Challenges faced by Private Hospitals in Kerala

This article is in continuation to following articles by me, published few days back.

Kerala Nurses, Minimum Wages, Fair Working Conditions

Flaws in Minimum Wages Act 2009 for Hospitals in Kerala

In the earlier articles we saw details of currently burning issue and perspectives of both parties (staff and management) as I have perceived. I also explained with examples how fundamentally flawed the Minimum Wages Act is.

In this article, I am trying to focus on other challenges faced by private hospitals and what society expects from them. Through this, I want to highlight that (in many cases) management’s greed doesn’t seem to be the main factor behind certain issues faced by the staff; instead these other challenges faced by hospitals also seem to be major contributing factors.

I will try not to go too deep into solution part as it will be covered in a subsequent article.

Allegation that hospitals are not law abiding

Nowadays we hear a lot about hospitals violating various laws/Acts. At a broad level we can classify these into 4 categories:

-          Against patients’ interest (ex: unhealthy instrument/drug maintenance)

-          Against employees’ interest (ex: exploiting through underpayment, deny benefits)

-          Against government’s interest (ex: avoid taxes, improper book keeping)

-          Against the environment (ex: improper waste management)

Note: Other important entities associated with private hospitals are investors, third party suppliers etc. and I don’t think there are any violations from their perspective that are widely discussed.

Before commenting on these violations, I would like to look at the term “law” from a philosophical angle. Kindly bear with me, I think this is very important.

What is law?

I am not referring to any dictionary or expert definition, instead simply using my common sense and see evolution path of any law. We humans are social beings, hence it is important for us to abide by certain guidelines/protocols for the collective benefit for all; this is also looked at as ‘ethical path’. On any specific topic, first a concept of ethics (or ‘not unethical under given circumstances’ – there is a subtle difference between this term and ‘ethical’) is born in the minds of one or more persons; then it evolves with further refinement and wider acceptance; finally a time comes when it is put into writing and upheld as law, with associated punishment and penalty in case of violations. So, can we define law as a “Collective, clear and firm ethical expectation about to-do and not-to-do which is put into writing formally”?

Challenges in law making process

One of the biggest challenges during law making process is the diversity at the ground level – if you try to make it too generic, it might end up being unfair to many people; but if you try to customize it for too many diverse scenarios, it will become too complex and impractical. It is important to strike a balance somewhere. And there will always be debates around this.

Another big challenge is the inertia of people’s mindset and resistance to change. Many laws come to existence due to visionary people (who are ahead in time) who try to implement them in spite of a great resistance. From this angle, you can also see some selfish people trying to disguise as visionaries and pass laws for their own profit, and not for greater good of public. Categorization between these 2 becomes another point for debates.

Lastly, keeping law updated with the changing times is another big challenge. I guess this is self explanatory.

Ethical vs. Legal: Is a coconut tree climber not a human?

Lets take an example which can be well understood by most people in Kerala. How many of us ensure that a person climbing coconut tree has adequate health/life insurance in case he falls down and gets injured/dies? How many of us are ready to pay a huge sum towards his treatment or towards support money for his family in case he falls while climbing tree in our own place and has no such insurance? How many of us even bother to think about such things? Think about it.

If you are one of those who at least think about this as an issue, I am glad. But I am sure by and large answer is close to zero. Most of the people only think about how to get coconuts plucked by someone for as less charge per tree as possible, and mutually discuss with a great concern about rising charges.

Alright, lets say tomorrow a human rights activist fights for coconut tree climbers and if a law is passed in this regard that mandates health/life insurance for these people and also mandates contributions from ad-hoc employers (common people) towards the same, do you think it will get implemented easily? Certainly not, isn’t it? I am sure there will be lot of people who will come out and say that such law is stupid and its government’s responsibility etc. etc. And of course, there will be debates on the charges, mode of payment, proof and so on. Some coconut tree climbers themselves will take risks, waive off such charges and pose unfair completion to fellow climbers. All these things happens in hospitals also; lets look at another example that can be more directly related to hospitals.

