A few studies on the secondary level of care show that it consists of institutions that provide both out-patient and in-patient with 5 to over 100 beds. These studies provide insight into the heterogeneity of these institutions in terms of scale of operation, services offered, technology employed, and the social background of patients using these facilities (Bhat: 1993, Jesani: 1993; Nanda & Baru: 1994, Baru: 1998). These studies have shown that there is variability in the quality and costs of services provided by these institutions. As a result there are no standards for these nursing homes and the consumer has no information regarding the costs he or she likely to incur when they seek care (Phadke: 1998; Nandraj: 1994). Given these trends it is essential nursing homes be required to follow procedures for providing information regarding facilities available, the rates of the services provided, maintaining patient records, and ensuring access to them, and also build in the provision for medical audit.

The heterogeneity of nursing homes and hospitals in the secondary level results in conflict of interests between the smaller and larger players in the market. In some cases the contradictions are so sharp that it leads to divisions within the professional organisation and, in extreme cases, leads to the formation of separate for a like the Private Nursing Homes Association in Andhra Pradesh or the Nursing Homes Association in Delhi. Even where there are legal provisions available for registering nursing homes, these conflicts often cripple their implementation. In some instances the differences between the smaller and larger enterprises were used by the government to initiate the regulatory process, as was seen in Andhra Pradesh and Delhi. While some progress was made, the owners of small nursing homes formed a powerful lobby and tried to slow down, if not reverse, the process (George, A: 1998; Bhat: 1994).

This was seen in the case of Delhi, when serious efforts were made to implement rules for regulating the nursing homes during the nineties through a series of negotiations between the owners the government and the owners of nursing homes. Firstly, the Directorate took the initiative to undertake a survey of all nursing homes and then they were inspected. After inspection, they found that only around 10 per cent of the nursing homes qualified to be registered. Those, which were found wanting were appraised of the kind of upgradation required for qualifying them for registration. Through dialogue with these owners, the medium and larger enterprises were registered. However, the real stumbling blocks were the smaller nursing homes, who were not only numerically strong but were also located in slums where there was a genuine constraint for space. These nursing homes were largely concentrated in the resettlement colonies in West Delhi. Due to constraints of space, they could not comply with minimum physical standards. By virtue of sheer numbers, they were able to bring strong enough political pressure to slow down the process of regulation. (Interview with senior official, formerly with the Directorate of Health Services, Delhi) A study of private nursing homes in Delhi not only vividly captures the heterogeneity but also their uneven distribution and overcrowding in residential areas. The issue of regulation of private nursing homes has become closely intertwined with town planning and land use that the DDA had raised a few years ago (Nanda & Baru; 1994; Priya, R: 1993). While it is the Delhi Development Authority that grants permission for establishing nursing homes, as per its master plan, the registering authority lies with the Directorate. In addition, the Directorate is supposed to oversee compliance of private hospitals to conditionalities but they have problems enforcing it, since there is no clear definition of who constitutes the poor. Issues like these can hamper efforts at regulation and therefore, thee must be addressed based on the evidence put together mostly through interviews with those who have tried implementing the legal provisions available. What is clear in such a situation is that if different authorities have control over different aspects then regulation by just the Directorate becomes difficult (Interview with officials in the Directorate of Health Services, Delhi).

In Uttar Pradesh there are no laws for regulating the private nursing homes. Very recently, the UP government has proposed a system of licensing for all practitioners but this has been opposed by the Indian Medical Association. The IMA is of the opinion that this will only increase corruption and will not serve any purpose. The secretaries of various local branches also opined that the idea of introducing licenses was duplication of efforts since doctors have to register with the Medical Councils. They did not really see the need for regulating the private sector but insisted on doing away with quackery instead (Interviews with Secretaries in IMA, UP).

The few unpublished studies from small towns in UP however underscore the need for regulations. These studies show that the private sector in small towns comprise mainly small and medium nursing homes, and promoters are from both allopathic and indigenous systems of medicine. There seem to be even instances of unqualified owners promoting such enterprises. These studies, being based on very small samples and case studies, may not give a representative picture but their findings, are consistent with impressions of informed observers and researchers of this sector. These case studies also provide some information into how practitioners of indigenous systems of medicine practice allopathic medicine (Bharti: 1993; Pandey: 1993; Tomar: 1993).

Some of these studies have also shown that government doctors have links with the private sector as consultants, or in some cases, as even promoters. This kind of a scenario exists in all states where private practice has not been banned as seen in Andhra Pradesh, Bihar, Madhya Pradesh etc. (Baru: 1998). This was not seen in the case of Delhi because private practice by government doctors is officially banned in this state. At the national level there needs to be a clear policy direction regarding the banning of private practice by government doctors, which should be adopted as the norm by state governments as well. This is an absolutely essential step to strengthen the public sector and at the same time rationalise the private sector. The recent efforts at setting up accreditation systems need to be supported and further strengthened. However, these need not preclude the government initiating regulatory mechanisms simultaneously at all levels of care. (Interview with President, IMA, Delhi).

A few studies have commented on the power that doctors wield in modifying and reversing State policy when it comes to any form of regulation. This phenomenon is not restricted to India but is seen in developed countries as well. Professional associations have largely adopted a conservative stance when it comes to regulating themselves or responding to external pressures to regulate them. The history of the British Medical Association and the American Medical Association and the positions that they took vis-a-vis a nationalised health service or regarding private practitioners and hospitals has been well documented. The peace and content of any regulatory effort by the State has met with resistance and challenges primarily from these associations. This is an important issue for the government to deal with while coming up with a regulatory framework because of which clarity on the objectives of regulation is very essential (Starr: 1993; Relman: 1987; Higgins: 1988; Quam: 1989).

Even in India, one finds that the picture is very similar. The social background of promoters of private institutions provides the base for political manouvering which can effectively block efforts for regulation. A Preliminary analysis of the members of IMA in UP shows the predominance of the bania and the brahmin castes which have considerable clout in UP politics. Thus, any effort as regulation can be blocked by these sections (3). However, as a slight contrast in AP, while the forward castes do dominate the social composition of hospital owners is more diverse and therefore it tends to break solidarity on caste lines. This could be an important factor for the process and outcome of efforts at regulation in the states.

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