Why India Needs a National Medical Accountability Framework

India’s healthcare system has reached a point where clinical excellence and institutional accountability can no longer be treated as separate questions. The country has globally respected doctors, rapidly expanding hospital networks and a growing medical-services economy. Yet the patient entering a private hospital still faces an uneven regulatory landscape in which prices, treatment protocols, grievance systems and disclosure standards vary widely.

This tension sits at the centre of Code Red — India’s Framework for Medical Accountability, the policy compendium developed by Raja Mukherjee and Bidisha Mukherjee Sen. Their proposal does not begin with the assumption that doctors are inherently untrustworthy or that private hospitals are inherently harmful. It begins with a more institutional question: who regulates the establishment in which medical decisions are financed, incentivised, priced and administered?

That distinction matters. India already regulates medical education and professional registration through the National Medical Commission. States regulate hospitals through a mix of nursing-home laws, clinical-establishment statutes and local rules. Consumer forums hear disputes. Accreditation bodies set quality benchmarks. But these mechanisms do not together create a single, citizen-facing system capable of inspecting corporate hospital behaviour, comparing outcomes, enforcing transparent billing and resolving complaints within a predictable period.

The real regulatory gap is institutional

The modern multispecialty hospital is not merely a building in which independent doctors practise. It is a complex enterprise with procurement systems, diagnostics, pharmacies, referral structures, insurance arrangements, investment targets, billing protocols and management incentives. Clinical conduct takes place inside that architecture.

Yet India’s principal medical regulator focuses mainly on the practitioner. If a doctor is accused of misconduct, the professional system can examine that doctor’s registration and ethics. But when the alleged problem comes from a hospital-wide incentive, a billing architecture or a chain-level commercial policy, the legal pathway becomes fragmented. The clinician may be visible; the institution shaping the environment may remain difficult to reach.

The Compendium describes this mismatch as an accountability gap: doctors are regulated as professionals, companies are regulated as businesses, and hospitals are licensed under varying State regimes, but the patient’s full experience is not governed by one coherent accountability structure.

Why the economics of the hospital matter

Medical accountability cannot be designed without understanding hospital economics. According to the research, pharmacy and consumables account for a major portion of revenue in the listed hospital groups studied, followed by procedures, diagnostics and outpatient services. This matters because regulation focused only on the headline surgical fee can miss the smaller additions that expand the final bill.

This structure does not prove wrongdoing. It demonstrates where incentives operate. A diagnostic chain can grow by increasing access, but it can also face pressure to increase test volume. A hospital pharmacy can improve reliability, but it can also become a high-margin captive channel. A procedure can be clinically justified, yet the patient may not have access to a neutral explanation of alternatives, expected outcomes or total cost.

Good regulation should therefore examine systems rather than merely punish outcomes. It should ask whether hospitals disclose tariff ranges, record adverse events, protect whistle-blowers, separate clinical judgement from commercial pressure and provide complete medical records promptly. These are governance questions as much as medical ones.

How the two authors built one policy architecture

The framework’s depth comes from the way the two authors’ specialisms are combined. Raja Mukherjee’s research contribution is most visible in the design of the National Health Regulatory Authority, the financing model, the proposed Medical Accountability Bill and the constitutional route through which national minimum standards could coexist with State authority.

Bidisha Mukherjee Sen’s research contribution provides the rights-based and comparative test for that architecture. Her work connects the Indian proposal with international regulatory models, develops the patient-rights and long-term outlook, and anchors the argument in sourced and verified empirical material.

The result is not simply a call for stronger regulation. It is a jointly conceived attempt to connect institutional power with citizen protection, fiscal realism, federal balance and measurable patient outcomes.

A two-instrument architecture

Mukherjee and Sen propose two connected instruments. The first is a National Health Regulatory Authority, or NHRA, designed to regulate qualifying establishments. The second is a Medical Accountability Bill directed at professional duties, disclosures, grievance resolution and patient remedies.

The proposed regulator

The institutional proposal is more specific than a general call for reform. The Authority would cover hospitals above a defined bed threshold and diagnostic chains operating across State boundaries. It would publish standard treatment guidelines, establish tariff bands for selected procedures, conduct inspections and impose civil penalties for verified violations. Appeals would move to a specialised tribunal and remain subject to constitutional judicial review.

The Compendium also tries to guard against an oversized bureaucracy. It envisages a lean establishment with a national headquarters and regional offices rather than a large administrative pyramid. The premise is that a regulator should rely on standardised data, risk-based inspection and transparent reporting instead of multiplying permissions.

The proposed Bill

The companion Bill addresses conduct by practitioners. It proposes statutory practising norms, disclosure of specified financial relationships, continuing medical education requirements and a duty of candour after adverse events. One notable proposal is a 72-hour disclosure window for adverse events, intended to replace silence and uncertainty with a clear institutional duty.

The framework also recommends independent State Medical Accountability Tribunals. This is important because ordinary litigation is often too slow, while internal grievance processes can lack independence. A specialised tribunal could focus on restitution, suspension, structured compensation and referral of criminal matters without replacing the constitutional courts.

