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1
Introduction
There is a well known story in mythology of Bali Raja and Batu Waman. Bali Raja was a noble king but Asur-a lower castruling part of the country which is now known as ‘Kerala’. He was a great, wise king and with his strength and intelligence not only conquered the earth round his kingdom but even invaded the kingdom of god. The king of gods, Lord Indra, was frightened that one day Bali Raja will conquer the entire kingdom of gods i.e. ‘swarga’. Therefore, he went to Lord Vishnu with an appeal to protect the gods from the might of Bali Raja. Lord Vishnu agreeing to protect the gods, took the form of a Batu Waman. i.e. small brahmin priest and went to Bali Raja. Bali Raja asked him what he wanted and Batu Waman requested him to give him merely three steps worth of land. Even though Bali Raja knew the trap, he readily agreed and Batu Waman grew into a huge giant figure and with his one step conquered the whole earth and swarga. The next step he kept on ‘narak’ and asked Bali Raja where to keep his third step. Bali Raja promptly asked him to step on his head and thus Batu waman pushed Bali Raja into the ‘narak’. But because he was a really benevolent king. he was allowed to revisit his Praja once a year. To this date the people of Kerala celebrate ‘Onam’ to welcome their king and show him that they are happy. I do not particularly like the philosophy underlying this story because Bali Raja was not an evil king. His only fault, if it can be called so, was that he was not from higher caste or from among gods. Today we cannot easily accept this philosophy of protecting the haves, even if the have nots are capable of rising above the ‘haves’. But I have been narrating this story for another reason to many of my students, to compare the three steps of Batu Waman to the three questions in clinical practice which encompass the entire field of medicine. The practicing doctor needs to answer only three questions.
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1) 2)
Management of the Sick Health-Care System
what is the diagnosis? what is the management? (includes investigations and treatment) and 3) what is the prognosis? Prognosis means the ability to predict what may happen in future if the disease is allowed to progress without treatment or even if it is treated as per his advice what are the consequences that the patient may face in future. In short, he should be able to clarify all the doubts and questions that a patient has in mind about the course of disease. This prediction is not based on conjecture or astrology but has to be based on sound knowledge about the course of disease and the effectiveness of the treatment. The entire medical practice thus depends on the ability of the doctor to answer these three simple questions – simple questions which assume gigantic proportions, like the gigantic steps of Batu Waman. In the same way when I look at any social problem, I like to know what is the diagnosis i.e. what exactly is the society suffering from? Therefore, what will be the steps required to improve the condition of the society and actually whether it will have any long lasting positive effects or will it prove to be a short term remedy and the sufferings will return in the same form or in some other form to trouble the society? Before we look at the problems in health-care system and how to solve them, it is necessary to know the present situation in this system. Therefore, let us first look at structure and functions of the medical system as is prevalent at present. I am not a historian nor a great scholar to go through the system of medical practice through the ages. Dr. Udwadia has written a beautiful book on how the medical practice has evolved in every part of the word from about 5000 years back reaching to the present–day–system of medical practice. I have only observed and given thought to the medical system as I saw it from the first day of my entry in the medical college in 1951 till today for the last 60 years and I propose to restrict myself to these years and propose to suggest some remedial measures which I think are necessary to improve the medical practice in the country, so that every one from the poorest to the richest can get the treatment he or she deserves. QQ
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The Present Scenario
Health–care-system is a very complex system. It is a system in which any person with any perceived illness seeks medical assistance to get rid of his illness, even if the perceived illness is false, in the sense that it may not be a true organic illness. The primary needs of the individual are food, clothing and shelter. Health and education come next in order. Food, clothing and shelter are considered most essential for the survival of an individual. Yet every need under these heads cannot be considered as essential. While rice, chapatti and dal maybe considered most essential, the same cannot be said about ‘pickles’, ‘papad’ and ‘pista’, ‘badam’ and such dry fruits could legitimately be considered as luxuries. Kashmiri chicken in five star hotel certainly cannot be called a necessity. Same is true about clothing. While shirt and pant or ‘saree’ can be considered as most essential, designer shirt or silk saree would come under items of luxuries. Most people do not realize that all the healthcare needs are not necessarily essential or vital for the survival of an individual. There are some essential services but there are other services which can be called desirable but not absolutely essential and yet other services accepted by the society could easily come under the term of luxuries. Most of the cosmetic surgeries belong to this last category. Even many of the so called preventive measures for long life such as use of a particular oil in food could also be considered as not essential, if not luxuries. Therefore, one has to realize that in health–care–system, there are essential services, there are desirable services and there are medical services which can be termed as luxuries. In actual clinical practice the health professional is not just a man of science. There is an admixture of art and science and commerce in the actual clinical practice. Also there are three tiers in the services provided under health-care system. Primary
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Management of the Sick Health-Care System
health care service which is offered in the dispensaries and primary health centres usually by a single doctor. These doctors treat the patients who come to the dispensary for their elementary diseases. The patients are not admitted in these primary health-care centres. These doctors also treat the people to prevent diseases. Preventive medicine has become a very important aspect of the management at the primary health level. Immunization, Vaccination, Counselling during the pregnancy, Advice on diet and Hygiene for the family are all essential parts of the primary health care of the society. Thus, primary health care is one of the most essential health care services needed by the society. Yet this is the most elementary aspect of the health care and needs very simple equipments, investigations and simple medicines. The doctors in these primary centres need to have patience, a lot of sympathy and a great ability to discern between simple and major illness. Thus, there is a lot of art and some science at this level. ‘Medicine is an art’ applies particularly to this primary health-care system. At the other end of the spectrum are extremely serious patients who are at a risk of losing their lives or at the risk of being crippled. The medical science has progressed a lot and many of such illnesses can be treated effectively now-a-days. Some patients can be cured and life of many others can be prolonged or made comfortable. But all this cannot be done without profound knowledge of the science of medicine and many high-tech equipments and sometimes use of newer drugs which could be quite costly. In short, the management of serious organic disease requires use of modern equipments and medicines and the profound scientific knowledge of the body– systems involved in the disease. Science plays a very major role and the art of medicine is often sacrificed by the specialists who offer these services. These medical services are offered only at tertiary medical centres. They cost a lot and can be managed only by expert consultants / specialists and super specialists. All the intermediate groups of diseases i.e. those which cannot be treated in dispensary or at home and yet are not so serious as mentioned above are all treated at the secondary level of the health-care-system. Nursing homes, private hospitals or Taluka and District level hospitals in the public sector offer these services. Standard equipments and standard drugs are mostly
The Present Scenario
5
sufficient and the medical professionals are specialists of basic level or general specialists. A good admixture of art and science is needed at these centres to satisfy the patients. Apart from these, there are plenty of ailments for which the patients seek the medical advice. Due to the modern pace in life there is an immense increase in the psycho-somatic disorders. The real ailment is 'tension or stress' but this emotional imbalance is manifested in bodily illness. Some of these psychosomatic illnesses turn into organic diseases but many of them remain non-organic in nature. Headache, backache, inability to work, flatulence (gases) and many such vague symptoms are instances of psycho-somatic diseases without any organic changes in the body. Diabetes, hyper tension, heart disease etc. are also phycho-somatic diseases but they cause organic changes in the body and, therefore, become organic diseases requiring major treatment. The first type i.e. non organic type of psycho-somatic illness needs more of psychological treatment while even in the second type, psychological treatment could help a lot. In addition there are many ‘imagined’ illnesses. All these except the organic diseases mentioned above could be called as ‘non essential’ health care needs. Lot of art is required in treating these diseases. But a lot of commerce also enters into this field and even the patients are willing to spend exorbitantly for getting rid of their ‘non-essential’ diseases. Medical professionals are not saints and they have entered the profession specifically to earn. They belong to a relatively more intelligent strata of society and are highly educated. Therefore, their expectation of earning is also legitimately high. This legitimate demand of the medical professionals cannot be termed as commercialization and the society must learn to accept it as due compensation for the service rendered. Therefore, commerce enters into the field of medicine at all levels. Commerce enters in the medical field from the primary level to the tertiary level and is most conspicuous in the management of the psychosomatic illnesses mentioned above. For the clinical practitioners, at any level, a fine balance has to be achieved between art, science and commerce so that the health professionals are not denied their legitimate dues while at the same time, they are not allowed to commercially exploit the patients who are too anxious to get well. There is no doubt,
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Management of the Sick Health-Care System
illegitimate demands are raised by some doctors and such demands must be termed as ‘over commercialization’. This overcommercialization needs to be curbed. There are many systems of medicine practiced simultaneously in every part of our country. Ayurvedic system of medicine is the most ancient system in the country and is respected by the masses even today. Hence, it is recognized by state as well as central government and plenty of Ayurvedic medical colleges churn out a lot of Ayurvedic practitioners. Even in this system there are general practioners and specialists. Same is true about Unani system. Started nearly 1500 years ago in the middle east, it is more popular among Muslims and is recognized by the governments. Homeopathy came in much later. First founded in Germany, Homeopathy became rapidly popular all over the world, as also in India and is now recognized as a system of medicine like the other two faculties. Each of them is governed by their own medical council and each separately register their practitioners. Knowing the importance of Allopathy as a more scientific system or, at any rate, the presently most practiced system, all the above faculties have incorporated some elements of allopathy in their training course. Even if it happens to be very inadequate, it offers their practitioners a legal right to practice allopathy simultaneously though they are not registered nor governed by allopathy State or Indian Medical Council. Indian Medical Council was established at the centre in order to establish a standard of education in the allopathic system. The council is expected not only to prescribe and maintain the standard of medical education but is also expected to oversee and regulate the functioning of the practitioners of allopathy in India. In order to do so, the council had to first prescribe the standard of education and prepare the curriculum for various courses for graduation and post-graduation. The council then had to define the exact role, the health-care professionals are expected to play. Every practitioner, therefore, must register under the Indain Medical Council. But the council has the most insufficient infrastructure amounting to almost nil to actually supervise the conduct of their health-care-workers. Broadly the council depends on complaints by their associates or by the public at large individually or through government channels and then decides whether the person
The Present Scenario
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actually is maintaining the standard or not. Even if the council finds the behavior of the doctor sub-standard, it has very limited powers. It can either warn the doctor or de-register him. Once a person is de-registered, he or she cannot practice in the allopathic system of medicine. But the legal system of the country is so peculiar that once de-registered that person no longer is a qualified doctor coming under the ambit of the medical council. Therefore, for any malpractice, if he continues to do so, the council cannot deal with him as he is no longer a member of its body! Only the department of law and the police under them can deal with such culprits and take necessary action against them. The council is helpless. With meager knowledge of the regulations under which the doctor is supposed to practice and with such over-burden of duties to maintain the law and order in the society, it is no wonder that the police also take no action and various doctors who are de-registered by the council or spurious (unqualified) doctors are practicing in the country in abundance. The results for the society are obviously disastrous. Thus, it will be realized that the structure of the health-care system in India is haphazard. There is no clear-cut pattern in the health care system in the country. Different categories of doctors practicing their own systems of medicines-allopathy, homeopathy, ayurvedic, unani and what not-all practice in their own way without the control of the government and without any co-ordination among them. The government has formed bodies to control the practice of the doctors in each of their special systems separately, Thus, just as the Medical Council of India was formed to regulate and control the behavior and standard of allopathic doctors. similar bodies were formed for homeopathy, ayurvedic, unani etc., But there is no central body to have an overall control over the health-care professionals in the whole country. Each of there bodies supposedly try to maintain the standard in their own system of medicine. The role of respective councils of other systems of medicine was to regulate the professional conduct of the health-care doctors in their respective systems. But what is true of Indian Medical Council, is substantially true for every other council like Ayurvedic, Homeopathic, Unani ect. The role of the council is thus limited to prescribing the curriculum for the courses of their respective systems and to prescribing rules and regulations for the college
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Management of the Sick Health-Care System
management to see that good standard is maintained in the medical education. Here again the maximum the council can do is to de-recognize a particular college or university. Political and money pressure. coupled with incompetence of the inspecting teams of the council, sufficiently dilute even this power of derecognition and sub-standard colleges continue to produce substandard doctors. But health is a concurrent subject and the state government has a bigger role to play in the health-care than the central government. Therefore, the state governments have formed their own Medical Councils like say Maharashtra Medical Council for the state of Maharashtra. Strangely these state councils are not subordinate to the Indian Medical Council but are completely independent bodies formed and regulated by the state governments. Therefore, even if the medical course or medical college is not recognized by Indian Medical Council because it is not maintaining the standard expected by it, the state medical council has its own right to recognize such a different course or such a college and the graduates coming out from such institutions are eligible to practice in that particular state. They can not practice outside their own state, if not recognized by Indian Medical Council nor can they go abroad because other countries recognise only Indian Medical Council. In a way it is not an altogether undesirable situation for a vast country like India with a population of more than hundred crores. It is not justifiable to have only one standard of health care system for the whole country as social and economic conditions in various parts of the country or in different states can be extremely dfferent. A particular standard which can be maintained by very wealthy states may be an impossibility for another state which is comparatively very poor. It may be noted that western Europe with a population of about thirty five crores is divided into several independent sovereign countries and each country has its own standard of medical education and its own rules. Similarly in U.S.A. with the population of about thirty five crores there are 48 states and under their constitution each state not only has its own medical council to define the system in its own state but such a medical council is also entitled not to recognize the qualifications of the medical professionals from other states. Such ‘outsiders’ are made to appear for their own
The Present Scenario
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test before they can practice in that particular state. Therefore, it is absurd to think of one universal system for a country of hundred crores of people whose social and economic conditions differ as widely as between different countries in Europe or different states in U.S.A.. I, therefore, said that the independence of such medical councils of each state is not so undesirable. However, it may be noted that there is no regulatory or coordinating mechanism between Indian Medical Council and State Medical Councils, which is the matter for worry. Even besides the medical professionals working in these recognized systems of medicines, there are any number of faculties of medicines which are practiced by the so called doctors of these unrecognized faculties. They are bone healers, acupuncturists, electro Magnetic Medical system and what not. Unfortunately the political leadership in various regions encourages these systems and the present government virtually takes no action against these 'doctors'. The people at large do not clearly know whether they are recognized professionals or not. Even within the allopathic system the role of each professional ought to be properly defined and regulated. There are M.B.B.S. doctors who are supposed to be ‘basic’ doctors. They were the backbone of the society in the form of general physicians or family physicians. They treated the patients primarily irrespective of which part of the body was affected and irrespective of the age/sex of the patients and refered the patients to a particular specialist only when the disease appeared to be more serious. Now there are not only specialists (M.D. & M.S.) but there is a plethora of super specialists. (D.M. & M.Ch.) Specialist is defined as a person who knows more and more about less and less. The recent advances in medical technology have undoubtedly contributed to the development of the super specialists. For example, in an organ as small as an ‘eye’ where an ophthalmologist is a specialist of eye disease, there are now super specialists who look at ‘retina and posterior segment’ of the eye, super specialists to look at the ‘cornea’ only and super specialists who deal with the tumors of the eye only. While the role of super specialist is becoming clearer and clearer, the respective roles of a basic doctor and a specialist are becoming hazier and hazier. Even the distinction between the various
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Management of the Sick Health-Care System
systems of medicine is getting obliterated. Eighty percent of the general practitioners now hold non-allopathic degrees like Ayurvedic or Homeopathic or Unani. But all of them, without hesitation, prescribe allopathic medicines and treat their patients allopathically. Similarly many allopathic pharmaceutical companies are manufacturing Ayurvedic drugs and their representatives are freely canvassing these drugs to the allopathic doctors. In short, their practice goes far beyond what was officially taught in their respective courses. In a way, therefore, 80 percent of the patients are being treated by 80 percent of non-qualified doctors. I emphasize that even qualified doctors become ‘non-qualified’ when they transgress the limits of the systems they were taught. QQ
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Health Care Delivery System
The Health Care Delivery System is equally complex. The main method of health care delivery was through private medical practice. The patient directly went to the doctor. He, in turn, established his own clinic or nursing home or hospital. The relationship between the doctor and the patient was direct. The fees charged by the doctor, therefore, were also totally unregulated and depended on the whims and fancies of the practising doctors or on general market value. Slowly institutional system of health care got established. The government both central and state as well as some public sector organizations like railways started establishing their own health care services. This was the beginning of secondary health-care service. Most of these health care services in public sectors treated the patients free of charge and the doctors working there were paid some fixed remuneration as per the quality of service they gave. Similarly hospitals or health-care systems were established also by many big corporates like Tata Streel, They also employed the medical practitioners at a fixed salary and treated the patients from their own institution free of charge. The growth of private sector in many other fields made entrepreneurs realize that health-care is also an industry and this resulted in establishment of many corporate hospitals and many trust hospitals. These are run more professionally. The hospitals provide more and more facilities in the form of modern equipments and employ the doctors to serve the patients coming to the hospital. However, the treatment is not free and the patients have to pay for every service they get. In order to strike a balance between the capacity of the patient to pay and actual charges, the patients in these hospitals are classified as per their financial status and the charges are graded accordingly. The doctors working in such hospitals are not on fixed salary but get their charges as per the
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Management of the Sick Health-Care System
patient they treat and the services they render, in the class the patient has chosen. More the patients, more the income. More the patients in upper class, more the income. Though some of these new hospitals are now restristing their doctors from practicing outside in the private fields, as yet majority of these doctors are free to practice privately in addition to their attachment at these hospitals. Religious institutions are playing a substantial role in the health-care delivery system. Christian missions have established many secondary hospitals, but strangely they have contributed so little to primary health care. Nowadays plenty of Hindu and other religious bodies have entered in great numbers to establish similar secondary hospitals. The treatment offered here is free or highly subsidized and there is an admixture of paid doctors on fixed salaries and honorary doctors who get paid, like in private and private charitable hospitals, but usually on a lower scale. As mentioned, very few of them have dared to enter the field of primary health-care. When a patient suffers a high-risk-illness and therefore goes to a tertiary medical centre, he is treated by super-specialists but, strangely, he meets his doctor less and less. Higher the risk of his illness, more he loses contact with his doctor. He is seen by junior assistants appointed in the hospital. In fact, there could he another strata of junior specialists who mainly look after him. Thus, he is able to meet his superspecialist only briefly and if would not be surferising, if the patient meets his super-specialist at the time of the procedure only. This happens too frequently in public sector but it is also the experience of those who enter major tertiary care charitable or private hospitals. The only exception is small, secondary care private hospitals and nursing homes where the patients most often meet and deal directly with the specialists. That is why these hospitals are most popular among the middle-class population. Thus, though the private sector has entered the field of health-care in a big way now a days, the entry is restricted to secondary health-care and even more significantly in the tertiary health care. General physicians in private practice form the bulk of the private sector participation in primary health窶田are, but with the majority of qualified allopathic doctors chosing to go for specialization this private sector has fallen into the hands of non-
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allopathic doctors, who nevertheless practise allopathy. The primary health-care-remains neglected, even in the private sector. A vast majority of rurual and semi-urban population depends on public sector for their primary health-care needs. It least 60% of the total population of the country could be served by the state i.e. central & state governments, municipalities, jilhaparishads and gram-panchayats. For them, the state has created a network of primary health-centres with their subsidiaries while municipalities have created their dispensaries in the cities. The treatment in all these centres is supposedly free; but inefficient and corrupt administration makes most of the patients to spend huge amount for their treatment. In additions the facilities provided are very meagre and the pay-structure of the employed health-care professionals is also very poor. Unattractive pay and unattractive service conditions can not attract good talents, and those who serve in these places constantly look for better opportunities and leave the job within a few years or become corrupt or are of hopelessly low calibre. Thus, the vast majority of the population in the country have a poor primary health-care service available to them both in public and private sector. For further care, the state has also established secondary care hospitals at Taluka and District places, while Medical College hospitals are probably the only centres offering tertiary care in the public sector, barring a few exceptions. Another system was introduced in the form of Employees State Insurance Scheme, only for industrial labour with low income. The industrial labour contributed 1/3, the owners contributed 1/3 and the government contributed 1/3, to make the total budget. Services were established with the object of giving total health care to labourers and doctors were employed to work as general practioners or in the hospitals specially created under E.S.I. Scheme. For primary health care, the doctors were employed as general practitioners and the patients were entitled to choose their doctor and submit their health cards to the doctor of their choice. The doctors were thus entitled to a payment proportionate to the number of cards each of them held. If he was popular and many labourers chose him, naturally he would get more payment and vice versa. These doctors were not supposed to practice in the private field. However, the renumeration given
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Management of the Sick Health-Care System
was so low and the administrative set up was also so poor that most of these doctors freely practiced as private practitioners and most of the labourers went to the doctor not so much for the treatment but for getting certificate of illness to take maximum advantage of the personal benefits offered by the company. Despite huge amount of money lying with the scheme, the employees state Insurance has become a great flop. I have tried to point out that the health-care delivery system is also not well defined and different systems are working at the same time in the same city or district. The rules governing the role of each doctor in each of the systems is extremely ill defined or even if the role is defined by the rules, these rules are not followed at all and any doctor from any system or any specialty freely wanders into the territory of others in order to make money and yet goes scot free. No action is possible as company / government rules are so flimsy, and medical councils have framed no rules in this matter. QQ
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Health Care System is An Industry
The medical practice or the health–care delivery system is also an industry and rules of industry must apply to the healthcare system. This is not realized by most of the people. Neither the patient nor the political and social leadership of the citizens is willing to accept this fact. If at all, they accept this fact most reluctantly. ‘Every life is precious and cannot be counted in terms of rupees', is the common statement which is still accepted by almost all sections of the society. But it is not true. This is borne out by the compensations given by courts or compensation boards in various cases of loss of limb or life. Every life is valued differently and that is a fact. As in every industry, money must be spent to create the infrastructure and employ professionals to run the services and the services must bring returns enough to continue the services and, if possible, to expand the services. The service renedered in this case is health service i.e. the service that makes a person disease free. Can this be calculated in terms of money? The answer is both ‘Yes’ and ‘No’ Even though the exact quantum in terms of money gained by a patient when he is cured of his disease cannot be measured easily, the overall effect on the society and its productivity can be measured. A person made healthy certainly can work better and this results in increase in his productvity and increase in the general domestic product – G.D.P. of the country. That addition to the society, quantitively or qualitatively, defines the total returns to the society by the actual treatment given under the health–care delivery system. Even in the case of children the health and education produce better citizens and therefore, better
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Management of the Sick Health-Care System
productivity when they become adults. This is the generalization of the value of health delivery system. It does not help to define the exact quantum of charges to be levied to each patient for the different sevices he or she gets, but surely can define the total budget to be spent on health. Also this itself proves the fact that no treatment can be free. It has to be paid for by somebody. In the so called 'free' hospitals run by government or by public organizations or by large private corporate industries, the payment is done not by the patient himself but is paid by the organization which creates the health care facility. In the case of public or private sector industries, the workers under them are contributing a great deal to the wealth created in their respective industries and the management merely takes out a chunk of that money to provide them good health care services. Therefore, indirectly, it is the worker who pays for his health care service. In the case of government and muncipal hospitals, the patients get free treatment but as I said earlier no treatment can be free. Therefore, the money required for creating such a health service is collected from the whole mass of people living in that particular state or city in the form of some taxation or the other. It is the tax money paid by entire population, a part of which goes for the health care system created by government / municipality but nobody knows the inter-relationship between the money collected and money spent. Thus the money spent on health becomes un– correlatable to the money collected through taxes. For example, a major bulk taxation Mumbai Municipal Corporation collects comes from octroi which is the tax collected for every kind of goods brought into city. This has no correlation to the health care system and yet a lot of that money is spent on the health care service by Mumbai Muncipal Corporation. It is not realized that a huge structure has been established for collecting the money, accounting for it and then planning the redistribution of that money to the various services / schemes of the municipality / government. This infrastructure itself eats away nearly 60 per cent of the money collected. Part of the remaining 40 per cent is allotted to the health care system but it is a well known fact that, out of this, a large percentage is lost in corruption. The percentage of such a loss could be anything from 20 per cent to 50 per cent. Thus, out of the total money, the population has contributed in the form of taxation, hardly 20 percent reaches
Health Care System is An Industry
