the population. Most businesses were individual or family owned,however there was an increasing trend of individuals considering hospitals as investment business for commercial return.The government was exploring PPPs and encouraging private sector to provide facilities in villages and small towns.The IFC report observes that “Low public expenditure by government, lack of expansion in the public health sector, increasing population with rising income levels indicates a high potential for growth for the private hospitals”.
An important, noteworthy development in the region is the active role of the International Finance Corporation (IFC - a World Bank institution) in not only promoting the growth of the private sector in these countries, but also actively financing its growth and expansion through measures such as lending and
Jakovljevic M, Groot W and Souliotis K (2016) Editorial: Health Care Financing and Affordability in the Emerging Global Markets. Front. Public Health 4:2. doi: 10.3389/fpubh.2016.00002 Jain N et al (2015) NSSO 71st round: Same data Multiple Interpretations. Economic and Political Weekly, 50(46&47), 84-87. Mukhopadhyay I, Selvaraj S, Sharma S, Datta P. (2015) Changing landscape of private healthcare providers in India. Paper presented at International Public Policy Association Conference. Milan. The term “healthcare industry” is used as an umbrella term while referring to hospitals, diagnostic centers, drugs and pharmaceutical- medical equipment and devices and the insurance industries. The hospitals sector is reported to be the major segment, and hence the term healthcare industry is often used while talking about corporate and other big private hospitals.  International Finance Corporation and State Bank of Pakistan (2011) Health and Social Work: Private Sector Hospitals. IFC Washington.
directly investing in hospitals for expansion, and also investing in private equity funds and companies that in turn invest in healthcare companies in ‘emerging economies’. In fact several large global private equity companies have created specific funds for investing in hospitals in South Asia and the MENA (Middle East North Africa) region.
Groups of private hospitals are also present and growing in Latin American countries such as Brazil, Mexico, Colombia and Peru. It is reported that the industry is,however, less developed in this region than in some the emerging markets of Malaysia, India and South Africa.Healthcare companies from the latter countries have expanded to multiple other countries and have listed on stock exchanges to access more capital to finance their expansion. Overall in LMICs across the world, the private medical sector is a growing and significant player in almost all healthcare systems.
Performance of the private healthcare sector – Blind optimism belied by troubling reality It is useful to recall the arguments that were made by international institutions such as the World Bank and some policy makers since the early 1990s, favouring growth and increased participation of the private sector in health care. It was claimed that private services are better in terms of efficiency and quality etc. Howeverincreasing number of studies and accounts point to the myriad problems with the private medical sector. While the Oxfam report is one important reference, studies have shown that the public sector provided better quality care than the private sector (Footnote 5).Studies on performance of health insurance programmes and other forms of PPPs demonstrate a range of problems with private providers.The pathbreaking book ‘Dissenting Diagnosis’ published in India based on testimonies of 78 ‘whistleblower’ doctors has ripped the lid on the myriadmalpractices in the commercialised private medical sector, includingunnecessary treatments and interventions, and irrational care driven by profit seeking by large hospitals, pharma industry – doctor nexus, institutionalised system of kickbacks, and inflated, arbitrary costs of care.
Danger of ineffective or ‘captured’ regulation, imperative of social accountability Given this context of large and often dominant private sectors within the health systems of many LMICs, the mechanisms for regulation are often weak, under-resourced, bureaucratic and inadequately effective ,. There are major gaps in policy design and implementation, human resourceconstraints, problematic organizational relationships, and major risk of ‘capture’ of the regulatory bodies by private interests. Regulation may be minimal, limited to addressing certain physical infrastructure issues, and standards may be influenced by either academic experts or the corporate healthcare industry. There is anemerging view that the problems with regulation of the private sector are not just narrow, technical issues of poor design, rather
 Cleaton-Jones I.P. (2015) Private Hospitals in Latin America: An Investor’s Perspective. World Hospitals and Health Services. 2015;51(2):7-9. Oxfam (2009) Blind Optimism. Dissenting Diagnosis - by Arun Gadre and Abhay Shukla, Penguin Random House India, 2016 Peters, D., and Muraleedharan, V.R. (2008) Regulating India’s health services: To what end? What future? Social Science and Medicine 66:2133-44.  Bloom, G., et al (2014)  Sheikh, K., Saligram, P., and Hort, K. (2013)What explains regulatory failure? Analysingthe architecture of health care regulationin two Indian states. Health Policy and Planning 2013: 1-17.
