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Why we shouldn’t privatise health care

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The writer argues against the introduction of private medical practice in the country

The issue of private practice has been in the web of national thinking for quite some time now.  The debate has been mostly in the public domain but, as a Bhutanese, who will be affected by any decision on the issue, it is our right and responsibility to think about it too.

I have personally come to the conclusion that health care should remain exclusively an affair of the state.  The feasibility and viability aspects of any proposition determine its outcome.  I believe the small size of our country and population satisfies both these considerations.  Besides, it keeps alive the legacy of the Bhutanese monarch caring for his people.  Then, more importantly, in a small society such as ours, it would weaken the thread of cohesion, to have two separate systems: one for the haves and the other for the have-nots; a mediocre government-run service for the poor and a fancy well equipped private service for the rich.  Such an arrangement would sow seeds for jealousy, resentment and eventually discontentment – elements that will not help in the realisation of a GNH society.

There are other concerns about privatisation of health care.   You can put a price tag on a pair of shoes or a branded compound bow.  The buyer could make a smart move, or be fooled; but fortunately there is always a next time and he will get it right, then.  At a hospital, however, where the seller is the expert and the authority, how are you going to make that sound purchase decision?  When treatment means putting potent chemicals into your body, or the conducting an invasive surgery, it is unlikely you will get a second chance to play smart.

The thought for privatisation is believed to stem from the growing demand for better health care services on the one hand, and the inability of the government to provide it, on the other, because of resource constraints.  But I believe, if one considers carefully and comprehensively, the resources are there.  Take into account the millions we spend each year in government referrals to Vellore, Kolkata and other places in India, and Bangkok in Thailand.  The actual figure, it is believed, is higher; add to that, the cost of privately funded treatment, which must be sizable, considering that our Bhutanese now travel all the way to Bangkok even for deliveries.  And, note, our people are always drawn to the more expensive hospitals, and spend generously.

It does not matter whether the funds are coming from state coffers or private pockets; it is all Bhutanese money.  If we can appreciate this point of view, realise how much we are spending anyway, it is not difficult to see that the prospect of establishing a good health care system at home is actually within our reach.  To use a parallel, it would be wiser to take a loan and buy the apartment outright, instead of paying huge rentals each month.  After that you can live in the comfort of security and a peace of mind.

When it comes to investing in health care, it is not a gamble and there is no risk.  Good health is the most precious gift in our lives, for without it, in spite of all the riches and power we may have, life is meaningless.

You will understand, just how desirable it is to have a good health care system with qualified doctors, right here at home, when a close and a loved one is seriously ill and the hospital is short of what is needed.

If we can convince banks to lend us money to build towns on prime agricultural land, surely they will support us to improve our hospitals.  Similarly, if we feel rich enough to spend millions of dollars on consultancy fees, surely we can afford to hire doctors from outside to meet our temporary shortfalls.

Even as we may plan to realise such a dream, I understand there is much that we can immediately do to help ourselves.  Aside from the issue of resource constraints, a fundamental complaint is about administrative control.  Voices from the hospital commonly echo of the maladministration by the health ministry and the civil service commission.  It is incomprehensible why it must be so, and continue to remain that way.  Now that the ballot box is here, cannot the will of the majority fix such a shameful problem?

The shortage of manpower is an issue that predictably features in any discussion of our health system.  While this is a legitimate challenge, we are profoundly guilty of being negligent and wasteful with this scarce resource.  We routinely make administrators of doctors, and retire them like civil servants, even though they may be at peak performance levels.  Why can’t we help ourselves, by letting doctors work for longer years?  When they get too senior in age, but are still willing to practise, they could work for fewer hours a day and a shorter week.  Even when they cannot see patients, they can still be available for consultation by junior doctors.  Senior doctors represent a rich and vast reservoir of knowledge and experience; we would be so foolish to throw it away, especially when we are so desperate in this respect.

Yes, we need to step up our handling of this special resource.  When the survival of a loved one rests with the doctors, you begin to see how godly these people are.  An experience like this humbles you to believe that any other work is only secondary to the medical one.

Our doctors in Bhutan, for the most part, represent the top academic performers of the education system.  Privileged by merit, this bright lot is sent to medical schools abroad at great cost to the country.  Upon return, they are expected to serve with visible illustration, their greater intellect and training, and gratitude to the government and people for the special training opportunities accorded to them.  It is in this light, that we find it regrettable that some doctors chose to opt out of the profession.  Imagine all that valuable training that will be shelved and eventually lost, and the opportunity cost to the people, and not just in financial terms, but also in terms of time loss.  Medical schools are not only expensive, but it takes one longer to graduate from one.  One cannot help but lose some regard for a person, who has the know-how and the skills to save lives, but simply abandons it all for another calling in his or her life.

But then, doctors are human, and it is the responsibility of the system to ensure that our doctors remain committed to their profession.  The work they do is special; it is at the tender most spot of every individual in society.  Therefore, our best efforts must be directed at facilitating their work; and we must also ensure they make a good living, so that they are not eyeing greener pastures elsewhere.  In addition to all that we may do, to keep them happy, it is fundamental that there exists a binding legal framework to secure the desired fidelity.

