Bringing back trust

Dr ALEXANDER THOMAS

India today faces a growing crisis of trust in healthcare despite remarkable advances in medical technology, tertiary care, organ transplantation, and specialist services. Over the years, through my work with several associations of health providers and accredited organizations, collaborations with state and Central government agencies, and my years as CEO at Bangalore Baptist Hospital, one lesson became repeatedly clear: most patient dissatisfaction does not arise purely from medical negligence. Patients often feel unheard, uninformed, emotionally neglected, or financially anxious.

Communication failures frequently become trust failures.

This understanding led me to strongly advocate communication skills and ethics becoming integral parts of India’s medical curriculum. Technical competence alone is not enough. Healthcare professionals must also learn empathy, listening, counselling, disclosure, and conflict resolution. Good communication improves patient outcomes, reduces medical errors, lowers litigation, and can even reduce healthcare costs.

Another major contributor to mistrust is the increasing perception of commercialization in healthcare. India’s private healthcare sector has undoubtedly contributed enormously to infrastructure development, innovation, advanced treatment, and expanded access to care. Yet many citizens increasingly perceive healthcare as becoming excessively revenue-driven. Financial targets, procedure-oriented systems, and aggressive commercial competition sometimes create the impression that healthcare functions more like an industry than a healing profession.

In recent years, this perception has deepened further as several hospital groups have become publicly listed companies. Public investment can certainly strengthen infrastructure, technology, and expansion. However, publicly listed institutions are also accountable to shareholders whose expectations are often closely linked to financial performance and growth. This can create a public perception — rightly or wrongly — that monetary priorities may overshadow patient-centred values.

At the same time, it is important to recognize that the vast majority of healthcare in India, whether public or private, continues to be delivered by small and medium hospitals, charitable institutions, mission hospitals, nursing homes, and individual practitioners who function with deep commitment and often limited margins. Unfortunately, public perception is frequently shaped by the actions and visibility of a smaller segment of large corporate institutions.

Another major issue affecting trust is the question of transparent costing in healthcare. One of the greatest areas of tension today among the public, insurance providers, government agencies, and hospitals relates to pricing and reimbursement. Healthcare costing in India often lacks standardization and transparency, creating suspicion and conflict on all sides. Patients may feel overcharged, while hospitals argue that reimbursements are unrealistic and fail to reflect the actual cost of delivering quality care. A study conducted by the government of Karnataka in 2017 highlighted the significant gap between government reimbursement rates and the real cost incurred by hospitals.

Transparent costing mechanisms are therefore essential. Healthcare providers, insurers, and government agencies must work together towards rational, evidence-based, and transparent costing systems that are fair both to patients and providers. If reimbursements become irrationally low or disconnected from operational realities, healthcare quality will inevitably suffer. No healthcare system can sustain safe staffing, quality infrastructure, infection control, technology, training, and ethical standards if reimbursement structures fail to reflect the true cost of delivering quality care. Transparency and fairness in costing are therefore critical not only for trust, but also for patient safety and long-term sustainability.

One of the most uncomfortable — yet rarely discussed — ethical challenges confronting Indian healthcare today is the growing inequity within the healthcare system itself.

In some urban settings, a small number of highly specialized consultants may earn extraordinarily high incomes running into `1-2 crore per month, while nurses, physiotherapists, technicians, support staff, and frontline caregivers who sustain the healthcare system may earn only `20,000-30,000 per month despite carrying immense responsibility. One of India’s foremost mission hospitals, internationally respected for excellence and ethical care, follows a policy that limits the ratio between the highest-paid and lowest-paid employee to approximately 1:15. Such models remind us that healthcare institutions can pursue both excellence and equity simultaneously.

This should not be viewed as criticism of success or excellence. Specialists who spend decades training and performing highly complex procedures deserve recognition and fair compensation. Yet the imbalance raises larger ethical and systemic questions.

Are prevention and primary care being undervalued? Are healthcare systems rewarding procedures more than population health? Can public trust survive if inequities in the system become increasingly visible?

The irony is that long-term public health depends heavily on nurses, health workers, support staff, family physicians, nutritionists, physiotherapists, counsellors, sanitation workers, and community health workers. Yet preventive and community-based care often remain poorly rewarded compared to expensive tertiary interventions.

The Covid-19 pandemic exposed these realities with painful clarity. Frontline workers across India demonstrated extraordinary courage and sacrifice under extremely difficult circumstances. Many worked under severe pressure with modest compensation and emotional exhaustion. The pandemic reminded society that healthcare is fundamentally a moral profession.

Patient grievance systems are another critical area. Through the National Accreditation Board for Hospitals & Healthcare Providers (NABH) and other accreditation initiatives, programmes, and collaborations we emphasized transparency, mediation, patient grievance committees, and institutional learning. Hospitals must move away from blame cultures and towards learning cultures. 

Dr Alexander Thomas is founder and patron of the Association of Health Providers India, Association of National Board Accredited Institutions, and Consortium of Accredited Healthcare Organizations. The unabridged version of this column appears on our website.