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A recent publication by the Institute of Policy Studies or IPS titled ‘Private Hospital Healthcare Delivery’ and authored by D.G. Dayaratne has looked at the issues of equity, fairness and regulation of the sector. In all the three areas, the study has concluded that the performance of the private hospitals is far from desired.
The study says that the “private sector is driven be the desire to maximise profits and hence concentrate their operations in densely-populated urban areas”. This is not an argument to discredit the private sector operations since private investments should always seek profits in order to survive in the market.
Unlike the public sector institutions which can be funded through compulsory payments made by taxpayers, private institutions have to depend on the payments made by their clients who are in this case patients. Hence, the problem with private sector hospitals, as the study has concluded, is “plunging those that cannot afford it into an adverse situation when they seek treatment which is not accessible in public facilities on an urgent basis”.
Hence, the private hospitals are supposed to fill a vacuum, but at an unaffordable cost. As a result, private sector hospitals are catering to a category of citizens who can pay which violates, according to the study, the principle of equity and fairness.
Private hospitals attend only to curative medicine
One cannot compare the private sector hospitals with the state sector healthcare system because private hospitals provide only one aspect of the healthcare to people, namely, ‘curative treatment facilities’. In contrast, the public sector healthcare system provides both the preventive medical facilities and the curative medical facilities.
Yet, the non-development of the public sector healthcare system in line with the demand for same and the technology that has been introduced to the global healthcare work has generated a general dissatisfaction about the standards and the quality of its services.
Public healthcare system has delivered some worthwhile results
Sri Lanka has been boasting about its public sector healthcare system introduced to the country during the last lap of the British rule covering both the preventive and the curative sides of medical facilities. The achievements made by this system during the initial period have been remarkable.
While the malaria epidemic was virtually eradicated by the preventive arm of the healthcare services, the people of Sri Lanka were given a better quality of life by both the curative and the preventive arms.
A Sri Lankan born in 1946 could expect to live only 46 years. By 1971, the expectations increased to 67 years and by 2012, they went up to 75 years. Similarly, in 1948, 90 babies out of every 1,000 babies born could not expect to live for the next five years. By 1990, this number fell to 20 babies and by 2012, further to nine babies.
However, more and better healthcare services mean more expenditure by the Government which could not be accommodated in the growing budgetary constraints of the country. Accordingly, the total expenditure on public sector health services which stood at 1.3% of GDP in 1950 remained around 1.5% in the subsequent period and increased to 2% in 2006 before it fell back to 1.3% in 2012, the rate which it had in 1950.
Public healthcare services have not grown along with global developments
Over the last six decades, there has been a tremendous improvement in the technology and the delivery system of the healthcare services in the world. For instance, medical diagnostic apparatus and robot-directed surgeries have now become the ordinary ways of curative medicine. The da Vinci robotic non-invasive surgeries are being performed throughout the developed world, making it easy for a surgeon to remove the prostate gland of a patient today.
Sri Lanka’s public healthcare system could not reach those benchmarks in view of the low expenditure allocated from the Government budget to health services. This writer recalls that the Colombo National Hospital, the flagship of the country’s public hospital system, got its Magnetic Resonance Imaging or MRI machine only after 1996 due to the dedicated work of some good-thinking officers of the Central Bank who found its necessity very badly after some of their colleagues who were injured by the devastating bomb blast in front of the Central Bank building in 1996 could not receive medical treatment properly.
In this background, there was a substantial excess demand for quality health services and to meet that demand, private healthcare service providers had to step in. At the same time, when the average income of Sri Lankans increased along with economic growth, there was a growing category of patients who could afford to pay for healthcare services. Thus, there were two categories of patients seeking curative treatment from the healthcare institutions: The rich category that could pay for the services and the not-so-rich category which could not afford to pay and therefore has to patronise the public sector healthcare institutions.
Private sector model
is defective
Hence, by all means, private hospitals provide a valuable service to the people of this country. But the model used by the private healthcare providers has been defective right from the beginning.
As the IPS study has also revealed, it is the public sector healthcare specialists who are serving as channelled consultants in private sector hospitals. Since the Government has not increased the salaries of those specialists serving in public sector hospitals, as a way of compensation, the Government has allowed those specialists to do ‘moonlighting’ and earn incomes commensurate with their skills, experience and qualifications.
Private hospitals also advertise boldly that those specialists are permanently attached to various Government hospitals to establish their credentials and thereby lure patients for channelled consultations. Hence, it is simply those specialists going on a ‘circuit’ from one hospital to another after they have completed their services at the relevant Government hospitals. This circuit visit of the medical specialists is fraught with several problems for the patients as well as the specialists.
Late appearance of
channelled specialists
First, since the private hospitals are not located in a single place, they invariably run into the heavy traffic of the city roads and are unable to keep to their appointments when they visit such hospitals. When one sits in a vehicle for hours in a disorderly traffic line, his mental state is not in proper condition to see a patient who is waiting in agony for him.
It has been a common practice for many such specialists to apologetically blame the traffic for their late appearance for appointments. Hospitals too without any sense of apology announce in their public address systems that the particular specialist will not keep to his appointment that day.