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them in the form of the health care service. None other than our former prime minister Shir Rajiv Gandhi stated in one of his speeches that the citizen gets only 11 paise worth service out of a rupee that he pays in tax. However the poor common man thinks that these taxes are paid by the rich and he gets free treatment and, therefore, there is nothing wrong about it. This is the most fallacious concept the common man has. In fact, 80 percent of the taxation comes from indirect taxation and, therefore, ultimately he alone pays all these taxes. When he buys vegetables or rice or cereal, it is he who pays the tax on the truck and lorry that brings these articles. It is he who pays the taxes that are levied on the merchant for his grain shop. The ultimate price of the vegetable could have risen three times or four times from what its price was in the village. It is surprising that social and political leaders are not bringing this to light to all the people at large. I can understand politicians-they have too many stakes in the present system. But I am deeply surprised that none of the N.G.O. and social workers / journalists sincerely interested in the welfare of the poor hardworking common man are not highlighting this aspect and not warning them against ‘Free Government Schemes.’ The politicians of the country continue to tax more and more, after promising the common citizen more and more ‘free’ services. There are other disadvantages to which I will allude to later. For the time being what I am emphasizing is that the health care system, in fact, is an industry and money must come in from some source to be spent on the infrastructure, the professionals and the consumables to be used in the health care system. The way it is coming, in the present ‘free health care in government hospitals’ is the costliest way. The people are paying through their noses, in return for very poor service. In the private sector the patient directly pays for the service he gets. As mentioned earlier the charges are not regulated but depend on the whims and fancies of the doctors and the hospitals. The charges vary depending on the economic status of the patient and the reputation of the health professional or hospital. So far, the hospitals and the doctors have not made any worthwhile efforts to regulate the charges. The principles adopted by most of the hospitals is what was termed in U.S.A. as 'cost plus'-which means whatever the costs incurred by the hospital or the doctor, additional profits are added as per their own
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Management of the Sick Health-Care System
calculation and this amount is what the patient has to pay. There were no efforts to find out whether the cost can be reduced by better administrative system or by the use of more appropriate equipments at lesser cost. Thus, here too, the patients have to pay through the nose for the services that they get. With more and more equipments used in the modern days and with high salaries to the professionals working on these equipments, the price of health care is mounting steeply and is now going nearly out of hands of the common man or even a upper middle class family. Secondly it is extremely difficult for a common man to suddenly collect and pay the sum in thousands and lakhs and he has to either sell family jewellery or some property`or take a huge loan to fulfil the health-care obligations. In a recent study about two years back in U.P. a social Institute of Science observed that if any patient got admitted and treated for any serious illness in any hospital private or public in U.P., 40% of them went below the poverty line due to the expenses incurred during the full course of his treatment. Though no such study has appeared in the state of Maharashtra, some authors believed that the figure for Maharashtra could not be less that 35% However, the system of unregulated private practice continues and in fact covers nearly 60% of the total urban health care system in the state. A few are lucky that their employers take care of their health expenses as mentioned earlier. About 25% of the total population is thus protected against the financial burden of the health care in these organized sectors. The bulk of them are government employees or corporate industrial workers. A new system is coming up of late i.e. the scheme of health insurance. Just like a person can insure for life, he can now insure for his health and the health of his family. Not every person falls ill. Presuming that one out of 250 falls ill in a given year and, therefore, needs to pay for the health service, it can be clearly calculated that he will have to pay hardly 1/250 of the total bill, if all the 250 persons have insured for their health. If the cost and profit of the company which provides such service was also taken into account, it could be 1 / 150 or 1 / 200 of the total cost. Therefore, on this presumption, if the total bill of a patient who requires the hospital service is Rs. 1,00,000/- (One lac), he will be paying only about Rs. 650/- or Rs. 500/- annually for such service. (Rs. 1,00,000/- divided by 150 or 200)]. Undoubtedly this
Health Care System is An Industry
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is an excellent scheme and the government and healthcare Institutions must make maximum efforts to encourage maximum number of people to adopt the Health Insurance Scheme. In Europe and in U.S.A. there is hardly a citizen who is not covered by health insurance scheme. However, in actual practice. the health insurance scheme is not as rosy as is pictured above. This aspect of insured health-care service will be dealt with in detail later. But basically it is a good concept to pay collectively for the health service and reap the benefit individually as and when required. Hence, the same thing was sought to be achieved through taxes (as health cess) in a completely nationalized health care system. This has been tried in England and Sweden. Even though the common man is guaranteed free treatment with the help of minimum health cess in England, the system is extremely faulty. It has become a white elephant for the government and the public at large are not very happy. Appointment for an operation could be after a year or more–if you live. Obviously coming to the other extreme of nationalized health service through taxation money does not seem to help. The nationalized health service scheme seems to be working very well in a few very advanced socialistic states like sweden. In sweden the health–care-system covers from ‘womb to Tomb’. In Sweden, a woman gets a special allowance from the government as soon as she becomes pregnant, and when a person dies, he / she (i.e. the relatives) gets special allowance for the final disposal of the body. Every thing is taken care of. But it must br remembered that swedish citizens pay extremely heavy taxes amounting to more than 40% of their income (I am told). It is relatively a small state and it is almost totally non-corrupt. Both the community at large and the government machinery have an extremely high degree of honesty and integrity. That is why, the scheme of nationalized health services seems to be working satisfactorily All these patterns of expenditures and incomes have been discussed merely to show that while considering the most suitable health care systems for our country, we will have to realize that money must come in for being spent on health care. Money in = Money out Modern Health Care System The advanced system of health–care has created two fold effects. Today the medical professional knows much more about
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Management of the Sick Health-Care System
exact physiology of the body. He has an extremely minute knowledge of the chemical processes that occur in each and every organ during its functioning. With equipments like C.T. scan, Ultra Sound or M.R.I. he can penetrate into the deepest part of the body and see the structural changes, if any, that could have distorted any organ in the body. There are umpteen number of tests like P.C.R. or enezyme studies or tumour markers by which minutest amount of pathological substance can be detected and thereby early diagnosis can be made - sometimes even before any symptoms have troubled the patient. Thus, there is no doubt that the disease can be diagnosed at an extremely early stage and can be treated much more accurately, thus giving patients maximum cure rate. However, most of these investigations need high technology and sophisticated equipments and the cost of investigations and the treatment becomes formidably high. These equipments cannot be operated by an ordinary worker and therefore, the workers need to be properly educated and need further specific training to operate these equipments. Naturally all of them have to be paid much higher salary than the average worker. This being an expanding field of science, the need of such skilled workers is equally high in the developed countries and therefore many of these trained workers easily migrate to the developed countries, leaving behind a great shortfall of such workers in our own conuntry. That in turn makes it imperative for the hospital to give them increased pay scale. Costly equipments, costly workers and specially trained doctors (super specialists); naturally the treatment cannot be but expensive. It is a common practice of our political leaders to install such machines in some big hospitals and profess that the hospital must find ways of making these treatments cheaper and affording for the common man and/or that such treatments should become available in the villages. The fallacy is apparent. This treatment can never be less expensive and can never reach the villages. Luckily such high cost treatment is not needed for many diseases and it has been proved by statistics that the treatment by such sophisticated equipments has not contributed much to the increase in average span of life of a common man. Much more has been achieved by hygiene, better living standard and primary health care. These sophisticated equipments have undoubtedly been selectively
Health Care System is An Industry
21
useful to some individuals who suffer from previously incurable diseases and to whom the modern management has given a much longer span of active life. In short, modern high-tech health care system is definitely very useful for a select few individuals who were previously incurable, but has very little impact on the society as a whole whose longivity has been only marginally increased by its modern techniques. QQ
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Management of the Sick Health-Care System
5
The need for Qualified Doctors
When we plan to improve our present health-care-system, we will have to look at each and every aspect of this system and think of improvement in every one of them. The discussion about how to improve the system becomes all the more important because our political leadership is far too ignorant about the administrative or organizational aspects involved in improving the present system. They work as if they are feudal lords and offer special benefits to those who approach them with their grievance-right or wrong. They are, in general, incapable of looking at the problems of the people as system failure. Yet I would like to remain optimist and try to suggest long term remedies in the coming chapters that may go a long way to improve the health–care-system in the country. So let us look at each fact of the health–care system in details. First let us give a thought to medical education. At the time of independence we had about 105 medical colleges churning out about 10,000 doctors every year. The need for the Health Care Professionals and the required organizational set up for the country was discussed in great detail by Bhore committee and Mudliar Committee. In fact, the pattern of primary health centre is based on the recommendations of the above committees. The committees recommended that there should be at least one doctor per 3000 population. This proportion was too low and it is now believed that the country needs one doctor per 1000 population. In bigger cities and wherever the specialization has advanced very much, the proportion of the doctors should be even higher-may be about 1 per 500 population But considering the need of one doctor per 1000 population India with population of 100 crores will need 10 lacs doctors. A doctor is supposed to practise for 35 to 40 years from the age of 25 to 60/65 which means 25000 to 30,000 doctors must come out every year from the various medical colleges. As there was such a great need, the number of medical colleges
The need for Qualified Doctors
23
increased very rapidly. Whereas earlier all medical colleges were in the public sector – owned by government or municipality-now the private medical colleges owned by private trust sprang up in much greater numbers basically because the government could not afford to create so many new colleges and the private enterprises found this a very lucrative business. There was nothing wrong in medical education being taken up by private medical colleges, except for the fact that the private entrepreneurs thought of medical colleges only as a profitable business. The main aim of maintaining and improving the medical standards was completely sidelined. Thus the standard of medical education has suffered a lot. The ambition of the parents to send their children to the medical profession was so great that the fees for the medical colleges rose exorbitantly and the government had to step in to control the fees to some extent. Today there are 273 medical colleges turning out about 31,000 graduates in allopathy alone. The number of medical colleges of Homeopathy, Ayurvedic and Unani Medical colleges is 167 Homeopathy, 169 Ayurvedic and 9 Unani respectively. It goes to prove that there is no real shortage of doctors in the country. There is a gross maldistribution. QQ
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Management of the Sick Health-Care System
6
Selection Pattern for Admission to Medical College
The pattern of selection for entry into medical colleges was supposed to be only by merits. But this principle of admission only on merit was diluted by the political decision of giving reservation for the scheduled cast and scheduled tribe to the extent of 16%. Initially the constitution accepted this special reservation only for 20 years to be replaced later by criterion of pure merits. However, the politicians thought it fit to extend this reservation perpetually. Not only that, on the recommendation of Mandal Commission, another 33% of other backward class were given reservation based on their castes. Constitution prohibited the ratio of reservation not to extend beyond 49%. However, there was a lacuna. The percentage of reservation could be increased even beyond 50% by any state provided such an extended reservation could be approved constitutionally by Central Government. Thus, the states like Tamilnadu increased the percentage of reservation well beyond 49%. The admissions in the respective reserved category however, must be only on merits. However, a minimum of 45% marks had to be obtained in 12th standard examination in physics, chemistry, & biology (P.C.B.) to be eligible for admission. It was reduced further by another 5% for reserved categories. Naturally, the students getting admission under reserved categories scored much lower than in open merit category students, and in the category of scheduled tribes & nomadic tribes students are admitted even today with marks as low as 40%. Immediately after independence, the number of students getting first class i.e. 60% marks was very small and the last student getting admission on merits would have secured as less as 52% marks. The minimum
Selection Pattern for Admission to Medical College
25
qualifying marks of 45% was justified in those days. Pattern of examination for S.S.C. and H.S.C. changed and students started scoring very high marks. Later, only the marks obtained in P.C.B. only (Physics, Chemistry, Biology) were considered and low scoring subjects like languages and maths were excluded while considering merits, and the percentage sored --- higher. Patterns of examination for S.S.C. and H.S.C. changed further and objective assessment was introduced, so that the students nowadays secure more than 80% in aggregate & above 90% marks in P.C.B. and yet some of them are unable to get admission on merits in the public sector medical colleges. Even then minimum qualifying marks remained at 45% in H.S.C. (i.e. 12 th standard)-that too in P.C.B. only-not the grand total. Full advantage was taken of this lacuna by the private medical colleges. They kept some reservation quota for foreign students, local students, trust students etc. and charged exorbitant additional amount as donation from students seeking admission under such categories, as long as they secured 45% or more marks in P.C.B. at 12th standard. Fortunately the Court’s intervention stopped all such so-called 'quotas' and the court directed the private colleges to admit all students purely on merits. Donations / Capitation fees were prohibited. However, now a new problem propped up. The marks obtained in the very same state as in maharashtra in different zones like Marathwada, Vidarbha, Pune and Mumbai differed a great deal, and comparison became difficult. So this difficulty was overcome by restricting the admission of the students of a particular zone to the medical colleges in the same zone. But meritorious students from other regions who wanted to enter into the medical colleges of Pune and Mumbai protested and the Courts had to accept their grievances. Court ordered that atleast 25% of the students from other regions must be accepted in the medical colleges anywhere within the state. In addition similar applications were made by the students from other states and again the Supreme Court ordered that an additional minimum of 15 % admission must be reserved on an all India competitive basis. Looking into all these aspects of comparison of merit between different zones in the same state and between students from all states of country, the Common Entrance Test (CET) had to be started in all states. CET was also justifiable
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Management of the Sick Health-Care System
because of another reason. The question papers for H.S.C. i.e. 12th standard were set up taking into consideration the average intelligence and capacity of all the students taken together. Passing percentage of H.S.C. is usually 70% or more and kept at that level all the while. Hence, the bright students get 90 to 95 percentage marks without much difficulty with this set of simple questions. Therefore, it was necessary to test the differential merit of these bright students for their selection in professional colleges and a relatively difficult question paper was in order. In addition there are several boards like I.C.S.E., C.B.S.E. which conduct their own 12th standard examination. Thus, taking into consideration all these aspects, CET was perfectly justified. Now the students passing H.S.C. have to appear yet again for Common Entrance Test for Medical or Engineering or any other branches of professional studies. It was presumed that there will be only one common test for one state and may be yet another one by Central Government for an all India selection. But private medical colleges took advantage of this new criterion and decided that they will have a separate CET for private colleges. The University Grant Commission has in addition created another extremely fallacious entity called ‘deemed University’. Originally the principle for considering any institution as 'deemed university' was that the institution has such a high standard far above the standard in the University of the area that they could examine their own students as per their own high standard and confer its own could not degrees. University which in any case had only an average standard could not interfere. But the rules governing deemed University are so fallacious that many new institutions with hardly any standard or reputation could fill in the forms and submit some data as required by the University Grant Commission and could obtain the status of ‘deemed university’. Thus, there are many medical institutions which have obtained the status of deemed university. They can decide the merit criteria and decide the pattern of admissions on their own. The deemed universities conduct their own CETs. Therefore, a student today has to appear for not less than 5 to 6 CETs and run from pillar to post to seek admission in one or the other college, if he wants to enter the medical profession. Needless to say that there have been number of complaints, with solid proofs, about partiality and corruption in these CETs conducted by
Selection Pattern for Admission to Medical College
27
private medical colleges or by deemed universities. Professional colleagues have authentically mentioned the cash they paid for their ward to secure adequate marks in C.E.T. and get admission. Actually there is no reason why the result of CET conducted by the state and/or CET conducted centrally on an all India basis, should not be acceptable to each and every medical institution, whether it be private medical college or deemed university or for that matter even Armed Forces Medical College. That would obviate the need of multiple CETs that the students face today. Ordinarily such one common CET would effectively curb the corruption and malpractices practiced by these private bodies. The question of admitting 15% students on an all India basis could also be resolved suitably. After all, health is a concurrent subject. The central government as well as the state government have a role to play in creating the health care structure. The desire of students from any part of our country to seek admission to any medical college anywhere is also fully justified. But why reserve 15% seats in every college as per the present supreme Court’s order? It would be much simpler for the central government to create 15% of centrally administered medical colleges in all states, and admit all students in these colleges only, on the basis of All India Common Entrance Test. There is no need even to create more colleges. Central Government can take over 15% i.e. one out of seven colleges in all the states and run them through central government funds. In case the municipal corporation as in Mumbai or Pune decide to have medical colleges from its own budget without the assistance of the state government or central government, such institutes definitely have a right to have certain percentage of seats reserved for the students of the city, say about 25% to 33% of the total seats. Similarly if any region / district decides to have a medical college and is willing to support such a college financially, if would be able entitled to have 25% to 33% regional reservation. Instead of reservation based on caste and tribes or religions, the regional reservation as mentioned above would go a long way in creating balanced growth of medical facilities in various parts of the country. The same principle could be applied even to the different communities. The reservation on the basis of religion, caste and
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Management of the Sick Health-Care System
creed is not only strictly against our constitution but it has additionally created a lot of resentment and animosity amongst different castes. The recent examples of Mina Vs. Gujjar in Rajasthan and the agitation for Maratha reservation which is creating apprehension amongst the other backward classes in Maharashtra, are the latest examples. It is ironical that during the period of independence movement, our leaders blamed the British rulers of adopting a policy of 'divide and rule' by creating electorates on the basis of religions. Gandhiji had to fight and use all his power of pursuation to oppose separate reservation for scheduled castes and persuade Dr. Ambedkar against such a move by the British. Pune agreement between them is very famous. Yet it is ironical that our present leaders are increasingly supporting such reservations on the basis of caste and our new politicians are willing to extend them even to Muslims and Christians, thus creating severe resentment and conflicts between various castes and religions. The reservation on the basis of castes has not given any advantage to the poor. On the other hand, only a few privileged people in these various castes are reaping the maximum advantage out of it. Even in U.S.A. Dr. Martin Luther King Junior and many other protagonists, the uplifters of the blacks in America, did not ask for reservation but instead created opportunity in education and other infrastructure facilities for the blacks and thus brought them up to the level of the whites. Those who have already been benefited by policy of reservation can contribute along with the state or central government or along with N.G.O.s to create educational and other infrastructural facilities including the medical educational and service facilities, with percentage of seats reserved for their own communities (again say 33%). These efforts by community itself to uplift the other members of their own community will not cause any animosity and are likely to benefit the poor much more than the ever expanding reservation system prevalent at present. It may be noted that minority colleges created by minority religions like Christian, Jain, Muslims etc. do have such a facility of reserving the seats for the members of their own religions and they have not caused much resentment in the society. It would be the golden day when the reservations based on castes are totally abolished and replaced by such efforts by various communities and N.G.O.s to uplift the
Selection Pattern for Admission to Medical College
29
members of backward communities. However, such reservations should not exceed 25% to 33%. Admissions are now based on marks obtained in the C.E.T. provided the student gets a minimum of 45% in P.C.B. in his 12th standard examination. One adverse effect of this system is that the students totally or near–totally ignore their 12th standard examination and remain satisfied with obtaining the minimum of 45% marks in P.C.B. in that examination. It is also illogical that languages and mathematics are totally ignored. Obviously this omission was done as demanded by the parents who have now developed a habit of complaining of ‘stress’ or ‘tension’ for their wards. Language is a means of communication and those who cannot communicate well can never become good medical professionals. Similarly the modern advances in the medical knowledge have made it more a science, less an art and the students have to be mathematically precise in their clinical practice after they graduate and start practising. Modern equipments are now mathematically derived and the student who does not have a mathematical attitude is likely to fail in treating properly, the complexities in cardiac, renal and such other diseases. Besides, examination is a test to know how much the students have absorbed out of what is taught to them. Therefore, if languages and mathematics are taught, his ability to absorb these subjects also must be a part of examination to decide his merits compared to the others. Therefore, marks obtained in languages and mathematics must also be considered while deciding the merit at 12th std. and CET must include questions in these subjects too. To keep the minimum qualifying marks at 45% in the present days is ridiculous. This is one of the reasons why undeserving students are able to manipulate and get admission in private medical colleges or under reservation category as long as they can obtain more than 45% marks in PCB in the 12th standard. It is tragic that many of these students are not able to complete the course at all and I have seen many parents suffering huge financial loss-despite their poverty-in trying to make their-ward a doctor and getting frustrated after 7 to 8 long years. Such a tragedy among scheduled tribes and such a corruption among the among influential and wealthy parents in CETs would be avoided, if the minimum qualifying marks are made 55% in
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Management of the Sick Health-Care System
aggregate and 70% in physics, Chemistry and Biology. As at present, the minimum percentage could be 5% less for all catagories having reserved seats. So, the minimum would be come 55% in aggregate and 70% in P.C.B. It could be safely presumed that candidates getting less than these percentages are not safe to be entrusted the task of caring for the sick. Also merit need not be decided only on the basis of CET. Merit can be best decided by taking into consideration a) the performance in 10th standard; b) the performance in the 12th standard and c) the performance in the common Entrance Test If all the three examinations were taken into consideration, a chance freak lower performance by a particular student in CET would affect him less, as his average performance would prove to be better. Similarly the corruption is likely to reduce, as it is not so easy to use the corrupt methods in all the three examinations. The comparision of 10th and 12th standard marks could be done on percentile basis. Properly re-calculated percentile basis removes most discrepancies. It is the best method universally adopted by developed nations. In short, having considered the present pattern of selection of students for medical education from the 12th standard, I would suggest the following important steps. (1) Admission should be purely on merits. The merit is decided based on CET examination, provided the candidate gets a minimum 55% marks in 12th standard overall, and/or 70% in P.C.B. The merits need not be decided only by the performance in CET. It would be better to consider the performance of the students at various levels from his 10th standard to 12th standard. At least overall marks in 12th standard, corrected by percentile method should be considered to 50% extent & CET would make up the other 50% (2) The omission of certain subjects like languages and mathematics while considering the candidate for medical admission is faulty. The performance in all the subjects must be considered and therefore these subjects ought to be part of the CET also, if overall marks of 12th standard are not to be taken into account. (3) The minimum qualifying percentage of marks for eligibility to enter the (medical) professional colleges must be
Selection Pattern for Admission to Medical College
31
raised from the present 45% in PCB to a minimum of 70% in PCB or 55% marks overall. (5% less for all 'reserved' catagories.) (4) Despite some criticism and adverse publicity, I still believe that S.S.C., H.S.C. and CET or equivalent examination conducted by different Government Boards are still the most impartial examinations conducted in the state. Hence, there should not be multiple CETs. Only one common entrance test conducted by the boards appointed by the government is not only sufficient but be made absolutely compulsory for all colleges whether government, private or colleges of the deemed university. Central government would be the only other body to conduct their CET on an all India basis. As stated above, if the central government takes over 15% of the colleges from all the states and itself administers them, these students will get admitted to the Central Government Medical Colleges. Thus, admission to the rest of the colleges in the state will not be hampered, delayed or interfered with because of the so called 'central quota' as is happening today. (5) Reservation on the basis of caste should be totally abolished. However, regions or communities willing to conduct their own medical colleges with their own expenses should certainly be allowed to reserve some percentage of seats but not more than 33% to the students of their regions or the students of their particular community. In short, reservation should be based on region or community, provided the region or community takes the responsibility of running their own medical colleges and hospitals. QQ
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Management of the Sick Health-Care System
7
FEE for Medical Education
Now let us look into the pattern of charging fees to the medical students during their entire curriculum. When I joined the medical college in 1951 just one year after India became Republic of India, we paid Rs. 175/- per term i.e. Rs. 350/- per annum as our tuition fees. There were, of course, other ancilliary fees so that effectively our term fee was about Rs. 250/- per term. The brochure then mentioned that the government subsidized the medical education to the extent of nearly 50% of the actual expenses. When my son and daughter entered the medical education somewhere in the early eighties i.e. more than 30 years later, the fees levied were exactly the same. But now they formed hardly 10% of the actual expenses incurred on medical education. Subsequently the fees were raised but the fees were most appreciably raised only after the private colleges came up. While medical colleges run by public sector are subsidized so heavily by the government, the private colleges have to bear the entire expenses as they do not get any government aid / subsidy. It is but natural that the students/parents must bear all the expenses in these colleges. The private medical colleges took advantage of this logic and started to charge exorbitant fees and the Court had to intervene again to regulate the fees for the medical students. Now a committee is supposed to supervise and determine the legitimacy of fees to be charged to the students. It is not clear what principles are used to determine the legitimacy of the expenses and, therefore, the legitimacy of exact fees charged but the formula appears to be obviously faulty. The medical colleges continue to charge very heavy fees, in these colleges. A medical student pays anywhere between Rs. 1.5 lac to Rs. 3.5 lac per year at present. The government too has raised the fees because of the financial pressure; yet the
FEE for Medical Education
33
