Study of Ethics in Hospital Industry in India

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Table of Contents
Introduction.....................................................................................................................................4
The Importance given to ethics in the practice of medicine in history...........................................4
Current Situation of Healthcare Infrastructure in India..................................................................6
The health care divide in India........................................................................................................7
Key findings that is ethically questionable in the hospitals.............................................................8
1. Doctor not available :...........................................................................................................8
2. Improper waste Disposals :..................................................................................................9
3. Failed to get appointment :..................................................................................................9
4. Admission to ward not available..........................................................................................9
5. Operation theatre was not free............................................................................................9
6. Medicines unavailable........................................................................................................10
7. Doctors suggest a visit to their private clinic......................................................................10
8. Doctors refer to private diagnostic centers........................................................................10
9. Over-prescription of medicines..........................................................................................10
10. Bribes demanded by staff...............................................................................................11
11. Diagnostic tests are done even when unnecessary........................................................11
The Hospital Service Providers’ Perspective.................................................................................11
1. Pressure on infrastructure:.................................................................................................11
2. Lack of resources:...............................................................................................................11
3. High workload:....................................................................................................................11
4. False charges of negligence:...............................................................................................11
Suggestions to enforce ethical functioning of Hospitals...............................................................12
1. Users’ Committees should be constituted to take up citizens’ grievances........................12
2. Provision of diagnostic services..........................................................................................12
3. Medicine supply..................................................................................................................12
Bibliography...................................................................................................................................13
Books..........................................................................................................................................13
Websites....................................................................................................................................13

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Introduction

A hospital, in the modern sense of the word, is an institution for health care providing patient
treatment by specialized staff and equipment, and often, but not always providing for longer-
term patient stays. Its historical meaning, until relatively recent times, was "a place of
hospitality"
Today, hospitals are usually funded by the public sector, by health organizations, (for profit or
non-profit), health insurance companies or charities, including by direct charitable donations.
Historically, however, hospitals were often founded and funded by religious orders or
charitable individuals and leaders. Conversely, modern-day hospitals are largely staffed by
professional physicians, surgeons, and nurses, whereas in history, this work was usually
performed by the founding religious orders or by volunteers.

The Importance given to ethics in the practice of medicine in ancient

history

From its beginning in the remote past, the practice of medicine was permeated by a code of
ethical conduct.
In the Indian tradition, a young student was initiated into medical training only after careful
assessment of his competence and suitability. The initiation ceremony was a grand ritual held in
the presence of students and teachers when the preceptor would solemnly issue commands
which the initiate was obliged to accept. The following extract from the commandments would
give a flavour of the ethical dimensions of medical practice two thousand years ago in India.
“You should remain a celibate, speak truth, adhere to non-violence, abjure envy and, use
substances that enhance intellectual power. You should sport a beard and moustache, avoid
meat and, at all times, obey my commands except under threats of the King’s ire, death,
unrighteous conduct (adharma) and calamities. You should look upon me as your master, follow
the course that pleases me and live with me as my son, helper and servant. You should be
vigilant, humble and careful and, at all times, maintain your presence of mind. You should move

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about with my permission; and whenever you move, even without permission on occasion, your
purpose should be to collect things for me according to your ability. When you aspire to become
a physician and seek professional success, wealth, fame and heaven hereafter, you should
cherish the welfare of all living beings and especially that of cows and brahmanas. You should
strive by every means to get your patients well and never entertain evil thoughts about them
even at the risk to your life. You should not, even in dream, covet other’s women or property
and should remain modest in dress, appearance and conduct. You should shun liquor and keep
away from sins and sinners. Your words should be pleasing, truthful, well-chosen, brief and
matter-of-fact; you should never lose sight of place and time, the constant pursuit of knowledge
and the improvement of equipment and skills.”

According to the Mahavamsa, the ancient chronicle of Sinhalese royalty, written in the sixth
century A.D., King Pandukabhaya of Sri Lanka (reigned 437 BC to 367 BC) had lying-in-homes
and hospitals (Sivikasotthi-Sala) built in various parts of the country. This is the earliest
documentary evidence we have of institutions specifically dedicated to the care of the sick
anywhere in the world.

