Date: 23 September 2010
Author: Dr. Sadanand Vinayak Nadkarni
About: MS. Gen Surgery, Former Dean of Sion Hospital (LTMGH), Ex-Medical Director – Bhatia Hospital, Advisor to Govt. of Goa- 2 years-Organized Trauma Care Service in Goa Medical College, Author – Management of the sick healthcare system
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.)