fees are around Rs. 18,000/- to Rs. 20,000/- per year. The students prefer government or public sector medical colleges because the training in these is qualitatively much better and not non-affording because the training is so cheap, except in the case of a few minority of the students. Naturally the students who get highest marks enter the government medical colleges while the students getting a little less marks are forced to take admission in the private medical colleges and medical colleges of deemed universities. The paradox of the present situation is that students getting very high marks get subsidized education and, therefore, in a way are supposed to be economically handicapped whereas those students who have secured marks less by a few percentage have to pay exorbitant fees and, therefore, in a way they are supposed to be belonging to the rich or economically affording class. Between students of equal caliber of intelligence, it is the rich or affording class who can provide better facilities-special tuition class and internet facility etc. to his ward, whereas it is the middle class parent who may not be able to provide such facilities and may depend on ordinary tuition classes at the most for his ward. Between them, therefore, it is the affording student who is likely to secure more marks than the unaffording student. Yet as mentioned above, it is the student who gets less marks who has to pay very high fees and the student who gets more marks pays lesser fees irrespective of the affordability of their parents and, in all probability, the affordability being quite the reverse. During my time in 1951-56, 15% of students were given partial freeship i.e. they paid only 50% of the stipulated fees, while another 10% were given full freeship; It means that they did not pay any tuition fees at all, except the ancilliary fees. The criterioa for giving partial or full freeship were purely economical. The parents had to submit a form and documentary proof to confirm their income and only the deserving candidates got such relief of not paying part or full fees. I myself might not have been able to complete my medical education but for the partial freeship which I obtained during the course of my education. It is ironical, therefore, that now when the fees have been raised so high, there is not a single seat with partial or full freeship in anyf of the colleges – government or private. Even in the government medical colleges, the fee structure, though reasonable, may not be quite so reasonable for
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Management of the Sick Health-Care System
many of the very poor students and, therefore, today, they are forced to give up the ambition of becoming medical professionals. The situation would be even worse for those who aspire to get admission in the private colleges. Thus, it can be seen easily that more and more percentage of students in medical colleges both in government & in private colleges are now belonging to the higher income group and the percentage of students from lower income group in medical colleges is steadily decreasing. Apart from the fact that deserving students are being denied the opportunity despite their merits, this has even more repercussions on the very pattern of healthcare. Both the students and teachers belonging to the rich class cannot easily think of simpler or cheaper substitutes in healthcare for the poor. They easily accept the costly modern technology as but natural and as a sign of real progress in medical management; thus contributing to the medical expenses rising by leaps and bounds. Should the expenses for medical education be subsidized at all? The subsidy in medical education is justified, if the doctors coming out from the colleges are sure to be absorbed in the national health services and that the people at large are served by them and in return they are given a reasonable remuneration. In countries like England and Sweden, highly subsidized medical education may be fully justified as their entire health care system is nationalized. But in our contry, where the student has a total freedom to select his field of practice-even go out of the country to the greener pastures in the foreign countries-the subsidy coming from the tax payer's money cannot be justified. Alternatively some provision has to be made to recover the entire subsidized fund with interest, if and when, the doctor leaves the country or enters into private business (I have deliberately used the word business instead of practice). Therefore the question of subsidy in medical education has to be very carefully looked into. The best solution for this is easy availability of educational loan at fairly low interest rate, say 6% which can be repaid by the student after he enters into regular professional field. Certainly some students-to the extent of 15% and 10%, from the poorer sections of the society-deserve partial and total freeshiprespectively as was the practice in the fifties and the sixties. The government would be fully justified in compelling these students to serve in the public sector for a stipulated period-say 10 years-
FEE for Medical Education
35
on a subsidized salary. On the other hand, the insistence of the government of compulsory service in the public sector by each and every student does not appear to be justifiable, if he/she is paying fully for his/her education. Similarly the fee of only Rs.18,000/- to Rs. 20.000/- in government medical colleges versus average fees of Rs. 2,00,000/- in the private colleges is too weird as explained above. Atleast 50% of the students getting admission in government/municipal colleges belong to high/very high income families. A few of them could buy the hospital. For example if the son of Ambani or Godrej or Kirloskar secures 98% of marks and gets admission in G.S. Medical College (K.E.M.) in Mumbai or B.J. Medical College in Pune, he pays the fee of only Rs. 18,000/- but the son of the poor accountant or head clerk working in his own office who secures 92% marks pays a fee of Rs. 2 lacs, if at all he aspires to become a doctor. The question of proper subsidy to proper students will be correctly approached and this paradox will be totally abolished, if the fees in the government colleges are also raised on par with the private colleges and, therefore, the subsidy is totally abolished. Now subsidy should be given only on the basis of the economic status of the family in two or three grades ot students in all colleges, government or private. The students with family income of Rs. 75,000/- per month or more will pay full fees. those whose monthly income ranges from Rs. 60,000/- to Rs. 75,000/- per month may get 25% subsidy. The families with income between 40,000 to 60,000 will get 50% subsidy. Those below this income upto Rs. 25,000/- per month may get 75% subsidy. and those below Rs. 25,000/- p.m. will get full freeship. These figures are mentioned somewhat arbitrarily but the actual figures could be worked out very easily taking into consideration family liability and their capacity to pay for the education OF THEIR TWO CHILDREN ONLY. The government need not consider even remotely the financial burden of the family beyond two children as in Singapore. In short the pattern of subsidy would ensure that the poor should get 100% subsidy, lower middle class may get 75% and the middle class may get 50% For the highest strate, there is no need to give any subsidy irrespective of which college he joins, government or private. Such subsidy, therefore, will be available to the students whether he joins a government college or private college or a deemed university college. The subsidy
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Management of the Sick Health-Care System
means that an equivalent amount will be paid to the respective colleges by the government so that their budget is not disturbed. Every student who gets subsidy will have an obligation to serve in government service or in public sector for a reasonable number of years as per the subsidy he has received or else he will have to return the amount of subsidy with interest to the government. A large number of doctors will then become available to serve the poor at various primary health centres or other public sector health care organizations. Otherwise the government will receive back the money they had spent on these students-money which can be now re-used for future students. QQ
37
8
Subsidising Private Medical Colleges
As pointed out earlier the government has appointed a board to determine the fee structure in private colleges and to see that the fees charged are legitimate. It is not clear what principles they use but it appears that the board merely verifies the expenses incurred during the previous year and sanctions the fee pattern to meet those expenses. There are no criteria to judge the legitimacy of those expenses. Therefore, the fees are as high as two to three lacs per annum as mentioned earlier. Even after paying such high fees, the students in private colleges are greatly handicapped because their attached hospitals have very low occupancy. The patients in these hospitals have to pay for their hospital expenses. The treatment cannot be totally free. Around 50% of the burden of the expenses incurred on the patients is borne by the students and forms part of their fees. Even then, the patient himself has to pay a fair amount towards his treatment compared to the fact that they get free treatment in government hospitals. Coupled with the fact that these institutions may be having relatively poor investigative and operative facilities and less experienced teachers, the result is a great reduction in number of patients coming in these hospitals. Therefore, the number of students admitted in these colleges is very high compared to the patients available in the hospitals and the patients feel more harassed by a large number of students examining each of them. Thus, a vicious circle is established. Ultimately this results in proportionately small number of patients available to the students to observe and learn his clinical medicine. In all technical colleges, the laboratory or workshop with all equipments suffices to give the students adequate
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Management of the Sick Health-Care System
training but not so in the medical college. For medical students, a large number of patients in the attached hospital is most essential for getting their clinical experience. The lay people should realize that a medical student does not interfere with the management of the patient. But he is constantly with the teaching staff & other seniors and observes every step in the process of clinical management and even assists them as directed. This actual observation and participation in the management of the patient forms a major part of his clinical studies; I would say nearly 75% of the education in clinical methods. Therefore, the most important need of the medical students is the hospital filled with numerous patients of different kinds of diseases. The Medical Council had recommended a ratio of 1 to 10 initially i.e. 10 patients per student admitted every year. That means if 100 students were admitted per year in the college, the attached hospital must have the facility to admit at least 1000 patients. In order words, there ought to be at least 1000 patients in the hospital on an average every day. Tha ratio was diluted later and now stands at 1 to 7, 700 bedded attached hospital for 100 admissions per year in the medical college. Many private college hospitals do have the number of beds but not the occupants whereas the government hospitals are full or even overburdened. The total number of patients in private college hospitals could be as low as 150 to 200. it must be realized again that the hospital fully occupied is not only the need for the students but it is a bigger need for the society because the student who passes with inadequate experience because of lack of availability of patients and has only book-knowledge will obtain the same degree and will be fully entitled to treat the people at large as a student who gets adequate clinical experience. Thus the effects of bad / immature doctors coming out of the medical college are borne for the next 35 years by public at large. So also the benefits of mature doctors coming out of the medical colleges will be reaped by the public at large only. Another factor needs to be considered i.e. the government hospitals/ medical college hospitals as well as district hospitals are too overcrowded and there is a vital need to reduce this overcrowding in these hospitals so that each of the patients gets adequate attention and treatment. Besides, overcrowding hampers medical education as much as scanty patients. The best way to disperse the patients to these private
Subsidising Private Medical Colleges
39
medical college hospitals would be to subsidize the cost of the treatment in private hospitals equally as in government owned medical college hospitals. What I am suggesting is that the expenses of the poor patients coming to these medical college hospitals should be subsidized by the government. The subsidy can be calculated as per what is spent for a similar patient AT A DISTRICT HOSPITAL. This amount could be safely considered as the most minimum amount essential for the treatment of the patients, with no other components added. The expenses incurred by patient in a medical college hospital have added components and could be broadly divided into three parts (1) the expenses required essentially for his treatment. I have taken it to be equal to the expense incurred by the government on similar patients in a district hospital and, therefore, suggested the abovementioned level of subsidy. (2) But the expenses of the patient in medical college hospital would rise appreciably because he is a material for the medical student to learn. The stay of the patient is necessarily increased to some extent and some of the investigations are done merely for academic purposes. As this part of expenses is entirely due to the presence of students in that hospital, it is legitimate that these expenses be borne by students. (3) But in good medical colleges research is an essential activity. Without research there will be no progress in the science of medicine. Since certain investigations or modalities of treatment are carried out purely for the research, it is clearly understood that this component of the expenses must be given either from the institution or recovered from the research grants provided by the private industries like pharmaceuticals or by autonomous government agencies like University Grants Commission (U.G.C.) and Indian Council of Medical Research (ICMR). The interests of the patients / volunteers are safeguarded by Research Council in that the patient must gain advantage or at least must not be harmed at all and that the patient is properly informed that these investigations and treatment are being done as part of research Today the government refuses to give a single paisa to the private medical colleges as a subsidy. "Why should we spend for ‘rich’ private trusts and the ‘rich’ medical students who, in any case, want to make money?" Strangely all experts are
40
Paying Patients in Med. College Hospitals
Management of the Sick Health-Care System
emphasizing the role of private public partnership in various other fields, for example in road and bridge construction. Similarly government factories are constructed on the basis of BOT i.e. build, operate and transfer policy. Therefore, there is no reason why there can not be a private public partnership in the field of medical education. It is not being done to benefit the private trust or agency which is running the college. The government and the public would get tremendous advantages by such subsidy. When the poor patient gets treatment at the same cost as in a district hospital but by more qualified medical teachers, the number of patients in the hospital is bound to increase and the experience gained by the students because of availability of wide varieties of patients would go a long way to make him a better doctor. It is in the interest of the society, therefore, that the medical college hospitals are filled with patients by giving them adequate subsidy to cover the treatment expense of the poor patients. QQ
9
41
Paying Patients in Med. College Hospitals
Indian Medical Council is very ambiguous about recognizing the affording class of patient as clinical material for the students. If the hospital keeps a section where patients pay for the treatment, that section is not recognized by the Medical Council as teaching beds. One reason given by the Council is that these beds form a section like a Nursing Home and the same bed may be occupied by a medical case under a physician one day, by a surgical case for the few days and a pediatric case at yet another time. Therefore, such beds cannot be allotted to any specific branch. The argument is quite valid but if the hospital was to have paying beds in each of the wards which are allotted to the specific teacher, then these beds ought to be considered as teaching beds. In U.S.A. almost all patients do pay for their treatment and yet form part of teaching material for the medical students. Even in attached hospital of Kasturba Medical College, Manipal, all patients pay. If 25% of the beds of each teaching unit were allotted to paying patients, it would have many advantages. First, obviously the hospital will have a source of income to run the hospital and thus will indirectly help the institution to reduce the fees for the medical students. But a bigger advantage is for the students in their medical education. A paying patient is more health conscious and more aware of his rights. His expectations of treatment are higher and in general he is well–informed and more easily available for follow-up. Besides he often comes with an early and possibly curable disease. Therefore, he is an excellent clinical material for the medical students. In addition and most importantly the students
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learn good bedside manners almost automatically. The patient being educated, health–conscious, affording, he or she is automatically treated with due respect by the student. The students do not pounce upon him or examine him roughly as they almost always do in the case of poor general ward patients. In contrast the general ward patients suffer from more advanced disease and often do not turn up for long term follow up. They form, at best, experimental material like animals. It is regrettable to say so but it is the common experience of each and sundry who have observed the plight of these patients in our country. Every clinical unit in a medical college hospital must have about 40 beds with a recognized team of medical teachers / consultants in charge as per the medical council rules. Usually each such unit has a separate ward; sometimes two units share a ward. It is suggested that all such wards should have atleast 25% of these patient-beds for paying class patients. That means out of 40 beds atleast 10 beds should be paying beds where the patient pays for his / her treatment. One part of the ward could be converted into rooms with extra facilities like separate toilet, a separate access and a few facilities for relatives while remaining 30 beds would be either free or partially subsidized-generally called the general ward beds. The medical students will necessarily be allowed to examine and observe the treatment of all these paying class patients and as stated above I expect the students to learn proper bedside manners and also observe the signs, symptoms and clinical picture of a relatively early disease in the special rooms in contrast to what he observes in the general ward, namely signs symptoms and clinical picture of a relatively advanced disease in a patient whom he may not be able to observe in the follow-up period. As these beds are specifically allotted to the teaching unit, there is no reason why the Indian Medical Council should have any objection to consider them as part of the teaching beds. Such a system has an added advantage of assessing the capability of the teacher to attract patients. The patients in the general ward have no choice but to come to these ‘free’ hospitals and their number does not reflect the clinical ability of the teacher. It is only a competent teacher who can attract patients in the paying class. The incompetent teacher will thus be easily exposed. There are many more additional advantages in having this system. The out-patients-
Subsidising Private Medical Colleges
43
department, laboratory and the operation theatre, all remain closed after the morning shift. The whole hospital works only in one shift from 8.00 a.m. till 3.00. p.m. Hospital services are closed after 3.00 p.m. except for emergencies during the rest of the day and night. If paying class of patients are to be treated. in this same hospital as mentioned, it will become necessary to use the evening hours to have such pay-clinics for the paying patients. The O.P.D. the laboratory and investigative facilities will also naturally remain open during these evening hours and in order not to disturb the treatment of the poor class, the operations and procedures for these paying class patients will also have to be performed in the evening. In short, the whole hospital will have morning hours reserved for the general class of patients while the whole infrastructure will be put to full use again in the evening hours for the paying class of patients. Double utilization of the available infrastructure, and therefore the standing expenses, will be better utilized. In addition, of course, the hospital will earn a very large income from these beds and that will cover a major part of the hospital expenses. That these patients may refuse to allow the students to examine them is a common objection raised by those who are against it or have fixed ideas. But it must be remembered that it is obligatory for every patient who goes to a teaching hospital to allow the students to examine him. As per the rules of the council, a notice has to be put up prominently and even signatures can be obtained from the patients before they are admitted and any treatment is initiated. This is the practice in the western world. This has a further advantage in that medical teachers or seniors remain available in the premises right upto evening time even upto 8.00 p.m. or 9.00 p.m. At present the seniors leave the hospital by 4.00 p.m. maximum and they are approachable only on phones thereafter. If and when private practice is allowed to these teachers outside the premises (legal or illegal) as is often the case to-day, they are busy elsewhere in their private practice and are reluctant to come to the hospital even when the situation so demands. They manage the situation by giving telephoning advice or telling the junior to go ahead and perform or advice the juniors to keep the case pending till morning. Such negligence will also be minimized by having the paying class in the hospital (a) because the senior doctors are readily available within the
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Management of the Sick Health-Care System
premises even upto late evening and (b) they have no external interest in terms of private patients elsewhere and, therefore, are necessarily and truyly available for the patients within the premises-whether general ward or paying class. After some years almost every doctor develops a certain philosophy and ethics of practice. Therefore, it is unthinkable that such a senior medical teacher will attend only to the paying class patients and ignore the general class patients, when both these classes of patients are in the same premises and the consultant is available there. Therefore, the general ward patients also will get better attention in this system. Even otherwise, the attention to the general ward patients i.e. poor class of patients will improve automatically, even in the out patients department because of yet another factor. At present, if the medical teacher is competent, he attracts many patients who are either very influential or affording. They seek treatment here, for various other reasons apart from cheap or free treatment, mainly because of the competance of the consultant teacher. In the present system, these affording patients attend the same O.P.D. during the same morning hours as the poor general class patients. Inevitably this influential or affording class of patients get preference over the poor and if the medical teacher is very popular, it may happen that he hardly gets time to see any general class patient. They are all seen by resident doctors or juniors and the senior teacher is consulted only if the juniors consider it necessary to show him such a case. The same thing happens in the investigation department and in the operation theatre. The rich or influential patients easily supercede the poor and the investigations and/or operations of the poor general class patients keep getting postponed for want of time to accommodate the rich or the affording. Everyone is a loser except this crooked class, which exploits the facilities meant for the poor. The senior medical teachers in the unit do not object much because their own share of influence in the society increases by treating these people. On the other hand, he has nothing to loose, as his salaries are fixed. There are a few exceptional techers who do object on moral ground to such entries of privileged class. But they are far and few between. They lose their sphere of influence in the society and remain static, irritable and generally not appreciated by anyone. All this would be prevented if the scheme of 25% paying beds
Subsidising Private Medical Colleges
45
is properly implemented. As the medical teacher will gain in actual terms as and when he treats paying class patient, he will now be more reluctant to adjust him in the morning hours and will insist on him coming during the hours of paying clinic. Therefore, the general ward patients will have the full attention of the medical teachers during the morning hours. The investigation time and the operation time being so reserved specifically for the general ward patients till 3.00 p.m. and for the paying class in the evening, there is no interference between the two classes, thus, giving indirect benefit to the general class patients. The more competent medical teacher will earn more than the teacher who is relatively incompetent. Thus, the need of 25% paying beds in a teaching hospital is so important that, in my opinion, the students, the university and or the state government should be willing to fight for it in the court of law, if the Indian Medical Council raises any objection to such a system on any ground. Free medical treatment should be abolished As I emphasized earlier there is nothing free. When a patient gets treatment free of charge, it only means that somebody else has borne these expenses directly or indirectly. In the case of govt. hospitals, it means that every citizen is paying for the treatment of that patient through direct or indirect taxes. Besides neither the patient nor the student nor the senior medical teacher becomes aware of the expenses incurred in the treatment of the patient and thus, does not even think whether the expenses could be minimized. Therefore, it is my firm opinion that the patient must pay at least some percentage of the expenses incurred for his treatment. QQ
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10
Effective Fees for Medical Education
When we consider the fees to be charged to the medical student, two important aspects must be taken into consideration. (1) expenses incurred by medical colleges and (2) the various means other than student fees that can bring income to the Institution. If the medical college indulges in unnecessary expenditure, such an extravagant expenditure need not be taken into consideration by the board. The Indian medical Council has clearly stipulated the space, furniture and the infrastructure for each department. Expenditure incurred on these is the most essential expenditure. Additional expenditure can also be allowed only if it can be proved to be important to qualitatively or quantitatively improve the standard of medical education. Generally I must accept that there is not much scope to reduce the expenditure on these grounds from the present level. But the expenditure on the salaries and perquisites for the medical teacher can be comfortably reduced by allowing the medical teachers, private practice on the premises on the 25% beds reserved for the paying class as discussed in details earlier. Medical teachers will get minimum salary for teaching as in other faculties, but he will earn more and more with his own skill through the private practice and the management need not pay for the perquisites such as non-practicing allowance, telephone, housing etc. In addition, there are possible sources of income other than the students fees. First major source is income from paying class of patients. 25% percent paying class patients can bring enough income both to the senior medical teachers and to
Effective Fees for Medical Education
47
the hospital. Even a hospital like Bombay Hospital can afford to have about 25% beds free of charge or highly subsidized. Therefore, much of the hospital expenditure can be expected to be recovered from the 25% paying class patients. Another source of income is Research Grant. One of the important functions of a medical college is research and large sums of money are allotted by pharmaceutical companies and medical equipment companies in private sector and the University Grant Commission(U.G.C.) and Indian Council of Medical research (ICMR) in the public sector but these are most scantily used. Used appropriately the medical college can earn lakhs of ruppes through research. I was told the Manipal University has more than 80 research projects bringing in over 6 crores of ruppes to the institute through research grants. Government hospitals especially are apathetic in utilizing these funds. Yet research is carried out but the funds are exploited by vested interests by clandestine methods. The hospital earns nothing. Yet another source of income could be the training courses for all paramedical services. There is need to have nursing course, technician’s course and even training course for ward attendants. Even administrative courses like MBA, Cost–Accounting, record keeping etc. could be undertaken with the help of the respective bodies in the various fields. There is no need either to extend the infrastructure or teaching staff and the same premises and the same staff can be used to conduct the training programmes for different paramedical services. As will be discussed later, the concept of absolutely free medical treatment must also be curbed; not so much for earning money but for many other vital reasons. However, suffice it to say here that some income would be added if general ward patients are also charged even 15% of the actual bill. I have already stated that the private medical colleges should also be entitled to a subsidy equivalent to the expenditure incurred by government in a district general hospital. If all these sources of income are properly used, the burden of fees on the medical students will be remarkably reduced and I believe that medical education would not remain as costly as it is today. In summary, the following steps are needed to streamline the fees structure and bring the fees down to a reasonable limit. (1) there is no justification for very highly subsidized medical
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(2)
(3)
(4)
(5)
Effective Fees for Medical Education
Management of the Sick Health-Care System
education in government medical colleges and exorbitantly high fees in private medical colleges. The fees in government medical colleges should be at par with the private medical college fees or based on expenditure incurred, as in the case of private medical colleges and approved by the board appointed by the government. There should be no distinction between the two. No student with merit should be denied admission to the medical field because he/she cannot afford. Therefore, irrespective of whether the student joins government or private medical college, he will be entitled to a certain amount of subsidy depending on financial circumstances of the family. The families with income of Rs. 75,000/- per month and above will pay full fees. But the families with income between Rs. 60,000/- and Rs. 75,000/- will get 25% subsidy. The families with income between Rs. 40,000/and Rs. 60,000/- will get 50% subsidy. The families with income between Rs. 25,000/- and Rs. 40,000/- per month will get 75% subsidy and those below Rs. 25,000/- income per month will get full freeship i.e. 100% subsidy. The admissions, however, will be strictly on merit. While determining the fees, only the legitimate expenditure by the hospital for under-graduate and post-graduate studies should be considered. The burden of unnecessary extravagant expenditure cannot be put on the students. The hospital must keep atleast 25% of the total beds in every clinical unit for paying patients. There is no need to charge these patients exorbitantly to compensate the general class patients. They will be charged appropriately as per costing. For the general ward patients, the hospital / management will be entitled to a subsidy from the government equivalent to the amount spent on an average on patients in district hospital. In addition all general ward patients will also be charged atleast 15% of the expenditure actually incurred. Reserch grants will contribute further to the income of the hospital. The remaining excess expenditure will be borne by the students and will form part of their fees. It is expected to be not more than 30-35 per cent of the actual expenditure on patients. As the hospital is going to have 25% paying beds the
(6)
(7)
49
consultant doctors / medical teachers will also earn directly as per their skill. It is expected that this would reduce the expenditure incurred on the remuneration for the medical teachers; especially on perquisites. It should be noted that the salaries of the medical teachers form a major bulk of the total budget for the medical college and its hospital. Medical college must make efforts to have research projects and earn some specific added income through the grant for research by the government, industries or other agencies. The consultant medical teacher undertaking the project must get paid appropriately. This aspect will he discussed again later. The number of students getting subsidy are not expected to rise above 40% to 50% In fact, those getting full freeship and upto 50% subsidy are expected to number 25% of the total admissions. But it should be noted that even if the number exceeds this figure, the total expenditure of the government on medical education is likely to be reduced and not increased from the present level of expenditure. However, if the situation demands the government, through the nationalized banks like State Bank of India should offer education loans to the students which will be repaid from one year after completion of education, over a period of 10 years. (This factor will have to be taken into consideration while determining the salaries of the doctors in public sector and will be discussed later.)