I should like to believe that my views will be shared in many quarters.  Let us keep our health system totally public and state-run; and let us do what is needed to get our standards to the regional level, and keep all our treatment and medical spending here at home.

 

Wangchuk, N.

Thimphu

9 Comments to “Why we shouldn’t privatise health care”
  1. dynamite | May 20th, 2013 at 17:53:00

    i agree

  2. VajraOne | May 10th, 2013 at 10:20:21

    Health care privatization is necessary, and Mr. Wangchuk’s argument for only state care is feudal
    On 9th May Mr Wangchuk argued in Kuensel’s Opinion column for sole state sponsorship and state management of health care services in Bhutan. While the intention appears to be noble, the arguments put forward lack substance and credibility. Let us take each idea and see where Wangchuk’s understanding is deficit, and where his interpretation is warped.
    Throughout our beloved Fourth King’s reign the theme was for a self-reliant nation and that can only become a reality if every individual strives to be self-reliant as well. It was never to create a state where its citizens are perpetually dependent on the largesse of a caring monarch. Today only in North Korea and Cuba health care is fully the state’s responsibility. And they remain so largely because their system systematically disallows private enterprise and individual entrepreneurships. The argument that because our monarchs are caring, we should simply wait to be cared for is unacceptable and is against the very philosophy that our monarchs have pursued.
    The rich and the poor classes are already a reality. And they were not created by health services standards. They are the direct fruits of creating enabling environment that nurture private enterprise and where the state guarantees the fundamental rights of private ownership. In such an environment the smart and willing create wealth for themselves and for those around them, while the lazy and the useless wait only for state largesse for their sustenance. The poor can hardly become rich by making the rich poor. You will not keep the rich from going to Bangkok or New York by simply shackling the medical doctors to state servitude. It should not be state’s intention to prevent private practice because they can be better equipped and better managed. It should be the state’s endeavor to provide quality care for those that cannot avail similar services in the private market. Stopping private practice is not the answer but to encourage it so that you give choices to the people. But it is the government’s responsibility to define the norms and standards of best practice and ensure regulatory oversight. It is mean to even suggest that private practice should not be allowed for fear of showing a potentially inept health ministry in poor light.
    The argument that the government spends more on doctors training needs to be analyzed. For doctors who go for MBSS under GoI scholarships, medical students receive no different stipend than what general bachelor students get as government stipend. It is only recently that due to the dire shortage of doctors in the country that the government resorted to provide support to those students who had privately found seats where government couldn’t and this was done in the hope that they will return to work for the government. If there is more cost, it is also because the medical students have to study more years to get their degree. Therefore, the argument that “upon return they are expected serve…” and “show gratitude for the government and people..” cannot be applied only to medical doctors but for all those who have availed similar opportunities. Why then single out only doctors? And it’s classic feudal thinking that “to keep them happy, it is fundamental that there exists a binding legal framework to secure the desired fidelity.” This is not the thinking of an educated person, but dangerous ravings of a dictatorial bend of mind parading as caring for the people. If such a thing is applicable to medical doctors, why shouldn’t the same be applicable to, say, engineers who too have availed expensive and long trainings at the expense of the government? It is this lack of level playing field that frustrates the medical doctors within the civil service.
    For many years the doctors have asked for no more than the same rules and privileges of any civil servants; doctors have never asked to be treated differently. Doctors, too, have never asked to work less. Doctors have asked for a normal civil servant’s life, and to compensate for anything beyond that commensurate with the time and effort needed if they were required to render additional services. And yet both officials and the common man expect the doctors to spend 24×365 on duty and then expect them to be happy to be treated no more than an ordinary civil servant who works 9 to 5 with full two days weekends and all other holidays in between. Never mind the chatting and the endless tea breaks during office hours. Also why those doctors who have already resigned not allowed to practise the art and the skills they have acquired? For all other professionals, they are allowed to practice for monetary gains their profession during their spare time even if they are civil servants, and are at liberty to do so when they are out of the civil service. Why are doctors who have already retired, resigned or left the service for various reasons not allowed to practice their art? There are two sets of rules here, and it is not certainly in favour of those who are working most in the most difficult conditions.
    So what needs to be done? Pretty simple. Privatization of health care services should be encouraged. This will defray the health care cost for the government as the ones who can pay will avail private services. This will enhance efficiency by reducing crowd at hospitals and, at the same time, bring more satisfaction for those who pay for services they are happy with. Further, privatization will create more jobs, generate revenue and provide choices to the people. Private enterprise is dependent on market forces. If people think that there is a private market for health care services that is economically viable for all doctors who are today in the country, better think again. Thimphu would not be able to support a sustainable private practice for even ten doctors!
    However, mere privatization is not enough. The health facilities and services need to be revamped so that they are efficient, world-class and patient friendly. This will enable those who cannot pay for their health care to avail the highest quality services from the government facilities. Privatization should be seen as the mirror that should reflect and, consequently, help improve the state of health care services in the country.
    What is also needed to be done urgently is to improve the management of government health services, including the appropriate management of health work force. Opportunities should be created for the doctors to excel in their profession not by creating bureaucratic inefficiencies but by creating career opportunities. That means a fair working condition, a fair pay commensurate with their time spent to provide services, and opportunities to enhance their skills through structured and graded training opportunities. In all these the basic principles of transparency and fairness should be upheld so that the right person gets what he or she best deserves and, thus, take away this sense of nepotism and favoritism that is currently so pervasive. Leadership with vision and the guts to get things done is the remedy called for to treat the malaise that is slowly killing the health care system in the country.