healthcare services have certain unique features requiring special regulatory strategies compared to other services or products. In fact regulation is a socio-political process which must address issues of quality, safety, affordability, access, transparency, accountability, equity and justice,. Further the goal of universal health care provides a basis for taking a Health systems perspective to manage the private sector, and the main aim of government policies must be to develop a healthcaresystem that ensures widespread availability of good quality, free or highly affordable care, so that this system meets the needs of the population as a whole, especially working people and marginalised populations. Linked with such a broader socio-political and people-oriented approach to regulation is the need to explore ‘bottom-up governance’, and related concepts of social accountability of regulators,and social regulation, related to the Health care system including the private medical sector. Social accountability refers to formal or informal mechanisms through which citizens and/or civil society organisations bring officials or service providers to account.‘Social regulation’ refers to action-oriented approaches designed to reinvent and democratise regulation, with greater participation and accountability of the regulatory process to users and the public.This includes developing participatory oversight mechanisms for regulatory bodies, such as patient and citizen involvement in monitoring of enforcement of rules and regulations related to health care providers, from a patient-oriented and rights-based perspective.
ll. Forging a people-centred approach to private healthcare: integratingsocial 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 LMICsis 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 withlack 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 casein 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.
 Same as footnote 16 Santos, F.P. and Merhy, E.E. (2006) Public Regulation of the Healthcare system in Brazil  Same as in footnote 5.
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 governmentshave 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 andfinances 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 arecontinuously 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 healthcare 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 ofPatients rights could be an important fulcrum for social mobilisation related toregulation 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.
III. Example of campaign experiences from India – developing a three pronged strategy
Documented personal experiences of patients, specific studies, and testimoniesby 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 60million 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 ‘masspoll’on patients rights in different parts of Pune district in mid-June 2017.The objective is raisingawareness 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, includinga 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 askedto give their ‘vote’, by taking the ballot papers and boxes to various residential societies, slums, villages, companies, colleges, self help groups etc., conductingthe 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, andprovided 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.
IV. COPASAH Thematic Hub on Accountability of the Private Medical Sector Today despite massive growth of the private medical sector across the world including LMICs, and major social evidence of the negative consequences of market failure, regulation of private medical sector remains patchy and weak in most LMICs. Despite large scale dissatisfaction related to malpractices, unethical practices, overcharging, and violation of patients rights, movements around these issues are often non-existent or very small. Hence there is urgent need for a platform which would help develop thediscourse on accountability of the private medical sector through involvement of activists and practitioners, along with facilitating exchange of experiences and perspectives.
Given this context the COPASAH thematic hub on “Patients rights and private medical sector accountability” would strive to develop a conceptual discourse and evolving framework for social accountability of the private medical sector, keeping in view the context of LMICs esp. in South Asia. The hub would promote networkingamong civil society organisations and networks on issues related to private health sector regulation and patient's rights, with a focus on South Asia. These efforts would support and complement existing networks like the People’s Health Movement. The thematic hub will engage in relevant knowledge generation through publication of papers and policy briefs. It is expected that this hub would help to orient and inform health activists and civil society members, enabling them to raise key issues related to the private healthcare sector, in the spirit of accountability and rights. Key planned activities by the Hub The thematic hub will work through organising global thematic webinars, networking and alliance building in South Asia, regional consultations, and capacity building of activists. Key activities would include - 1) Forming an e-group of the Thematic Hub, and sharing regularly about accountability of private medical sector and patients rights, especially in South Asia context. 2) Organising a Regional consultation on accountability of private medical sector and patients rights involving civil society activists from India, Pakistan, Bangladesh, Nepal and Sri Lanka, during December 2017 at Mumbai. 3) Organising webinars on accountability of private medical sector and patients rights, focussed on South Asia context but with relevance for various LMICs.These would have involvement of interested civil society activists and health professionals from various countries. 4) Developing policy briefs and widely disseminating these; sharing literature on this theme,which would be uploaded on COPASAH website. 5) Preparations related to the theme for the Global symposium on Health sector accountability, including organising various workshops and sessions. SATHI, a Health rights organisation based in Pune, India would be anchoring this thematic hub. SATHI team members may be contacted at – … (dedicated email address for hub) COPASAH website: www.copasah.net