If legitimate principles of income and expenditure are strictly followed, I expect that fees for the medical education may not exceed Rs. 1 lakh per month. In addition this financial regulation will help a good deal to improve the standard of medical education. It may also help in reducing the overcrowding in government teaching institutions. Free treatment is the Costliest treatment, with poorest returns. Free treatment is becoming the costliest treatment. The results of free treatment in public hospitals are disastrous. Neither the doctors nor the students nor the patients become aware of the cost involved in the management of the disease. This is the most disastrous effect of the so called free treatment.
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Management of the Sick Health-Care System
Secondly as explained, earlier if the hospital budget is spent through tax money, hardly 13 to 15 paise remain available for the actual hospital expense from every rupee collected by taxation. If the money was collected in one form or the other more directly, the effective amount available for the health care system would become two to three times more than what is available now. The third adverse effect of the free treatment is that the whole management is in the hands of bureaucrats who have very little knowledge and expertise in this field. The allocation and utilization of the funds, therefore, is very haphazard. While C.T scan and M.R.Is. are installed, the simple drungs like anti T.B. drugs, antibiotics etc. are not available for the patients. But the worst effect of free treatment is that the medical professionals work on a fixed salary 'that too quite meagre, compared to the number of years they have spent and efforts they have made to qualify. So, many ethical and able doctors leave the paid jobs and enter the field of private practice which is considered both lucrative and satisfying. Those who remain, work without enthusiasm or zeal. As long as the medical officer attends on time, it makes no difference how much he works and how different he is qualitatively from the others. The fixed salary, total lack of incentives and extremely poor administrative supervision result in totally demotivating the doctors. They get very poor job satisfaction and such demotivated doctors with fixed pay cannot serve the people properly. In fact, many develop a severe antagonism to the very patients they serve and this gets transmitted to their juniors and students. The laxity in administration makes it very easy for the same doctor to look for the greener pastures, start private practice (allowed or not allowed by rules of service) and earn directly. This again makes him even less available in his primary field of government hospital or medical college hospital as the case may be. As the income of the doctor is totally independent of the service he renders or the satisfaction of his patients, the most needed doctor-patient relationship never develops. Thus, he becomes apathetic and oftentimes quite rude while treating his own patients. On the other hand as the patient himself never pays for his treatment, his own (idle) expectations keep rising without his own inputs. In our democratic set up, the number becomes important and the large population or their leadership keep
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demanding more and more facilities. The medical 'market' is always too eager to sell, keeps advertising more and more about the newer equipments, drugs, prosthetic supports etc and the politicians and the beurocrats easily succumb to the pressure from both sides. Thus, the government hospitals keep adding costly equipments without considering whether they are going to be really useful to the people. The limited resources available with the government are thus spent on unnecessary modern equipments leaving no money for spending on the more essential simple drugs and equipments. While a free class patient may get his C.T. scan or endoscopy free, he has to pay from his pocket for the simple investigation of haemogram and blood sugar. More often, the free C.T. Scan or Endoscopy is usefully exploited by the influential or affording class, leaving the poor where they are. He has to buy medicines from his pocket for his diabetes, blood pressure or antibiotics for his infections. This paradox is seen every day in almost every hospital throughout the country. Yet it is not realized that the root cause for this paradox is the so called free treatment as explained in details above. Therefore, this system needs to be drastically changed. It is not, as though the system of, doctors on a fixed salary basis, can not work at all. But such a system of ‘paid’ doctors can work only if the management is excellent. The management has to define the role of each doctor, and each strata very precisely and set up defined targets for every specific aspect of his work. It must have an excellent ‘feed-back’ system and must get monthly reports (verifiable through good supervision) about the performance of each item and work through is M.I.S. (management information services) as it is called such reports must be to give salary rise or promotion (or demotion or dismissal). An additional ingredient required is honesty and integrity among the majority of the administrative and professional staff. With adequate salary structure along with such superior management skills, the system of salaried workers (doctors) can certainly work. We are nowhere near this. QQ
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Management of the Sick Health-Care System
11
Selection of Medical Techers
The choice of the medical teachers leaves much to be desired. As per the Indian Medical Council rules, there are broadly three categories of medical teachers – lecturer, reader (variously called Assistant professor, Reader, Associate professor etc. from time to time) and the professior. Post graduation in the subject and the teaching experience of three years as a senior resident or equivalent are the minimum qualifications to become lecturer. Three years' experience as a lecturer qualifies him to become a reader / Associate professor and after five years as Associate professor he can aspire to be a professor. Generally this appear to be on par with the stipulations in the western countries. There is always a big rush of qualified post graduates to become a lecturer, not because they like the teaching professon but because they wish to gain further experience in their own field of speciality. The applications for the post of reader / associate professor are far less and sometimes it is difficult to get the post of a professor filled; the applications are so few. Meagre salary, bureaucratic attitude, lack of incentive and poor job satisfaction are the main reasons why the consultant doctors are not attracted to the field of education. I have also suggested that if these consultants from the level of Associate professor onwards, are allowed practice within the premises, that may be sufficient incentive for many of the consultants who are academically oriented or are not happy with the many gimmicks and marketing and unfair medods they have to adopt in private practice. But today it is a discredited field because of lack of incentive and inappropriate infrastructure. But not every one is inclined to practice and there are a few who are genuinely interested in teaching and research and it is necessary that the medical college hospitals-government or private – should encourage those who are truly interested in teaching and / or
Selection of Medical Teachers
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research. The lure of private practice whitin the premises for such consultants is unproductive. For them some other incentives must be available. There are three desirable types of medical teachers. The first one is 'practice oriented'. They mix the art and science of clinical practice and render good medical service to the patients. This category is in the largest number. But as I mentioned earlier, many of them leave medical college hospital and enter into private practice which is more lucrative and more satisfying though more intriguing. Actually these teachers would have been an ideal example for the students to learn from and it is for the sake of retaining such consultants in the field of medical education that I have suggested private practice within the premises with 25% of the beds reserved for the paying class, Private practice allowed outside hospital premises is disastrous not only because the medical teachers are out of the premises for practice but, in addition, they develop too much of commercialization. In turn, they neglect their duties in the medical college hospital and thus become the worst examples for the students to learn from. Unfortunately, such a system of allowing private practice outside the premises is advocated and allowed in most of the government and private colleges due to the advice of the accountants and bureaucrats who are highly satisfied by the reduction of expenditure on the medical teachers. Besides, it relieves them of a big administrative burden. In the municipal medical colleges, for example, nearly Rs. 15,000/- to Rs. 20,000/per month are saved per each consultant if he opts for private practice. Totally, in the eyes of the accountant, the corporation would save around Rs. six to eight crores. But they forget that the same teachers would have earned much more than these 20.000/- rupees per month and further brought another two lakhs of income to the hospital, if practice was allowed within the premises. In addition, the true benefit is the improvement in the medical education which will benefit the society for the next 2 generations in the form of better doctors coming out from the hospitals. This has been discussed in great details earlier. But the administrative burden on the accountants and bereaucrats would rise five fold. The second type of teachers who are equally desirable are teachers who read a lot and are truly interested in teaching. Every good teacher may not be a good practising
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Management of the Sick Health-Care System
clinician, just as the best directors are not the best actors and the best coaches are not the best players. Teaching is a different art altogether and such teachers who are academically oriented and have enough art of teaching must be sought after. Similarly some amongst them may be deeply interested in research work and should become assets for the institution. The teachers who have truly come for teaching or for research are very few in Mumbai. Hardly 20 percent of the teachers at the most can be expected to belong to these two categories. They need different incentive. As mentioned earlier research workers can be encouraged to utilize the grants from the pharmaceuticals or I.C.M.R. funds and the college itself must have enough funds available for research. Foregin institutions are pouring funds for good research. Unfortunately in the present system, while every worker under him is paid adequate compensation, the consultant teacher, himself, who undertakes the project is not allowed a single rupee for the work he undertakes. This is most unfair and may be the root– cause why most of the teachers are reluctant to take research projects. This also leads to clandestine practice of the pharmaceutical companies paying in the form of gifts, foreign tour and so on to the Chief Investigator, thus inducing research workers to give favourable results for the company. The disastrous results of such corruption in research are obvious and drugs and medicines which can be harmful are finding their way easily into the market. Substantial payment to the research worker directly through the grant will help to make research more fruitful and honest. Similarly a good teacher must get adequate facilities to write books and monographs. Writing books and monographs separately for students, nurses, technicians etc. is a task in itself and apart from too much time consumed for it, it is also very expensive. Hence, he should be provided with adequate facilities to write such books. Such incentives would go a long way to improve the standard of medical education in the medical college. Both these classes of teachers deserve non–practising allowance and other perqisites, subject to performance. Therefore the performance of the medical teachers must be assessed, as per the specific expectations from each category. Performance Assessment of Teachers Unfortunately today there is no assessment of the performance of the medical teachers. It is only a confidential
Selection of Medical Teachers
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report of each staff member. The confidential reports submitted every year are a big farce. Basically the annual confidential report was meant to ensure at least the minimum output of work from every worker. If there were no adverse remarks, he / she was considered satisfactory. There was no added credit if the person worked more satisfactorily i.e. if he gave very good or excellent performance. The next promotion usually went with seniority. Of late, competitive selection (for example by M.P.S.C. or U.P.S.C. interview) has been introduced and 50% of the posts are filled by promotion and 50 % are filled by competitive selection. However, if one looks closely into the method of the so called competitive selection, it would be realized that there are no performance criteria and no performance records on which the selection is based as mentioned earlier. The ability of medical teachers needs to be assessed (a) by his clinical ability i.e. record of number of patients treated, number of different diseases tackled with their ultimate results. or (b) by his ability of teaching; the performance of the students in different examinations; under-graduates and post-graduates or (c) by the research work that the teacher has done. This last i.e. research papers read or published is no doubt considered during the assessment for competitive selection, but the quality of these publications is not analyzed at all. In fact, ‘The pepers read or published’ being an important column in the application form, everyone tries to write or read some paper or the other in some journal or some regional conference. Most of them are trash. There is no distinction between the papers published in ordinary journals as compared to the papers published in well known journals or international journals. It is necessary, therefore, to substitute the system of confidential report by a performance record. It is important that the performance assessment must be done separately for each of the above three qualities required of a medical teacher. Administrative compliance, complaints or compliments from students or patients, ability to organize and conduct allied activities like seminars, lay education, participation in socially important events. clinical programs etc. could be the other facets considered in the assessment of the teacher. Unless such records are maintained and submitted to the selection committe in such a form with objective data, the competitive selection
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would remain a farce and at best, lead to the selection of more vocal street–smart applicants. The recent cases of massive corruption in these (MPSC) selection boards are eye-openers which have failed to open our eyes. Selection Process The M.P.S.C. is so slow in its selection process that the posts are not filled for years together and thus the vacant posts are once again occupied, by seniority alone on temporary basis from the junior cadre. These ‘temporary seniors’ are continued for a decade or more. It would be preferable if the M.P.S.C. is substituted by another formal organization specifically appointed by government to enroll medical personnel and other professionals in the government organization. The confidential reports must definitely be replaced by the more objective performance record in which the performance of each would be graded as excellent, very good, good, satisfactory and unsatisfactory. It would be an excellent idea to inform every employee his / her performance report. This will help him-if he is dissatisfied, to protest and to put forth the objective data to get his report corrected. On the other hand, if he knows that his performance is good it will encourage him to do better. If his unsatisfactory report is confirmed, he knows definitely that he has to improve or perish. Such report once confirmed by the senior authority must be seriously considered at the time of competitive selection. Thisway some junior teachers may supercede the senior inactive teachers; and that will help to improve the medical service and medical education. It will create a fair competition amongst the teachers. During my tenure as Dean, I had done a small experiment and adopted this procedure. The then assistant commissioner Mr. Karandikar was also very keen to promote merit. Those employees whose work was declared just ‘satisfactory’ but did not have a record of ‘good’ or ‘very good’ for atleast 2/3 rd of the period in their present post were denied promotion. The result was dramatic. Every lecturer and reader stepped up his/her performance and was keen to prove his/her mettle. Personally I conveyed the performance record to each and every member of the medical faculty. Those reports were personally prepared by me and were given as confidential letters personally to each of them. Thus, the confidentiality was also maintained, as required under the present rules. It was only the
Selection of Medical Teachers
57
employee himself who could divulge his performance report to others-otherwise it remained confidential. There was another unexpected but highly desirable result. Earlier when only the adverse remarks were conveyed to a few of the members, they raised a lot of noise and complained bitterly about ‘partiality’ ‘corruption’ and so on in their conversation with other colleagues in the common room. All other members of the staff, not knowing what their own report was, promptly sympathized and the association of the teachers jumped on the authorities concerned namely, the Dean or the Commissioner to get the reports annulled. When I gave their performance reports stating clearly where they stand, a large majority, who now definitely knew about their own good report, were totally reluctant to join those few who received adverse remarks. Thus, it was much easier to discipline the teachers and make them perform their duties well. Unfortunately, after Mr. Karandikar left, as usual, senior committee members raised many objections and the practice reversed back to promotion seniority-wise. The committee doubted every adverse report. Yet this small experiment-even for a couple of years-has convinced me that if objective data are recorded, performance reports are prepared and submitted to each member separately (and confidentially if necessary) and if these reports are used seriously at the time of promotion, it has a highly desirable effect. A competitive spirit develops and medical services improve. Besides the whole process is extremely transparent as rightly demanded by the association of the employees. As discussed earlier every one need not to be a good clinician but every teacher must show proficiency aleast in one or two desirable qualities of a teacher namely, clinical work and / or teaching and / or research. This will also help in ensuring the balance between academically oriented teachers and practice oriented teachers. Mandatory number of medical teachers required are clearly notified by Indian Medical Council. In large cities where the work load in the hospital is high, the number of clinical teachers is short of the real need in clinical subjects. At present one professor, one associate professor and two lecturers, together form one unit and are allotted 30 to 40 beds for their clinical work. There are atleast 6 to 7 resident doctors who are doing their post-graduation; 2 students every year for a 3 years’ course.
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They work and move around together all the while. Therefore, the total numbers in a unit are too many. Actually, they were not meant to be flocking. It would be more advantageous to have one professor, one lecturer along with 3 resident doctors to form a compact sub unit and the associate professor along with one lecturer and three residents to form another sub unit. This way the role of each member will become more defined and all of them will have adequately defined work. Howeven, in general it can be safely assumed that the number is too small to cater to the large number of patients attending medical college hospitals. As the pay scales of the teachers are being raised from time to time and as the hospital earns zero revenue, managements including those in the government become reluctant to appoint even one additional teacher than required by M.C.I. and if at all more teachers are enrolled, the expenses rise. That results in higher fees for medical students. This peculiar viscious cycle naturally affects the quality of medical care given to the patients in medical college hospitals. Regrettably no one is worried and the authorities point their fingers to the Indian Medical Council rules in justification of less number of teachers. The only exception appears to be the large reputed hospitals of medical colleges in Mumbai where number of teachers have gone up much above the stipulated numbers of Indian Medical Council due to the public pressure. This inadequacy of qualified professionals in the medical college hospitals can be corrected by appointing part-time or honorary qualified professionals to help in the services in the hospitals. The Medical Council strongly objects to the appointment of part-time or honorary doctors as teachers. I, therefore, make amply clear that qualified doctors thus appointed will not be called ‘Lecturer’, ‘Associated Professor’ or ‘professor’. They will merely work as ‘Honorary Surgeon’ or ‘Honorary Physician’. the appointment of the honorary or part time consultant – one in each unit – will help a lot both in improving the medical service as well as medical education. There are many successful consultants in the city doing good medical practice. They cannot be successful unless they have proper grasp of the art and science of the branch in which they practise. No doubt that there are some successful consultants whose success depends only on their business acumen. These are ‘commercially successful’ doctors. It will not be difficult for a
Selection of Medical Teachers
59
good management to differentiate between the really competent doctors and the commercially successful doctors. Experience of these competent doctors or the skill in their hands and their capacity to observe and interprete the signs and symptoms of the patients will make an excellent example for the medical students to watch and learn from. As mentioned earlier, good teachers may not be skilled clinicians or surgeons but even their own teaching ability will increase by observing such skilled colleagues right in their own unit. Similarly retired or most eminent consultants who have highly specialized knowledge could be invited as emeritus professors. They will examine and treat such patients as are specifically referred to them by the concerned unit. The idea is to have the actual demonstration in their respective highly specialized field for the under-graduates and post-graduate students. In fact, such a practice exits in engineering, law colleges and IITs. Many industrialists or professional experts are invited to give lectures, and many visits to successful industries / institutions are arranged. There is no reason why similar practice could not be started in medical colleges. Today jealousy and the bureaucratic stiffness are the only reasons why this is not practiced in medical colleges but it is high time we do so. The addition of honorary consultant in the unit will help to minimize the expenditure as well as to relieve the burden of increased workload in the hospital. Besides, they will be able to claim teaching experience and become eligible to be lecturers, associate professors or even professors at the end of ten years. The availability of such senior teachers will enable the teaching institution to overcome the acute shortage (of senior qualified teachers). It will help to replace 'old dead-wood' by fresh competent professors and associate professors. Thus, there will be three consultants including three resident doctors, and an honarary surgeon or physian in each sub-unit. Highly specialized emeritus professors can also help and guide the unit in their more complicated cases and impart deeper knowledge in complicated cases. As exphasized earlier they are not designated as teachers, therefore, they cannot set the question papers or become examiners. Beyond demonstrating and imparting their knowledge and skills to the students who desire to learn from them, they play no direct role in the mandatory medical education system.
