Health regulations need a base to top approach

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Why in News?

Health regulations are crucial, but their execution in India requires a nuanced and calibrated approach.

More About the News: 

• At the end of May, a tragic fire engulfed a private neonatal care nursing home in New Delhi, leaving a profound impact on us all. Instead of focusing on the systemic failures in healthcare regulations that contributed to such incidents, political parties engaged in a blame game, and media coverage sensationalized the event, erroneously claiming that numerous nursing homes in Delhi operate without licenses. Sadly, the intensity of attention quickly waned, leaving grieving parents to cope alone. These tragedies often spark debates over assigning blame, overlooking the underlying systemic failures that lead to such events.

Excessive Regulations

• Over Regulation in States: The issue of regulation has long been a focal point for health program managers. Rather than a shortage of health regulations across Indian states, the problem lies in their abundance. Some states require over 50 approvals from various regulations, creating a burdensome compliance process for healthcare facilities. Despite this, many government officials and stakeholders argue that the private health sector in India lacks sufficient regulation.
• Slow and Inefficient Approval Process: Facility owners often face delays in obtaining necessary approvals, even when applications are submitted well in advance.

Unrealistic Standards

• Clinical Establishments Act, 2010: Another challenge is the presence of unrealistic healthcare quality standards. Both national and state governments are known for drafting policies that appear flawless on paper. However, the Clinical Establishments (Registration and Regulation) Act of 2010 serves as an example of well-intentioned legislation that has not been widely adopted. This is due to the realization by state governments, through discussions with stakeholders, that many provisions of the Act are impractical to implement.
• Indian Public Health Standards (IPHS): Similarly, the Indian Public Health Standards (IPHS) were introduced in 2007 with subsequent revisions, aiming to set essential benchmarks for quality healthcare services in government facilities. Despite this effort, after 17 years, only a small percentage (15% to 18%) of government primary healthcare facilities meet these standards. It's evident that in the pursuit of ambitious goals, healthcare regulations and standards in India have veered towards being unattainable and challenging to put into practice.

India has a mixed health-care system

• Private Sector’s Role: India's healthcare system is characterized by a mix of public and private sector involvement. While there's a prevailing belief that government health facilities adhere to regulations better than their private counterparts, the reality is more nuanced. Private healthcare facilities play a significant role, delivering around 70% of outpatient and 50% of hospital-based services in the country. In states like Maharashtra and Kerala, where health indicators are relatively better, it's not solely due to exceptional government facilities but also because of the robust private sector meeting the healthcare needs of the populace. People often choose to seek care at private facilities, indicating their trust and preference.
• Bias in Regulation Enforcement: However, despite the significant contribution of the private sector, there's a perception of unfairness and excessive enforcement of regulations against it. Instances like the incidents in Delhi hospitals in 2017, where both a government and a private hospital were involved in similar cases, highlight this disparity. While the private hospital faced temporary license suspension, the government hospital saw only the formation of an inquiry committee, raising questions about equitable treatment.
• Regulatory Burden: Effective regulation should not make stakeholders feel targeted. Currently, the burden of responsibility largely falls on healthcare providers and facility owners, leading to frustrations over delays in approvals and renewal processes. Many private nursing homes and clinics face prolonged wait times for approvals, even when applying well in advance. The sluggish approval process is a significant concern for facility owners, impacting their operations and compliance with regulations.

Affordable Care is a Crucial Need: 

• Affordable Care: In India, affordable healthcare is essential, especially given the diversity within the private healthcare sector, which ranges from single-doctor clinics to large corporate hospitals. Single-doctor clinics and small nursing homes are often the primary healthcare providers for middle and low-income populations, delivering essential services at a fraction of the cost compared to larger hospitals. Understanding why people prefer private nursing homes over free government facilities is key to addressing healthcare accessibility and affordability. Regulations should be designed to support and facilitate these smaller facilities, keeping healthcare costs low and affordable.
• Ensuring Quality and Practical Implementation: Ensuring the quality of healthcare services is a shared responsibility among all stakeholders. Regulations should be practical, focusing on feasible implementation rather than merely aiming for a 'world-class' tag. Guidelines should harmonize multiple existing regulations and simplify the application process, ensuring timely disposal of applications to prevent bureaucratic delays.
• Tailoring Standards to Facility Size: Regulatory standards should be differentiated based on the size and capacity of healthcare facilities. Expecting smaller clinics to meet the same standards as large corporate hospitals could lead to increased costs, which would be transferred to patients, making services unaffordable. Essential safety measures should be enforced across all facilities, with subsidies or funding provided to help smaller facilities comply with regulations.
• Inclusive Regulation Formulation: The formulation of healthcare regulations should involve representatives from doctors' associations, various types of healthcare facilities, and community members. This inclusive approach ensures that regulations are practical, effective, and aligned with the needs of both healthcare providers and patients.
• Responsible Communication: Political rhetoric and sensationalized media coverage can increase mistrust of healthcare providers and facilities, potentially leading to violence. Responsible communication and constructive dialogue are essential to address concerns while maintaining public trust in the healthcare system.

Focus on Primary - Care Givers

• Support for Smaller Facilities: It is imperative for India to promote single-doctor clinics, smaller healthcare facilities, and nursing homes. These entities are crucial for delivering primary care and play a significant role in keeping healthcare costs low. Understanding why individuals opt for private nursing homes over free government facilities highlights the necessity to support these smaller healthcare providers.
• Subsidies and Funding: The government should provide subsidies and funding to help smaller facilities adhere to safety and quality regulations. Rather than burdening them with excessive regulations, these facilities and their doctors should be supported. The recent fire tragedy in Delhi serves as a poignant reminder of the importance of addressing root causes rather than just treating symptoms. Simplified and implementable regulations, developed collaboratively with key stakeholders, are essential.
• Balanced Regulation and Implementation: Fairness in implementation, timely decision-making, and expedited processes for license renewal applications are vital. Supporting smaller healthcare facilities with subsidies and assistance to enhance quality and safety is necessary. India's healthcare system is increasingly focused on admission-based inpatient services, neglecting outpatient care that can be provided at lower costs.

Some key strategies from NHP 2017:

• Promote Primary-Care Providers: Support and promote single-doctor clinics, smaller healthcare facilities, and nursing homes, recognizing their role in delivering primary care and maintaining low healthcare costs.
• Provide Financial Support: Implement subsidies and funding programs to help smaller facilities comply with safety and quality regulations without increasing costs for patients.
• Simplify Regulations: Develop regulations that are simplified and implementable, formulated with input from key stakeholders including healthcare providers and community members.
• Ensure Fair Implementation: Ensure fairness in the regulatory process, with timely decisions and expedited renewal processes to prevent bureaucratic delays that hinder smaller facilities.
• Support Outpatient Care: Shift focus towards promoting outpatient care services, which can be delivered at lower costs, to balance the current emphasis on admission-based inpatient services.

Conclusion:

To achieve the goals outlined in the National Health Policy, 2017, India's health-care regulations need to be drafted from a bottom-up approach, considering the practicalities and capacities of various health-care providers. This will ensure that health services remain people-centric, accessible, affordable, and of high quality.