Changing healthcare provision and employment opportunity

Respondents highlighted broad trends in employment options in the healthcare sector as the predominant model of provision has moved from public hospitals, and small and medium privately owned hospitals (often referred to as ‘nursing homes’) to a burgeoning corporate sector. In the current period, government employment has dwindling appeal for many respondents who cited difficult working conditions in urban public hospitals, poor pay offered in government as compared with most private hospitals, little enthusiasm for postings to remote and under-equipped facilities and the public sector’s inability to absorb a growing number of graduates with specialist training.

Respondents described a shift in the infrastructure of the private sector away from the owner-practitioner and towards work in large hospitals either as full-time employees or as visiting consultants. The opportunities to work in or run a small hospital have been reducing in recent decades, and a senior surgeon described the low-budget private nursing homes as ‘a dying phenomenon’. Respondents cited the challenges faced by small hospitals. These include the difficulty for small setups to meet all regulatory requirements related to hospital infrastructure such as separate staircases, overhead tanks and sprinklers in the premises. They are unable to match the range and sophistication of corporate hospitals’ services and to meet changing patient aspirations; few are equipped to handle insurance schemes and lose those patients. For doctor-owners, the options are to tie up with corporate entities, hand over to a hospital management company or to close down and then join a corporate hospital as a visiting consultant or ‘panel’ doctor.

Staffing agencies also now provide doctors—and nurses—‘on-demand’ to hospitals. It has become common for new medical graduates to approach such companies for employment. In order to withstand competition in a crowded field, doctors have also resorted to the use of online ‘doctor-discovery and booking’ platforms such as Practo, which have emerged in large cities to enable self-promotion to potential clients. To appear near the top of its list requires payment of extra charges, but helps increase one’s visibility in the market.

Doctors in debt

Medical education and the costs of setting up a practice both push doctors into indebtedness. Increasing numbers of students aspire to do postgraduate specialisation to stay competitive in domestic markets, as well as to open opportunities for migration. As noted above, the number of institutions and places for government training has been surpassed by private colleges, where many students have to pay hefty admission fees that are largely unregulated. One respondent noted that fees for training for radiology can cost the equivalent of US$100 000, around 17 times higher than in government medical colleges. A common route for a medical graduate had been to set up a new practice using family savings or small loans. This path to employment is, however, increasingly difficult. Any attempt to open one’s own clinic or hospital requires a loan because of the high costs for land, infrastructure, equipment and other resources. Some respondents suggested that all these debts put doctors under pressure to exact maximum financial returns from medical practice and earn more in order to repay their loans as soon as possible.

Emerging new forms of employment relations

Old ways into private practice are thus becoming difficult. As the price of land and technology has become prohibitively expensive, even the strategy of starting out one’s practice in a large residential apartment has been undermined by more stringent enforcement of government building regulations in recent years. On top of this, there is a saturated market for many areas of medical practice in Mumbai and Pune, as one ophthalmologist noted: ‘when I started to practice in the 1980s, there were about 30–35 ophthalmologists in the city and today the number in Pune is 500 plus’. This scenario disadvantages new starters who lack the reputation and client-base of established practitioners. As a specialist explained, for many doctors now ‘there is no choice but to work in a big hospital’.

For those who do find work in the larger, usually corporate, hospitals, there can be significant employment benefits on offer including regular pay, access to advanced technology and infrastructure and well-trained human resources. Doctors working with corporate hospitals do not need to make investments nor worry about issues that would otherwise occupy significant portions of their time as owner-practitioners such as staffing, administration and renewal of a facility licence. Instead, they can focus on clinical practice. Some doctors perceive that doctors' attachment to reputed, big hospitals with brand names also has a positive impact on their patient as big hospitals are assumed to employ the best doctors. There are personal aspects that are attractive too. Larger hospitals also have security guards within the hospital premises that provide better protection against violence from patients. Prestige and credibility is derived from work with a reputed hospital, and indeed it was noted that young male doctors considered being associated with branded hospitals as advantageous in attracting a future spouse.

However, there is widespread precarity in employment conditions in private healthcare, especially for young, early career doctors. Access to employment in larger hospitals is limited by the small number of unoccupied posts and hospitals’ preference for doctors trained in complementary medicine who are cheaper to employ and can perform many of the same tasks. The competition means that many doctors have little control within employment relations. It was noted by many respondents that managers are able to terminate the contracts of workers at short notice. Another respondent described being asked to pay a bond to a hospital that they would receive back only if they stayed at the hospital for a certain number of years. Those specialities and hospital departments that generate smaller revenue than expected face a constant struggle to justify their continued presence in the hospital. In some hospitals, full-time contracts are used which prohibit practising elsewhere and involve heavy workloads and low pay: described by our interviewees as ‘exploiting’ doctors and paying ‘pennies’.

Respondents reported a major disparity in pay between junior and senior doctors in corporate hospitals. For example, junior doctors may be paid 100 000 rupees per month (US$1400) while senior doctor pay can exceed 10 million rupees per month (US$140 000). Given increasing competition and difficulties in practicing as a medical doctor, some medical graduates are opting for different professions. After completing the MBBS, they take a Masters degree in business administration, law or hospital management and pursue careers in related industries like pharmaceuticals, health insurance or the medical devices industry. Further up the professional hierarchy, doctors with established reputations often avoid full-time contracts in order to practise across several hospitals and can generate greater income. For a small number of such doctors, corporatisation trends have proven very lucrative. The last 20 years have seen the ascension of the ‘star doctor’: renowned doctors who become a type of celebrity. Usually, surgeons can attract wealthy patients, command large fees, hold multiple appointments across several hospitals and often appear in the marketing materials. Respondents noted that hospitals will charge higher fees from patients in order to accommodate the increased cost of employing ‘star doctors’.