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Yet they will contribute a lot to the standard of treatment and education in the medical college hospitals. The service will improve and the education will become more practically oriented. To me this step is as important as 25% paying beds in each unit. I do not expect Indian Medical Council to agree easily to such a modification. Technically and legally I see no reason why the Medical Council should object to the appointment of additional consultant doctor in each of the teaching unit. However, if council does object I feel it is time that the students, teachers and the management stand up and go to the court of law against the Indian Medical Council to support this system. QQ
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12
Working Pattern in (Med. College) Hospital
It is evident from all the discussion so far that to run a good medical college, it is absolutely essential to run a good hospital. The administration of the hospital, therefore, assumes great importance in determining the standard of education in the institution. Unfortunatley the importance of the ‘system’ or ‘management’ is not realized even by the very educated class leave apart the politicians and journalists. Individuals are blamed for shortfalls, but the system under which individuals are working is not even remotely discussed. So the blame falls on individual doctors if the services are poor. Occasionally individuals are glamorized if they perform something exceptional but the system of working which enabled the individuals to work properly is totally ignored, if indeed it was contributory. It must be realized that it is the system of working that promotes good workers or makes them to leave the institution and it is the system which gives a wide scope to the inefficient, corrupt persons if it is faulty. Therefore, we have to consider a little in details how the hospital works or must work. Every employee-and medical teachers or doctors are no exception-wishes to minimize his work and find idle space during his own working hours; though he wishes to earn the maximum. Minimum work for maximum salary is an accepted principle in the present scenario. The task of the management, therefore, is to work against this tendency and ensure that every worker gives his optimum, if not the maximum, output of the work
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entrusted to him and to offer him incentives if he gives more output than the average. Let’s look at the working of a clinical unit. Every unit has only one day in a week for attending the outpatients. Emergency i.e. serious patients coming out-of-turn for urgent treatment to the hospital, are also treated by the same unit on that very day. Thus, resident doctors and junior consultants remain busy examining large number of patients that come to the outpatients department, while at the same time they are called to attend to urgent cases admitted directly to the ward (or through the critical care units, if such were established in the hospital). In addition patients are referred from other branches, for example, the surgeon may be called to see a patient in the medical ward or a female patient in a medical ward may require an opinion from a gynecologist. The cross references are plenty everyday. Again the same doctors of the same unit attend to these references of other braches. On the surgical side small urgent operations like incision of an abcess or reduction of a fracture have to be performed on the same day in the evening hours. Some patients in the outpatients department may require small non-urgent operations and could be sent home without being admitted like a biopsy or removal of a cyst and so on. Again these operations are done on the same O.P.D. day after the O.P.D. hours are closed (the cards are given to the outpatients generally from 8.00 a.m. to 11.00 a.m. and the last patient is seen by about 12.30 p.m. to 1.00 p.m. Thus, the team is engaged with multiple duties on the same day. At the same time many patients are admitted from O.P.D. and yet some more serious patients are admitted as emergencies from Casualty department. Therefore, the day becomes too heavy as the patients are being admitted whole day long till 8.00 a.m. next day. All these patients as well as emergency cases must be examined and treated, their histories are to be recorded, investigations are to be done and so on. Therefore, the next day becomes heavy too. But for the next four days, the juniors and seniors in the non surgical units, have no other specified duty except a round of indoor patients which may last about two to three hours. So, they are relatively free on all the four remaining days of the week. In the surgical department there are two operation days in a week which keep them busy. But again at least two days remain when the specified duties are very few and
Working Pattern in (Med. College) Hospital
63
the team has a lot of time to spare. The senior residents and the lecturers are expected to take tutorials for the under graduate students and it is strange that they prefer the same emergency day for taking tutorials as ‘they have to stay the whole day in the premises in any case.’ Thus, the pattern of working has been made most suitable for the doctors but not necessarily suitable either for the patients or for the medical students. Seniors and residents are always busy, everyday, somewhere between 9.00 a.m. and 12.00 noon, when they take a round to see and decide the treatment of all indoor patients. The medical students too are given bedside clinics during the same hours right in the wards and as mentioned earlier, this is the main part of the teaching of the medical students. Nine a.m. to twelve noon is the time specifically reserved for indoor or outdoor patients and for teaching undergraduate students in the hospital. But there are many allied activities like clinical meetings, functions like hospital annual day, guest lectures by eminent professionals from other parts of the country or from the foreign institutions, or there are meetings of the various committees like Drug Committee, purchase committee with the Dean. Invariably all these lectures as well as administrative meetings and hospital functions etc. are all held in the morning hours somewhere between 10.00 a.m. and 12.00 p.m. it is exactly this time which is easily spared for any function or lecture or meeting etc. Afternoon hours are more or less left free, so every one retains these leisure 'working' hours. When described in details, it looks obvious that the working system is not proper and needs correction. The various functions need to be redistributed over the whole week. Yet I am surprised that enough attention is not given to change the system. In the modern days the need for hospitals is becoming less and less and many patients can be treated without being admitted. Such procedures are termed as ‘Office Procedure’ or ‘Day Care Surgeries’. Therefore, the outpatients department needs to be expanded a great deal. It is no longer just a room for consultants. There is a need to have a minor operation theatre or procedure room and a few beds to keep the patients for a few hours right in the OPD. If such a system is to be followed, it is obvious that the team of doctors attending the OPD cannot have any other duty like attending emergencies. There is
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also a need to group the patients and call them at different hours so that every one gets proper attention. For example, patients referred from peripheral hospital or primary health centre, dispensary etc. have to be given a specified time as they are refered by qualified doctors and from the same government administrative machinery. So it is advisable that patients coming directly to the hospital may be attended say from 8.00 a.m. to 10.30 a.m. while patients referred from various peripheral centres be attended from 10.30 a.m.to 1.00 p.m. Non urgent minor operations need not be rushed through on the same day. These minor operations can be conveniently done by appointment, on a day prior to O.P.D./Admission day. The team is relatively free after morning rounds in the wards and the patients will be easily followed up next day in the O.P.D.. Urgent minor surgical procedures have to be completed in the evening on the O.P.D. day as is the practice today. But this clinical unit which is attending to the outpatients department will not have any emergency duties nor will it examine any referred cases on that day. This way the team will also have adequate time to examine the cases which have been admitted as routine admissions from the OPD and write their history properly and plan their investigations. Emergencies will be attended and referred cases will be seen by a unit which has only the routine hospital round duty i.e. by the corresponding unit. For example. If ‘A’ unit has outpatients duty on Monday, ‘D’ unit will be on the emergency duty on Monday Again, ‘D’ unit will have OPD on Thursday and ‘A’ unit will attend emergencies. Mondays and Thursdays are corresponding days. This way emergencies will be looked after promptly and immediately because the team has no other specified duties. Similarly it must be a strict rule that senior residents or lecturers will not have any routine teaching programme like tutorials, demonstrations, lectures etc. on their OPD and emergency days. Tutorials will be taken in the afternoon hours, on any of the non – OPD / non – emergency days. Secondly it is unclear why the doctors of a unit are available to his O.P.D. patients only once a week – that too for just 2 hours. In private hospitals, consultants are available almost daily for the patients for their follow up treatment. So it is paradoxical that in the medical college hospital, the patient can see his own doctor only after one week, as there is only one OPD
Working Pattern in (Med. College) Hospital
65
day for each unit. This is intolerable. There is a definite need to have afternoon OPD clinics of about two hours twice a week for the old patients for their follow-up advice and treatment. This is especially needed in the medical departments, where they can have follow-up specialized clinics like ‘diabetes clinic’, ‘cardiac clinic’ and so on, in addition to the general follow–up clinic. In short, every clinical unit has multiple duties 1) OPD duty 2) care of indoor patients, 3) looking after emergency and referred cases, 4) formal teaching duties like tutorials, lectures etc. 5) writing histories and keeping proper medical records and 6) follow up of old patients. In the surgical departments, the unit has to perform actual surgeries a) minor day care emergency operations; b) minor day care routine operations; c) routine major operations on the indoor patients and d) the emergency operations. These duties and operations, must be conveniently spaced in the whole week so that the team is answerable to one duty at a time. This also ensures that the team is busy in its clinical work every day for all the working hours. As this increases the answerability of the team, clinical services are bound to improve a good deal without many modern equipments. Medical education would also improve simultaneously, if only the system is changed and accountability is increased. If 25% of the beds are reserved for paying class, obviously the seniors in the team will have their paying OPD clinic and operations in the evening hours, twice or thrice a week. However, they will not have any (private) paying clinic on their emergency day and only follow-up clinics on their operation days. No new cases on these days. They can see all new cases on any of the other days. In short, the specific duties of every clinical unit must be specified. No one can perform two duties at a time. If allotted multiple duties at the same time the answerability of any workernot only doctors-is reduced. Hence, the time table should be arranged in such a way that every one is entrusted with only one of the duties at a time. The brief pattern of duties is shown below :-
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Working Pattern in (Med. College) Hospital
Management of the Sick Health-Care System Tyfical Time-table of a Unit (Unit 1A) - Surgical
Unit 1A
8 am to 11 am
Monday Tuesday (Day 1) (Day 2) OPD Day Grand Round Gen. & refered OPD
Wed. Thursday Friday (Day 3) (Day 4) (Day 5) OP. Day Emerge Post. OP ncy Day Day
Saturday (Day 6) Winding up Day
Ward Round %
Ward Round & Clinic
Ward Round
O P
1pm 11 am to 1 pm
1pm to 2 pm 2 pm to 3.30 pm
4 pm to 6 pm
6 pm to 8 pm 8 pm to 10 pm
R Ward OPD New adm. Sp. Investig- procedure ation Minor Office Opera. & (Emerg) records e.g. abscess Private OPD (Consul.)
A
O.T. planning Ward Clinic
C I O N S
E
A
Follow-up OPD R G E N C
minor operation in OPD (Planned)
T
S
S I O
Typical Time Table of a unit (Unit 1A) - Medical Sunday
N S
Monday (Day 1)
Tuesday (Day 2)
OPD Day
Grand Round
Spel. Clinic
Gen. & refered OPD
Ward Round
11am to Direct Palnnig 1pm (Semi-Pay) Ward OPD Clinic 1 pm to 2 pm
E M R G E N
Sp. Clini follow-up
Unit 1A
By Rotation
E
R
Clinic M E
T
E
P
E
R Dieect (Sempaying) OPD
O
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C Y Day
Y
8 am to 11 am
Wed. Thursday (Day 3) (Day 4)
Friday Saturday (Day 5) (Day 6)
Sunday
Emerge ncy Day
Follow up
Winding up Day
By Rotation
Ward Round
Ward Round
Ward Round Clinic
Ward Round &
E M E
Ward Clinic
Clinic &
+ all records
R G E N
Follow-up Specl. O.P.D. Clinic II
C Y
2 pm to 3.30 pm
Minor Minor Special Procedure Procedures Clinic I (Emergn.) (Planned) +follow-up
4 pm to 6 pm
Ward New Adm. Investig.
6 pm to 8 pm
Private OPD (Consul.)
8 pm to 10 pm
E M E R G E N C I E S
Day
Joint P. G. Programs, Seminars & Discussions etc.
Joint P.G. programs, Seminar, Discussion etc.
Working Schedule (Major Departments) Unit 1
Routine Clinical work for general patients stops at 3.30 pm 4 pm to 10 pm reserved for private patients. 4 to 6 pm & 8 to 10 pm - Private OPD for other consultants from other unit Tuesday & Saturday - 5pm to 9pm Operation day for private patients - Unit 1 A Similar Timetable for all units
Sub-Unit 1A Sub-Unit 1B (Monday OPD) (Thursday OPD) Professor Asso. Professor Lecturer Lecturer Sr. Registrar Sr. Registrar 1st, 2nd, 3rd Year 1st, 2nd, 3rd residents Year residents
Unit 2
2A (Tuesday OPD)
2B (Friday OPD)
Unit 3
3A (Wednesday OPD)
3B (Saturday OPD)
(If need be, Hon./Part-time Asst. Surgeopn in each sub-unit In OPDone resident will sit with one consultant in each room.
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Management of the Sick Health-Care System
13
The Dean
The head of the medical college hospital is Dean. A person who holds the post of professor is eligible to compete for the post of the Dean after five years of experience. The Dean is an academic post. He comes from amongst professors who are expected to be masters in their own subjects. As I had discussed previously, these professors ought to be good either in their professional work or teaching or research. It is pertinent to note that the teaching staff does not have any formal training in administration. They do not attend any training course-not even a few lectures-to understand administration. The professor who heads the department i.e. senior most amongst professors in each department learns some administration out of compulsion because he is forced to take part in the administration. All this clearly proves that the post of Dean is an academic post and his primary duty is to promote good medical education, research and provide good medical services to the patients through properly supervised system of clinical practice. It is surprising, therefore, that such an academic person is suddenly forced to spend 90% of his time in purely administrative aspects of running the hospital. On the other hand, there are administrative posts in the colleges and hospitals like Assistant Medical Officer (A.M.O) or Assistant Dean. (now a days called Asstt. Commissioner) who look after all the administrative aspects. For them the ladder stops at the post of Asstt. Dean. They are not eligible to apply for the post of Dean. Similarly, now people are getting trained and qualified in hospital administration and/or business administration, and others obtain degrees in I.I.M.s. or do financial management etc. or become masters in administration. It is a crime to waste medical talent on the administrative duties which he normally does not understand fully and to waste the talents of qualified administrators by not
The Dean
69
appointing them to do the administration. Even in India, in Triruanantapuram, Kerala e.g. the Dean has his office in the medical college which is about 2 to 3 Kms. away from the campus of medical college hospital. The hospital campus is managed by hospital superintendent. In institutions like All India Institute of Medical Science (AIIMS) of Delhi or Chandigarh, the Dean is an Academic Head and is not burdened so heavily with the administrative duties. The hospital is looked after by another person. It is high time that the hospital management should be entrusted to the qualified hospital administrators; MBAs or even graduates from Institute of management. The problems and solutions which I am trying to emphasize here will be easily understood by the IIM graduate and they would easily surpass the ideas mentioned herein. The Deans, apart from the academic activities, should be involved in the administration only to the extent of major policy decisions like budgetary provision for each department, purchase of additional equipments for various departments either to maintain the present services or for expanding the services. Dayto-day routine administrative problems must be dealt with by the administrative person appointed for that purpose. He need not be a medical professional. What is true for the Dean ought to be true for medical superintendents in secondary care hospitals in muncipalities or district hospitals in the state governments. The medical superintendent ought to be concerned with the clinical aspects of administration namely, appointment, supervision and maintaining performance records of all medical and paramedical personnel. He has to plan the schedule of working, emergency duties, etc. of clinical departments, as also the need for more equipments for modernising the medical services. But all the purely administrative functions of the hospital like maintainence and repairs of buildings and equipments, electrical and civil work administration of the meniral and entire staff, salaries and leaves must be the function of an administrative officer who may be suitably called hospital superintendent or chief administrator. Similarly, the financial management of the hospital must be entirely relegated to the Chief Accountant or Financial Manager. The entire staff at the registration, billing and medicine supply counters must work under the chief accountant, In the
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Management of the Sick Health-Care System
government and muncipal set-up. The accontant in not answerable to the Dean and has almost the same independant powers as the judiciary has, in respect to the collector of the district. At present, this semi-independant authority of the accountant is playing more obstructive role than constructive role in the hospital management. They are not responsible for any short-falls in the services. Yet they have the full authority to raise audit objections for purchases - for that matter - for any expenditure proposed by the superintendats. I have already suggested, in an another chapter, that the registration and billing department should work under the accountant, so that the department will be responsible to show adequate collection of the charge from the patients. If the Dean or the superintendent is not answerable for the collection of the fees for medical services or the charges of investigations or medicines supplied, they will also be freed from the pressures from politicians and relatives to reduce the charge. And the chief accountant will become answerable to show adequate collection of charge on the one hand, and purchase of essential intems for clinical services on the other. The obstructionist will now become practical and constructive. Their answerability towards proper functioning of the hospital will increase. A major problem of successfully running medical services will be solved. QQ
71
14
Medical Curriculum
I would not go too much into the details about the curriculum for the undergraduates. Basically a student used to spend 1 1\2 year to learn normal structure and function of the body i.e. the studies of anatomy, physiology and biochemistry during the period of first MBBS. Another 11/2 year in second MBBS was devoted to the study of diseases of the body and drugs and medicines to be used for the patients – pathology and pharmacology. He also studied medico legal aspects in the subject of forensic medicine. The students are posted in the hospital in the morning hours from 9.00 am to 12.00 noon after the completion of the first M.B.B.S. for a continuous period of 3 years. They attend various departments as per the schedule recommended by the Indian Medical Council. It is here that they get maximum practical experience by observing patients being treated both in the ward as well as in the out patients department, through bedside clinics by the senior teachers. The knowledge of preventive medicine, ENT (Ear, Nose and Throat) and optholmology (eye disease) are studied in the 3rd MBBS during the fourth year while in the final examination 41/2 years later, the student appears for Medicine, Surgery, Obstetric & Gynaecology and Paediatrics. If the student passes the examination, he is excepted to work as an internee for a period of one year, working in the department of medicine, surgery, obstetrics and gynaecology and preventive medicine wherein he works at urban and rural health centres. Thus, it is long course of 51/2 years. There is a craze amongst experts of several new branches in the medical field to insist on including their portion in the curriculum of the M.B.B.S. course. Yet, despite criticism and shortfalls, and insistence of new branches to add to the course, I personally feel that the medical course as implemented for the last 50 to 60 years or more is quite adequate. Unfortunately the Medical
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Council has decided, of late, to reduce the first M.B.B.S. course to just one year. One year is too short a period to learn the normal structure and function of the body. The period gets shorter due to the fact that admission process gets prolonged every year and the students get admitted to the college as late as in September instead of in June. Thus, the period for the actual study of anatomy and physiology turns out to be hardly 7 to 8 months. Unless the basic knowledge of normal is sound, the abnormal cannot be grasped. It is the opinion of almost all teachers that shortening the course to one year for first M.B.B.S. is not adequate. It should be reverted back to 11/2 year at least. Secondly, the habit of condoning the shortfall in the period of education must be strictly prohibited. If the students get admitted in the month of September they cannot appear for the examination in the month of April of the next year and will have to appear at the next term namely October (or November). It is true that admissions are delayed for no fault of the students but the fact remains that the period of training was not completed. The same thing is true when the absence is condoned for final M.B.B.S. examination for reasons such as illness, strike and such other circumstances. It is unpardonable. Period of training as scheduled is the most minimum that is required to train him to become a good matured doctor. Hence prolonged absence due to any reason, however genuine, is not pardonable. The ill effects of partial training are finally suffered by the population at large. As regards the curriculum of the other branches of medical faculties-Ayurvedic, Homeopathic, Unani etc.. It is an established fact that most of them do practise allopathy to a very large extent. To some extent this has helped the community because 80% of the general practitioners now belong to these other faculties of the medicine. Therefore, it is imperative that their curriculum is adjusted to include atleast two years of allopathic medicine during their course. The exposure to the allopathic system for these students at present is too inadequate. Exposure to allopathy for two years would be akin to creation of a ‘basic’ doctor with the training which is much below the standard of M.B.B.S.; however, adequate for basic needs of the large poor population. The Indian Medical Council is strongly opposed to the idea of training an ‘inferior’ type of doctor and has thwarted the efforts of
Medical Curriculum
73
the politicians to create three years, four years programme at various times. However, the same council stands helpless when the graduates of the other faculties practice allopathy freely as mentioned earlier. Therefore, I feel that increasing their exposure to the allopathy for a period of at least two years is a good compromise-solution to the present problem of shortage of general practitioners for the community especially in rural and semi-urban areas. After completion of internship, the M.B.B.S. graduates are now compelled to appear for a common competitive test if they desire to enter into postgraduation studies and become specialists in various branches. Nearly 80% of the students desire to do postgraduation. Earlier there was no such competitive (C.E.T.) test and the students were selected as postgraduate students in various branches as per the marks obtained by them at M.B.B.S. examination. The competitive test has now added a new burden on the students during the period of internship. Actually this period of internship was the best time in the life of a medical professional; some ‘donkey’ work but almost no responsibility and no examination to face! It would have been the best time, when they could have been made to develope a deep interest in social and administrative aspects of clinical practice, so that they would be better prepared to face the competition in actual life and give proper service to the community when they are thrown into the field of medical practice as full-fledged responsible doctors. Men, money and material are the three ‘M’s, every body has to learn to manage to become a professional. A glimpse of training of financial and personnel administration and administration of medical store could have been usefully included during this period of internship, through lectures, seminars, visits to these departments and discussion with the officers in the various departments of the hospital – if only they did not have the burden of competitive tests. A good perspective about socio-economic conditions and the psychology of the people in rural and urban areas and of the poor and lower middle class would also help to make these doctors more sympathetic to the needs of the common man, through lectures by competent social workers and teachers in social studies. As I mentioned earlier, majority of students are now from the upper strata of the society and have very little idea of how 60-70% of the population manage to live.
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Therefore, I suggest that the competitive test (C.E.T.) should be taken immediately after M.B.B.S. – say within 3 months after the M.B.B.S. examination. The portion for the competitive test is not different from the portion for the M.B.B.S. test. The student has to choose the subject in which he wants to specialize. Therefore, for this test examination, three months period after the final M.B.B.S. examination is quite adequate. It would be an ideal timing when the graduate is quite fresh with his M.B.B.S knowledge and can take another examination easily in his stride. The management course and socio-economic awareness course can now be conducted in the remaing 9 months. Even the students are aware of the importance of the subjects I mentioned above, namely financial and personnel administration and socio economic aspects of society and most of them are very keen to undergo this training. There is no need to have any examination. If one is taken, it would be optional – for an individual to know the proficiency he has reached. Lack of knowledge of the socio–economic problems of the poor society is one of the root–causes of the alienation of the doctors from the masses; greed for money being the next important cause. However, there is an absolute and urgent need to introduce a post–graduate course in General Practice. Like the other P. G. courses, this course will also be for the duration of three years. Today, there is no special training for a general practitioner. Not only that, it is a gragedy of sorts, that those students who are unable to secure a post graduate seat in any speciality, finally decide to go in for general practice without any special training. No wonder, the most important primary health care remains the most neglected aspect of health care system. with more and more emphasis on 'super speciality modern medicine.' If specialization was provided for 'General Practice' - M. D. (G. P.) it is quite likely that good students with good marks would opt for general practice. Like all other P. G. students, these students also will have a three year residency program. In the morning hours, from 8 am to 1 pm they will be posted, by rotation, in various departments, like Medicine, Surgery, Ob & Gyn. Paediatrics Orthopaedic in one unit or the other, for a period of 4 months each and will have an option of choosing any three
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minor specialities for a period of 3 months each, like E. N. T., ophtolmolgy, dermatology, psychiatry, preventive medicine, etc.. Last 6 months, they will return back to general medicine. While attending these specialities, they will learn more about when to adimt and what is to be done after discharge as much as what is being actually done for the patients in the wards. Naturally O. P. D. and follow-up clinics are mandatory. And in the evening, they will attend attached dispensaries, from 4 to 9 or do a Night duty in the dispensory. Even ofter passing the M. D. examination and starting general practice, they could continue to work for a further period of 3 years in any non-teaching secondary care hospital. The society will gain a lot, if such matured doctors enter general practice after due formal training. Finally, I firmly believe that super speciality departments should have no place in the medical college premises. They hamper the flow of patients in general specialities. Also the general specialists develope a tendency to refer and push, even the cases that they could have handled easily. This tendency would no doubt, be curled to some extent, by evolving the charges for consultants, as mentioned elsewhere. It would be wiser to establish super speciality centres, close to but not within the medical college and hospital premises. QQ
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15
Referal System & Charging Pattern
Another important feature of the hospital system which is neglected totally is the way patients approach any hospital any time. There is no step-wise ladder, hierarchy while approaching higher medical centres as per the seriousness of the illness. Often the patients attend directly the medical college hospital or major tertiary hospital, but as many as 50% of these patients could have been treated more conveniently at secondary centres or even primary centres like dispensary or primary health centre. Ideally the medical college hospital or any tertiary hospital should get only referred cases from the vast network of primary and secondary centres established by government or private sector. I presume, it is so in developed countries. Thereby, the number of patients to be seen at the hospital is limited and adequate attention can be given to each patient. At present, not only there is an immense overcrowding, but there is no sense of guilt among the attending doctors. The residents, full time doctors and the public administration proudly mention that they treat 100 to 200 patients or even more per day in their outpatients department. None realizes that it is not a matter of pride but is a matter of shame that such a large number is compelled to attend the outpatients department during that short period of 3 to 4 hours just once a week. Neither the care can be good nor can records be properly maintained. The medical college hospital which cannot maintain proper records cannot be called as a centre of education at all. Therefore, there should be a system of referral for the patients to attend such hospitals. For example, in the city of Mumbai, there are number of municipal dispensaries. Many of them have very poor attendance. Then there are