    VajraOne

  3. online | May 10th, 2013 at 00:22:24

    Earlier I wrote as if I am not in favor of the point made by the author just because I expected the author to provide more arguments to convince those against the idea of not privatization. Those in favor of privatization thinks the it is the panacea for some of the problems we face with health services at the moment but infact it is not. Not only privatization cannot improve the services but it will also create other unnecessary burden on the society. People with a little disposable income thinks that they would enjoy better services from private providers but as the author pointed out health market doesn’t function as any other market(many reasons to market failure). Providers will only come with services that are salable( can make more profit with little investment) like out patient services and send it to state hospitals when the problem is major( because most private providers cannot afford to establish a facility where they can do major things). So it will put more pressure on the state hospitals when it comes to high cost interventions and divert the resources required for other services. In Bhutan it would be wise to invest on the already existing system and improve it ( through quality process management of services) rather than opening up private providers. (Just look our neighbor india where many private practice flourishes- Do you think health services are better there? ask some bennarjee, chatrajees, thakurs….they will envy our system. ( we may not realize it unless we feel victim to catastrophic expenses on health).

  4. pembaz | May 9th, 2013 at 21:08:50

    People say that we should not have private hospitals just because they might be having friends and relatives in the health system to help them out whenever they have works at the hospitals. Now its a new era and the changes is on in all the departments and the sectors, so why don’t we have a change and improvement in the health system just by allowing those who have the resource and manpower to start private hospitals…In fact, if the private hospitals come up, its not just the rich people who can afford to pay will use the facility and others will be neglected, because its not only the rich that will fall ill at all the times, even if you are not rich, you may fall ill one day and that day you will realize that you should have a private hospital where you can get a fast and better service when you are in dare need….

    I should say that, when you say that we don’t want private hospitals, its like saying that you don’t want private business too……Just think, of some like FCB run by government and we don’t have any other grocery shops in the town…….Do you think that everyone will have enough needed items in their homes to run the house……I don’t think that will be posible, you will be starving to death within days/weeks.

    So if we don’t think now for our distance problem and act now, it will be like starving our selves and future children to death because of the lack of optional health facilities..!!!!!!!!!

  5. New_Man | May 9th, 2013 at 15:00:34

    I think it is the privatization that improves the service and brings out the best in the profession. There should be some amount of privatization. It would be beneficial for those who can afford.

  6. Timbu | May 9th, 2013 at 13:56:32

    as mr.norbu wangchuk is expressing his deep concern about the healthcare system of our country regarding the private practice, i support your idea but that doctors and nurses who are fed and educated like any other professionals also have the right to opt for his or her likings at any stage of his career. and create better service conditions to those who choose to remain in the system.
    it is very interesting that the healthcare system remain with the state but at the same time people would not realize the importance of free healthcare system unless they start paying. a systematic approach to the establishment of private practice is a must to develop the nation wholly. this should not at any cost increase existing gaps between haves and havenots.

  7. the badger | May 9th, 2013 at 13:25:59

    Look at the services in the Govt hospital its crap, you must wait in long que and must know someone to avail services…on the contrary look at the new services provided by Dr Sonam and Gado, pay some fees and we get good service…..we are not in a communist country, people who work hard and make money should have the right to avail better services, there should be competition …any entrepreneurs who wants to open a hospital should be allowed, Insurance companies should work in hand with health care providers and people should be given the choice to avail and insure their health and opt for services like any other countries. The more you want to invest, better service plans should be availed. Competition should
    be the order of the day. The attitude of the public servants should change including doctors, the general public is always at the mercy of the bureaucrats, civil servants, private citizens are second class citizens. We need Govt hospitals and this should be given a good competition from other service providers, but people should have options for private and government facilities.

  8. sorryla | May 9th, 2013 at 13:09:46

    while the author has mentioned of the points, the solution is not given vividly for the ailing health care system. it is true indeed, that the most brightest go and pursue medical courses but turns sour in facing the reality in life; his friends who were just mediocre are bosses and advantages are few for the doctors. i found that doctors in Bhutan are the poorest compared with global colleagues and much more….

  9. online | May 9th, 2013 at 12:46:23

    Ah..wasted my time reading the article…I do not find answer to your title question . Infact it I read an ambivalent argument. what I could comprehend is that no privatization-no spending outside, be satisfied with what is available. I dont think any rationale man will be convinced by such proposition.

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