I wanted the title to be improving Health-care System in India. But I refrained from adding the word ‘System’. When the system does not exist, where is the question of improving it?
Look at the scenario in Health-care. Though Allopathic System is widely accepted and practiced, there are Ayurvedic & Unani Siddha & Homeopath doctors; – “Ayush” as they are called and they practice allopath freely without any fear of action against them. Even, among the allopath the role of each group is not defined, even conventionalty. There are M.B.B.S. doctors who are supposed to offer Primary Health-Care or assist the specialists in hospitals, and there are specialists. Then there are full-time paid doctors in state and corporate section, while others do private practice and earn their bread and butter and cheese if you like. But family physicians freely prescribe the costliest drugs and ask for costliest of the modern investigations, while specialists treat cough and cold, or abdominal pain due to indigestion or simple menstrual disorders. The full time paid consultants openly enter into the field of private practice – ‘outside the office-hours’ but office hours not being well defined, they practice inside the office hours too. A corrupt officer is more faithful to his bribe-giving master than to the state; similarly, these specialists remain more faithful to their private patients, ignoring their original patients in the govt. or corporate section. All this needs to be corrected, through stern administrative action.
The most important need of the society is primary health-care, but it remains the most neglected service. In fact, primary health-care is better in the public sector than in the private sector. Almost 80% of the M.B.B.S. doctors choose to do post-graduation and become specialist. So, only those who fail to get a seat for specialization become primary health-care providers – they join state service or enter into private practice. And what is the experience, they have gained? Nothing, A specialist is trained for 3 years, a family physician not even for 3 days? The massive shortage of P.H.C. providers leaves the field wide open for non-allopath and 80% of the rural and semi-urban and urban slum population is served by non-allopaths who freely practice allopathy – without any proper training. Thus nearly 100% of the primary health-care services are in the hands of “Quacks”.
What is the result? First inability to diagnose. Not having learnt clinical methods and the simple art of differential diagnosis, they are not confident about their own findings and need support. Secondly, their main source for knowledge is now M.R.’s (Medical Representatives) and agents promoting high-tech CT scan / MRI’s etc. Thus the practice of using costly drugs, costly investigations, starts at the primary level itself. Their only other alternative is to send the patient to specialists who, in turn, strongly advocate surgery or procedures and hospital admissions. Even small, simple diseases cause intense panic and immense expense which, in turn, adds significantly to the modern psycho-somatic illnesses like high-blood-pressure, Heart-disease and diabetes. The viscious cycle continues – but needs to the stopped – at least slowed down.
“Advances” in the medical field are making matters worse. The press and the visual media keep high-lighting ‘miracles of Modern Medical Science.” A 10 day child with heart disease successfully operated – a new cardiac procedure and the patient goes home in 3 days – cancer detected when no tumour was palpable and treated successfully without operation (Julia Roberts)
A crazy demand is created for bringing in “modern medicine”, and thus for high-tech equipments and costly medicines. We boast that the Indian medical system has become very advanced and can compete with the developed countries. The statement is quite true. It is as true as that Narayan Murthy’s Infosis and Azim Premji’s Wipro are among the top10 companies in the world or that Mukesh Ambani will be the richest man in the world by 2014. It does not disprove the fact that 38% of the Indians are below poverty-line or 60% of Mumbaikars are living in Zopadpattis. The people needing and / or offording the ‘ Miraculous’ treatments are one in a lakh. Most people need primary and secondary care at a reasonable cost, by competent health providers, which they are not getting.
So what can be done to improve health-care in the country?
1) G.P.’s must get proper training. In a medical college admitting 100 students, at least 10 to 15 posts must be available for a 2 years training in general practice. They will rotate through all departments like medicine, surgery, paediatrics etc. in the morning shift and work in dispensaries (run by medical college) in the afternoons, under the guidance of experienced physicians.
2) We must face the fact that Non-allopaths are doing allopathic practice and covering up the shortage or G.P.’s in rural and semi-urban areas. But, a report published today (Sunday Times 19th Sept 2010 P 15) confirms my belief that their services are substandard (almost disastrous). It should be made mandatory that they must get trained in allopathy by working in district – hospitals 18 months to 2 years and obtain a certificate. Otherwise, they should be considered as unqualified quacks and dealt with.