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upgraded municipal centres and there are secondary care hospitals spread throughout the city. But not even 10% of the patients are referred from these secondary care hospitals or dispensaries nor is it obligatory that the patients must be seen only if referred by general pactitioners or peripheral centres in public sector or from private sector nursing homes. It is high time that such a system is established. It could be fully justifiable to treat a patient with nominal charges (or even free of charge) if he has been referred through the proper channel to the secondary or tertiary hospital. If any patients is not relieved within a few days in any acute condition or within two to three weeks in any chronic condition, the doctor at the primary centre must refer the patient to a consultant at the secondary centre or if the patient is considered serious enough directly to the tertiary centre i.e. medical college hospital or district level hospital. Similarly patients not getting relief at the secondary centre within a stipulated time or patient needing highly specialized, major care must be referred to the tertiary centre by the consultants of the secondary centre. Under the present circumstances, even the patient may be allowed the right to present himself to such a higher centre, if he is not satisfied with the treatment in the stipulated period. It could be further stipulated that patients suffering from specified diseases like cancer, symptomatic heart disease, burns beyond 25% or major accident cases with multiple injuries or internal injuries must necessarily be referred to the tertiary centre, after getting urgent life-saving treatment at whichever hospital he was seen first. Parameters for referral from one centre to the other can be stipulated as best as one can and they will get revised as years pass by, through review of data and experience. Such patients who come through the proper channel must be justifiably treated with nominal charges, as mentioned earlier (or even free, for the time being). However, many patients may not be willing to get treated at the lower centres and, therefore, would insist on coming to the secondary or teritiary hospitals directly. Such patients, even if they attend general OPD, must be charged about 50% of the charges as defined for the paying patients. Also if the patients are referred from the private sector, they can also be charged upto 50% like the patients coming directly. However, care must be taken that no patient should suffer delayed treatment in this system. Some
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administrative steps would be needed to fine-tune the system but suffice it to say that the system can be tuned to give adequate relief to the maximum number of people, with a periodical review to improve the system. year by year. Secondly from each clinical unit especially of the major branches like medicine, surgery, gynaecology, paediatrics, orthopaedic and ophthalmalogy, seniors could attend one such secondary centre once a week and a consultant from secondary centre could visit a single primary centre so that the primary centre is ----- attached to that secondary centre, so-to-say. Lectures from medical college hospitals could similarly attend up-graded primary centres once a week. If this is done, after major part of the treatment at the teritiary centre is over, many of the patients from that particular secondary centre could be referred back and then be followed up at that secondary centre without the need to come to the tertiary hospital. Such a pyramidal system will improve the medical services for the general public, as also will pave way to disburse the crowd of a tertiary centre to various smaller centres. Necessary clinical records at the medical college hospital can now be maintained more easily and, therefore, clinical reseach will also get boosted. Everybody gains and nobody loses. So far, all attempt to charge the affording patients in public hospitals have failed basically because the charging pattern was based on the income slab and it was impossible to determine the exact income slab of the patient at the window of registration. It also increased the work of the clerks, whose salaries and promotions were unaffected, whether they collected the charges or allowed the patient free treatment. Therefore, even when a patient declared his income above the stipulated limit, it was the very office clerk who dissuaded him and advised him to declare his income in the range of free treatment. The situation would change in the new pattern as suggested above. (a)the charging pattern has been developed as per the patient’s behaviour and his desire to get treatment out of turn. (b)There is a direct incentive for the senior consultants/medical teachers, if they refuse to treat affording patients in the general OPD and insist on their coming to the paying clinic and (c) The burden of collecting adequate income for the hospital can be put on the Accounts Section, by some steps. Basically, the
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main step would be that the staff working at the Registration Section, responsible for ensuring proper collection of charges will work directly under the Chief Accountant and the Chief Accountant will have a certain budgetary responsibility to ensure that a fixed percentage of the total budget of the hospital is collected directly from the patients who receive treatment there. This aspect need a more detailed discussion but it is a complicated lesson in management and hence, I am avoiding the detailed discussion on it. QQ
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16
Service Charges for Patients
When we think of the charges in hospitals for medical services, we must emphatically realize that there are two clearcut separate components in them. One is hospital expenses determining the hospital charges and the second is the charges of the medical expert / professional / specialist, the professional charges. Strangely the aspect of professional charges of the doctors is ignored not only by government institution but almost equally by charitable hospitals and private hospitals who give fixed salary to their specialist doctors. Actually, it amounts to the Marxian thesis of buying the labour (of the doctor) and taking the full returns of the product by the owner-the capitalist. The scheme does not work in this situation. Besides it is condemnable as far as any professional, be he a lawyer, C.A. or the like. Hence a look at the pattern of payment to the specialist doctors / medical teachers becomes imperative. First the principle must be accepted that there cannot be ‘free’ service from a professional. (Herein, we will restrict to the consultants / specialists / medical teachers). It is generally said that 80% of the doctors treat 20% of the affording, affluent population while the remaining 20% of the doctors are burdened with the responsibility to treat the remaining 80% of the non–affording population. What does it mean? Presuming that there are 100 doctors and 2000 patients. Eighty of these doctors are treating 400 people; the ratio of doctor : patient is 1:5 The remaining 20 doctors are treating 1600 people. The ratio of doctor : patient is 1:80 That means he treats 16 times more potients than the former. Presuming that the former charge Rs. 100/- per patient (These figures are for showing the proportion, not actual), for the latter, only Rs. 6 have
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to be charged per patient, as he is seeing nearly 16 times the number of patients compared to his counter–part treating the rich. In short, whatever be the average fees charged by the doctors of the affluent class, a mere 6% of that amount will give the doctor of the poor, an almost equal monthly income. Presuming that a little lesser income will do, it is difficult to digest that a patient cannot pay rs. 5/- in small towns, where middle class pays Rs. 100/- and Rs. 10/- in cities where the average private charges are Rs. 200/- per visit. Even if it is presumed that the ratio has changed, and it is now 70% doctors for 30% affluent class and 30% for 70% of the poor, the ratio rises to 15% of the charges by the former class, or a little less - Rs. 10 in small towns and Rs. 20 in cities. As mentioned and as will be discussed further in detail, there will be a good number remaining who must be treated free of charge, but in the case of these, some one else will have to pay the professional fees. Either the government or the many aid groups, trusts or N.G.O. s (including foreign NGOs.) or the students in the medical college must accept the burden of paying the professional fees. But in my opinion, professional services should never be free. They will be quite affordable to every one under the system, I am advocating. It is high time, medical and consultant associations condmn all so called ‘free medical camps’. They are farcical and no one gains, everybody loses. It is very important to give particular attention to the income earned by the doctor in public sector and maintain it at a comparable level, if not the same level, compared to the earnings of his conter-part in private sector. There is an immense job satisfaction for a consenscious doctor while working for the real needy ill patients. Besides these is a greater security and many long term benefits in paid jobs and hence, he will easily accept some difference in his monthly income. But if the difference is too much, they are bound to leave the public sector or the medical colleges and crowd the private sector. That is what is happening at present. Overcrowding of doctors in private sector automatically leads to unindicated investigations and operations, costly medicines given to the patients for favouring companies (for a price, of course), and all sorts of mal–practices seen rampantly to-day. It is not presumed that all these mal-practices would be totally corrected. They will be minimised to a significant
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extent, as the public sector grows healthily on the sound principles of management. The healthy growth of public sector will create a healthy competition between the private and public sector. Also, the contribution of the poor patients for their own health-care, in the form of professional fees of the consultant, will help to retain many eapable consultants in the public sector field. As far as the hospital charges are concerned, the poor strata, and the low income strata which largely seek medical services certainly need a lot of subsidy. Yet I maintain that the ser-vices should not be free, except for those below the poverty line, (after some sort of scrutiny and written exemption from an authorized person in the hospital). Nor should it be arbitrary, the so called ‘token’ charges, for they have no correlation to the actual expenses. If the ‘Gold-Card’ or ‘Smart – Card’ is issued to every citizen of the country, (a scheme which Mr. Nilekani (of Infosys fame) has been given charge of,) it will become very easy to decide how much subsidy who deserves. But there are two ways available even at present. Costing is not difficult. At least a crude costing exercise could be easily done for each of the services – O.P.D. visits, admission to wards, cost of X-rays and an average cost of standard routine investigations, and for operation and procedures. The new modern investigations like Endoscopies, C.T. Scan, I.C.U management will have to be individually valuated. The costs involve (a) cost of original set up including construction cost and purchase of equipments etc. for the first time (b) Annual costs including maintenance, repairs, and various taxes to government, electricity, water bill etc. (c) The expenses on general staff from sweeper, wardboy to nurses, technician and administrative staff; (d) specialized technical staff or specialized nurses in the case of all special modern equipments; (e) consumables, depreciation etc. and (f) the junior doctors (excluding the consultant / medical teachers, whose charges have already been dealt with) Of these (a) and (b) must be borne by the government. On the other hand maximum effort must be made to collect the charges of consumables and standard depreciation of the equipments. (e) This is the most minimum recovery of the total hospital expenses incurred, which must be recovered. Then
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depending on the socio economic status, the charges of (c) could be recovered i.e. costs of general staff and technical specialist staff, as also (d) as will be applicable to sophisticated equipments and procedures, in modern high-tech equipments and must be recovered. As regards (f) junior doctors, it will be considered later. In general, till this exercise is completed, at least 10% to 15% of the expenses in each section of services must be charged to every patient. The rest of the expenses be subsidized by the government. This is as regards taluka and district level hospital, the equivalents in mumbai and other large municipalities being municipal hospitals. In the case of medical college hospitals too, free treatment in the general ward must be abolished and the patients in the general ward must be made to pay proportionate charges. As stipulated earlier, the medical college hospitals should get as much subsidy as the patients in district hospitals. But in addition, the students pay about 30 % of the expenses incurred on them. For reasons to be discussed, the students should be paying, as much for their paying class patients (i.e. same as what they subsidise the general ward, in absolute figures). The charges for general ward patients then would be quite manageable. For those who can not afford there are many donor trusts, NGOs and religious bodies who are too willing to help patients in medical college hospitals or district level hospitals. As far as paying patients in medical college hospitals are concerned, it is accepted that the charges here cannot be and should not be equal to the charges in private sector. I have stated earlier that the patient who comes to the medical college hospital is particularly at a premium because of the presence of the medical students and the necessities of teaching and research. Also marketing in the public sector is very poor and hence they will not be able to compete with hospitals in private sector. They are expected to serve a relatively middle economic class, not elites or higher middle class. Therefore, these paying patients, too, deserve partial subsidy. Therefore, in addition to the partial payment by the medical students, subsidy equivalent to a) & b) should be equally justified. Besides, both general and paying class patients can get their investigations and therapy exempted (paid by the research company) if they agree to offer themselves for the research projects.
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In addition the doctors professional fees could also be kept at about 75% of the average fees in the private sector. Thus, there will be a fair reduction in the cost of health–care for these middle class paying patients and that will hopefully balance the grudge and handicaps of medical students examining them and a relatively longer stay in the hospital. Overall, the paying patient will pay about 40% less in hospital bill and also 25% less in professional fees. In short 1) free treatment should be abolished or at least minimized in medical college hospital as well as in all public hospitals : 2) all patients must pay some proportion of medical expenses, general ward patients must bear at least 10% of the expenses if not more. Such charge should not be mentioned as ‘nominal charge’ but should be strictly proportional to the full-fledged charge, as a fixed percentage. The public should be reminded that 90% expenses are subsidized and that the subsidy will be progressively removed as the economic condition of the population improves. 3) The investment required for the further expansion of the medical facilities to improve the services must necessarily be borne by the government or the Institution running the medical college. In summary the present pattern of administration of the public hospital and the administration of the medical college is extremely irrational. The system gives unwarranted concession or subsidy to those who do not need it and leaves a wide scope for corruption. The fees of the medical students should be based on sound financial principles and the charges of the health care provided in the hospital must also be recovered appropriately from each of the beneficiaries namely the patients, medical students and the industries and the government. Poor people will benefit more than at present and education will also improve immensely. The subsidy will be given exactly to those who need it and in exact proportion they deserve. ‘From each according to his ability and to each according to his needs’ is the first principle of socialistic society. The hospital will become viable, the competence of medical staff would improve and the society will reap long term benefits for the next 2 generations. QQ
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17
Supply of Medicines
In the private sector, nothing in free and the patient has to buy his medicines. Food and Drugs Administration keeps a control on prices and quality of the drugs and within its limited man-power and authority. it is doing a commendable job. I do not propose to discuss this aspect, as it covers a wide field of pharmacentical industry and the drug control by F. D. A. (Medicines includes orals and injectables or skin-application, dressings etc.) But in order to control wild prescription of costly drugsoften quite unnecessorily - I suggest that the "basic doctors, i. e. general practitioners should be prohibited from prescribing high-cost high-tech investigations, as well as high cost medicines and modern medicines introduced in the last 2 years. F. D. A. could be pursuaded to force the companies to mark these medicines as "To be prescribed by consultants only." The medical council and luckily the pharmaceutical companies are seriously considering a total ban on gifts, presents, conferences or foriegn tours, offered by companies to doctors as in inducement to prescribe such high cost medicines. It is a welcome step. Earlier it is implemented, the better. These two measures would hopefully reduce the unnecessary expenditure on drugs and medicines by the common man. In the public sector, the state govt. and the muncipal corporation buy medicines, through a process of tenders. A tender committee goes through the tenders and accepts the lowest compatible tender, for each particular medicine. As a professor of surgery and later as a Deam, I was a member of the tender committee of Mumbai. Muncipal Corporation and, I feel, the system of selection of drugs was fool-proof. There has never been a complaint about faulty supply of medicines,
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injectables in the B. M. C. in the last several decades. Despite criticisms, I am inclined to believe that the process is quite good in the government too. But the compulsion to buy only the lowest quotation, leaves all the doctors in the state with a choice of a single brand of any particular drug. It is advisible to accept upto 3 or 4 different brands, or all those brands which are close competetors in price and leave the option to various health centres to opt for any one of them as per their choice. The state will have a very marginal higher expenditure but the doctors will have some freedom to choose the brand they prefer. It will also reduce the chances of the item, becoming not available due to short supply due to any extraneous causes in the approved company like strike, disputes, mismanagement etc. There will be adequate alternatives available. However, the main difficulty in the supply, apart from lack of budget, is a highly centralised system of the state government. It causes long scrutinies and thus long delays in supplies reaching peripheral hospitals and primary health centres. Once the tenders are approved, the purchase procedure should be decentralised and the districts. if not the talukas–should be authorised to puchase and disburse the drugs wihtin the limits of their budget. The hospital should have the freedom to choose the particular brand from among the approved brands. This way the complaints would be reduced to a minimum. One great advantage of tender purchase by the state is an extremely low price that companies quote for such bulk purchases. Compared to their market price, medicines and injections are quoted, at least 30 - 40 % lower-sometimes even at half the cost - than the market price. Hence, the patients in the public sector will still benifit a lot, even if they have to buy these medicines at the public hospital. As stated earlier, the government or the municipal corporation gets these medicines at about 70% of the retail price-or even lower. Hence, selling at 'cost-price' still means 30% reduction in cost for the patient. I have aheady grouped the patients in 3 groups. i) These who attend primary health-centres or public dispensaries and are refered to secondary or tertiary hospitals. They have come through proper channels, and therefore are
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entitled to highly subsidised charges. A fixed charge of Rs. 2 per one day's medicines in villages and Rs. 5/- in towns and secondary hospitals would be chargeable to them. It could he 'free' for all those below poverty line. ii) Those who attend public hospitals directly or those who are refered from the private sector will pay the 'cost-price' actually incurred by the government or municipality companies can be asked to mark 'govt. price', along with M.R.P. on all supplies to the state. iii) Private paying class patients will have to pay the market price–M.R.P.. They can be given even 10% concession over the M.R.P., as an incentive to attend public hospitals. I have also emphasized that the whole section of medical supplies should be under the chief accountant. Thus the chief accountant will be answerable to balance the purchase and sale of drugs. If some patients below the povety line are totally exempted and others subsidised as mentioned, the accountant will be able to claim this subsidised amount from the government on paper, so that he can balance the expenditure with income. This will greatly reduce chances of pilferage and thefts. The doctors must be prohibited from prescribing drugs not quoted in the tenders. If required the superintendant is always authorised to make special purchase within some financial limits. Thus the supply of medicines will be more assured than before. Pilferage, thefts and unnecessory costly prescriptions will be prevented to a large extent and a part of the expense on drugs will also be recovered from those who can afford to the extend they can afford. In Summery a) High cost medicines and modern medicines introduced during the previous two years should be prescribed by consultants only. Basic doctors should be prohibited from prescribing these drugs in public sector. b) Tender committee should approve 3, 4 or more brands, which are reasonably close to the lowest quoted brand. It will ensure supply. c) Hospitals should be free to purchase any of the approved brand wihtin its budgetary limits.
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d) The process of purchasing should be decentralised to the district level–if possible even to the taluka level. e) Medicines should not be 'free' except for those below poverty line and a fixed charge of Rs. 2/- for village and Rs.5/for town-dwellers should be charged to all at primary centres and also in hospitals when they are refered properly from primary to secondary to tertiary health care centres. f) In hospitals, the patients attending 'out of turn' or refered from private sector should pay 50% of the the 'cost price', which the govt. / corp. has paid. Paying class should pay the market price. but can get 10% discount. g) The whole 'Suuply of Medicine' section should work under the chief accountant, so that the expenditure and the sale income is properly tallied. This will help to prevent pilferage and thefts. QQ
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18
Adequate Emopuments for Medical Personnel
The problem of inadequate salary for the medical professionals is discussed several times but inadequately attended to. The salary structure of any professional must be considered in the light of what another person in another field with equal merits is likely to get. This is termed as horizontal parity. In short, the salary should be some what similar to what his counter part with equal merit in the field of computer, I.T., engineering is likely to get. In the case of doctors as well as the legal professionals, this rule does not seem to be followed. The result is obvious. Doctors with good merits or skill avoid joining the medical service especially in the government. If at all they join, they aspire to gain additional income through clandestine practice of one sort or the other. This is not desirable, and everybody knows this. The government knows about these methods of clandestine practice but is unable to take strict and adequate action (a) because of its own laxity and (b) because it will be left with shortage of doctors if action is taken against them. Adequate salary and perquisites will not prevent all clandestine practice but will certainly minimize it. It will also enable the authorities to implement rules more effectively because there will be sufficient number of applicants waiting to take up the job, if a vacancy occurs. Doctors who choose to do postgraduation and therefore join major hospitals as resident doctors are paid even much lower salary, as ‘they are learning’. They are considered as 'students' and, therefore, they
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get ‘stipend’ not salary. The government makes another spaceous argument that it is spending so much money for their education. Both the arguments are very fallacious. A doctor who passes his M.B.B.S. examination and opens a dispensary right across the hospital and starts treating the patients without any supervision and guidance can collect far more in terms of fees from his patients, whereas the doctor who treats relatively more major illness in the medical college hospital and that too under supervision and guidance of senior consultant and therefore is likely to make less mistakes than his counterpart across the road, is considered a student. At best he is an apprentice. He spends his full hours of service in the hospital and that too for the kind of illness which is as grave as or graver than in general practice. Therefore, there is no justification to pay him salary far less than the doctor in regular service. Another dangerous argument is made and accepted by almost all without hesitation is that when he finishes his course and leaves the medical institution, ‘he is going to mint money’ – a most dangerous argument. The logic of this argument is, in fact, an open invitation for the doctors to exploit the patients as much as they like, after they become specialists. This argument should be thrashed even before it is uttered. Therefore, it would be in the interest of the society, if the resident doctors and the doctors in the public service are paid adequately and the residnts are paid, if not equally, nearly comparable to the salaries of other doctors in service. Another factor to be considered is the amount of money spent for the education. If it is presumed that medical student spends Rs. 15 lakhs for his entire course of education and if that is considered as loan, the E.M.I. (Equal Monthly Instalment) on Rs. 15 lacs even at a soft loan interest of 6 to 8 per cent would be not less than Rs.1000/- per lac (i.e. Rs.15,000/- E.M.I.). If the fees are lowered, and he completes the education with Rs.8 to 10 lacs, the E.M.I. would become 10 thousand and if his education was subsidized as suggested earlier because of his economic condition, his repayment would be equivalent to this E.M.I. Therefore, they must be compensated, to an equivalent extent, while considering their salaries. One would realize that the salary given to M.B.B.S. doctors and the residents as well as junior specialists are too low. I easily accepted the fact that the government cannot pay
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such high salary say Rs.35,000/- to 40,000/- to M.B.B.S. doctors and Rs.50,000/- and above for a junior specialist. But as I have emphasized again and again in my previous pages, the paucity of the funds with the government is due to their insistence on giving the so called 'free' treatment to every one. The government may give all other facilities free if it can afford but at least the fees for the doctors for their specialized services must be recovered and that should form part of the income the doctor could earn. In fact, repeated salary revisions (without adequate governance) have never helped. I have found again and again that services did not improve a bit, when fixed salaries were raised even to double or triple the original figure. In fact, if the salaries are raised beyond a reasonable limit, the professionals seem to slacken and become even more inefficient. The proportion of improvement in the quality and quantity of service to the salary paid is parabolic. When salary is low, services improve with better salary structure. But after the optimum is reached, the services decline when the pay is increased. It is, therefore, very essential that the professionals are given part of their income as fixed salary while the rest he will have to earn for himself, through properly devised incentives. The earnings of the doctor improve automatically, if and when he gives the better service. The doctors in public service (M.B.B.S.) level, should get, at the present level of prices and living index, at least 20 thousand per month to spend. Therefore adding the E.M.I. of Rs.10,000/for the first 10 years the salary cannot be less than Rs.30,000/p.m. The E.M.I. can be deducted proportionately from those who got subsidy or loan during their education for the first 10 years. As mentioned again and again the professional charges should not be free. A private practitioner charges about Rs.20/- in small towns, going upto Rs.50/- in bigger towns/cities (Mumbai is an exception where charges are even higher-) Hence, every patient could be charged Rs.2/- for first visit and for follow-up every weak in all primary centres, dispensaries etc. as professional charges while the rate may be increased to Rs 5/- in bigger places. In hospitals, the same amount on an average could be added in hospital charges and it will contribute towards the junior doctors salary. As mentioned, the resident doctors should also get an amount
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sufficiently close to their amount. I felt that the salary of 75% of that of service doctors would be justifiable, to be increased to 80% and 85% in the second and third year of their post graduate course. If they continue in service, these years should be considered for terminal benefits like gratuity, pension etc. The benefits of continuation of service should be granted to the resident doctors too. It must be borne in the mind that the government spends hardly 1.1% of G.D.P. on health while even small countries like Malasia seem to be spending 7 to 8% The suggested better payment to the doctors would not raise this percentage beyond 2 to 2.5% I expect. But that will give far better results than buying costly equipments at various hospitals, only to lie idle within a year or two due to bad management and inefficient doctors. QQ
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19
Nursing Homes
What is true of primary health care is almost equally true of secondary health care system. The glamour of complex knowledge and high technology of tertiary care system, coupled with aggressive marketing by the companies manufacturing these costly equipments, have easily diverted the attention of the socialites, the politicians and even the general educated population from the need to stabilise and improve secondary health care system. The very high cost of installing these high tech super speciality departments diverts the meagre funds available and thus creates shortage of fund for the much needed secondary health care. As mentioned earlier, in public sector, taluka and district hospitals in the state government and peripheral hospitals in muncipal corporations provide the secondary health care, while private nursing homes and medium hospitals and charitable medium hospitals help the affording class in the private sector. Nursing Homes cater to more than 60% of these paying class of patients. Individual consultants opened their small nursing homes to treat their own patients who needed indoor treatment and/or operation. They provided a minimum of 4 - 5 beds to a maximum of around 30 beds. The facility is created by buying one or two flats in residential buildings. So far, the doctors have proved to be poor management experts. The owner consultant has to depend on other consultants to see that his beds are occupied. Generally at least 60% occupancy is considered essential for a nursing home to run profitably. This dependence on other consultants, who had no monetary stakes in the hospital, increased their greed and ambition and made the owner agree to whatever they do and whatever personal charges they asked for, thus increasing the costs for the patients while lowering the quality of management. The family physicians started demanding a a
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percentage of the fees charged by the consultants or by the hospital. Naturally, this tendency is seen far more in metropolitan cities but has spread even to the small towns. But, even worse, these nursing homes are having a huge standing expense and gross under utilisation of the manpower and equipments. In the O.P.D. whether there is one consultation room or four rooms, a servent, a nurse and a receptionist has to be appointed. The operation theatre, could be utilised for hardly 2 - 3 hours, instead of its capability of 12 hours in two shifts. Even if the ward is empty, the number of resident doctors, nurses and menial staff can not be reduced. Thus, the owner consultant is forced to compromise quality in lieu of quantity. Untrained nurses, incompetant semi-qualified resident doctors, cheap equipmentsbe it suction machine, E. C. G. machine or X-ray or sonography machine are the order of the day in many nursing homes. Government is making rules and regulation which the nursing homes are unable to follow and the various inspectors are making hay while the sun shines. The whole burden of this mismanagement and bribes falls on the patients who are, thus, paying exorbitant charges for a poor quality of treatment. The remedy is quite simple and very effective; if only 8, 10 or more consultants were to join together and create their facilities, the problems could be solved both for the owner as well as the patients. O. P. D. consulting rooms, investigative facilities, operation theatre(s) and intensive care unit can be established as a common property the expenses being shared equally by all. Naturally, the profit/earning will also be shared equally by all. All the space, equipments and manpower would now be fully utilised by their own patients. Hence they need not compromise on the quality of manpower or equipments which they can easily afford now. There is no dependence on 'other' consultants any more. Even the general productioners will be more sub-dued, as patients would always prefer a well equipped hospital with adequate facilities and trained staff, irrespective of what their G. P. s advise. The ward and the beds could be independent or shared as per what the owners prefer. Together they could buy 4 to 5 or more storied, one wing of a building, with a separate passage, stair-case and even a parking space for themeselves, as decreed by supreme court recently. Instead of begging for attachment in some major charitable or private institution, they