Toyota Innova vs. Maruti 800 vs. Tata Nano

Several years back there was no Toyota Innova or Tata Nano in the Indian market, but Maruti 800 was a big hit. Maruti 800 didn’t have hi-fi safety features like air bag, ABS etc. but still it was accepted as a legal, safe vehicle. Then, when cars like Toyota Innova came into picture, many people realized and learned about advanced safety features, but was Maruti 800 made illegal on the grounds that every consumer deserved such features?

Instead of banning Maruti 800, even Tata Nano (which is perhaps slightly inferior to Maruti 800) was allowed to come to the market. Why? Because the dream of many more Indians owning four wheelers was perceived to be much bigger and practical compared to the risks involved (including lives of people). All these cars are just different; they cannot be each other or serve each other’s purposes, even though all of them are meant for commuting/travelling. Lets see how we can apply this in case of hospitals.

As I understand few decades back many private nursing homes and hospitals came into existence in Kerala and were seen as quite successful entrepreneurial attempts. Now many of them are struggling, why so? What changed? One important reason that I see is too much of comparison between small and big establishments and trying to bridge the difference between them. They are just different and serve different purposes! So, are we doing a mistake by comparing small hospital to a corporate hospital even though both of them are meant to provide ‘good healthcare’ to people?

With introduction of many corporate hospitals, our society has got its Toyota Innova hospitals. But who knows? Maybe our society is waiting for an influx of Tata Nano hospitals too. Instead of allowing such evolutions, are Maruti 800 hospitals getting killed in a thoughtless fashion? A point to ponder upon, isn’t it?

Comparing small establishments vs. big ones

For clarity sake, lets take a look at various pros and cons of small and big establishments. As I see, big establishments have following positives:

-          They can afford to come up with grand ideas and implement the same quickly

-          They can assure and provide better quality through streamlined processes

-          They can save money through bulk deals and streamlined operations, and they can utilize the savings to come up with better infrastructure, fair wages to employees, reduced charges to customers

-          They can afford to have dedicated and expert staff to focus on specific areas, and hence can operate with higher effectiveness and efficiency, as well as complying to all laws of the land

Now, here are negative aspects of big establishments:

-          It is possible that they use muscle and money power to get away with no penalties/punishments in case of violations

-          It is possible that their greed and mistakes remain well covered under the sophisticated masks

-          It is possible that people at ground level are sometimes too much process driven that they become inflexible/insensitive towards customers

In case of hospitals, I believe both small and big ones should co-exist; a limited comparison between each other is healthy too, neither of them being ideal solutions, but one shouldn’t try to become other in the process. Sometime back there was a huge cry by small retailers when corporate/multinational retailers came into picture. I did welcome entry of latter ones to the market for the same reason mentioned above. And to be frank, considering the diversity in India there seems to be enough space for both to survive and thrive. But looking at latest developments, I sometimes think that there may indeed be merit in rumors that big players (or their lobbyists) want small hospitals to stop operating and shut down!

Same set of laws for small and big hospitals

Now, the most important question: is it fair to expect small hospitals to compete with big ones by complying with same set of laws or should there be a different set of laws so that small players don’t perish due to harsh laws?

It would be incorrect if I say that law makers haven’t considered this aspect at all; there are indeed some provisions that already exist and help small hospitals breathe. Ex: canteen/cafeteria is not mandatory within premises for a small hospital. However, I feel there are more opportunities to customize this further and without such customized set of laws many hospitals (especially in rural areas) might be facing a close down.

Sorry for a rather lengthy foundation. Lets see what these laws are that we are talking about. More details are below.

Laws and Restrictions – Heightened Expectations

These days hospitals are increasingly bound by many Acts and laws; recently I saw a list of 52 different Acts that a hospital needs to follow!! Increasing number of inspections are being conducted, restrictions and penalties are imposed (I won’t say that they unnecessarily harass all the time, though sometimes one does wonder about such possibility!). The departments I am referring to are labour department, electricity department, PF department, ESI department, pollution control board, drug inspectors, income tax department, municipalities, fire safety department and so on; the list grows.

While I wholeheartedly agree that checks and balances are must to maintain an order, I insist that government should not make things so difficult that the focus of management goes more towards fine prints of these acts rather than providing better healthcare to patients. Please note and remember that most private hospitals are run by practicing doctors themselves and it is indeed sad that they are sometimes treated rogue criminals. I definitely think that healthcare sector needs a special recognition and special support from government instead of just insisting to follow endless number of rules.