King Ashoka is said to have founded at least eighteen hospitals ca. 230 B.C., with physicians and
nursing staff, the expense being borne by the royal treasury.
Stanley Finger (2001) in his book, Origins of Neuroscience: A History of Explorations into Brain
Function cites an Ashokan edict translated as: "Everywhere King Piyadasi (Asoka) erected two
kinds of hospitals, hospitals for people and hospitals for animals. Where there were no healing
herbs for people and animals, he ordered that they be bought and planted."

Current Situation of Healthcare Infrastructure in India

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India’s healthcare infrastructure has not kept pace with the economy’s growth. The physical
infrastructure is woefully inadequate to meet today’s healthcare demands, much less
tomorrows. While India has several centers of excellence in healthcare delivery, these facilities
are limited in their ability to drive healthcare standards because of the poor condition of the
infrastructure in the vast majority of the country.

Of the 15,393 hospitals in India in 2002, roughly two-thirds were public. After years of under-
funding, most public health facilities provide only basic care. With a few exceptions, such as the
All India Institute of Medical Studies (AIIMS), public health facilities are inefficient, inadequately
managed and staffed, and have poorly maintained medical equipment.
The number of public health facilities also is inadequate. For instance, India needs 74,150
community health centers per million populations but has less than half that number. In
addition, at least 11 Indian states do not have laboratories for testing drugs, and more than half
of existing laboratories are not properly equipped or staffed.
The principal responsibility for public health funding lies with the state governments, which
provide about 80% of public funding. The central government contributes another 15%, mostly
through national health programs.
However, the total healthcare financing by the public sector is dwarfed by private sector
spending. In 2003, fee-charging private companies accounted for 82% of India’s $30.5 billion
expenditure on healthcare. This is an extremely high proportion by international standards.
Private firms are now thought to provide about 60% of all outpatient care in India and as much
as 40% of all in-patient care. It is estimated that nearly 70% of all hospitals and 40% of hospital
beds in the country are in the private sector.

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The health care divide in India

When it comes to healthcare, there are two Indias : the country with that provides high-
quality medical care to middle-class Indians and medical tourists, and the India in which the
majority of the population lives—a country whose residents have limited or no access to
quality care.

Today only 25% of the Indian population has access to Western (allopathic) medicine, which is
practiced mainly in urban areas, where two-thirds of India’s hospitals and health centers are
located. Many of the rural poor must rely on alternative forms of treatment, such as ayurvedic
medicine, unani and acupuncture.

The central government has begun taking steps to improve rural healthcare. Among other
things, the government launched the National Rural Health Mission 2005-2012 in April 2005.
The aim of the Mission is to provide effective healthcare to India’s rural population, with a focus
on 18 states that have low public health indicators and/or inadequate infrastructure. These
include Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu &
Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim,
Tripura, Uttaranchal and Uttar Pradesh. Through the Mission, the government is working to
increase the capabilities of primary medical facilities in rural areas, and ease the burden on to

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tertiary care centers in the cities, by providing equipment and training primary care physicians
in how to perform basic surgeries, such as cataract surgery.

While the rural poor are underserved, at least they can access the limited number of
government-support medical facilities that are available to them. The urban poor fare even
worse, because they cannot afford to visit the private facilities that thrive in India’s cities.

Key findings that are ethically questionable in the hospitals

The findings in this report are a result of surveys and interviews with patients, doctors and
social workers in and outskirts of Bangalore and Chennai.

As approximately two-thirds of the hospitals in India are public or government driven, most of
the survey results are based on interactions with government hospitals. After years of under-
funding, most public health facilities provide only basic care. With a few exceptions, such as the
All India Institute of Medical Studies (AIIMS), public health facilities are inefficient, inadequately
managed and staffed, and have poorly maintained medical equipment.

1. Doctor not available :

The survey indicates that approx 40 % of the patients could not meet a doctor in their
last visit due to unavailability in a government hospital. Almost all the doctors practice
privately. On an interview with a doctor, he admitted that he had faced difficulty in
reporting for duty at the government hospital due to appointments at his private
practice.

2. Improper waste Disposals :

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 Hospitals use large amount of sensitive chemicals to control diseases. Further, they
contain materials, utensils containing large amount of pathogens. When hospital wastes
are not properly disposed off, they can cause many health hazards to healthy people - as
pathogens and sensitive chemicals enter their body via water, food or air. Though this
issue is decently addresses in the cities, many of the hospitals in the outskirts of Chennai
and Bangalore dump their waste in vacant lands near their facilities.

