The Lift Line

When every incentive in the room, financial, institutional and psychological, points towards the operation and none rewards waiting, over-treatment happens without anyone deciding to over-treat.

Why This Editorial Matters for Your Exam

This column, written for Hindustan Times by Chandrakant Lahariya, a practising physician, is a health-governance essay disguised as a medical one. Its subject is a common operation, but its argument is about incentive design, regulatory gaps and the ethics of a fee-for-service system, which is why it sits across GS2 (health policy, regulation, welfare schemes) and GS4 (professional ethics, conflict of interest, informed consent). It also supplies a set of numbers, on Caesareans, hysterectomies and PM-JAY enforcement, that recur in Prelims.

GS Paper 2: Issues relating to development and management of health; government policies and interventions; statutory and regulatory bodies. GS Paper 4: Ethics in private and public relationships; conflict of interest; probity in professional life.

Concept Meaning Why it is testable
Tracer procedure A common, well-defined intervention whose rate reveals system-wide behaviour, as cholecystectomy does for elective surgery The method matters more than the organ
Fee-for-service Payment model in which providers earn per test, admission and procedure, rewarding volume over appropriateness The structural driver the column identifies
Slow medicine Moving quickly when treatment clearly helps and deliberately when evidence supports observation; asks what happens if nothing is done The column’s proposed corrective

Background and Context

The tracer. Gallbladder removal is among the most commonly performed operations in India. A 2026 study in BMJ Public Health by Mohite and colleagues, published on 5 February 2026 from a community-based survey of 28,395 participants across high-risk and low-risk regions for gallbladder cancer, records 3,290,339 cholecystectomies in India in 2022, a figure the paper draws from a commercial procedure-count database rather than any official registry. The column rounds this to about 32 lakh and extrapolates that nearly 1.8 crore people may have had the operation over 2021 to 2025. India has no comprehensive national registry of surgeries.

The guideline. Most gallstones are found incidentally on an ultrasound ordered for something else, and most never cause symptoms. The European Association for the Study of the Liver’s 2016 clinical practice guideline states that asymptomatic gallstones are, in most cases, not an indication for cholecystectomy; symptoms develop at roughly 1 to 4 per cent a year, and about 20 per cent of carriers become symptomatic within 20 years. Surgery is beneficial for recurrent biliary pain, acute inflammation, bile-duct obstruction or pancreatitis. The column’s point is that actual Indian practice diverges: “multiple gallstones” on a report is followed by a nudge towards a laparoscopic procedure that is short, widely available and insured.

The wider pattern. The column lists Caesarean sections, hysterectomies among low-income and rural women, stenting in stable coronary disease, spinal fusion for uncomplicated back pain, knee replacement before conservative treatment, some appendectomies and tonsillectomies, and endoscopies or scans that never alter treatment. The data behind two of these is well established. NFHS-5 (2019-21) recorded a 21.5 per cent national Caesarean rate, 47.4 per cent in private facilities against 14.3 per cent in public ones, up from 40.9 per cent in the private sector at NFHS-4. On hysterectomy, NFHS-5 found 3.3 per cent of women aged 15 to 49 had undergone the operation, 70 per cent of them in private facilities.

The regulatory architecture. In Dr Narendra Gupta v Union of India (April 2023), the Supreme Court directed the Union Health Ministry to ensure all states and Union Territories adopted its 2022 guidelines on preventing unnecessary hysterectomies within three months, in a petition filed in 2013 over insurance-funded removals in Bihar, Chhattisgarh and Rajasthan under the Rashtriya Swasthya Bima Yojana. The Clinical Establishments (Registration and Regulation) Act, 2010 has been adopted by 12 states and all Union Territories except Delhi, per the Health Ministry’s portal. The National Medical Commission’s Registered Medical Practitioner (Professional Conduct) Regulations, 2023 were held in abeyance in August 2023, so the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 remain the operative code.

The Analysis

1. The column’s central move is to shift the unit of analysis from the doctor to the system. It says plainly that this “does not mean doctors or surgeons operate with bad intentions”, and that cholecystectomy is an excellent operation when indicated. The claim is that systems influence clinical thresholds: when financial, institutional and psychological incentives point towards intervention and none rewards restraint, unnecessary surgery becomes easier without anyone consciously deciding to over-treat. For GS4 this is the textbook distinction between individual culpability and structural conflict of interest, and the more useful of the two for a policy answer.