A simple example is waste management, this being another burning issue in Kerala. Of course it is important to promote concepts like “segregation of waste at source”, “dispose/manage waste at source” etc. However, in Kerala these days government has miserably failed in managing waste and conveniently transferred the entire headache to people and establishments, but without providing proper supporting infrastructure. As I see, each establishment installing their own waste incinerators (which cost lakhs of rupees) is a big joke; it is huge waste by itself and the process is not environmental friendly too. And in some places they don’t have extra land to do such improvisations, so what should they do?

Another example: There is no liberal supply of electricity or water to hospitals, a place of interest for everyone irrespective of age, religion or sex. Hospitals are treated just like any other commercial establishments and harshly/indifferently treated by such departments most of the times.

Yet another example: Now pharmacies are supposed to keep duplicate bills (carbon copies) for a long period and produce in case of inspection. This is non eco-friendly as enormous amount of paper, ink get wasted in the process and moreover it is impractical as most carbon copies become ineligible within a short time period due to oxidization process. Proposal of sharing computer copies is not welcome too, which actually is a perfect solution to the issue.

Help by kind hearted individuals in various departments

At this point, I definitely have to recognize and appreciate contribution of many kind hearted individuals in various departments who understand contributions by small hospitals (through personal experiences or otherwise) and hence extend their helping hands in many ways so that such hospitals stay afloat. They use their discretionary powers in this regard.

Unfortunately such discretionary powers with some individuals also lead to next important challenge – corruption.

Corruption

This is not a surprise in India, isn’t it? Law enforcing officers are always empowered with lot of ability to take subjective decisions, and are largely unaccountable if their decisions are contested and ruled against. This gives them supreme power that can potentially cause lot of damage to an individual or a business, hence doors get opened for corruption. Agreed that today is no longer license raj of the past, but it is not completely clean either. I guess there is no much point in writing more about this, as the topic is well known to everyone.

Bad management of government schemes

At one hand, various government departments expect hospitals to comply with idealistic rules and all their fine prints, but on the other hand, government itself is not managing schemes like RSBY (BPL), ESI etc. very well. Ex: They don’t pay hospitals on time and keep huge amount pending from their end. They themselves recommend patients to certain hospitals and then deny claims saying treatment should have been referred to somewhere else. This is really a discouraging trend for small hospitals who don’t have a luxury of huge cash reserves.

Bad Patients

This is an important challenge faced by hospitals and individual doctors that I must speak about. Not all patients are innocent, they are also human and cannot be blindly trusted. Most of the patients are good, but some of them often fall under one or more of following categories too:

- Rogue: They abuse and even physically attack doctors without sound reasoning

- Unnecessarily suspicious: They lack faith in doctor from the very beginning

- Impatient: They want fast results without caring too much about pros and cons; but later they will be ready to blame doctor for taking higher risks

- Irresponsible: They don't follow all the instructions by doctors but will be ready to blame the doctors later for failed treatment

- Defaulter: They get the treatment first but will refuse proper payments later

Perhaps some doctors/institutions also fall under ‘bad’ category thus causing lack of faith in people; hence can we call this a chicken and egg story?

In any case, these bad patients cause lot of headaches to doctors and institutions, and also bring their spirits and service motives down. It is to be noted that mistakes by 1% of people make life difficult for rest 99% in the name of tightened laws, increased safety precautions etc.

Challenges with respect to staff

In the earlier article (Kerala Nurses, Minimum Wages, Fair Working Conditions) I mentioned about issues that hospitals face with respect to nursing staff. But it is important to note that issues have increased with respect to all kinds of staff. Some of the issues are as below:

-          Healthcare sector, like many other sectors in India is not able to attract people with some smartness and communication skills; many such people go towards BPO jobs, retail jobs etc. where they can get better working conditions and pay.

