Abstract
Although the ramifications of a weakly regulated, commercialised private sector have always been prevalent, the COVID-19 pandemic has further exposed its magnitude and implications for patients in India. Although much is being studied about the health system’s response to the pandemic, the recipient of the system, that is, the patient seems to be less attended in analysis. This article analyses patients’ experiences while seeking healthcare from the private sector in the context of state-imposed regulations over them during the pandemic. A qualitative study was conducted in Maharashtra, India and 30 in-depth interviews of patients who faced difficulties in availing treatment from private hospitals during the pandemic were conducted using purposive sampling. The study reveals the myriad of catastrophic challenges patients faced, their vulnerability and helplessness with private hospitals during the pandemic. It demonstrates the character of ruthless privatisation that operates in health care with rampant overcharging and the failure of regulation of the private sector during the crisis. The study concludes by pointing out the need for state intervention in the regulation of the private sector and emphasises the need to strengthen the public health system and place effective accountability mechanisms with the legal instrument to safeguard people’s interests from corporate privatisation.
Introduction
The private sector will not cater to starving, sick, dying people who don’t have money. This massive privatisation of India’s healthcare is a crime.
Given the numerous instances of overcharging and profiteering during the pandemic in the private, and particularly in corporate hospitals, in India, not many people will disagree with this astute observation by noted author Arundhati Roy.
The COVID-19 pandemic has widened and exposed the deep fault lines in the health system worldwide—in both the public and private healthcare sectors. It has generated an unprecedented humanitarian crisis, wherein the almost entire population has felt the brunt of this disaster, particularly poor and marginalised people. Among all affected services, one that had a catastrophic impact is the healthcare crisis. Besides the impact of the disease, this crisis was a manifestation of a deficient public health system and a weakly regulated, commercialised private health sector in India. It has further amplified the issues like inequities and injustice in seeking healthcare that have existed forever. The public health system in India, which struggles to deliver health services even in ‘normal times, has been piteously strained with the burden of the pandemic’.
In response to such a despicable situation, countries or local settings, including the central and the state governments in India, have taken various special measures to provide affordable treatment to people and protect their patients’ rights. With regard to private sector engagement, two notable developments took place during the pandemic. First, Given the shortage of resources in the public system, the government had no option but to engage with better-resourced and dominant (Kapoor et al., 2020, p. 6) private sector to augment the health systems capacity and meet public health exigencies, enforcing public obligations of private healthcare providers. Second, quite remarkably, for curbing profiteering and overcharging by private hospitals, some Indian states took an exemplary decision to regulate COVID treatment rates from private hospitals (see Table 1).
Key Timelines of Regulatory Measures by Maharashtra State.
Undoubtedly these measures were progressive, however, they lacked effective implementation and could not create an effective deterrence against rampant profiteering, non-transparency of charges, overcharging in private and corporate hospitals. This article seeks to understand and analyse what patients’ have experienced in private hospitals and to what extent the private providers followed the state-enforced regulatory measures.
Attempts to Regulate Private Health Sector During the COVID-19 Pandemic
During the pandemic, a large section of private hospitals, especially corporate hospitals, were operating differently and chasing the opportunity to maximise profits (Nathanael, 2020). In response to several complaints of overcharging during the pandemic, around 15 Indian states have directed private hospitals to regulate rates covering 20%–80% of their beds for COVID-19 patients so far (Bhuyan, 2020). Against the backdrop of states’ slack approach regarding private sector regulation, the decision of rate capping on private hospitals stands quite phenomenal. Maharashtra has been at the forefront of announcing regulatory measures, including rate capping on 80% of beds, which is the highest percentage of bed reservations among other states. Taking a step forward, Maharashtra state had declared that coverage of the Mahatma Jyotiba Phule Jeevandayi Arogya Yojana (MJPJAY), the State level Publicly Funded Health Insurance (PFHI) scheme for secondary and tertiary healthcare for lower-income groups, would be extended to all its residents (The Economic Times, 2020).
