Here is a three-pronged plan to bring in much-needed efficiency in the public-healthcare system
There is a gross disparity in availability of health services and the health indices are very poor in slum and peripheral areas. The life expectancy at birth is around 64 years for India, 67 or 68 for Maharashtra but for a Mumbaikar it is a dismal 57 years. Tuberculosis (TB) is increasing and there is near 100% increase in deaths due to this. The incidence of malaria is also on the increase and in both diseases, resistant strains are causing a serious threat. Extremely resistant TB accounts for nearly 10% of the new cases. There are probably two and a half lakh patients of TB in the city.
The Infant Mortality Rate (IMR) in Mumbai is around 40 per 10,000, but it is deceptive. It was found that IMR was as high as 55 to 60 in some slum areas and inaccessible peripheral localities. Immunization is 90 to 95% successful. But 45.5% of children and 37.4% of women are anaemic—the percentage rises to 76% and 42%, respectively for the slum areas. More than 50% children under the age of three are underweight, 49% are stunted and 21% are wasted. Though HIV /AIDS was under control, the withdrawal of assistance by Bill & Melinda Gates Foundation is resulting in shortage or non-availability of drugs and there is a lurking fear that AIDS may re-appear.
The teaching hospitals are over-over crowded—out patient department (OPD) attendance being around 32 lakhs in a year. King Edward Memorial (KEM) Hospital claims to see 4,000 to 5,000 OPD cases every day; the figure for Lokmanya Tilak Municipal Medical College (Sion Hospital) being 2500 or so. Sion Hospital conducts 16,000 to 17,000 deliveries every year—a child is born every half an hour. How can one do justice to these patients?
The same is true of peripheral hospitals. But, though crowded, mostly they are under-utilised. There is dearth of full-time specialists and honorary specialists avoid taking responsibility due to “lack of modern facilities”.
Similarly, primary centres are more concerned about govt. programs like immunization, Maternal and Child Health (MCH) and directly observed treatment (DOT) for TB, but early good primary care is hardly administered there. The result is people are forced to attend private clinics and nursing homes despite financial difficulties. The growing middle class is squeezed to pay high price in private hospitals only because of the mad rush and confusion at public hospitals. The total outcome is very poor health service for the large majority of the people except those who can afford i.e. the organized section of the society.
And I have not even touched upon the burden of non-communicable, life style diseases. Cardiac diseases take the highest toll of even the young age population. About 10% of the adults are likely to be having diabetes. And the poorer sections of the society are equally vulnerable to these illnesses. The biggest killer is trauma. Assaults and accidents bring nearly 4000-5000 patients every month to Sion Hospital alone with mortality of 20% or more. Majority of emergencies of all sorts are managed in public hospitals in Mumbai. Private hospitals have hardly any emergency service worth the name except for cardiac emergencies. Thus, there is a great burden of modern diseases on the public hospitals, which they cannot handle efficiently.
Why are these inequities, insufficiencies? The main reason is that there is no system. Anybody can attend any clinic or hospital. Even tertiary care is given to the patient who goes there—not to the patients who need them. Any medical officer can refuse to treat a patient quoting one reason or the other—usually lack of facility and sometimes lack of assistants. If we look at the duties for health service personnel, it will be realized that administering primary and secondary care is but one of the multiple functions and is being given the least importance. Even if a case was seen at a primary centre and then referred to a hospital for further care, there is no preference given to such a patient. He/she is just one among the crowd and may not be seen at all by the relevant speciality.
On the other hand, most people seek direct consultations at the teaching hospitals, thereby increasing the work-load there unnecessarily. It is believed that at least 30% of the cases could have been treated at primary centres; while referred patients from private doctors also directly approach the specialists and are usually seen with priority.
Thus public dispensaries are reduced to zero significance, the medical officers become least interested, primary centres are least utilised. There is no scope for expanding primary care. Yet, primary care must expand.
I had suggested a three pronged plan –
a) There should be a primary care centre for every 20,000 population. It will run round the clock, served by about four doctors in each of the morning and evening shifts and helped by a physio-therapist, and a psychological counsellor. Only simple investigations (not costing more than Rs500) will be allowed and only simple medications (not costing more than Rs250 per daily dose) will be prescribed. The patients will have to be referred to the hospital if more is needed and in the hospital, these patients will be seen with priority at specified time of OPD. They will be treated free of charge (or nominal charge as of now). Any other patient attending directly will be seen at a different timing and will be charged fees (at least 25% of the market price). Such a duel system of charging will ensure that the poor are properly treated, and the marginally affording middle class will also be looked after but with reasonable charges that will bring revenue to the public sector for further expansion. About 20 to 25% beds will have to be reserved for the latter group in the hospital.
b) MBBS doctors, who do not secure a post-graduate seat, should be specially trained for the role of primary physician. The medical world is moving fast towards high technology. That affects the teaching pattern as well and the medical student is taught recent advances in medical technology. Thus, he becomes totally incompetent to practice medicine with more observation and less investigations and cheap but effective medicines or surgical procedures.
These graduates should be offered a two year course in general practice wherein they will work partly in primary centres and spend part of the time in hospitals rotating through various departments. At the primary centres, they are allowed to prescribe only simple investigations and cheap effective medications as stated earlier. In this two years’ time, they will develop immense confidence to treat the patients “under adverse circumstances”.
c) “Advanced technology” needs to be de-glamorized. It is extremely sad to see the social activists strongly supporting the demand for more and more super-specialists and new modern equipment “to improve the health service”. Modern facilities cannot reduce costs. They improve services only selectively. De-glamorizing is a difficult task so I leave that discussion here.
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(Dr Sadanand Nadkarni, is former Dean of Lokmanya Tilak Municipal Medical College (Sion Hospital), author of several books, a serious thinker of medical issues and hugely respected for a series of path-breaking ideas on improving the delivery of medical services to the aam aadmi. His book “Management of the Sick Healthcare System” is among the first to speak out about medical malpractice and other issues.)