Should government doctors be permitted to engage in private practice? This perennial question is also a deeply contentious issue that intertwines with healthcare delivery, medical ethics, and public welfare.
It is once again to the fore as a bill seeking to impose a complete ban on private practice by government doctors across the Union Territory by a National Conference legislator. The bill also imposes heavy fines on violators.
In regions like Jammu and Kashmir, this question is not merely theoretical but a pressing practical concern, as evidenced by recent incidents and political discourse. The moot question is how to balance the right of a medical professional to earn a livelihood while performing the fundamental duty of a public servant to the state and its citizens.
To arrive at a reasoned conclusion, one must dissect the motivations for a ban, its potential impact on patient care, and the complex interplay of winners and losers in such a policy shift.
Rationale for the ban
The rationale for the ban is curbing systemic abuse and ensuring full-time service in public hospitals. The primary argument for prohibiting private practice is rooted in the rampant abuse of the current system.
The scenario described during the recent visit of the Minister of Health to the Sub-District Hospital (SDH) in Pattan, where only 30% of doctors were present, is not an isolated anomaly but a symptom of a widespread malaise.
The manipulation of duty rotas is a well-known tactic, whereby a specialist might formally offer one day a week at the government facility while strategically taking four days off, dedicating the remainder to a lucrative private practice. This orchestrated absence creates a vicious cycle of long queues and neglected patients in public hospitals, driving more people towards private clinics. This, in turn, further incentivises doctors to neglect their public duties.
This conflict of interest directly harms patient care in government institutions. Surgeons operating during official working hours but falsifying records to show procedures conducted "after duty hours" is a grave ethical breach. When private profit becomes a priority over public service, it leads to a decline in both the quality and quantity of care.
When senior specialists are physically or mentally absent from their government posts, patient load falls on junior doctors, training suffers, and the overall morale and accountability within the hospital system erode.
This can be compared with the education sector. Just as a teacher conducting private tuitions might be tempted to dedicate the best efforts to paying students, a doctor with a parallel private enterprise faces an irreconcilable conflict of interest. State employment must, at its core, demand loyalty to the state and its people.
The Many Dilemmas
The moot question is: Will a ban improve patient care? The proponents of a ban, citing models in the Middle East and other nations, argue that it would unequivocally improve patient care in the public system. By ensuring the physical presence of specialists, it would increase the availability of expert consultation, reduce waiting times, and ensure that complex procedures are performed within government facilities, strengthening them institutionally.
It would eliminate the perverse incentive to divert patients or delay treatment for private gain. The "staged ban" approach, first in premier teaching and research institutions like SKIMS, then cascading to the Directorate of Health Services, allows for a phased implementation, letting the state build capacity and learn from initial experiences.
However, this optimistic outlook is fraught with significant risks, primarily the threat of brain drain. The exodus of three cancer specialists from SKIMS following restrictions, which left a vacuum at the premier institution, serves as a stark warning.
If a ban is implemented without concurrent systemic reforms, the state may face a mass departure of experienced specialists to the full-time private sector. This raises a critical question: Does the region have sufficient specialists in the private sector to absorb the patient load if the public system weakens further? If not, the very people, the patients, the policy aims to protect could be the ultimate losers, facing a crippled public system and an inaccessible, expensive private one.
Winners and Losers in a Banned Scenario
A dispassionate analysis reveals a disparate distribution of gains and losses.
After speaking with different groups in the medical fraternity, there is a clear divide. Former medical faculty largely support the proposal because they believe it will improve discipline and ensure doctors remain available where they are needed most in public hospitals.
Those unhappy with the move are mainly government doctors who currently engage in private practice, especially in teaching hospitals. The public, meanwhile, has only one expectation: when they need care, the right doctor should be available at the state-run facility first. The private sector should be their second resort.
The potential winners would be the economically weaker patients, the government healthcare system and dedicated government doctors.
If the ban succeeds in revitalising government hospitals, the biggest winners would be the poor and middle-class patients who rely entirely on public healthcare. They would gain consistent access to specialist care without being forced into the private market.
A successful ban could restore integrity, accountability, and efficiency to public health institutions. It would bolster the government's argument for increased health funding by demonstrating a commitment to reform.
Many honest doctors who currently serve with dedication would benefit from a level playing field, free from the pressure and perverse incentives created by their privately practicing colleagues.
If the ban comes into existence, the potential losers would be the patients (in the short term), government doctors (financially) and likely initial hiccups in the private healthcare sector.
During a transition period, patients could suffer from a sudden reduction in overall healthcare capacity if a specialist exodus occurs. Government doctors would lose a significant source of income. Without a substantial and commensurate increase in government salaries and benefits, this would lead to profound dissatisfaction.
Though the private healthcare sector would eventually gain from an influx of specialists leaving government service, they might initially struggle with the sudden surge in demand and competition.
The Path Forward
Beyond a simple ban, there is a need for a nuanced approach. The binary of "ban" or "not to ban" is overly simplistic. The solution lies in a multi-pronged strategy that addresses the root causes of the problem. This could include the following:
Constitute an Unbiased Committee: The state must immediately form a high-level, impartial committee comprising medical administrators, ethicists, public representatives, and senior doctors from both within and outside the government. This committee should thoroughly assess the advantages, disadvantages, risks, benefits, and alternatives, providing data-driven recommendations.
Address the Compensation Issue: The core of the problem is economic. Private practice is a business because it is immensely profitable. To demand loyalty to the state, the state must offer a compelling alternative. This does not necessarily mean matching private sector incomes rupee-for-rupee, but creating a compensation package that includes a respectable, performance-linked salary, excellent perks, assured career progression, and a robust post-retirement security plan.
Strengthen Monitoring and Accountability: The state must invest in a transparent, technology-driven attendance and performance monitoring system. Biometric systems, live operation theatre logs, and independent audits can curb the manipulation of records. Strict, non-negotiable disciplinary action for absenteeism and ethical violations is non-negotiable.
Phased Implementation: A staged ban, beginning with teaching hospitals and new recruits, is a prudent approach. It allows the system to adapt and provides a clear signal of the government's intent, giving doctors time to make informed choices. Introduction of evening OPDs in public hospitals (can be with partnership), appointment of dedicated administrative officers in hospitals, and allowing MBBS doctors on compulsory rural service to also work in urban areas.
From prohibition to persuasion
While the abuses of the current system are undeniable and demand urgent rectification, a blunt, punitive ban could backfire spectacularly. The loser in a poorly implemented ban would be the common citizen, for whom healthcare would become even more elusive. The winner in a well-structured reform would be the entire society, which would benefit from a robust, trustworthy public health system.
The state must choose not merely to prohibit, but to persuade. The loyalty of a doctor to the state can only be expected when the state demonstrably values the service of its doctors.
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