The Study Context
During the pandemic, financial exploitation, denial of treatment, instances of discriminatory treatment, and rampant violation of patients’ rights in private and corporate hospitals have been amply reported from almost every state of India. Although the health system’s response to the pandemic has received much academic and policy attention, one of the relatively ignored areas for further inquiry and analysis has been patients’ experiences during their interface with private and corporate hospitals. Given this critical gap, this study was planned to understand patients’ experiences while seeking healthcare from the private sector in the context of state-imposed regulations over them during the pandemic.
These patients’ experiences were collected from different parts of Maharashtra state. Maharashtra is one of the most affected states, with the highest number of COVID cases and deaths (Government of India, 2020). Interestingly, as mentioned earlier, among various states of India, Maharashtra took the lead in declaring unconventional decisions of regulatory measures on private hospitals, which is rather significant given the regulatory stalemate for nearly a decade now in adopting the Clinical Establishment Act in the state (Shukla et al., 2021). Additionally, private hospitals in Maharashtra outnumber those in the public sector by a ratio of more than three to one (2,492 compared to 711—Kapoor et al., 2020, p. 4), with the majority of the private sector, operating on a for-profit basis.
This article aims to analyse a range of issues patients faced during the COVID-19 pandemic in availing treatment from the private health sector in Maharashtra. Further, it critically examines the state government’s COVID-specific rate regulation implementation. It contextualises the study findings in relation to commercialisation and regulatory failure of the private sector, as well as a push for privatisation at a policy level. Finally, learning from the pandemic experience, the article argues for bringing in effective accountability of the private sector to ensure its effective contribution to realising Universal healthcare for all.
Methods
Data Collection and Analysis
This qualitative study was conducted in the state of Maharashtra, India. In-depth interviews with 30 respondents were conducted from October to January 2020. Purposive sampling was employed in selecting the respondents. Patients who faced difficulties in availing treatment from private hospitals for COVID-19 or other health conditions during the COVID-19 pandemic (since March 2020) experienced denial of healthcare or COVID-specific state entitlements and violation of patient’s rights were identified for the study. Identifying such patients was primarily facilitated by civil society organisations and networks working on health issues. Shortlisted patients or their family members who were willing to share their experiences were included in the study. In case of the patient’s death, the immediate family members were interviewed. Before conducting the interviews, respondents were informed of the aims and objectives of the interview. The interview guide was used for conducting the interviews, covering key issues related to the patient’s experience in private hospitals such as issues in availing treatment, denial of care, excessive billing, non-transparency in billing and treatment, unnecessary care, improper behaviour of health staff, impact on the medical and financial condition of the patient, and so on.
Given the COVID-19-related constraints on travelling, all the interviews were conducted telephonically. Interviews were audio-recorded with prior consent from the respondents and recordings from the interviews were transcribed verbatim.
The qualitative analysis was conducted using a thematic framework approach. Initially, the coding was informed by an interview guide which was further adapted inductively based on themes arising from the interview data. Interview transcripts were coded focusing on forms of non-compliance to state measures by private hospitals, forms of financial exploitation of patients, hurdles faced in availing the publicly funded health insurance schemes, and its negative impacts on the patient and the family in association with profit-seeking behaviour of the private sector.
Profile of Respondents
Respondents in the study present a wide range of issues in seeking healthcare from private hospitals during the pandemic. Respondents belonged to urban, semi-urban and rural parts of Maharashtra state. Of the total 30 respondents, seven were women, while the rest were all men. The respondents ranged in age from 24 to 85 years. Of the total respondents, the majority were COVID-positive patients. Their experiences were from July 2020 to December 2020. Barring a few exceptions, most respondents belonged to the lower–middle-class background. Two respondents were admitted to large charitable hospitals, four to large private (corporate) hospitals, 10 to medium-sized hospitals, and 15 to small private hospitals. The patient’s hospital stay ranged from 2 to 25 days, and the total bill amount varied from 75,000 to 14 lakhs. Eleven patients had bills exceeding three lakhs, and two patients had bills over 14 lakhs. There were 13 deaths among the total respondents. Only five respondents had filed complaints against overcharging by private hospitals.