3. Failed to get appointment :

This is partially due to unavailability of doctors and less number of hospitals in a certain
areas. There are always long queues to meet a doctor and hence there is always a set of
patients who fail to get an appointment due to the number of people already waiting in
the queue. They are often asked to come on the next day.

4. Admission to ward not available

Due to the inadequate infrastructure in the hospitals, there are instances where the
patients were denied admission to the ward. The higher number of patients and lower
number of hospitals are the main reasons behind the same. The patients often have to
bribe the hospital staff for admission.

5. Operation theatre was not free

Many of the patients are being asked to wait up to one month due to non availability of
operation theatre. When I discussed this issue with a hospital staff, he said that he is
also aware of cases where patients have lost their life due to the wait.

6. Medicines unavailable
This is one of the most common complaints in a government hospital. Patients often fail
to get medicines from government dispensaries, either due to actual shortage or

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 diversion of supplies. No proper record of medicine inventory is kept and hence the
patients are asked to buy the medicines from outside for a higher price. There are a lot
of mal practices known to happen with management of drugs/medicines. There were
cases reported were the staff at government have sold expensive medicines to private
drug stores. Sometimes the new medicines are exchanged for expired medicines.

7. Doctors suggest a visit to their private clinic

It’s a known fact that most of the doctors working for a government hospital practice
privately. There have been instances where doctors have suggested them to visit him at
his private practice. Many of the patients do the same in expectation of receiving better
care and consultation.

8. Doctors refer to private diagnostic centers

Many of the doctors are known to have relationships with private diagnostic centers in
their area. Some of the doctors refer their patients to private diagnostic centers.

9. Over-prescription of medicines
Another common issues reported by patients visiting private and government hospitals
alike. There are many reasons why doctors over prescribe medicines.
Doctors over prescribe medicines if
 Doctors may be receiving commission from the nearby drug store or drug
manufacturer
 Doctors are not sure of the medicine for cure of illness
 Doctors are not sure of the doses required

10. Bribes demanded by staff

The hospital staffs in government hospitals are known to demand bribes. On my visit to
a government hospital in Bangalore, it was interesting to note that even the securities
demand bribe from the patients.

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 11. Diagnostic tests are done even when unnecessary
Similar to over-prescription of medicines, the doctors may have financial arrangements
with diagnostics centers. They often sent the patients to these centers for unnecessary
tests.

The Hospital Service Providers’ Perspective

1. Pressure on infrastructure:
Despite capacity constraints Government hospitals are forced to admit patients because
of pressure from co-doctors or local politicians. So, the hospital is almost always working
beyond capacity, resulting in low quality of service.
2. Lack of resources:
Lack of resources/funds often means diagnostic instruments are not in working
condition, forcing doctors to ask patients to get tests done from private laboratories.

3. High workload:
Acute shortage of manpower hence, they are not able to attend to all the patients,
resulting in long queues and delays

4. False charges of negligence:

People come to the government hospital as a last resort, after trying to get treatment in
local nursing homes or doctors, by which time, in most cases, the patient’s condition is
critical. Any adverse eventuality is blamed as negligence on the part of the hospital.

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Suggestions to enforce ethical functioning of Hospitals

1. Users’ Committees should be constituted to take up citizens’ grievances.

2. Provision of diagnostic services: The diagnostic services can be outsourced to

private players, where they receive payment from government on per-patient basis. This
is already being conducted to some extent in some hospitals in Delhi.

3. Medicine supply: Patients often fail to get medicines from government dispensaries,
either due to actual shortage or diversion of supplies. To check for the second possibility
government dispensaries should display the drugs received every month and furnish
daily stock position.

Bibliography
Books
Stanley Finger (2001) Origins of Neuroscience: A History of Explorations into Brain Function

Websites
http://www.articlesbase.com/health-articles/importance-of-hospital-768379.html
http://en.wikipedia.org/wiki/Hospital#Criticism

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http://www.qcin.org/nabh/index.php
http://www.livemint.com/2007/04/01225656/Corruption-in-government-hospi.html
http://toostep.com/debate/are-indian-government-hospitals-the-worst-in-the-world
http://www.expressindia.com/news/fullstory.php?newsid=62392
http://www.manavkalyan.com/Social_main_article3.htm

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