مسائل اخلاقی در بخش مراقبت بهداشتی در هند

The issue of ethics and economic efficiency in the provisioning and delivery of services becomes complex in the Indian context where health indicators are poor. In an attempt to explore this issue, this round table article first provides an overview of the field of ethics in health care, the health care sector in India and its facilities, the key institutional actors and finally, the key ethical issues concerning the different players in health care – the physician, the bio-pharmaceutical industry, and the chemist. In its second part, the article reports on a discussion of the issues with a panel of experts across geographic and organisational settings.

Vasanthi Srinivasan: Thank you. You have laid out the range of issues on the subject of ethics in health care quite comprehensively. The issues discussed reflect the complexity of the sector, the multiple stakeholders involved, the different interests of each of these stakeholders, the weak regulatory framework, and the question of self-regulation at the level of medical professionals and organisations. What would be the three recommendations or suggestions that each of you has to any of the stakeholders that would contribute to building a more ethical health care systems? Rijit Sengupta: A critical issue, which was raised by Ravi as well, is the role of the drug controller (DCGI) both at the centre and at the state level. The Ministry of Health and Family Welfare must develop a mechanism that promotes co-operation and consistency across the drug controller functions in the states. Most of the services in this country have a dedicated sector regulator but the private health care sector (private hospitals and clinics) neither has a regulatory framework nor a regulator. The government must articulate its position in terms of regulating the private health care sector, given the proliferation of private providers in this sector which is only going to increase. The third thing would be with regard to the marketing of drugs. The government must move from developing voluntary guidelines to stricter regulatory norms as far as marketing and distribution of drugs is concerned. These are my key recommendations. Deepak Sapra: The core of my argument is based around affordability and I have a few recommendations on that. In the Indian context, one aspect that really impacts affordability is the time it takes for drugs to get approval – this aspect was pointed out by Ravi in his presentation. It would be a very important aspect in health care overall. In order to increase affordability we would have to reduce the time it takes to get approval for various kinds of drugs and we have to make sure of getting more people into the market as early as possible. Another aspect, on the same point, concerns the affordability of drugs which are still governed by patent. On this my recommendation is that we must look at compulsory licensing not just from the perspective of patent protection but also from the perspective of number of patients it is likely to impact. To my mind, compulsory licensing could be one way, especially in certain critical diseases where alternatives are not available. This could get more drugs into the market in a manner that is affordable to a wider mass of people in a country like India. I am conscious that it is a very dangerous argument, because it could open the flood gates and therefore you need to be very careful. It needs to be selectively done in the case of those products where there are no substitutes available and where there is a real case for public health or where a large number of patients are not being able to gain the benefits of that medication. My third point draws upon the emerging thinking around innovation, which Ravi and Rijit also spoke of. I agree that the scope for innovation in this sector is phenomenally high at the moment because of the various kinds of possibilities that exist in the value chain. My recommendation to venture capitalists would be to be consciously on the lookout for the models which incorporate innovation in the health care industry, especially around delivery, and to start in places which are not conventionally considered important markets or important customer segments. There is a lot of value at the bottom of the pyramid and there is a lot of value in taking it forward. There are various innovative approaches that people are trying out and people have done it in different parts of the world. We should be able to encourage innovation and get it into the Indian scenario. Another aspect I would like to draw attention to is that there is tremendous potential to leverage technology to reduce many of the barriers that exist, especially around information asymmetry. We could collaborate with the leaders in the field over this. Vasanthi Srinivasan: I have a PhD student who is researching on scaling up of health care services and one of his areas of interest has been telemedicine. Many telemedicine initiatives have been announced in the public-private partnership mode but the incentive structures that are built in are unclear. What is likely to be the future of telemedicine given that it could enable affordable access to health care in rural areas? Deepak Sapra: For this, we would have to look at collaboration with different players in the value chain. Ravikumar Banda: Telemedicine is a subject close to my heart. There are all sorts of problems around it and I have seen companies struggle. The point in telemedicine is taking the product to the end customer. How do you reach it and how do you make the whole path smooth? It's like this: People say if you have a small margin and large volume, it's a great business to do in health care. But reaching a large volume of people requires hectic marketing and that's a hugely expensive proposition. In order to aim at very big markets, you should be able to reach a large volume of people and that gap has to be first looked at. There we need to think how to reach a large sector of people without going through the classical pharmaceutical marketing method, which is a very expensive proposition. Only if we bridge that gap, I think more and more innovations will occur which will simplify telemedicine. People forget that if a farmer can be saved a trip from his village to his city for medical consultation, he is willing to pay for the telemedicine service. So we must think of how we can cost telemedicine cleverly to make it accessible to the end user. To reply to Vasanthi's question, my three suggestions would be: Firstly we need to integrate MIC with the enforcement agency. We need to have MCI tie up with IMAs (which are very powerful bodies in this country) to integrate all the doctors and put back a programme in which they are exposed to ethical values and made aware of what that would do to their practice. I think their own living will improve. Secondly, we seem to have forgotten the existing public health care system through general hospitals and medical college hospitals attached. We were providing good medicine through that system where the poor would get a certain amount of care. Today they are all in a dilapidated state, and we need to improve them. The funds allotted by the World Bank to improve the public health system are not being used effectively. We need to urgently strengthen the public health care system. Thirdly and most importantly we need to integrate the regulatory mechanism of the pharmaceutical industry into one body. We need to put in place much more rigour and time lines in executing these regulations, be transparent and evolve guidelines by involving the pharma industry. Vasanthi Srinivasan: Thank you all for making this such an enlightening discussion.