-          The last part mentioned above i.e. better working conditions and better pay may not be true always, but many youngsters go towards bigger cities thinking that they might get a good break. So, it is not just doctors who are hard to fill in rural hospitals, but any staff

-          Hardship is another thing that current generation is averse of; everyone is looking for easy jobs and easy life, thanks to new age entertainment options and technology. This problem is seen in all sectors and healthcare sector is also not spared

-          Challenges are with doctor staff as well whose demands for increased salaries and facilities have only been in upward direction in past few years

-          Thankfully hospitals still get some good people somehow and running the show

Fake Drugs

Just yesterday I read in a news paper about drug companies who were trying to promote their drugs in illegal fashion in nexus with certain government authorities and doctors. Along with such things, the healthcare sector is also plagued with issues due to fake drugs. This particular issue is not related to day to day running of a private hospital, but I thought it is important to mention this as these kinds of things also tarnish image of the healthcare providers at the ground level, for no mistake of theirs.

Donation vs. Extortion

Doctors and hospitals are perceived to be rich and many people come for “donations”. Here is a separate article on this that I had written sometime back. This is perhaps least of all challenges, just adding it for completion sake :-)

When “Donation Request” became “Extortion”

Lack of Unity and Rivalry

This is one thing where hospitals have to blame only themselves. Though some of the associations are present and working hard to bring private hospitals together, the scenario seems to be far from perfect. Presence of numerous such organizations, different agenda, politics and ego/blame games between them etc. do not do any good to anyone. This issue does not directly affect day to day running of the hospitals, but has long term effects on the sector as a whole.

I am not deeply associated with anyone else, just interacting within QPMPA from sometime, hence cannot comment too much on this issue without studying further.

Non compliance of collective decisions taken (due to rivalry, unfair completion strategies or due to simple disagreement with decisions) also seems to be an issue.

Conclusion

In the process of growth or just sustenance, some hospitals may have failed to comply with some laws or Acts, but I think most such hospitals were just trying to do the balancing act in the best interest of everyone. Also, sometimes probably they didn’t try too hard to stay/be compliant with certain law (particularly new ones) seeing that the said law is unreasonable and impractical under non-idealistic conditions around.

But do hospital owners/management have right to take such decisions and exceptions? Is it not taking law in their own hand? Well, strictly speaking it might be illegal, but many a times it might be perfectly ethical under the given conditions.

Solution

So, looking at all these issues, what are the solutions? Any discussion of an issue without a solution recommendation becomes useless.

But before we go into the solutions, I request you to patiently wait with me on one more thing. We also need to look at the expectations of government and society on any hospital: in simple words the expectation is to provide “good healthcare”. So, we need to see what it really means. Here is a separate article on that:

What is an ideal healthcare system?

Coming to solutions, I think there can be a variety of solutions for the problems stated so far and my thoughts on the same is detailed in a separate article:

Solutions for problems in private hospitals in Kerala (Coming Soon)

Thanks for the reading patiently; your comments/criticism/feedback are always welcome.

About me

Here is a brief note about myself to give you some perspective about my writings related to Kerala healthcare sector. I am neither a doctor myself, nor a healthcare professional of any kind, I acknowledge that my knowledge is limited in this area. I am further limited by language problem being a native Kannadiga in Kerala and many related communication by government getting published only in Malayalam.

However, these days I am actively involved in management of a private hospital where my father is a partner. I have worked in depth to ensure that salaries of all the staff are paid at least equal to or greater than minimum wages specified; having around 9 years of employment history myself, I am quite passionate in this area. During this process, I got an opportunity to hear opinions of many staff and also a chance to study their incomes/hikes from various perspectives, and also impact of the same on the institute’s profitability/survival. I have also been participating in some of the QPMPA discussions and learning things. This entire experience is an ongoing learning process and I am just sharing my current thoughts here.

I hope you have found this article thought provoking and some suggestions worth considering.

Disclaimer: The views expressed here are purely mine and do not reflect views of owners/partners/staff of the hospital where I am currently working; certain facts that I have stated is as per my best understanding but cannot be taken as official data. The intent behind this article is to provoke further thinking towards greater good with respect to healthcare field and definitely not to hurt anyone’s sentiments or create imbalance of any kind. Also, I humbly accept that this topic has a history and is multifaceted, and hence I may have missed or incorrectly written some points out of genuine lack of knowledge; kindly pardon me for the same and feel free to bring such things to my notice so that I get a chance to stand corrected.