2. Insurance is an accelerant, not a brake. Reimbursement is easy to define for an operation and hard to define for observation, counselling and follow-up. That asymmetry shows in every private-versus-public gap in the data: Caesareans at 47.4 against 14.3 per cent, hysterectomies 70 per cent private. The Ayushman Bharat PM-JAY experience is instructive both ways. The scheme, launched on 23 September 2018 with Rs 5 lakh cover per family per year and extended to all citizens aged 70 and above from October 2024, has a National Anti-Fraud Unit whose automated triggers include “unnecessary procedures”. By August 2026 the Health Ministry reported 2,359 hospitals de-empanelled, 1,200 suspended, 29 FIRs and penalties of Rs 328.49 crore, with fraud detection saving Rs 676.14 crore as of end-July 2026. The machinery exists; it covers only scheme claims, and it polices fraud rather than appropriateness.

3. Price regulation removes a margin, not a decision. The National Pharmaceutical Pricing Authority’s order of 13 February 2017 capped drug-eluting coronary stents at Rs 29,600 and bare-metal stents at Rs 7,260, cutting prices by roughly 85 per cent. It is the clearest Indian example of the state attacking the profit in a procedure. The column’s list still includes stenting in stable coronary disease, which is the lesson: capping the device price does not change the threshold at which a cardiologist recommends the device.

4. The reversal of the care sequence is the deepest point. Health care once began with a symptom. Over two decades, the column argues, corporate hospitals and health packages have reversed it: healthy people are tested, a risk factor is treated as a disease, an abnormality becomes a label, and the label generates anxiety, visits, tests and sometimes procedures. The parallel it draws with ultra-processed food, “fast medicine” sold as convenience and mistaken for development, is rhetorical, but the underlying mechanism, supply creating its own demand, is standard health economics and worth naming in an answer.

5. Measurement is the precondition for everything else. The most damning line in the column is that India cannot say how many elective operations are performed, for what indications, or how many were necessary. Even the 32 lakh figure comes from a commercial database. The Choosing Wisely campaign, launched by the American Board of Internal Medicine Foundation in 2012 with nine specialty societies listing 45 low-value tests and treatments and now spanning more than 80 societies and over 600 recommendations, shows the alternative: professional bodies naming the interventions to avoid, backed by data on how often they happen. India has neither the lists nor the counts.

Data and Institutions Vault

Prelims-grade facts:

The tracer:

  • A 2026 BMJ Public Health study (Mohite et al., February 2026) records 3,290,339 cholecystectomies in India in 2022, about 32.9 lakh.
  • The study surveyed 28,395 participants aged 30 to 65 across high-risk and low-risk gallbladder cancer regions.
  • EASL 2016 guideline: asymptomatic gallstones are, in most cases, not an indication for cholecystectomy.
  • Asymptomatic gallstones become symptomatic at about 1 to 4 per cent a year; about 20 per cent within 20 years.
  • India has no comprehensive national registry of surgical procedures.

The wider pattern:

  • NFHS-5 (2019-21): Caesarean rate 21.5 per cent nationally; 47.4 per cent in private and 14.3 per cent in public facilities.
  • NFHS-4 to NFHS-5: private-sector Caesarean rate rose from 40.9 to 47.4 per cent.
  • NFHS-5: 3.3 per cent of women aged 15 to 49 had undergone hysterectomy; 70 per cent of these in private facilities.
  • Dr Narendra Gupta v Union of India (April 2023): states to adopt the Union’s 2022 anti-hysterectomy guidelines within three months.
  • NPPA capped coronary stent prices on 13 February 2017: Rs 29,600 drug-eluting, Rs 7,260 bare-metal.

The regulators and schemes:

  • NMC Registered Medical Practitioner (Professional Conduct) Regulations, 2023 held in abeyance from August 2023.
  • The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 remain the operative code.
  • Clinical Establishments (Registration and Regulation) Act, 2010: adopted by 12 states and all UTs except Delhi (MoHFW portal).
  • Indian Medical Association v V.P. Shantha (13 November 1995): paid medical services are “service” under the Consumer Protection Act.
  • PM-JAY launched 23 September 2018 at Ranchi; Rs 5 lakh cover per family per year; extended to all aged 70 and above in October 2024.
  • PM-JAY enforcement by August 2026: 2,359 hospitals de-empanelled, 1,200 suspended, 29 FIRs, penalties Rs 328.49 crore.
  • PM-JAY National Anti-Fraud Unit uses AI and machine-learning triggers, including for unnecessary procedures.
  • Choosing Wisely (ABIM Foundation, 2012) began with nine specialty societies and 45 low-value interventions.

