The starkest change I noticed after moving to Chennai was the unusual flux of Bengali patients. Even for relatively minor ailments, one can see the Bengalis coming all the way to Chennai. I assumed they had come to visit some relative and had a health checkup as an aside. Quickly I was disabused of my notions – these people had come to Chennai to have regular health care. It seemed implausible, yet true. Having limited Hindi knowledge and zero fluency in Bengali, I never got around to unraveling the cause of this medical exodus. In the medical landscape of our vast country, Bengal is an outlier – where people seek healthcare disproportionately (and sometimes inexplicably) from another state, far off from their own. To be honest, West Bengal has some of the best doctors. For reasons best known to them, these people choose to come to Chennai (or Vellore). The key word here is “choice”.
As many other novelties in life, it wore off after a while and it had become a routine affair, until I heard about the KPME bill. Some erroneously call it an act – it isn’t, unless it is passed. For the first time, I wondered if Karnataka would join Bengal, in a situation where people seek healthcare outside Karnataka. The crucial difference is that they will not “choose’’ it, but perhaps be forced to do it. The proposed KPME bill has such far reaching consequences.
Predictably the social media became abuzz with activity. The vigilante public was baying for the private doctor’s blood. The doctors put up a valiant fight. Having been pushed to the wall, they have called for a state wide strike. The politicians have let the issue fester and are trying to fish in the muddled waters – as is usual for their tribe.
I am not going to describe the bill or list out its pros and cons. People far more qualified than me have already done that. I would instead try to show why the public would be better off supporting the doctors than the politicians.
I realized was that this is a type of Prisoner’s dilemma in game theory- a mathematical construct where two completely ‘rational’ entities don’t cooperate even if it appears in their best interests to.
Here’s an example from Wikipedia
Two members of a criminal gang are arrested and imprisoned. Each prisoner is in solitary confinement with no means of communicating with the other. The prosecutors lack sufficient evidence to convict the pair on the principal charge. They hope to get both sentenced to a year in prison on a lesser charge. Simultaneously, the prosecutors offer each prisoner a bargain. Each prisoner is given the opportunity either to: betray the other by testifying that the other committed the crime, or to cooperate with the other by remaining silent. The offer is:
- If A and B each betray the other, each of them serves 2 years in prison
- If A betrays B but B remains silent, A will be set free and B will serve 3 years in prison (and vice versa)
- If A and B both remain silent, both of them will only serve 1 year in prison (on the lesser charge)
It is illustrated by the image below ( in game theory, this is called a payoff table)
Since each prisoner aims to maximize the payoffs, the dominant strategy is to betray – which results in a strong Nash equilibrium in the game. As you can see, the mutual cooperation is a better strategy, however neither entity can be sure that the other party will cooperate. So in the absence of information, there is a tendency to betray.
Now imagine the game played multiple times – an iterative version of the same dilemma and both players remember their previous encounters. It can be shown mathematically that for purely selfish reasons, mutual cooperation yields better outcomes.(The math behind this is quite complex though)
What does this have to do with the KPME bill?
The two entities in question are the public and the doctors. Although this is not a public vs doctor’s issue, just like the policeman in the scenario, the government has successfully made it so – to hide its own inefficiency and failures. As in the Prisoner’s dilemma, with imperfect information, the natural tendency is to betray the opposite party. This tendency can be short circuited to some extent by improving the information flow. After all, if both entities can trust each other, they are likely to realize that mutual cooperation is the better strategy (that maximizes the payoffs for both) in the long run.
While the public can almost certainly derive some term benefit by supporting the bill, they will be left to the lurch in the long run. In the same way, the doctors would pay a price in the long run if they were to adopt a strategy that maximizes their returns without regard for the public.
This is a type of iterative Prisoner’s dilemma where each entity has an opportunity to communicate freely, thereby identifying the strategy that will result in a win win situation. We must realize that healthcare is not a zero sum game – both doctors and public can benefit, if only we can reduce the distrust and communicate freely.
So the two things that the doctors must do urgently are
- Disseminate authentic information to enable an honest debate
- Work towards reducing the trust deficit
Let’s say the public/government still goes ahead and the KPME bill becomes a law. What would happen?
Doctors would have no reason to work in small nursing homes. They would be shut down. The hospitals with deeper pockets might continue for a while – but they would allocate the funds elsewhere and would shut shop.(it’s not as difficult as it sounds). The doctors would find better opportunities elsewhere and move. The brightest young boys and girls , after seeing the war waged on doctors, would decide that it isn’t worth their while to do medicine, causing the inexorable brain drain. Since the government hospitals don’t come under the ambit of this law, they would most likely remain the same. The rich and powerful would go to nearby states to seek healthcare. The poor though would be caught between the devil and the deep sea – an inefficient government hospital and a non existent private option.
Soon they would have no other option than to start looking for options – and perhaps they might land up in Chennai ! (who knows I might be saying “Kannada gothilla” very soon to someone!)
KPME bill is a disastrous spiral into to the abyss. The people must realize that while on the surface it looks like a doctor vs patient issue it is not.
IT IS A GOVERNMENT VS PUBLIC ISSUE.
Failure to realize this might make the public act on imperfect information, just like the prisoners. And the outcome won’t be good for doctors or the public.