Findings
Non-compliance with State Regulatory Measures
Hefty Deposits and Inflated Billing
Although the government issued a notice that private hospitals would be penalized if deposits were collected for admission, they continued to charge patients for deposits. Almost all the respondents were required to pay a deposit before admission to a private hospital, ranging from 50,000 to 2 lakhs in most cases. Patients with cashless private insurance were also required to pay a hefty deposit of around 1.5–2.5 lakhs in corporate hospitals. A respondent with experience from the corporate hospital shared, Despite having a private insurance policy, we had to pay a 2.5 lakhs deposit. Many respondents were brutally told that they should not bother to come to the hospital if they did not have money. Another incident shared by a respondent illustrates the inhuman behaviour of hospital staff. Despite lying on the floor for four hours, feeling breathless, the respondent’s brother was not taken to the ICU until he paid a deposit of ₹50,000. There have been anecdotal reports of patients who lost their lives due to the inability to pay an advance payment or bill. A respondent who faced denial of care and lost a patient due to a failure to pay the deposit reported that The hospital asked for a deposit of Rs. 4 lakhs before admission. We were denied admission and the next morning, our patient died because we did not have that amount of money with us.
The study highlights a much-discussed issue of the widespread overcharging of patients at private hospitals. All respondents in the study reported inflated bills for both COVID and non-COVID treatment at private hospitals. Despite state measures to regulate rates for COVID treatment in private hospitals, they do not seem to have adhered to these regulations. Private hospitals did not inform a single respondent about government measures regarding rate capping. Instead, there were instances where hospitals used tactics to circumvent the state measure. For example, one respondent with experience from a big private hospital said,
During admission, the hospital staff hurriedly took our consent form for 20% beds which fall outside the rate capping. This was only discovered when we complained about excessive bills, and hospital staff showed us the consent document. It was mere fleecing of patients where our consent was obtained in a hurry without informing us about the government notification.
Some respondents were also threatened with termination of treatment if they failed to pay the bill.
These experiences not only illustrate how brazenly private hospitals have flouted state measures, but it also raises a question on public obligations of the private sector in the provision of healthcare.
High Cost for Medicines and Other Expenses
Medicines are considered critical areas with high out-of-pocket expenditure for patients. Many respondents reported that private hospitals did not inform them of separate charges for medicines or the need to buy medicines from outside, incurring additional expenses. Here, two medium-sized hospitals offer very striking examples. A COVID-positive patient, aged 30 years with no co-morbidities, was given a list of medicines priced at ₹56,000 right at the time of admission to the hospital. In another case, 38 years old COVID positive patient was charged ₹89,000 for medicines during 9 days of hospitalisation. In two cases for a short distance of While the rationality of care cannot be assessed with study data, it indicates the need for detailed auditing of patients’ medicines. For PPE also, hospitals had charged quite exorbitant. As reported in the study, most hospitals had set on average ₹2,500 per day for PPE.
Indebtedness
Nearly all the cases in the study present a sobering account of indebtedness for treatment from private hospitals. Although out-of-pocket payments and subsequent push into debt for private hospital expenses are not a new phenomenon, it was probably more prevalent than ever before during the COVID-19 pandemic. The lack of beds and availability of services in public health facilities and government COVID centres led to most patients resorting to treatment from private hospitals. Respondents reported using various means to raise money to pay the hospital bills, such as selling cows, land, jewellery and vehicles, borrowing from relatives, taking out loans from local money lenders, or withdrawing their Provident Fund (PF). Consequently, some respondents lost their land, and those who utilised their PF lost their financial security. Some families who lost a breadwinner in a family, now face a dual burden-loss of livelihood and huge debt due to massive hospitalisation expenses.
Irregularities in Billing
Other serious concerns reported by most respondents included non-transparency, irregularities in the bills, and false billing. Some patients were charged for services that they did not consume, for example, oxygen, mineral water, ventilators, ICU stay, etc. In some cases, patients did not receive detailed bills for each item consumed during the hospitalisation. Some respondents reported receiving handwritten bills. Two respondents received a handwritten bill for a significant amount of above ₹9 lakhs! Few others were given the bill on a piece of paper. One respondent shared an experience from the big private hospital that
hospital management verbally informed us the bill amount of Rs 14,21,000/- and did not issue us any printed bill. However, after the follow up for three months, a printed bill of Rs. 9.42,057 was issued, which had the discrepancy of 4,80,000 with the originally informed amount.