⚠️ Watch the trap: The 32 lakh figure is an estimate the BMJ Public Health paper takes from a commercial procedure-count database; it is not government data, and no Indian registry produces such a count. Separately, the NMC’s 2023 professional-conduct regulations were notified and then suspended; a statement that they are “in force” is wrong as of September 2026.

The Debate

FOR (over-treatment is systemic and must be governed): The private-public gaps in Caesarean and hysterectomy rates cannot be explained by clinical need; guidelines say observe and practice says operate; insurance pays for the cut and not for the wait; and the state has already had to intervene through the Supreme Court and the NPPA. Without a registry and reimbursable restraint, the pattern will scale with the hospital sector.

AGAINST (undertreatment is the bigger failure): India’s dominant problem is people who never reach a surgeon at all. Gallstones in high-risk regions carry a gallbladder cancer association the same BMJ study documents. Consumer-court liability after IMA v V.P. Shantha makes waiting legally riskier than operating, and patients often demand the procedure. Curbing volume without protecting access would hurt the poor first.

Balanced verdict: The column is careful to say the issue is the threshold, not the operation, and that framing survives the counter-argument. Both under- and over-treatment are threshold failures with the same root cause: a system that cannot see what it is doing. A registry serves both sides; so does a primary-care tier able to refer the sick and reassure the well.

How to Think About This

When a health question mentions private-sector behaviour, resist the two lazy frames, “greedy doctors” and “market efficiency”, and ask instead what the payment rule rewards. Then check three regulators in order: the professional code (is it in force?), the establishment law (does it apply in this state?), and the payer (does the insurer audit appropriateness or only fraud?). In India today the answers are: suspended, partly, and only for fraud. That triad is your body paragraph.

Diagram-in-Words

Incidental finding scan, label, anxiety Fee-for-service, insurance pays for the cut, not the wait Threshold drifts down nothing rewards restraint 32 lakh operations, uncounted no registry, no indication data Count by indication national surgical registry Pay for restraint reimburse observation, audit Restore the gatekeeper primary care, second opinion
Over-treatment is what a system does when intervention is rewarded and restraint is invisible. The levers work by making restraint countable, payable and the default first contact.

Takeaway Box

Lift line: When every incentive in the room, financial, institutional and psychological, points towards the operation and none rewards waiting, over-treatment happens without anyone deciding to over-treat.

Prelims hooks: BMJ Public Health 2026 (Mohite et al.) records 3,290,339 cholecystectomies in India in 2022; EASL 2016 guideline says asymptomatic gallstones are usually not an indication; NFHS-5 Caesarean rate 21.5 per cent, 47.4 per cent private, 14.3 per cent public; NFHS-5 hysterectomy 3.3 per cent of women 15 to 49, 70 per cent private; Dr Narendra Gupta v Union of India, 5 April 2023; NPPA stent cap 13 February 2017, Rs 29,600 drug-eluting; NMC 2023 conduct regulations held in abeyance August 2023, 2002 IMC code operative; Clinical Establishments Act 2010 adopted by 12 states and all UTs except Delhi; IMA v V.P. Shantha 1995; PM-JAY launched 23 September 2018, Rs 5 lakh, 70-plus cover from 29 October 2024; 2,359 hospitals de-empanelled and 1,200 suspended by August 2026; Choosing Wisely, ABIM Foundation, 2012.

Mains keywords: supplier-induced demand, fee-for-service, clinical threshold, tracer procedure, low-value care, appropriateness audit, surgical registry, informed consent, conflict of interest, slow medicine.

Ethics and interview angle: A surgeon can bill for an operation that guidelines say is unnecessary, and the patient is asking for it. Is the ethical duty to the patient’s request, the patient’s interest, or the system’s integrity, and what does informed consent mean when the information is the doctor’s to frame?

PYQ linkage: Connects to past UPSC Mains questions on the regulation of private healthcare, the design of Ayushman Bharat PM-JAY, professional ethics and conflict of interest in GS4, and the balance between access and quality in health policy.

Sources: Hindustan Times, BMJ Public Health (Mohite et al., 2026), Supreme Court, Dr Narendra Gupta v Union of India, MoHFW Clinical Establishments portal

Source: Thirty-Two Lakh Gallbladders a Year Is a Health-System Signal, Not a Clinical One — Ujiyari.com | Free UPSC & State PCS Editorial Analysis