Tired specialists cannot serve patients properly
Second, when the specialists visit the private hospitals for the appointed consultations, they are over-exhausted. It has been noted that after they have seen a few dozen of patients, they are unwilling even to listen to what the patient would say about his ailment.
Like a worker on an assembly line in a factory, the specialist tries to dismiss the patient as quickly as possible either because of tiredness or because he is late for his next appointment. The result is that a patient hearing is not given to the patient.
Waste of time by patients
Third, patients have to wait for their appointments for long hours in the channelled areas of private hospitals. Since the number of patients is more than the number which a private hospital can accommodate safely, the scene there is exactly like the scene one may observe in the OPD section of a Government hospital where there is always a heavy demand for medical services due to the free service officered by them.
Even at the best hospital in the city, a common scene is that some of the patients have to wait standing until their time comes. By any standard, that is not the way to treat a patient.
Unannounced cancellations
Fourth, there is the problem of unannounced cancellation of appointments by specialists, maybe due to their having been called upon to attend to their formal duties in the Government hospitals or due to their being help up long hours at the previous circuit. This is a dangerous trend from the point of view of the patients since there is no alternative provided to them by the hospital.
Some patients would have travelled long distances to reach the hospital for consultations and some patients may be having medical emergencies. In any case, if a patient is unable to consult the specialist at the appointed time, it is a heavy cost to him in terms of time, money and required medical treatment.
The only solution offered by the hospital is the refund of the fees paid by him. This is like failing to fulfil the obligations under a contract and in all other cases, such non-fulfilment would have resulted in ‘blacklisting’ of the contractor concerned. However, in this case, there is no redress to the patient, though the hospital has entered into a contract with him.
No time to learn
new skills
Fifth, these specialists are professionals and they have to upgrade their knowledge continuously since the knowledge base is expanding day by day. They have to be alert on new research on treating ailments and new illnesses that may appear from time to time. They cannot depend on the knowledge they have gained at the time of completing their postgraduate qualifications.
But they are also human beings and when they spend long hours moonlighting, they have less time for families and career advancement. This is an occupational hazard and if they do not enrich themselves with new knowledge, they run the risk of incorrectly identifying the patient’s ailment. Wrong diagnosis leads to wrong medication and it will sometimes become fatal for the patient.
In-house patients too taken care of by visiting specialists
This is about channelled consultations. But even the in-house treatment of patients is fraught with the same deficiencies since it is the moonlighting specialists who look after those patients.
If a medical emergency arises, though the physician is on call, it is not an effective arrangement since the physician may be with a patient who has channelled his services in a consultation chamber. If it is the same hospital, the physician might leave the channelled patient to take care of the in-house patient. Either way it is an unsatisfactory arrangement.
The channelled patients will have to wait long hours until the physician appears; the in-house patient does not get the full attention of the physician. If it is another hospital, it is most likely that the specialist may prescribe the medication over the telephone without seeing the patient to the house-officer or the nurse in charge. Why has this sad state of affairs arisen? There are two reasons.
Public sector specialists should be paid properly
In the first place, the Government has not implemented a proper compensation policy for the specialists serving in the Government sector. A medical specialist has to put in a minimum of 10 years to acquire his qualifications: five years to earn a bachelor’s degree and another five years for the postgraduate qualifications.
Such human capital should be compensated properly but the salary structures in the Government sector is such that even those who are not required to put in long years to gain the required competency are compensated at the same levels or sometimes higher than the medical specialists.
A good comparison is the salary of a Government medical specialist at retirement is less than the total package paid to a staff officer on confirmation in State sector banks. When the medical specialists agitated for higher compensation, instead of increasing salaries, what the Government did was to allow them to moonlight in private places, creating an enormous problem for the patients as well as the whole healthcare system of the country.
Private hospitals should have
a permanent cadre
The second problem is that the private hospitals do not have a permanent cadre of medical specialists. If they had a permanent cadre, all the issues raised above with respect to channelling as well as in-house treatment of patients would not arise.
Since there is no demand for permanent specialists by private hospitals, there is a short supply of medical specialists as well. As a result, the private hospitals have to lure specialists from Government hospitals.
Benchmark good
hospitals abroad
This writer had an experience with an international hospital in Bangkok, Thailand. That hospital had specialists on its permanent cadre and therefore any of the problems relating to channelling did not arise there. The doctor was available at the appointed time and he spent, on each occasion he was consulted, about half an hour with the patient.
Since there is a permanent cadre in the hospital, if one physician is not available there is always another specialist in service and the patients did not have to leave the place disappointed. The best of that arrangement was that if it was necessary to consult a physician from another specialty, that was also arranged promptly by the hospital.
Hence, it was possible to treat a patient by putting all the heads together since all these physicians communicated with each other by using the hospital’s intranet. In their case, it is the hospital that takes responsibility for a patient and not the moonlighting specialist.
Doing better than Government hospitals is not enough
It appears that private hospitals in Sri Lanka are trying to do better than the Government hospitals. That is a laudable goal. But they should try to benchmark not with the Government hospitals but the high calibre foreign hospitals. In that respect, they have a lot to learn about courtesy, diagnosis of ailments by putting several heads together and using the most modern diagnostic equipment and how patients should be treated.
(W.A. Wijewardena can be reached at [email protected].)