In another case, on the demand of a proper bill, the doctor responded that he was the only one who agreed to admit our patient in such a critical condition and we should be thankful that he was at least treated for a week rather than asking for papers and bills!
Such instances demonstrate the struggle of patients just to obtain proper copies of their bills. The reluctance to provide a proper bill was experienced in both small and big private hospitals. This raises concerns about the functioning of big private hospitals that are otherwise claimed to run and deliver high-quality care.
It is not uncommon to detain dead bodies in private hospitals until their families pay the entire bill. Some respondents reported similar instances of such insensitive behaviour by private hospitals. Patients’ rights charter, as well as the health rights advisory issued by NHRC clearly states that under no circumstances, a dead body be withheld for non-payment of a hospital bill or any other reason (Deshpande, 2019). The state government also issued a similar order during the COVID-19 pandemic. However, in reality, as the study reports, private hospitals have not bothered to follow it.
Erosion of Trust in the Medical Profession and Hospitals
Opaqueness in Treatment and Evasive Behaviour by Staff
Over the past decade, the erosion of trust in the medical profession has been a growing concern in India and globally. Trust is critical in healthcare because it is a means of bridging the vulnerability, uncertainty, and unpredictability inherent to the provision of healthcare (Calnan & Rowe, 2008). The COVID-19 pandemic seems to have impacted doctor-patient trust as well as people’s trust in the healthcare system. One respondent expressed how helpless they felt, Our experiences have scarred us so much that I think it would be better to die at home rather than go to a hospital, where all they want to do is extort money from you. It echoes the sentiments of many other respondents in the study.
During the pandemic, social distancing seemed to have distanced humanity from itself, leading to an increased communication gap between doctor and patient. In some cases, doctors interacted with respondents to only convey bill amounts. One respondent with experience from a charitable trust hospital shared that the PPE clad doctors talked to us from a distance of some 16–17 feet behind a barricade. In most hospitals, relatives were not allowed to enter wards due to COVID-19. Consequently, the patient’s relatives had no contact with their patient after their admission to the ward. Linked with this, many observed the lack of transparency in medical treatment. Most of the patients’ relatives complained of not receiving accurate information about the line of treatment and timely updates on the condition of patients. A respondent from a private medical college hospital shared that
nobody was updating us about what was happening. We felt completely lost and helpless. Nobody kept us informed about what was happening; we felt completely lost and helpless. One morning, we suddenly heard an announcement that my mother was to be taken in for an operation. We were completely unprepared, we begged and pleaded with the security staff to let us talk or see my mother before the operation, but they were rude and did not concede. The reception staff was equally evasive.
Some respondents also expressed serious doubts about the rationality of treatment and the updates on their patient’s condition.
Denial of Patients’ Right to Get the Medical Records
Ironically, one-third of respondents never received medical reports, diagnostic investigation reports, or discharge summaries after medical discharge. According to some respondents, hospitals conducted COVID tests on patients but never shared their test reports with them or did not inform them about the positive test results but stated on the death certificate or discharge summary that the patients died from COVID-19. Further, some patients were treated for COVID, but their positive test result was never communicated to their relatives. Despite repeated requests and follow up with hospital management, many respondents did not receive medical records. Such practices were observed across various types of private hospitals. Another respondent shared the hilarious experience of getting a false COVID report from a small hospital. The patient’s COVID report ID number did not exist in the lab record! This may be indicative of a nexus between laboratories and hospitals that manipulates the reports, requiring further investigation.
Dereliction in Quality of Care
With regard to the quality of services, according to some respondents with experience in corporate hospitals, Doctors were hardly present. After their one round in the morning, only nurses were present in the hospital. In that case, too, junior nurses used to handle most of the work. Some respondents reported that COVID positives, COVID suspects, and non-COVID patients were all admitted to the same ward in some small hospitals. In some small to medium-sized hospitals, doctors and nurses were working without masks, hand gloves, and PPE kits even in the wards, and the irony was that patients were charged ₹2,500 for a PPE kit per day in one such hospital in their bills. A few respondents indicated that some hospitals made a false claims regarding services, like ventilators, and misrepresented the patients.