3) M.B.B.S. doctors or G.P.’s must be banned from using very costly medicines, including anti-biotics as also from advising very costly high-tech investigations and procedures. They must refer such cases to a specialist. The list of such costly drugs (as also drugs introduced in the last 2 years) and also very costly investigations can be easily prepared with the help of F.D.A. and duly notified. Action can be taken against hospitals and diagnostic centers, if they perform such tests and against pharmacies if they sell such drugs, prescribed by non-specialists.
This will greatly curb their abuse and markedly reduce health-care costs.
4) Middle class people suffer the most. Public hospitals are over crowded and private hospitals are unbearably costly. Medical college hospitals as also other public hospitals should work in 2nd shift (afternoon 4 pm to 10 pm) to serve ‘paying class’ patients with reasonable charges and 25% beds in the wards be reserved for them & full time, specialists should be offered incentive payment – practice within the premises. Private practice outside the premises should be totally banned for all full-time paid doctors.
5) The society must bring increasing pressure on Nursing Homes to improve their standard and display their charges clearly. Accreditation must become mandatory. This will lead to ‘Group Practice, & the Nursing homes will be able to sustain the expenses needed to maintain the standard of their staff and of their equipments.
There are many other things that need to be done and I have discussed these in my (recently published) book.
Management of the Sick Health-Care System
The price of the book is Rs. 100/- only (postage & cheque clearance changes Rs. 25 interested readers can contact me or the publisher with a cheque of Rs. 100/- & their address (Rs. 25/- extra outside Mumbai Area for postage & cheque clearance.)
Saturday, November 27, 2010
Struggles Ahead
And who are the buyers? 40% people below poverty line or poor have to depend on public sector and 30% upper class plus those who are well covered for their health needs prefer high-tech major hospitals. So, we sell our product mainly to the middle 30% people only. But the income of 50% people is shrinking while the number of specialists is increasing.
WHAT IS THE STRUGGLE AHEAD?
1) Increasing over crowding of specialists in cities has to be reduced.
2) The expenses are becoming unmanageable even to upper middle class, while the quality is declining. This results in shrinkage of the medical field.
3) There is no referral system, no functional demarcation-compartmentalization, if I may call it. The resulting insecurity and confusion explains the morbidly increasing heart attacks among young doctors.
4) We are totally neglecting primary health care and the public sector at our own peril. It is in our own interest that primary care improves and public sector expands. That will absorb more G.P.s and specialists, that will help expand the medical field, and that will reduce assaults on doctors, if public unrest is subdued.
5) The concept of free treatment for the poor is creating havoc not only for doctors but also for the very poor who are supposed to benefit by free treatment.
The most important challenge ahead is to offer improved services at reduced cost. A report by D.H.S. in 2005 indicates inadequacies. Inadequate space, untrained staff and gross under utilization of space, O.T.s, I.C.U.s equipments and personnel along with increasing regulations and rising public expectations are making most nursing homes non-viable. But what we refuse to even mention is the conflict of interest between the owner and the freelance consultants who have no stakes in the place and who can and do shift their allegiance elsewhere, easily, for personal gains. The only remedy is Group Practice. A small hospital of 50 beds by 10 or more specialists will bind them together. The hospital will afford to employ good staff and up-date equipments. Specialists will be interested in training the staff & R.M.Os, so infra-structure will improve. The flow of patients from all partners will guaranty full utilization of space, equipment & staff and the freelance consultants will lose their importance. Group practice is the answer for the future.
A linkage with major tertiary hospitals on well-defined terms can become mutually beneficial. The offer of fortis recently, is a step in the right direction. It has offered to take up difficult cases, treat and re-transfer the patients from Nursing Homes and help with Para-medical assistance. In turn, Nursing Homes ought to demand that Fortis reduces its economy and general ward beds and admit only major cases therein.
Simultaneously, the general specialists will have to assert their separate importance in treating the middle class. The biggest task is to fight the high-tech market and maintain our biggest asset namely stress on appropriate, cost-effective technology, early decisions, short-stay and thereby reduced costs. We need to denounce loudly the misuse or overuse of costly technology and costly therapies. It will be necessary to flood the press and medical journals with articles to show where and when patients can be treated successfully without them. I believe patients can be persuaded to accept such protocols. However, maintaining meticulous records is a must, for this. It is possible that insurance companies and foreign funds from U.K. & U.S.A. would strongly support such an approach.
