First National Conference on Ethical Healthcare (NCEH) 2018, Alliance of Doctors for Ethical Healthcare (ADEH), All India Institute of Medical Sciences, New Delhi, 21-22 April 2018

‘First time in the history of Indian medicine such a conference is taking place!' Dr Nigel Umar Beejay from the United Arab Emirates (UAE) was speaking at the National Conference of Ethical Healthcare on 21 and 22 April 2018, at the All India Institute of Medical Sciences (AIIMS), New Delhi. As rightly described by him, this conference was the first of its kind in India with a dedicated focus on ethical, rational care in the private health sector in India. It was organized by SATHI (Support for Advocacy and Training in Health Initiative) for the Alliance of Doctors for Ethical Healthcare (www.ethicaldoctors.org) (ADEH), which is an emerging national network of few hundred doctors committed to promoting ethical and rational healthcare while challenging current malpractices within the medical profession.

The book Dissenting diagnosis written by two physician-activists working with SATHI, Drs Gadre and Shukla, based on striking testimonies regarding malpractices in the private medical sector, was well received by the people at large and a section of the medical community. A strongly perceived need to promote ethical and rational healthcare brought together around 250 doctors from many cities of Punjab, Kerala, Maharashtra, West Bengal, Delhi and other parts of India, leading to the emergence of ADEH in October 2016. Since its inception, ADEH has been active in advocacy and awareness among doctors as well as the public at large, and is engaged in raising a voice on behalf of rational and ethical doctors. ADEH has a dream to bring universal healthcare (UHC) to India, a system that would eliminate money transactions between doctors and patients at the time of service delivery. This conference was a move towards realizing these objectives of the ADEH network.

More than a hundred doctors, activists, researchers and policymakers gathered at this conference, spending their own money for travel, to share their experiences and brainstorm over various themes. These included representatives from international networks implementing innovative initiatives on ethical and rational medical care—Dr Vikas Saini from the Right Care Movement, USA; Dr Jose Carlos Velho from Slow Medicine, Brazil; and Dr Nigel Umar Beejay from Abu Dhabi. There was a video message from Dr Bernard Lown, a world-renowned cardiologist and activist and a Nobel Peace Prize winner, who appreciated this effort.

Among the panelists and presenters were Dr Randeep Guleria (Director, AIIMS, New Delhi), Dr K. Srinath Reddy (President, Public Health Foundation of India), Dr Vinod Paul (Senior Neonatologist and Member, NITI Aayog, Delhi), Dr Gurinder Sinh Grewal (Senior Gastroenterologist and Past President, Punjab Medical Council), Dr Shah Alam Khan (Professor, Department of Orthopaedics, AIIMS, New Delhi) and Dr Peush Sahni (Professor and Head, Department of Gastrointestinal Surgery, AIIMS, New Delhi and Editor, The The National Medical Journal of India).

Dr Vikas Saini, the keynote speaker, talked about a paradigm in modern medicine that is shifting medical care away from a personalized one to detached and mostly driven by profiteering. He shared his experience from the Right Care Movement, which is trying to address overuse and underuse of treatment. Dr Abhay Shukla (co-author of Dissenting diagnosis), elaborated on the drivers of commercialization of healthcare and the unique role of ADEH in combating it. He talked about marketization and corporatization of healthcare. He also raised issues around the survival of doctors, who wish to practise ethically.

All the sessions were insightful, informative and evoked much discussion.

During the session on ‘Challenges faced in advocacy for ethical healthcare’, the panelists shared their struggles, challenges in their efforts in advocacy for addressing crucial policy initiatives such as corruption in medical education, fighting the unethical nexus between the vaccine industry and some of the office bearers of the Indian Academy of Pediatrics, and running the ‘No Free Lunch’ movement, which appeals to doctors to say ‘No’ to bribes by the pharmaceutical industry. Reflecting on the present situation in the private healthcare sector, Dr Vinod Paul said that in this era of churning, voices like ADEH should be louder.