Attempts for Grievance Redressal
As enshrined in the patient rights charter, patients’ rights seem to have been widely violated during the COVID-19 pandemic. The establishment of a grievance redressal mechanism for patients is one of the critical clauses of CEA, which was passed by the Central ministry of India in 2010. However, as of 2019, Maharashtra Medical Council had 700 cases pending (Shelar, 2019), which indicates the perfunctory state of the Grievance Redressal mechanism (GR) for patients in Maharashtra. The patients’ rights charter by NHRC and MoHFW in 2020 and the health rights advisory issued by National Human Right Commission in 2020 have mentioned the need for grievance redressal. In response to many media reports on the looting of patients in private hospitals during the pandemic, the state formed committees for grievance redressal in some cities. As reported in the study, although respondents were faced with a violation of patient rights in multiple forms, most were so frustrated and fatigued that they were not inclined to file any complaint about them. A small number of respondents who filed a complaint had approached the municipal corporation’s grievance redressal committee or grievance redressal forum at the city level or met a corporator or local MLA. Barring the exception of one respondent who used multiple channels to raise the grievance and finally received some resolution, others’ attempts did not yield satisfactory outcomes. One respondent with a clear case of overcharging and irrational care from the big corporate hospital shared that
when I argued with hospital administrator regarding the bill, he responded that private hospitals are helping the government cope with the COVID-19 burden hence they should not be taken to task. Then the hospital administrator asked, Aap Kitana Denge?—how much are you willing to pay? A few days later, I received the revised bill but did not receive any requested documents and explanations. So, we approached various grievance redressal forums instituted by the city corporation and escalated the case to the city commissioner. However, the case is still pending a final resolution from the Technical Committee.
This case indicates the hospitals’ sloppy approach to raising and negotiating the bills. It also raises serious questions on the functioning of forums of grievance redressal.
Impediments in Availing Publicly Funded Health Insurance Schemes
Although PFHIs are promoted and implemented to provide cashless healthcare services to the poor, studies have shown a significant gap in achieving its noble objective. As mentioned above, the Maharashtra state government extended coverage of MJPJAY to its citizens during COVID-19. With this, each patient admitted to MJPJAY empanelled hospital should have availed of the entitlement; however, many respondents reported the myriad issues in availing of the scheme. The primary complaint of most respondents was that hospitals do not inform patients about the scheme. MJPJAY scheme empanelled private hospitals to refuse to enrol patients under the scheme citing various reasons such as patients not eligible, procedures are not covered in the scheme, documentation being incomplete, the hospital’s quota for enrolling patients under the scheme being over and so on. Some hospitals made an excuse saying their empanelment on the scheme is expired. A few patients also reported about hospitals double charging by drawing money from the government as well as from the patients. Few patients were falsely denied the MJPJAY scheme because they tested COVID negative when MJPJAY covers 996 procedures and does not focus on COVID treatment alone! The few respondents who could avail of the scheme entitlement had to navigate through a series of hurdles and follow up intensively with hospital and scheme-related staff. According to one respondent from a big charitable trust hospital,
The Aarogya Mitra (scheme facilitator based in hospitals) was completely dominated by the hospital and could not help me either. I was so frustrated with their stance that I made three videos explaining what was happening and uploaded them on social media. I went to the MJPJAY district co-ordinator and submitted my case to him, showing him the ICMR approved COVID positive test report. I also complained to the Deputy collector, the local corporator and other political leaders. Finally, hospital management approved the scheme but only from when they actually proceeded with my application, having me to pay for the first two days of the admission.
On the whole, it seems despite applying the scheme to the entire population, most respondents remained deprived of its entitlements and saddled with out-of-pocket health expenses and debts during the COVID-19 pandemic, proving the cashless nature of the scheme is only a mirage.