One member of management staff at a large hospital in Mumbai highlighted the value of such doctors to hospital marketing teams and the moves made to retain them, revealing that ‘one senior doctor who gets a lot of VIPs has now become the trustee so that he won't leave that hospital’. However, another respondent—a surgeon—was unsure how long this privileged position would continue, arguing that as large hospitals become more established brands in their own right, they will be less reliant on famous doctors and opt to hire cheaper alternatives.

Performance targets: ‘Were you not convincing enough?’

The shift from smaller to larger private providers, and from clinical autonomy to following standardised plans and protocol as defined by corporate hospitals’ management, is evident. Opinion on whether it should be viewed as progress differed, with some respondents seeing this as replacement of a low-quality market segment by one with greater technology, life-saving capacity and transparent systems. However, many saw this as part of a broader shift away from a patient-oriented healthcare provision towards systems of revenue generation that, according to one small hospital owner, are ‘faceless, impersonalised and less accountable’. For these respondents, family practice or small hospitals were much more connected with their patients. The incursion of commercial considerations into everyday practice in the form of performance targets was a particular area of concern for our respondents. Monthly targets for revenue generation or patient throughput are reportedly set for full-time as well as for visiting consultant and panel doctors at the time of their appointment. A doctor who misses their targets for two consecutive months receives a verbal or written memo, and contracts can be terminated if performance against these does not improve. At times of contract renewal, the commercial value of the doctor is assessed on the revenue they have generated for the hospital.

Respondents also informed us that the pressure of meeting targets increases as the end of the month approaches. The success rate of converting outpatients to inpatients by recommending a procedure or surgical treatment requiring admission has become significant for the meeting of organisational targets. As a gynaecologist described it, if the inpatient revenue they generate is proportionately far less than outpatient revenue ‘then doctors are asked “why is it so? Were you not convincing enough?”’

Large corporate hospitals build their reputation on the twin selling points of inpatient ‘hospitality’ and of use of advanced technology. This in turn contributes to irrationalities in medical care as prolonged hospitalisation and large batteries of tests become normalised. Unnecessary tests are performed to attain the targets needed to ensure the return on the purchase of costly equipment: ‘Because of targets, machines require 1000 patients or investigations per month. So, it definitely involves a lot of unnecessary investigations, a lot of treatment modalities’ (Ophthalmologist). This situation is compounded by growing use of private insurance to pay for healthcare and attitudes that see this insurance as legitimising irrational provision of care.

As our respondents acknowledged, financial imperatives are not new to the private sector in India, nor are they unique to larger hospitals, as smaller private providers also have to remain financially viable. However, the point was made that targets in small hospitals are limited to the owner-doctor’s requirements for meeting loan repayments and are not individually applied in that way to other doctors attached to it.

Participation in networks of cash-for-referrals, referred to as ‘cut practices’, has been longstanding within Maharashtra’s healthcare system, encouraged by the financial strains on smaller private providers. Now the incentives are for practitioners to by-pass smaller hospitals and refer their patients to specialists in the larger, corporate hospitals in search of more substantial commissions. In the words of one gynaecologist: ‘since the corporate bill is much bigger even the crumbs are bigger’. Respondents explained that refusal to engage in paying cash for referrals could prove particularly detrimental to younger doctors without an established reputation and who might otherwise struggle to attract patients, impacting in turn on their ability to repay debts.

‘Doctors are pawns’

While doctors’ pay and conditions seem generally better in larger, corporate hospitals than in smaller private facilities, there are accompanying behavioural expectations and significant reductions in autonomy for medical professionals. The growth of a healthcare management cadre is evident in burgeoning management departments, new managerial posts such as operating officers, executives and supervisors, and the widespread incorporation of business practices. Most managerial staff are the products of business management training institutions. Respondents felt these staff prioritised financial concerns of their institution over the realities of healthcare—in ways that left one urologist comparing such hospitals to patient ‘factories’. The comment from a retired state health official that ‘doctors are pawns, they are supposed to be the conduit to earn money’, reflects a commonly voiced cynicism about the healthcare industry and its ways of working. Doctors also felt they must accommodate the priorities of hospital managers, as one radiologist noted: ‘if you want to work with corporates you have to have a certain mindset… in short you have to keep the management happy’. Senior consultants can express resistance to management decisions but do not have a ‘deciding say’ in the running of the hospital. Junior doctors have even less opportunity to do so.

The division of labour within wards in corporate hospitals allows little time for patient interaction with senior doctors as the majority of care is provided by junior doctors and nursing staff. This results in a loss of status: ‘Patients interact with doctor as if doctor is the employee of the hospital and hence should give the services’ (Gynaecologist). The growing use of standard treatment protocols introduced by hospitals and by health insurers was felt by many to be an additional constraint on professional autonomy. While some felt this helped to standardise prices and improve transparency for hospital bills, other respondents noted that it further eroded the autonomy of healthcare workers in providing discretionary fee waivers to patients considered unable to otherwise pay.