The session on ‘How to move towards UHC in India’ was informative in which various terms, definitions and key aspects of UHC were discussed in depth. It was said that it is necessary to build a mechanism to address and link three key policy directives— coverage of the entire population, coverage for a significant range of healthcare and cost of coverage. Dr Srinath Reddy insisted that if at all the private healthcare sector needs to be involved, standard management guidelines and ethical practice would need to be taken care of. Dr Anant Phadke suggested six steps towards UHC: (i) ban all irrational, fixed-dose combinations; (ii) allow cost-based pricing with reasonable profit to pharmaceutical companies;(iii) employ a uniform code for pharmaceutical marketing practice s;(iv) fix the same fees for private and public medical colleges;(v) regulate cost in the private healthcare sector; and (vi) generate political will to ensure this policy change.

The session on ‘Challenges faced for right/ethical healthcare in the global context’ was led by eminent speakers from international networks, namely, Dr Nigel Umar Beejay, Dr Jose Carlos Velho and Dr Vikas Saini. They brought forth universal cross-cutting issues such as loss of trust between the doctor and patient, and growing commercial interests. It was interesting to learn about the initiative of ' Slow Medicine’, which is a movement to balance the existing over-emphasis on procedures and surgeries under pressures from equipment manufacturers.

The session on ‘Corporatization of healthcare and its impact on doctors’ had doctors working in different healthcare provider setups, a researcher and a public health expert. This session threw light on the pervasive ‘business model of healthcare’, massive investments from global players and its impacts on overall medical practice. Dr Sanjay Nagral opined, ‘I don’t see much difference across different types of hospitals including a corporate one.' Dr Puneet Bedi described small hospitals as ‘medical dhabas’. He revealed how corporates maximize profit by insisting on money-making procedures.

‘Healthcare practice watch’ was a thought-provoking session to address the issue of irrational use of medical interventions. A po sition paper was presented on ' cord around the neck—not a sole indication for caesarean (unless diagnosed as type b [locked])'. While discussing the grey areas of irrational practices in the context of lack of standard treatment guidelines, Dr Peush Sahni raised the question: ‘Where do we look for evidence for rational and irrational practices?'

The participants were eager to hear from new entrants to private practice about the struggle they have to face to uphold ethics in their day-to-day practice. Four young doctors from Pune, Nasik, Chennai and Delhi passionately shared their narratives about various challenges in setting up their practices and in remaining ethical. These challenges included hegemony of seniors, cut-throat and cruel competition, kickbacks, performance targets and work pressure. It moved the participants and helped ADEH to strengthen its resolve to fight the ills of the healthcare system.

An important session of the conference was Commendation of Crusaders for Ethical Healthcare! ADEH took this opportunity to commend the crusaders among medical practitioners who have taken the risk of standing up against unethical practices despite various pressures. Dr Vipin Vashishtha, Dr Jagdish Chinappa (for their courageous fight against pressures of the vaccine manufacturing industry) and Dr Yogesh Jain (for exemplary community health work of Jan Swasthya Sahyog in Chhattisgarh) were presented their commendations by Dr Samiran Nundy and Dr Bimal Jalan (former Governor, Reserve Bank of India).

At this conference, ADEH became a part of an emerging global movement for more humane and non-commercial healthcare. The Joint Communiqué among Indian and international representatives of like-minded doctor-representatives from the ‘Right Care Movement’ and ‘Slow Medicine’ describing the common framework was released during the conference. The joint communique appealed to a global audience: ‘We the undersigned organizations declare that we need a new kind of healthcare that puts relationship ahead of the transaction.'

This inaugural conference made a good start towards gathering doctors to realize the dream of ethical, rational, equitable and sustainable quality healthcare through UHC. It has shown that doctors want to be a part of the change!

This conference appealed to four key stakeholders—the government, doctors, hospitals and citizens. The important demands were: (i) stop commercialization of medical education; (ii) stop imposing revenue generation or conversion targets of any kind on doctors; (iii) do not give or take commission or referral charges; and (iv) for citizens: never indulge in violence of any form against any doctor or healthcare provider. ADEH hopes to use this appeal to a wider audience and also for advocacy with the government.

Acknowledgements

We thank Mr Archana Diwate and Dr Kishor Khilare for their help in taking notes of various sessions during the conference.