Discussion
The study vividly demonstrates the catastrophic situations people faced while seeking healthcare from private hospitals during the pandemic. It illustrates the harsh reality of rampant profiteering by the weakly regulated private sector and the blatant disregard for state-imposed rate capping and rampant violation of patients’ rights. On one side, findings reveal how aptly the Maharashtra government has taken regulatory measures on the private health sector to provide COVID care. An issue as contentious and disputed as rate regulation became feasible, although to a limited degree, during this unprecedented public health emergency because political will, public interest and social obligation for healthcare provision became paramount. However, on the other side, since the regulatory measures were taken impromptu invoking the Epidemic disease-related acts, it does not seem to be well organised. Hence, many private hospitals refused to comply with government guidelines (Financial Express, 2020) and continued to gravitate towards profiteering, even in times of crisis.
While the study brings forth the experiences of a small sample of patients from some parts of Maharashtra, findings appear to be ubiquitous across and outside the country. Beyond Maharashtra, there have been numerous reports in the media of patients dying, sometimes outside hospital doors, after failing to gain admission to private hospitals in many other locations throughout India (Owain et al., 2021). India is not alone in experiencing this distasteful and unethical practice of private providers. Such practices have been reported in Bangladesh, Oman, Iran, Brazil, the Philippines, Egypt, South Africa and Pakistan (Owain et al., 2021).
With regard to the protection of patients’ rights, although the NHRC’s Patients’ Rights Charter predates the pandemic, in hindsight, had this charter been adapted by various states in its substance, it would have at least offered some semblance of protection to patients from overcharging and financial exploitation during the pandemic. But unfortunately, various states have not adopted it. Underneath this continued deferment of adaption of the Patients’ Right Charter lies a lack of political will and the government’s unspoken but evident laisse-faire perspective. Further, recognising the need for the protection of health rights and patients’ rights during the pandemic, the National Human Rights Commission (NHRC) issued a wide-ranging ‘Advisory on the Right to Health’ with 59 recommendations in September 2020 (National Human Rights Commission [NHRC], 2020). However, this too was scarcely adopted by states.
Broad vignettes one could draw based on the analysis of patients’ experiences in the study are—(a) In the absence of well-established regulatory norms, enacting discretionary regulatory steps during an emergency may serve the political optics, but it is a less effective approach. (b) For any semblance of deterrence against overcharging and profiteering, regulation; and particularly rate capping, needs a credible system of grievance redressal. (c) There is an incentive for private hospitals in denying the benefits of government schemes (particularly insurance schemes) to patients and (d) Though acutely felt during the pandemic, non-compliance with the state regulatory mechanisms and patients’ rights is not a new story; it shows a deeply embedded culture of impunity and non-answerability.
As much as it is important to delve into specificities of an accountability deficit in the private corporate health sector in India, even at the risk of taking too expansive view, deeper questions will not be adequately answered unless a political economy lens is applied to how the global landscape of private actors in health underwent some massive changes over last two decades. Particularly notable changes with far-reaching consequences are—First, changing the role of the state from serving public provision to promoting and supporting the private sector. In effect, in many developing countries, including India, the institutional capacity of the state to deliver public health services has been severely undermined, and the private health sector fills the resultant vacuum. Second, the Proliferation of financial markets in the health sector denotes the increasing role of financial motives, markets, actors and institutions in healthcare. As Lethbridge (2014) articulates, the link between financial investors and healthcare is not new, and in countries where private healthcare providers invest in healthcare, provision for profit is a large and established industry. Yet, the growth of private equity in India’s health sector is astounding. For example, it has been noted that private equity investment in India’s healthcare increased over 13.5 times from US$94 million in 2011 to US$1,275 million in 2016 (Nathealth, 2017). Third, the push of neoliberal market solutions by the World Bank, the United States Agency for International Development (USAID), and the Gates Foundation actively influenced and shaped health policies of sovereign countries which encouraged and scaled up private and corporate sector provision in many poor and middle-income countries (Chapman, 2014).
In addition to these influences, the state’s capacity to regulate the private sector was systematically weakened (Sheikh et al., 2013). Most high-income countries have an extensive and effective regulatory system built up over many decades that regulates prices, quality levels of service, and citizens’ entitlements. In contrast, as De Groote et al. (2005) state, the lack of institutional capacity characteristic of many low- and middle-income countries constraints constructive engagement with and regulation of private sector providers. In addition, regulations are often inappropriate or outdated, and enforcement is weak; thus, the states where the public provision of healthcare has failed to provide minimum standards of decent universal and affordable healthcare are those least able to oversee that private sector providers do so (Bloche, 2005, pp. 207–228).