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would have created their own secondary care hospital, where they have a role in management too. The patients will get not only better quality of treatment but it will be cheeper too. Everyone gains and nobody is a loser. Why is it no happening? First is a techincal / legal sgag, at least in Mumbai. The municipal corporation allows the change of use, for nursing homes only on the ground and first floor but not above that level. It may not be difficult to convince the authorities, to allow a whole wing upto 6 th floor to be converted into a mini hospital, provided that their is not a single residential flat in that section. This change of rule is absolutely essential. But the consultants are reluctant because, a) Natural inertia–people like to think and act as per existing tradition and are most reluctant to any new line of thinking. In fact, inertia is defined as 'a body remains static. unless forced to do otherwise', and 'force' is definied as the energy. 'that makes the body move.' b) Consultant doctors are high intellectuals and are highly sceptical and suspicious of each other. They can not come together easily. There are a few sporadic cases in Pune, Bangaluru etc. where doctors have successfully combined to establish their own hospital but they are exceptionally few only to prove the law. Hence, they will have to be forced. Financial contraints and even increasing obligations of new regulation are making some of them to think. Stringent application of rules and insistant expectations of people for good standard of treatment would go a long way to make the doctors act faster. Mandatory display of hospital charges and a system of accreditation (topics which are discussed later) will surely force the doctors to abandon their present single owned nursing homes, in favour of joint venture of establishing a proper hospital. Suffice it to say here that STABILISING AND IMPROVING the secondary and primary Health Care System is the need of the hour not the glamorous high tech tertairy Health care 90% of the people do not need tertiay care. QQ
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20
Health Insurance
It is true that the cost of health care is rising year by year and it is difficult for the common man to meet the expenses; if ever he suffers from any major disease requiring admission and/or operation. It may be difficult even to the upper middle class to suddenly take out Rs.1,00,000/- to Rs.2,00,000/- or sometimes even more when illness strikes. One possible remedy is to think of it and provide for it. Health Insurance – popularly called as ‘Medi claim’ is the right step to provide for the expenses of the health care under the Health Insurance Scheme. A person pays a fixed amount per annum for himself and for his family which ensures the payment of total expenses of say rupees one lakh to rupees five lakhs as per the insurance premium he has paid. Not every one needs hospitalization. If one out of 200 people is likely to fall ill and if the expense for his treatment is Rs. 1,00,000 (One lakh), but everyone pays a premium to share the risk, then the premium for each of these 200 people will be Rs. Five hundred only 1,00,000 ÷ 200 = 500. This is a simplified explanation of how the rate of the premium is calculated. Nevertheless, it proves that the premium to be paid is far less than the actual bill. On paper this appears to be a complete solution for the financial difficulty of the common man about paying the hospital bill. But in practice it is not so. The Health Insurance Scheme, as practiced, suffers from many lacunae. Most important lacuna is that the health insurance policy excludes many diseases with a list of 13 types of diseases like birth-defect, pregnancy and most important pre-existent diseases under the terms of medi-claim policy. The insurance companies stretch to a limit this last exclusion namely ‘pre-existing disease’. For example, if a patient has blood pressure and after some years he suffers a heart attack, the insurance company is likely to deny the benefits of the policy by claiming that the heart attack was due to high blood
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pressure which was a pre-existing disease. Luckily recently the courts have come down heavily on such over-stretched interpretation of the rule of “pre existent disease”. So nowadays major diseases that could arise from the pre existent diabetes, hyper tension etc. are not excluded as pre-existent diseases, if the major illness occurs after 2 years. It is a welcome step. There are companies which allow treatment even for the pre-existent diseases, after certain stipulated period, say 1 year after the pre existent disease was detected but the premium is raised stiff high. But the most important defect in the present system of health insurance is laxity of the patient himself. He feels secured that he is covered for a big amount of the bill, say rupees five lakhs. The immediate tendency of the hospital and the consultant is to raise their charges by making them double or even more than what the uninsured patient pays; even though most institutions and most consultants will deny this. Even the companies seem to presume that the bills are inflated and, therefore, almost all the health insurance companies object to the anticipated bill and try to reduce it as much as possible. This, in turn, makes the hospital issue an inflated anticipated bill and the vicious cycle continues. The patient himself remains unbothered initially as he feels that he is covered by insurance and does not object to the inflated bill. But he forgets that in case of second illness he may not be left with any balance amount to pay for the second bill and that his next premium is likely to rise. But more importantly, as the patient is insured, the consultant and the hospital tend to investigate the patient more extensively and prescribe costly drugs even if it was not so imperative. The patient is, in fact, happy because he thinks that he is getting a better check up through many investigations done on him. This is the most important reason why the expenses of treatment become high under the Health Insurance Scheme. Very soon, over investigations and prescription of ‘latest’ costly drugs/procedures becomes a habit for the consultants and the hospital is only too pleased with this trend. In order to prevent the practice of inflating the bill or to prevent the shock of unexpected high bill for the patient whether he is insured or not, the Medical Council of India had issued an order that charges like bed charges, operation theatre charge, fees of the doctor, surgery charges, investigation charges should
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all be displayed in all hospitals. Medical fraternity strongly objected to it and ridiculed this directive which, according to them, was comparing medical practice with a grocery shop. The Medical Council and the government are not insistant anymore. But to me it appears, that this was an extremely important step to curb the practice of raising opportunistic bills either because the patients are not so knowledgeable or because his expenses are reimbursed under company rules or health insurance. It should be noted that the Medical Council did not specify any pattern of charges. Therefore, while one consultant charged Rs.200/- for consultation, another was free to charge Rs.500/- if he so decided. Insistence was on declaring whatever are the charges, so that the patient is forewarned about likely expenses. There was no plausible reason to object to the displaying of charges and in my opinion the government needs to implement this directive very strictly As explained earlier, the tendency to over investigate or overtreat will not be resisted by the patient, even if the charges are displayed. Not only the patient does not object but he is somewhat happy that he is getting very ‘thoroughly’ investigated and is being treated with costlier (meaning best of the) drugs as long as the bill does not exceed the amount for which he is insured. Ideally it is necessary that the patient should critically evaluate both the needs of the investigation and the treatment as also compare the cost incurred, with costs in other hospitals. This is impossible under the present system. However, the patient will critically evaluate the need for the various investigations and the need for costly drugs, at least to some extent, if he has to pay some part of the bill. The best insurance policy, therefore in my opinion, would be the one which will cover upto 80% of the bill and the patient will have to pay 20% of the bill from his own pocket. Coupled with the insistence that all charges must be displayed in the hospital, this step of making the patient pay directly, from his own pocket, atleast 20% of the total bill will help in curbing the tendency mentioned above. That in turn will also help to reduce unnecessary investigations in other patients to some extent. Health care will become a little cheaper than at present or the annual insurance premium will come down. Health Insurance for the poor and Elderly Worst effected are the elderly and the poor. The health
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insurance does not help all the people. Health Insurance companies refuse to insure any person above the age of 50 years/ 55 years at the most. The health insurance is not available to any elderly person above age of 55 years unless he has been insured for his health from the earlier age of his life. One lesson to learn is to insure one's health almost on the day one starts earning. The insurance premium at that time is pretty low and worth paying even if one is sure that he will not need any hospitalization. Similarly the poor are greatly handicapped. Even though schemes are announced for the poor wherein the poor people can pay about Rs.300/- per year or Rs.25/- p.m. to get covered for the expenses upto Rs.50,000/- these schemes are not put into practice by the companies. (such an insurance policy was announced during Mr.Vajpayee’s regime), In fact, a circular was issued to the Insurance agents not to accept any policy for less than one lakh rupees even while the circular mentioned above was announcing the scheme for the poor. So, even if the poor man wishes to insure for his health it is impossible for him to do so. Only those who can pay a premium of more than Rs.2000/- and going up to Rs.8000/- to Rs.10,000/- for getting insurance cover of one lakh, can take advantage of health insurance scheme. For 60% of the population in our country the Health Insurance Scheme is not available at all. This needs to be corrected. Though I have repeatedly suggested the measures to bring the expenses of health care down, I must say that making the health care cheaper is not going to be a very easy task. Measures I have suggested might help only partly to bring the expenses within the reach of common man. It is therefore, imperative that the government itself works out a scheme akin to the health insurance, collects relevant health cess from every one above poverty line, as also from elders above 60 years of age and arranges to pay for all these people through its own health care scheme. Families below the povery line will have to be registered separately and given insurence cover. As emphasized again and again, free treatment is not a solution but payment done through health care scheme would be a much better way of ensuring health care to the needy. The servicecharges suggested earlier will have to be paid to the hospital by each patient but now these will be made through government
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insurance scheme, if not from private companies. Consumer Protection Act v/s Cost Reduction However this also would become difficult if the health care continues to remain as costly as it is today and further efforts are necessary to see that the cost should be reduced. I believe that there are enough number of doctors in the society who have a sense of social responsibility and good conscience and all these doctors would be eager to see that the cost of health care is reduced. They would be willing to avoid unnecessary investigations-especially the costly ones and try simpler medicines and/or perform operations without using the high-tech equipment, so that the cost of treatment can be reduced substantially. As mentioned in the chapter of medical curriculum, if social awareness is created amongst students during their internship programme and throughout their post-graduate studies, the number of such doctors would definitely increase – provided that doctors', own emoluments are not reduced drastically in the name of economy. One cannot get a good professional for low cost but a good professional can definitely reduce many other costs because of his deeper knowledge of the subject and sympathy for the patients. But the greatest impediment to all such doctors in their attempt to reduce the health–care cost is the Consumer Protection Act made applicable to the medical profession. However genuine the efforts of the doctors, avoiding modern investigations or avoiding costlier drugs or high tech equipments can definitely result in a failure in a few cases. In many of these cases, where treatment fails, the failure may not be attributable to the avoidance of these costlier methods. It may be purely incidental and stastically the results of such conscientious doctors may even be better than the results of those doctors who freely use high tech investigations, high tech operative equipment and costliest of the drugs. For example, while I was In-charge of Trauma ward as professor of surgery, I treated several cases of head injuries without the use of any high tech equipments. I merely used some logically simple methods of treatment of unconscious patients. My results compared well. In fact, they were a little better than the results in the world literature for the same severity of the head injury. C.T.Scan of the brain was avoided in more than 50% of the cases. Yet C.T.Scan not done
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on any of the patients would now be considered as a serious lapse in the management in a case of head injury. Actually, C.T.Scan is merely an investigation and the transport for C.T. Scan itself can cause dangerous complications but in the eyes of the people and even judiciary, it has become part of the treatment because of the powerful marketing of high technology and the views of elite experts. Therefore, not doing a C.T. Scan for the case of head injury could become a sufficient proof of negligence. Even today C.T. Scans in cases of head injury are avoidable in more than 50% of the cases of head injury but who will dare to refuse to do the C.T. Scan test, only to be held up for negligence in the consumers court under the consumer protection Act ? The consumer protection act was enacted to protect the consumer’s right of compensation if the promised qualities were not provided in actual use after he purchased any useful article for a price. Deficiency in service was compensated under the consumers protection Act. Unfortunately the treatment given by the doctors to the patients was also considered “service” and the patients became entitled to sue the doctors for the deficiency in service and claim compensation. Doctors started insuring against the medical negligence claims. These insurance policies are called ‘Professional Indemnity Insurance’. Even though such a policy does relieve the doctor from the burden of paying the compensation, it does not relieve him of the severe stress in his day-to–day clinical practice as also from possible disreputation he gains in the society, as and when such complaints of negligence are publicized in the press. Thus, doctors go into a defensive shell by advising more investigations, calling more specialists or super specialists, giving more drugs or costlier drugs or using high tech equipments which are presumed to be safer than the old styled equipments and procedures. Everything adds to the cost of health care. There is a further addition of the premium of professional Indemnity Insurance to be recovered from the very same patients. In U.S.A. I met a team of 3 orthopaedic surgeons, who together paid a professional indemnity of 2,50,000 dollars per year i.e. 80,000 dollars per head merely to protect themselves and that was more than 20 years back. Naturally the consulting and operation charges got revised upwards proportionately for the patients who were treated by the team. The ill effects of such heavy health–care
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costs have now become evident in U.S.A and most low income population is virtually denied any heath care service there. In fact, president Barack Obama has won his election with one of his main promises that he will give affordable health care to the common man. Yet we are going in the same direction. The application of consumer protection act to medical practice has become counter productive. A team of workers in social sciences studied health–care in U.P. and Bihar and found that 40% of those who were admitted to major hospitals for major illness went below the proverty line, at the end of hospitalization. Luckily the Supreme Court in a very recent judgement has come down heavily on the complaints of negliegence against the doctors and declared that…. “Doctors will not be able to treat patients freely and conscentiously, if they are burdened with such litigations. Doctors cannot assure that patient will be cured and adverse outcome or error in the judgement, cannot be considered as negligence.” At the same time it must be considered that some patients have genuine reasons to complain. They are inadequately attended and inadequately treated but such negligence can more easily be defined. Not attending the patient when the patient was serious and/or when juniors in the hospital had reported that the patient is serious, or not taking simpliest of the precautions or using entirely wrong method of treatment are all obvious causes of negligence and the patient has a right to complain and seek justice. This is criminal negligence and the patient can sue the doctor under criminal law, since a long time. However, if he decides to avoid costlier methods of management, the doctor must explain to the patient the reasons why he thinks them avoidable and record the same in the case notes. Therefore, he should be fully protected, if he reasonably proves that the patient was explained the pros and cons. Secondly the doctor must be fully protected if he keeps adequate record and proves that under the course of management he adopts, his results for similar disease with similar severity are comparable statically with the results of the other specialists, or results in the literature. In short, statistical proof of the successrate by his method of management should protect him fully against any complaint of negligence. As yet there is no evidence that courts have accepted such statistical proof, nor has any one offered such a defence in any case within my knowledge. But this
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idea needs to be propagated and adopted. The conscentious professional doctors will thus be encouraged to try cheaper methods of treatment and bring down the cost of heath care. Alternatively it would be much better if the law was made applicable optionally i.e. the patient may be allowed to opt out voluntarily from the application of the consumer protection act and promise the doctor that he will not enter into any litigation over the decision and methodology adopted by the doctor in the treatment of the patient. He will still be entitled to complain against gross negligence as mentioned earlier. Such voluntary rejection of the consumer protection act by the patient will go a long way in freeing the doctor of the hidden fear of litigation by the patient which in turn will help in reducing the cost to a remarkable extent. It must be realized that most doctors are equally or even more worried about failure of their treatment or of any complications. There is no need to add panic to his tension. Personally I am convinced that, in most illnesses, the patient can be treated with nearly ½ the cost (or may be even less) without materially affecting the result. Most of the time, there is sufficient time to switch over to the modern methods, in the few cases where this simplier line of treatment fails; so that not much harm is done even if the first line of approach fails. At times unexpected complications do develop without anybody’s fault and the patient dies or becomes handicapped or his expenses mount sky-high. Immediately the blame-game starts but leads to nowhere. The out-burst of the relatives is understandable, as apart from a huge financial loss, they suffer a big emotional shock, especially if the patient was an earning member in the family. Dr. R.D.Lele had suggested that in such cases instead of litigation, there should be “a no-faultcompensation” that may be paid to the family through certain funds created by the hospital or government. These incidents are indeed very rare. Therefore, if only 5% excess bill was collected from each patient and all that money was deposited for this ‘nofault compensation’ scheme, the families who unexpectedly face such disaster would atleast be financially compensated. I think the scheme of this sort is worth being considered seriously. In short, Consumer Protection Act has become a greatest obstacle in reducing the cost of health care. The fear of litigation has compelled the medical professionals to go for more
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investigation, more reference and costlier methods of managements, than what he would have done normally. If this obstable was removed, atleast socially conscentious doctors would try to avoid unnecessary expenses and give affordable treatment to the common man. At the same time sufficient protection can be given to the patients (a) for unexpected adverse result and (b) against gross negligence by unscrupulous or incompetent doctors. The risk of patients falling in the hand of incompetent doctors can be further reduced by some more administrative methods such as... (1) defining role of various ‘grades’ of doctors like general practitioners, specialists and super specialists (2) accreditation of the medical centres i.e. dispensary, diagnostic center nursing home and hospital etc. Research on Cast Effective Clinical Practice Medical science is progressing very fast. Now, there is no part of the body which can not be mapped and/or seen. C.T. scan and M.R.I. can show the structure of only organ and any distortious therein. Endorcofric instruments can visualise not only the gastrointestinal and genito-uninary tracts but can now enter bloodvessels and perform carrective procedures. Knowledge of stemcells is helping to create healthy tissues to replace diseased ones. Minutest quantities of enzymes and other bio-chemical ingredients of the body can he detected to diaguose various diseases, like Dancers of their very onset, and Lazers and rediation can destroy the unwanted cells. High-grade technology is enabling handicapped persons to move their antificial limbs or even their own paralysed lumbs. Babies can be formed in the laboratory and transported across the world to the placed in some-body's womb. The news-papers and television media are widely showing these miracles of modern science, all over the world and thus are creating a fond hope in every mind that their 'incurable' disease may be cured now. What is forgother is that all these modern inventions cast lakhs or even millions of rupees, to treat a single patient. But the 'Market of these hightechnologies is very aggressive. The specialist doctors, and the upcoming generation is too enamoured by these inventious and even the political leaders are led to believe that the society will benefit by adopting all these new technologies. 'We will fuid the money' 'money is no problem' are common pronouncements
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heard from them, when the purchase of these 'State-of-art' technologies is being discussed. But money is short. The state spends only 1.1% of the G.D.P. of health-even if it is prosurmed to be spending 5% as was reported recently, the amount will fall dismally short to cater to the primary and secondary health-care needs of the average citizens. Yet high-tech-equipments are purchased both in public sector and private sector. The aggressive marketing of these, and the general attraction of the average health-conscious population results in massive usage of these equipments, with heavy expenditure for the patients, but not necessarily with better results. Most often there is a grass abuse and the ultimate results are same or even worse than before. The patient may or may not have benefited but the family was definitely ruined. This grass abuse of modern equipments and modern drugs ought to be embed. But it is not going to be easy. It is a fight against the stream. There is an lugent need to initiate research as to when and where the use of these 'modernities' is not at all indicated, when and where the picture is hazy and its use is, at best, doubtfully beneficial and, therefore, the limited field when and where the modernities are definitely useful. The research of this kind will establish the 'Limitations' or 'uselessness' in the use of every modern investigative and treatment modality, especially when they are very costly. The research will thus offer complete protection to those specialists who limit these uses, and save costs to the patients a type of protection that will stand, in the count of law, of complaint of deficiency in service was lodged. I have prefered to call this 'Research for Cast-effective Clinical Practice.' To site an example, repeated C.T. scans in a case of head-injury is quite unnecessary. In fact, if a patient rapidly improves in his level of uneousciousness or if he was not unconscious at all, C.T. scan may be hardly needed. The patient, however, needs close clinical observation. Similarly, there are enough case-records in the world literature, to prove that some of the cheaper combinations of chemo-therapentic drugs are as effective as the newer costlier drugs. In every clinical field, cheaper alternatives are often available but convencing data has to be re-established by proper research methods to convence the practising doctors to boldly go against the stream and adopt the cheaper modalities of treatment.
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Who will fund such research activities? Obviously, the 'market' would be least interested in promoting such a self-destructive activity. The 'Elite' consultants and superspecialists are most likely to denounce such research, as 'playing with the lives of the poor people'. The central government has established Indian Council of Medical Research' I.C.M.R. to promote research but the chunk is taken away for research on 'modernities' or for 'fundamental research.' Thus, only the State government with a political will or a socially conscious large trust can initiate such a research activity. It is time that the state government should provide a large fund under state council of Medical Research and promote such an activity. A Journal of cost-effective clinical practice will be a natural out-come and will propagate ideas to effectively control the costs of medical treatment for the poor. Publications in this journal will compare the results of different protocols of treatment including investigations, in the same disease with similar sevenrity, with comparision of the costs incurred. It will help practsing consultants to choose cheaper methods of treatment–at least for their non-affording patients. Similarly, costs can be reduced by better administration, and fuller utilisation of the facilities provided in the hospital. This aspect is allowed to elsewhere again. Publications about successes in reducing costs by management techniques will also help the un-initiated hospital managers to try the 'new' management methods. The maximum retail price (M.R.P.) of the same drug manufactured by different companies varies as much as 3 times or even more. This discrepancy has been reported in the media–but very rerely. The Journal of cost-effective clinical practice can keep on high-lighting these discripancies–and even the response of the coampanies. That will create a healthy delete. All these methods of cost-reduction-without materially affecting the final results-can be initiated and widely published– only if a -cost-conscious' state governments allots a substantial fund, under the state council of Medical Research and pays the chief research officer adequately. I hope it will be done soon. QQ
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21
Accreditation
First let us look at the system of accreditation of the medical service centers. Today any doctor can admit and treat or perform any kind of operation in any nursing home or hospital without any regulations about the needed facilities. Some doctors perform procedures even in their own dispensaries. There are no rules laid down in this respect. Many patients have suffered serious consequences due to the inadequate facilities compared to the severity of the procedure. Sometimes there do occur sudden deaths but very often the patients develope grave complications in these inadequate nursing homes and they are then hurriedly transferred to some higher center for further management. It is possible that a lot of damage has already been done before the patient reaches the better center. The results are disastrous or the expenses unbearable. This definitely amounts to negligence but it is difficult to prove negligence as no rules are laid down and most consultants and hospitals would plead that the case was not, in fact, so difficult; it was manageable in their hospital even though facilities were a ‘little’ inadequate, and the complication was unexpected. In order to prevent such incidents, a system of a accreditation has been established in developed countries. Accreditation means that each dispensary, diagnostic center, nursing home or hospital is graded depending on various factors like space available per patient, investigative facilities, emergency facilities including Intensive care unit (ICU), the caliber and proportion of nursing staff, technical staff, menial workers compared to the total number of beds, the qualification of all the staff including the specialists and so on. It is like designating hotels as 3 star hotel, 5star hotel etc. Unless specific facilities are available, the hotel cannot be designated as 5 star hotel. Similarly unless full facilities and fully qualified staff in adequate proportion and fully qualified
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consultants are available for the patients that hospital cannot be termed as 5 star hospital. Officially there is no such designation as 5 star hospital but general public itself uses this nomenclature for many of the top class hospitals in the city. Under the system of accreditation, they may be termed as ‘A’ grade hospitals or some such term. It is not necessary that every health care service center be ‘A’ grade only. Under accreditation there will be official designation of the grade of each hospital or nursing home or a diagnostic centre or even a dispensary. The idea of accrediting the health care institutions has been mooted several times in the last 20 years but it has not been effectively implemented. One reason of course, is the total apathy of the government which is extremely reluctant to increase its own workload and apathy of the general public who do not realize the importance of accreditation for their own health. On the other hand, the health care professional as well as the managers of heath care centers are also scared of the accreditation system, though this fear is not openly expressed. One fear amongst the health care providers is that after accreditation system is introduced, those with lesser facilities might be derecognized or banned and thus they will be thrown out of the profession. This fear is totally unfounded. The aim of accreditation is not to derecognize any institution but to grade it so that people at large would clearly know about the adequacy or the inadequacy of the facilities in the hospital or nursing home where they seek medical assistance. Of course, not all the consultants and medical centers have this fear. In fact, most of them will be very happy not to accept any risk, even when the patients in blind faith try to compel the consultants to treat them at their own centre–despite inadequate facilities. Today such conscentious doctors are put under great pressure by some patients, who want to get treated there either because of faith or because these centers offer low cost treatment. But the very same patients turn around to abuse the doctors and the hospital for the inadequacy of the hospital and sue them for medical negligence under the consumer protection act, if the result is not satisfactory. So for most of these conscientious doctors accreditation would be a boon as they will be able to refuse such high risk cases or take consent of the patient and relatives in writing that they are willing to take their treatment here despite knowing the inadequacies of the center.