The central government has passed the clinical establishment Bill-2010 and accreditation is on the card soon. The association along with F.E.Q.H of Mr. Gadgil is already on the job. Accrediation will be good for us, but it can spell disaster if we remain careless and ignore the aggressive high-tech high-cost market. The insistence of costly equipments with unproven merits can result in many nursing-homes being declared “inadequate” for major cases. Planum ventilation, HEPA; 6 channel monitor etc. are but a few examples. We will have to insist that well maintained records showing adequate results for the patients treated at the centre should be an equally important criterion of adequacy.
Compartmentalization and frontal attack on the concept of free Treatment are the other important struggles ahead. Strict compartmentalization between private and public sector is as much our need as that of the government.
Senior service doctors are quite well off-could be much better off than many of us. We must not only strongly advocate a total ban on private practice by all full-time doctors/specialists but also actively assist the authorities to implement the ban. Similarly, we must continuously attack the concept of Free Treatment. The first step would be to denounce Free Medical Camps as an unethical practice and an insult to our brethren in service, except in disasters. Also, working as an Honarary, without per case minimum payment or free health check-ups ought to be condemned outright.
Even in public sector professional services must be charged. Even for the common man, these work out to be only 5% to 12% of the charges in private. But evaders must be fully charged. That will widen the net, and expand the public sector and offer work-based incentive payment to service doctors. For example, government and municipal servants treated in public sector do not pay at all, if they are treated in their respective hospitals. If they were to be treated in approved hospitals, the govt. pays even if the patient does not. But here nobody pays. Collectively, the medical fraternity is the looser. Please realize, these families make upto 15% of the total population. Other evaders are
1) Accident victims-despite third party insurance. The public hospital fails to collect the money; the insurance company gains and both the hospital and the doctors lose.
2) Foreigners- sometimes they do get admitted to public hospital; yet they are treated free of charge. An Australian lady was charged Rs. 300/- for fracture radius, ulna treated with Elizarov method.
3) My study in Goa indicated that atleast 40% of the patients who attend public hospitals for emergencies belong to be affording class. Infact, they don’t mind paying but there is no provision to collect the charges.
4) Politicians, MLA’s, Corporators etc.-less said about them the better.
Despite poverty, 80% of the people are reported to utilize private services for their primary health needs. It is a pity, we have donated this field to AYUSH doctors. This is mainly because everyone who wants to specialize gets training and experience in the teaching hospitals. But there is not a single day’s training for someone who wishes to become a general practitioner. We must demand that there should be a two year diploma course in general practice in every medical college and atleast 20% of the M.B.B.S graduates be absorbed therein. Similarly there is need to define the roles of G.P.s and consultants. In my opinion, G.P.s should be prohibited from prescribing very costly antibiotics and other drugs or advise very costly investigations. Such cases must be referred to the specialists. F.D.A. can easily prepare a schedule of such drugs and investigations. Specialists, in turn, must not see any patient unless he is referred by or was atleast treated first by a general practitioner. Compartmentalization will make clinical practice more peaceful.
I believe we have a strong case to make C.P.A. non applicable to health services, because it is contract based on faith-and not just a contract. (Visit my website for the full high-court judgement) Suffice it to say we should anticipate problems and advise the policy makers or the authorities to correct their policies before rules are framed. If we do not do it-others do-mostly the envious elements or the market. We ought to talk both to masses as well as authorities a lot more.
On my part, I have written a book, in which I have analyzed the present scenario and given my blue-print for action. It is priced Rs.100/-.
I have also created a website and a forum within it. We need to discuss a lot on these issues, I request you to buy my book and discuss or add your comments on the website and forum.
MANAGEMENT OF THE
SICK HELTH-CARE SYSTEM
(What is Wrong - What Can the Done)
By
Dr. S.V.Nadkarni
Former Dean, L.T.Med.College, Sion,
Tel :- 9320044525
Available with
Vora Medical Publication
Near J.J.Hospital , Signal Trafic Byculla,
Tel- 23754161, Telfax-23704073
E-mail : voramedpub@yahoo.co.in
Website : www.healthandsociety.in
FORUM
Social Need for Cost Effective CLinical Practice
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