What would change for the patient?

Policy reform becomes meaningful only when it changes the experience of a person under stress. The proposed Citizen Rights Charter translates accountability into operational deadlines and remedies.

The proposed remedies are equally significant. They include refund of excess billing with interest, structured compensation for quantifiable harm, interim monetary relief in catastrophic cases, non-monetary directions such as apologies and procedure changes, and sanctions against repeatedly non-compliant facilities.

Such provisions would not guarantee that every dispute ends in the patient’s favour. They would guarantee something more basic: that the dispute enters a defined, independent and time-bound process.

Protecting clinical judgement

One of the most important aspects of the framework is what it does not seek to do. It does not propose that a regulator replace medical judgement with rigid bureaucracy. The authors distinguish accountability for departure from published norms from liability for every adverse outcome.

Medicine involves uncertainty. Two competent clinicians can sometimes choose different pathways. A sound law should not punish reasonable judgement merely because a result was poor. It should instead require a defensible record: the diagnosis considered, the treatment chosen, the risks disclosed, the consent obtained and the reasons for departing from a recognised standard where departure was necessary.

This can protect doctors as well as patients. Clearer norms reduce retrospective ambiguity. A transparent system can distinguish a genuine complication from negligence, and an individual error from an institutional failure. In that sense, accountability is not the enemy of clinical autonomy; it is one of the conditions that can make autonomy sustainable.

The constitutional and federal question

Health is primarily a State subject, which makes any national proposal politically and legally sensitive. The Compendium responds by describing the national regulator as a floor-setting institution rather than a replacement for State authority. States would remain able to adopt stricter standards and maintain local grievance structures.

The proposed route draws on constitutional mechanisms that permit coordinated legislation while retaining federal participation. Whether Parliament and the States would ultimately accept that route is a matter for democratic debate. But the design recognises that a patient receiving care in one State and seeking remedies from another should not fall between incompatible systems.

A national healthcare market already exists. Patients travel, hospital chains operate across borders, insurers work nationally and medical tourism is international. The central policy challenge is to create national minimum protections without erasing local responsibility.

Can India afford it?

The research estimates a three-year setup cost of approximately ₹1,200 crore for the Authority and associated tribunals, with a projected annual household saving of ₹15,000 crore from reduced over-billing. These are policy estimates rather than guaranteed outcomes, and they would require independent fiscal validation before legislation.

Even with caution, the comparison clarifies the economic logic. The cost of regulation should not be measured only through the regulator’s budget. It should be weighed against delayed complaints, unnecessary expenditure, repeated tests, billing disputes, loss of wages, litigation costs and the broader collapse of trust that drives defensive behaviour by both patients and doctors.

A phased implementation roadmap

The proposal recognises that a new regulator cannot be switched on overnight. It recommends a three-year implementation sequence.

This sequencing is sensible because healthcare regulation depends on credible data. Before penalties become routine, the Authority would need common definitions for adverse events, treatment outcomes, infection rates, readmissions, billing categories and case severity. Without that groundwork, comparisons could punish hospitals treating the most difficult cases.

The strongest case for reform is trust

India’s healthcare debate is often framed as a conflict between private enterprise and public control. That framing is too narrow. The stronger question is whether a sophisticated healthcare economy can thrive without a credible architecture of trust.

Hospitals need investment to expand capacity. Doctors need room to exercise judgement. Patients need clarity, dignity and remedies. Insurers need reliable outcomes and billing data. Governments need institutions capable of enforcing standards without micromanaging treatment. These interests are not inherently incompatible.

A well-designed national framework could strengthen the entire market by making quality more visible and poor conduct more costly. It could reward institutions that already invest in clinical governance. It could provide doctors with clearer protections against commercially driven pressure. It could give patients a route other than social-media outrage or years of litigation.

A blueprint, not a finished settlement

The Mukherjee–Sen framework should be treated as a serious policy blueprint, not as the final word. Several features would need parliamentary scrutiny: the constitutional route, the composition of the Authority, penalty limits, funding, data privacy, overlap with existing regulators and safeguards against defensive medicine.

Its value lies in bringing these questions into one coherent design. It moves the debate beyond isolated complaints and asks what institutional architecture India now requires for a healthcare economy in which private providers hold a dominant share of in-patient capacity.

The central insight is difficult to dismiss: accountability cannot stop at the hospital door. The Republic regulates the qualification of the doctor, the sale of the medicine, the finances of the company and the safety of the building. It must also be capable of regulating the institutional relationship in which a vulnerable citizen receives consequential medical care.

India does not need a system built on suspicion. It needs one built on verifiable trust. A national medical-accountability framework, carefully designed and federally negotiated, could be the beginning of that transition.

Research acknowledgement: This Economic Statesman article is an independent editorial adaptation of the policy work jointly developed by Raja Mukherjee and Bidisha Mukherjee Sen. The body of the article reflects Mukherjee’s work on regulatory design, financing and constitutional structure, and Sen’s work on comparative models, patient rights, long-term outlook and empirical verification.