Many learnings could be drawn from the pandemic regarding the overall health system and healthcare delivery. The study suggests at least four broad lessons from the pandemic. First, the pandemic has underscored the fact that private corporate healthcare does not offset the workload of the public health system. Second, it has blatantly revealed that the corporate health sector will always put profits before patients and invent ways to not cater services to non-affording people even during an emergency. Third, with relatively no historical precedence of robust regulation, enactment of emergency measures such as rate capping and auditing hospital bills is complicated as accountability and transparency culture in the private corporate health sector is weak. Finally, it points to the futility of PFHI implemented through the weakly regulated private sector. Given the nominal contribution of PMJAY during the COVID epidemic, overclaiming PFHIs as the one-stop solution to healthcare for poor people comes under serious question (Upadhyay, 2021).
These lessons should have nudged the government to create a mechanism for regulating the private health sector without further delay. However, contrary to this expectation, the government is creating a favourable environment for further privatisation and corporatisation of healthcare (Chakravarthi et al., 2022). Public–Private Partnerships in the form of PFHI schemes with the key role of the private sector are being promoted as a vehicle to UHC with a blind eye to deep-rooted issues in the performance of the private sector in the implementation of PFHI schemes, as evident from existing research (Ghosh, 2014; Wagle & Shah, 2017). Two recent developments demonstrate an astonishing contradiction in the government’s temporary regulatory actions and long-term policy prescriptions. One is NITI Aayog’s report on investment opportunities (Government of India, 2021) in the health sector published right amid the pandemic. Under the broad rubric of ‘Ease of Doing Business’, there is a strong pitch for venture capitalism and private equity investment in India’s healthcare segment. It is an open invitation and an assurance that government will safeguard investments, assets and profits. Second, NITI Aayog has also asked states to accelerate setting up medical colleges on the Public–Private Partnership model and augmenting district Hospital facilities with private partners (The Mint, 2020). The state governments of Maharashtra and West Bengal have already invited EoI from the private sector. Incidentally, NITI Aayog’s document on investment opportunities in the health sector does not even cursorily comment on the need to regulate private and corporate healthcare (Marathe, 2021). It is striking how decisively the government has shifted from regulator to enabler of the private health sector.
Conclusion
In the study of the private healthcare sector, there is ample global evidence of the marketisation, commercialisation, corporatisation and privatisation of healthcare. However, patients’ perceptions and experiences of interfacing with private are seldom analysed. This article offers insights from the first-hand experiences of patients and their relatives. It exposes the harsh reality people faced while seeking healthcare from the profit-seeking, poorly regulated private sector during the pandemic. As the study points to the widespread profiteering practices by the private sector with various consequences for patients and their rights, it asserts that the pandemic has further crystalised evidence that the unaccountable behaviour of the private health sector is not merely an isolated instance of the single erring hospital, but it is a trend. So, what the government rightfully did during the pandemic to curb overcharging, is needed even in normative situations when there is no pandemic. Further, it clearly exhibits the need for the state’s intervention in the regulation of the private sector. Finally, it strongly suggests an acute and urgent need to strengthen the public health system and place effective accountability mechanisms with the legal instrument to safeguard people’s interests from corporate privatisation. At the macro level, while emphasising accountability and regulation of the private sector, the advent of markets in healthcare needs a renewed and truthful enquiry into fundamental questions like—Is healthcare only a market-based commodity? If not, what are the essential public good characteristics it must retain? And what role would regulation play to safeguard the public good characteristic of healthcare?
Footnotes
Acknowledgement
Authors acknowledge Dr Abhay Shukla in the conceptualisation of this study and Dr Abhijit More, Shripad Kondhe, Ravi Desai, Santosh Jadhav and Ms Vaishali Gaikwad for their contribution to the data collection.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Ethical Approval
This study was given the ethical approval from the institutional ethical committee of Anusandhan Trust.
Funding
The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This work was supported by the Funds for Global Health Rights.