The focus has to shift from preventing violence to restoring doctor-patient trust
When a wise man asked Confucius about the essential elements of governing a state, he replied, “It is to provide food, protect people with weapons, and gain trust from people." To the next question of which should be abandoned first if the state is forced to choose between forgoing food, weapons or trust, Confucius advised to abandon weapons first, then food. However, he advised never to abandon trust. Perhaps, but he never anticipated so much of mistrust between patients and doctors/hospitals that it would erupt into gruesome violence against the latter.
Trust is hard to define as it is vague and fuzzy. Trust in medical services can be seen as trust in physicians and medical institutions, and involves two questions: whether the physician and medical institutions are competent to make a diagnosis and provide treatment; and whether they will act in the best interest of the patient. Indeed, trust is inseparable from vulnerability, as there is no need for trust in the absence of vulnerability. But, broadly, the salience of trust depends on the circumstances of patients, the extent of risk, the characteristics of their illnesses and needs, and their access to information.
Cases of violence are often gruesome. Much of the violence against doctors/hospitals is aimed at junior doctors in public hospitals who were sometimes not even involved in the treatment. A case in point is a brutal assault, in Kolkata in June 2019, on a junior doctor who was not even involved in the treatment of the patient who had died. Outraged relatives turned the hospital into a battleground. The doctor suffered a fractured skull and needed a craniotomy.
While explanations of eruptions of violence rely largely on the country’s supply-demand imbalance in healthcare, pervasive negligence, deterioration in the quality of healthcare, and the overcrowding of public health facilities, it is intriguing why little attention is given to serious cases of mistreatment or misdiagnosis, preventable deaths, high levels of corruption, and the conspicuous absence of mass protests and violence against heterogeneous private healthcare providers ranging from quacks and unlicensed doctors to “5 star" corporate hospitals equipped with world-class medical services. What is, of course, common to both public and private health care services is a weak regulatory system. Our point of departure is to shift the focus to a clearer and deeper understanding of trust in both public and private healthcare facilities.
We draw upon the two rounds of the nationally representative India Human Development Survey (IHDS) data conducted between 2005 and 2012, and use levels of confidence in doctors/hospitals as a proxy for patient-doctor/hospital trust.
A slight majority of households show high confidence in government hospitals/doctors or public provision of health care, while nearly three-fourths of respondents displayed high confidence in private doctors/hospitals in 2012. As both public and private health care providers display considerable heterogeneity, it is difficult to pinpoint the reason for this confidence gap.
Relative to the least affluent (i.e. those in the first asset quartile), the most affluent (i.e. in the fourth quartile) are more likely to have high confidence in private healthcare. The most affluent prefer expensive private medical care whose quality they trust.
Adults with high levels of education of 11 years and more are less likely to show high confidence in government healthcare, but more likely to in private healthcare, relative to those with lower levels of education (6-10 years). If the better educated are also better informed about negligence, drug shortage, malpractices in government hospitals, this is hardly surprising.
Households with moderate burden of non-communicable diseases (NCDs) such as diabetes, hypertension and cancer, are more likely to have high confidence in public healthcare, relative to those with no such burden. The absence of any significant association between NCDs and private healthcare is intriguing.
The role of mass media in sensationalizing malpractices and deaths in hospitals, and provoking mass hysteria and protests against hospitals/doctors is often exaggerated. Women who listen regularly to radio are more likely to have high confidence in the public provision of healthcare, relative to those who do not. In sharp contrast, men who listen regularly are less likely to have high confidence in public healthcare. Men who read newspapers regularly are more likely to have high confidence in government healthcare, relative to those who do not. Similar associations are observed with respect to private healthcare.
Although health is a state subject, there is substantial infusion of funds by the central government. However, the 2019-20 budget allocation for health is a measly 0.34% of India’s gross domestic product. So, the first priority should be to hike expenditure on health substantially. Even more important is a reorganization of the healthcare system and effective regulation. The primary healthcare provider should be a strengthened public care system with a clearly defined role of the private system, especially in specialized services.
The focus has to shift from preventing violence against doctors to restoring patient-doctor trust. Indeed, cracking down on violence and enhancing security measures are unlikely to fundamentally alter the problem of patient-doctor mistrust.
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