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Thus, only a few of the unscrupulous consultants or hospitals would be unable to continue their unscrupulous practices. The hidden fear in the minds of institutions or consultants in these medical centers which do not have full facilities is that they will no longer be able to treat all the major or serious cases as they are doing at present. There will be a natural restriction on their accepting each and every case that comes to their centers. They do not appreciare transperancy due to their greed. Thus grading of all the medical centers would be beneficial to the doctors, to the health-care centres and will also benefit the public at large. They would now know where they are going and the relative limitations at that centre and will, therefore, be able to choose right type of hospital for themselves. Similarly very small centers like dispensary, OPD polyclinics and diagnostic centers will now be compelled to keep certain minimum facilities like oxygen and emergency kits ready at their centers for the unexpected complications that can arise during the management of the simplest of the diseases. They will have to keep adequate paramedical staff also as per the standard prescribed. Therefore, all in all, the chance of negligence will be greatly minimized if each and every center is graded and it is made compulsory that hospital or medical center must display their grade prominently at their centre. Define the role of each category of doctors The role of different doctors is also not properly defined. As mentioned earlier there are non-allopathic doctors as also some old-styled diploma holders (RMPs) who practice allopathy. Their exposure to allopathic training is poor. Therefore, I compared them to the bare foot doctors in China. I am sure this comparison will not be liked by all the non-allopathic faculties but the fact remains that they are not adequately trained compared to their MBBS counter parts who can be called as ‘basic’ doctors, fit to be family physicians or general practitioners or assistants in hospitals under different consultants. Then there are specialists and super specialists. In addition there are some paramedical professionals who are now–a–days claiming to be doctors and are in fact officially allowed to treat patients in their own speciality. There are physio therapists, dietitians, clinical psychologists and so on who can independently practice in their own special field.
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The role of each of them is not well defined and it is extremely common to see each of them intruding into the sphere of the others. Several non–allopathic as well as MBBS doctors ask for investigations like C.T. Scan, M.R.I., Angiography and multitude of costly specialized blood tests as they proudly equate themselves with higher categories in knowledge and ‘experience’. They are also seen prescribing the costliest of the drugs or the latest of the drugs with total impunity. Their only training in the use of the new drugs is the talk of the medical representative of the company which markets these drugs. All this needs to be curbed and the role of each strata of health-care professionals must be properly defined. I realize that there will have to be a grey zone and that gray zone may be fairly wide where junior consultants will be competing with the professionals in the next upper strata. But at least beyond this grey zone, the role of every strata will be more clearly defined. Thus, if it is presumed that non–allopathic doctors are needed to cater to the poorer section of the society, then their practice should be limited only to the villages and semi-urban areas and in slums in urban areas if they were to practice allopathy. Of course, they are free to practice in their own speciality i.e. Ayurvedic, Homeopathic and Unani, anywhere as they are fully qualified in their own branch. Similarly it should be imperative that they must refer the case to higher centre if the patient is not relieved within two weeks. Similarly the M.B.B.S. basic doctors should be allowed to practice anywhere as family physician or as Assistant to any of the consultants in nursing homes or hospitals or in their private clinics. But here again they should be allowed to order only simple investigation and prescribe only established drugs. General practioners (allopathic or others) should be strictly prohibited from ordering high tech investigation and prescribing treatment with costlier drugs or drugs which have come into existence only in the last one or two years. If, in their opinion, such investigation or treatment is needed, they must refer the case to the consultant or to a hospital and take their opinion. It is only the consultant or the hospital which should be allowed to prescribe these higher investigation or costlier lines of treatment. The consultant was not basically supposed to treat any patient directly nor was he supposed to continue treating the patient for the entire period of the patient’s illness. Therefore, it should be
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ethical that the consultants should see only the patients who are referred to them by the basic doctors or, at best, could see those patients who have initially taken treatment with basic doctor and are not satisfied with the treatment given. Seeing those records should be mandatory. Seeing any patient directly without the patient being first seen by a G.P. should be considered unethical. Similarly, once he has investigated the case and advised the treatment or performed an operation, he ought to refer the case back to the family physician for continuing the treatment on the line of advice that he has given and call him for follow-up after certain period of treatment is over. It is absolutely necessary that the consultant and the general practitioner remain in touch with each other throughout the process of the treatment. The role of super specialist and the specialist is not yet properly defined, wherein the former seems to be competing with the specialist and both the specialist as well as super specialist seem to treat the same type of patient. There has to be some distinction and the super specialist must leave simple cases for treatment by the specialist and accept only the patients who require high tech management or more intense management. But in practice, this appears difficult to implement. The overlap appears inevitable, at least at present. If the role of each of the strata of health care professionals is defined to some extent, the chance of unnecessary investigation, costly drugs and incompetent treatment will be reduced to a large extent. Accreditation along with the definition of role of the doctors together would improve the health care management to such a degree that complaints of medical negligence will become near zero and may be the consumer protection act may become redundant. Strict implementation Rules are made irrespective of whether they can be properly implemented or not and all aberrations and all excuses for not properly following rules are accepted with ease. If rules cannot be implemented, we have a tendency in India to overlook irregrlarities and ‘adjust’ so that there is least headache to the administration. This is the biggest bane of the country. Thus, making rules and regulations is a meaningless farce. In the health-care sector, this is seen very conspicuously. The Healthcare system is divided into health-care provided by government/
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municipality or by health-care system created by private sector. Large corporate bodies also create their own health-care system for their own employees or for general public. For example, railway employees are catered to by railway hospitals. Tata steel and Reliance have their own hospitals. In most of these hospitals full time paid doctors are appointed in all the branches of medicine. The general rule is that employed doctors are prohibited from entering into private practice. Similarly Employees State Insurance Corporation (ESIS) appointed doctors to treat the labour (this fact has been referred to earlier). These doctors were paid per family that registered under them for medical service, but the payment turned out to be very insufficient and the system failed. But no steps were taken to improve the pattern of payment to these doctors. Instead rules were allowed to be violated. Another section of full time paid doctors and consultants is medical teachers employed in medical colleges. The task was considered important enough so that these consultants were also prohibited from entering into private practice. However, most of the full time paid doctors are highly dissatisfied with the salary and perquisites given to them. Though often this dissatisfaction is justifiable, there are equal number of occasions where this dissatisfaction is totally unjustifiable. Normally it should have been the duty of the administrator to straighten out the problems and evolve pattern of payment and rules compatible with the expected services from their employed doctors. This rarely happens – mostly because employed doctors form such a small uninfluential group that both politicians and administrators in industuries can easily afford to ignore them and their grievances. Also because the administrators are equally apathetic towards their primary duty to cater to the health care needs of their employees or of the people at large. Strangely this is equally true of all the corporate bodies. Multi-nationals or big corporate houses are happy to allocate sufficient funds to satisfy their employees but are not at all particular to see that the money is well spent and that their employees get medical service worth the amount paid for it. The employees are also happy as long as their medical bills – true or false – are reimbursed and, therefore, often indulge in procuring inflated bills from their doctors and share the booty with them. The management knows about it but prefers to ignore it. This is one of the reasons for ample
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corruption among professionals in these hospitals. But the bigger disadvantage of the apathy of the administration is that most of these employed doctors indulge in private practice. Some of them do justice to their duties and also do private practice but there are more number of doctors who ignore their primary duty in favour of private practice. For them the fixed pay is merely a ‘stand by’ or ‘a support’ while they earn their main income from private practice. Public sector administration and even the corporate administration to some extent are most reluctant to increase their headache by properly implementing the health-care system. They are not bothered if the doctors indulge in private practice and earn their additional income because this stops them from complaining about inadequate salary. That reduces their own headache of administration. Thus, almost everyone tries to enter the field of private practice, irrespective of the compartments in which they work, because there is 'money in private practice’. Indirectly private practice is considered synonymous with the right of the doctors to exploit the patients. This increases the competition in the field of private practice and leads to gross malpractices. This, in turn, brings the private practice into great disrepute. Actually the division of labour is quite clear. It is reported that about 25% to 27% of the population is covered for their health needs under the organized health care services provided by the government, railways or by private companies and corporates. The doctors who are employed in these hospitals, therefore, must be strictly prohibited from entering into private practice. As mentioned again and again earlier, incentive practice for the affording class of patients in their same section can be allowed to all these doctors, so that they will earn their additional income in the same institution if they prove to be more meritorious. The same thing should be true of the medical teachers in all medical colleges and of the doctors employed by government at the district hospitals or primary health care centers. They cannot have the cake and eat it to. There are obvious advantages in the full time service. The hours of service are fixed, long term benefits amount to nearly 30% to 40% of their salary and they have facilities of leave, traveling allowance, provident fund and pensions after retirement etc. If these full time doctors are forced to have a choice and are thus strictly prohibited from entering into
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private practice, the number of doctors in the private practice will be reduced. That in itself will help in reducing the malpractices in private practice to some extent. There is a second population group comprising the poorest section of the society of nearly 40% of the total population who are helpless. They are incapable of getting medical assistance with their own income and, therefore, are totally dependent on the government, municipalities, zilha parishads and the state and central governments who have set up large infrastructure starting from dispensary, primary health centers, upgraded dispensaries, taluka level hospitals to district hospitals to highly specialized medical college hospitals or other specialized hospitals. Ideally twenty five per cent to thirty per cent of the medical personnel ought to be absorbed in this section. But at present only a small percentage of doctors are working in this public sector serving poor people. Their apathy and the laxity of the government machinery makes it easy for these doctors to break the rules and enter into private practice. As mentioned earlier these doctors could be paid adequately but their performance must be assessed by the charges collected or the number of patients treated, so that sincere doctors will be better rewarded than their colleague counter parts by early promotion. This was discussed in more details earlier. But under no circumstances should they be allowed to enter into private practice. That leaves only a small section of about 25% people who are not covered by either their own organization or by government machinery but could afford to spend for their health. A certain percentage of patients from organized sector and from the poor section who are dissatisfied with the services offered to them in their respective hospitals would prefer to take treatment in this private sector. The total number may, therefore, go to 35% to 40% of the population. With the controls mentioned earlier namely accreditation of the hospitals, specific duties for each strata of the medical personnels, display of charges as suggested by Indian Medical Council and the over-all control of the Health Council, the private sector also would become more disciplined. The charges would be more regulated and malpractices would be minimized. QQ
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Miscellaneous
There are some other aspects of health-care system which remain uncovered, the main being the need and inadequacy of paramedical services, transport of serious patients and ambulance services and disaster managemet or critical care management in the peripheral parts (not cities, where it is overemphasized as usual) The need for nurses is supposed to be double that of doctors, presently they are less than half the total number of doctors – the deficit is 4 times the actual need. Physiotherapiests are clustered in big cities, technicians are scanty, but strangely the need is only half-felt because the ‘basic’ doctors manage to do half of these jobs, while some other functions can be conveniently neglected. It is a pity to see doctors doing clerical or semi clerical, purely administrative work or paramedical work – Not so much a problem of dignity but of wasteful expenditure of creating a doctor at a formidable cost and giving him a job which could easily be done by people who are being trained at a much lesser cost. Sometimes, I feel that we have too many ambulances but indiscipline and total apathy to coordinate gives us a paradoxical picture of inordinate delay in getting an ambulance while plenty of them are parked idly, all over the city. We lack administration and management. I have decided to refrain from entering into these aspects in greater detail because 1) I myself have very scanty data and experience in this field and 2) because what I have written so far appears to be too complex and ‘head-breaking’ if I may coin such a word. Will this one Man Committee report – self appointed – work? Will it serve any purpose ? I do not know. If it falls in the hands of high level medical administrators, or bodies or persons in high places in any social field, who are concerned about our health-care system, it would atleast ferment discussion, and
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something would come out of it. Otherwise, it will achieve only one thing – satisfaction for myself that I have expressed my views. I wish best luck to myself. I have added two of my earlier articles. The first one, written nearly 35 years ago, advocated a bill to be given to every patient in teaching hospitals - even if he does not pay a paise. The idea was to create "cost canciousness" among students and teachers, which may lead to a concept of "Cost Effective Health Care Management". The second article is a word of caution to the poor and middle class patients. It explains why high tech modern hospitals become ivory towers and how the management therein would invariably become too expensive and often impersonal. It is advisible to go to middle ranged hospitals for simple or moderate illnesses and reserve these hospitals, only for serious or previously untreatable diseases. I hope, readers will benifit by absorbing these thoughts. QQ
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BILL FOR THE PATIENT IN MEDICAL COLLEGE HOSPITAL
For Teaching Economics of Healing
Medicine is an art based on a scientific footing. This basis is mainly the chemical and physical processes involved in the physiopathology of the body. The materialistic and western influenced attitudes plus the advances in modern technology, have made a medical teacher and a student feel that these are the only important sciences to be taught and learnt to become a successful doctor. He is thus being taught more and more details of the physico-chemical processes, or what may be termed as ‘organic’ changes, more and more of the detailed investigative approaches involving the great technological advances and is taught to plan his treatment on the ‘Sound Basis’ of these scientific facts. In terms of the best results, I have myself no doubt that some of these, if not all, have vitally contributed to the quality of medical treatment. And yet, this is the most important reason, in my opinion, for the education becoming unoriented to the practical needs of the medical graduates in our country. For medicine, in its fuller concept, is an art based on the above-mentioned scientific footing. In actual practice, many other factors come into play in determining the care of the patient–the social factor, psychological factors, environmental factors, the religious biases, etc. But the most important and vital barrier to the effective practice of the knowledge learnt in the present way is the knowledge of Economics of Healing. In practice what to do and what should be ignored, which investigations are necessary and which can be avoided, and with what material difference, which equipments to buy and which would become burdensome, the choice between the
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best drug and the cheap drug, everything is determined by the socio-economic factors rather than anything else. But the graduate full of knowledge of physico-chemical processes often lacks the knowledge of the economic influences on the medical practice and fails to satisfy his patients and thus gets rapidly frustrated. He tends to blame the masses for their ignorance, being little aware of his own ignorance. What he has not learnt in the college covers much wider field than what he has. The present set up of full-time ‘non-practising’ teachers and free treatment to all patients in the teaching hospitals makes this deficiency in teaching even more glaring. The entire cost of hospital, equipment and the treatment is borne by the government or some autonomous bodies, while neither the teacher, the student nor the patient becomes aware of the actual costs incurred in the whole process. This results in growing dissatisfaction among all with everincreasing demands for equipments and facilities, which more often than not, contribute so little to the qualitative or quantitative improvement in the results. In short, neither the teacher, nor the taught and least of all the patient, ever even think about the cost involved in the so called modern methods and the relative benefit derived out of this added expenditure. In actual practice as soon as the medical graduate goes out of the college, he is confronted, at every minute, with the cost involved and its relative or comparative benefit to his patient. This makes him unable to take decisions, especially the ‘cheaper decisions’. Ultimately, some may learn, by themselves, the relative economic and medical values, but many swing to the opposite side and think that science taught in the medical college is meant to be forgotten and everything in practice is Art. This way the word Art becomes synonymous with pure commercialisation, cheating and fraud. Some of the graduates who are too good in their science and fail to learn the real art by themselves i.e. the moulding of medical practice to these socio-economic factors, return back to the full time job and, in turn, not only continue to teach the pure science but fully ridicule any practical dilutions in practice. Thus, the whole cycle of wrong emphasis leads to wrong choice of teachers, further emphasis on modernity and the society pays more and more, to receive less and less benefit
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in the poorer countries. The doctors trained by our college become progressively ineffective in treating our people, because the local people cannot afford such treatment. Strangely, the richer countries, already advanced, in such technologies and the relatively affluent people there can afford them. This mutual satisfaction between those masses and our doctors seems to be one of the most important factors, why ‘scientific doctors’ are draining to the west. Are we not training them for their needs, and not ours? Secondly, the present pattern of ‘modern or technological’ approach is leading to ‘Office-type Doctors’ with a progressive deterioration of clinical judgement, which is being substituted by investigative procedures. I emphasize that investigative approach is used to substitute and not to aid clinical judgement. Again the result being same quality to the patient at a higher cost and the cause being non-economy-oriented medical education. My personal experience, after having worked in newer and smaller colleges and slowly shifting to the city of Mumbai, shows me clearly that by conscious efforts, clinical judgements can be improved and managements economised to half or even one-fourth. The present mode of selection of senior teachers by the Public Service Commissions again shows the same lack of importance to ‘clinicians’ as teachers, and indifference to medical economics. Research and publications are the mainstay, but there is not a single ‘column or a confidential reference regarding the candidate’s ability to treat and teach. Result - unnecessary and elaborate modern investigations on the poor, advanced cases, long hospital stays, often at the cost of essential early treatment all for the sake of research and publications - for the sake of promotions - expensive nonproductive medicale education. Clinicians who could teach, what I am advocating, are available in plenty, but they seek direct rewards in practice and would not turn to full-time teaching jobs, which become unrewarding both monetarily as well as job satisfaction-wise, as such a person is usually condemned as a ‘non-scientific teacher’ a dilutor, non-research-minded, non-progressive etc. And yet, some objective method ought to be found to find out, retain, encourage and promote such ‘clinical’ teachers, who
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treat well and yet economically. Such teachers automatically will teach students the art of clinical judgement. Today, there seems to be no way, for the Deans, Administrators, or Service Commissions to sort out such types of teachers. Can we find a way out? The answer is not simple but a simple beginning can be made in this direction, which can expand later to cover the problems that I have posed. And the simplest way to start would be ‘to bill the patient’. Every patient, who is admitted to a medical college hospital, should receive a bill of expenses, at the time of discharge, irrespective of whether he pays it or not. This bill must be given to him by the resident doctor, so that all concerned would have seen it. The concept of the bill for the present is for medical education and hence the charges evolved can be only crudely accurate and need not be commercially accurate. They will give a comparative picture of the money spent over each patient over each disease, and would help to statistically evolve the comparative benefit derived to the patients or the masses through additional expenses for modernities. For a 600 bedded hospital with 15,000 admissions a year, this involves, making about 50 bills a day and the total extra establishment would not be much. Such a scheme will automatically make all money-conscious. The impact of additional space, personnel or equipment will be immediately reflected in the bill and the teacher and the taught would necessarily ponder over it–whether this was essential or not. Some may now substitute clinical judgements to investigations bringing the costs down. It would now be possible to sort out a better clinician as one who gives better results with lesser costs, and attempts could be made to retain and promote him or encourage him by offering larger responsibilities and/or monetary incentives. It would be necessary for making the scheme more educative, to arrange regular forums for discussions, seminars, monthly meetings, etc. where clinical results would be evaluated with the bills of expenditure. Cost effective management The positive concept of health is essentially due to the economic influences in the modern society. The need to keep productive, moneyearning population not only not-ill but fit, fit
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for skills and possibly fitter than before, through the medical progress is a pure product of understanding of economic influences in modern society. Unfortunately, it is becoming necessary in our country to teach the medical profession, especially in medical colleges to distinguish between essential treatments and treatment for positive concept of health. For it will be correct and scientifically appropriate to charge fully for the latter and increase the direct income to the medical colleges, independent of the state or public money. Such accrual of direct wealth could make for a self-expanding medical education system and only such self-expanding medical education system and only such self-expanding colleges are likely to retain permanently their utilitarian character. Again the beginning is in introduction of medical economics and the first step is billing the patient and critical evaluation in periodical discussions, seminars, etc. The answer is not that simple of course and involves many more basic changes in the system. While a lot of discussion centres round the content of medical education, extremely little time is spent over the need to select proper teachers, and still less to medical and hospital organisation in the utilitarian way. It is easily forgotten that the student learns from what he sees and not what he hears. Today, he is learning to do less and argue more (discuss is the euphemistic word), because that is what some of the teachers do. He cannot decide, without multitudes of reports, because that is what he sees. He fails as a house-surgeon, to talk and explain to his patients about the nature of illness and details of treatment and show sincere sympathies, but merely replaces them by ‘efficient Organic and technological’ approach, because that is what he sees in the hospital. This would be only a beginning to give a social bias and practicality to our education system. Other aspects like social, religious, psychological, environmental, (rural and urban) factors, also might have to be brought home to the new students’ notice. Such an expansion of teaching of Art, will necessarily restrict the horizons in the knowledge of science and modern technology. A hue and cry would develop that our students would be unable to compete with others in the Western World, and would be found to be unfit there. It is for the
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educators here to decide, would it be better for the country or worse? It is for us to decide whether we train our students for foreign fitness or for internal fitness. This is what I call, ‘Indianization’ of Medicine. Another common argument put forth is that these things need not be taught, and students would learn them automatically, when they go out in society, I have myself conceded this fact in the case of many. But it is at the expense of many more years, but more discomforting is the fact that a progressively larger number of students fail to learn this or accept and adapt to it without a sense of guilt or shame. Secondly, it is leading to wrong choice of clinical teachers. Let us also remember that commerce, business management, teaching, and politics are also being taught today and with advantage. Were not the former generations practising them and learning by themselves? Lack of natural inheritance in the new students in all fields today makes it imperative to include such aspects in the formal education. I urge that these things should not be brushed aside, as politics, trade unionisms, or purely non-educative subjects; for they, more than the paper-definition of the contents of education, will determine the progress of medical education in India and its usefulness to the Indians. (The Indian Journal of Medical Education Vol. XIV No. 2) (July-Dec. 1975) QQ
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High-Tech Modern Hospitals Are they really usefull?
At the time of independence, the country had very few medical colleges. Over the next 25 years, the number, was steady at around 105, and they turned out about 10,000 M.B.B.S. doctors every year. The main objective then was to provide a ‘basic doctor’ for the ‘basic’ medical needs of the population. So, most M.B.B.S. doctors opened their dispensaries and became ‘family physician’ advising the patients not only on their medical problems but equally often on their social and economic problems. But, with rapid expansion in medical knowledge, the tendency to specialize in one or the other branch of medicine increased so much, that nearly 80 to 90% of M.B.B.S. doctors became ‘Specialists’ and their place, as family physician or basic doctor was mostly taken over by other faculties of indigenous medicine like Homeopathy, Ayurvedic, and Unani faculties. But the last 25 years have seen further expansion not only in medical scientific knowledge but also, to a far more extent, in medical ‘Technology’. Newer and newer, electronic, ultra – sonic, and magnetic highly computerized equipments came into use in the medical fields, as modern diagnostic tools or therapeutic equipments, and this has resulted in a distinct change in the attitude and philosophy of modern medical professionals. The knowledge and especially the skills of the ‘specialists’ proved inadequate to properly utilize these ‘high-tech’ equipments and a new creed of ‘super-specialists’ was born. Cardiologist, nephrologists, Urologist, neo-natologist and what not! The number of the super-specialist branches and the superspecialists is ever increasing, in both medical and surgical fields.
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Naturally, it has resulted in establishment of more and more modern ‘High-tech super specialist’ hospitals or the general hospitals have opened new ‘super-specilaist’ sections in their general set-up. It is a common belief that this modern technology has 'revolutionized’ health-care, that it is contributing greatly to raise the average life-span of the population and in general offering a much healthier life to the society. How far is it true? The question appears silly on the face of it, but I would rather discuss it. Specialists (and super-specialists – to a smaller extent) did exist in yester-years, but most of the M.B.B.S. doctors became general practitioners. Even those who specialized almost always had a few years of experience in general practice either before or immediately after obtaining the post-graduate qualifications. Most specialists preferred to combine general practice with specialist practice at least in the initial phase of their professional career, if they did not have G.P. experience before going for post-graduation. There were no further degree courses for superspecialization and therefore, after practicing as specialist (say a physician) for 10 to 15 yrs, if he developed an inclination for a particular smaller branch, he gradually shifted towards it and became a ‘Super – specialist’ (say a cardiologist or neurophysician) at a mature age of about 40 or above. In general, therefore, these super – specialists had a much wider base of medical practice and a much deeper understanding of the social and economic circumstances of the general public they served. But the situation has totally changed today. Medical education and especially the selection pattern for post–graduate courses in so peculiarly distorted that even the M.B.B.S. medical student refuses to learn the entire medicine fully before he obtains his degree. He plans carefully for his post–graduate ambition from the beginning. If he is interested is surgery he would prefer to concentrate on that subject only and study medicine, ophthalmology, obstetrics etc. only for passing marks. Immediately, a 3 years course for post-graduation and he is a qualified specialist. Even without any experience, immediately he competes for ‘super – specialist degree’ and if successful he is ‘super – specialist’ 2 years later at a tender age of 27 to 28. A lot of theoretical knowledge but no experience whatsoever in actual practising field and extremely narrow social and economic
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perspective of the very people whom he decides to serve in practice. He lacks, the broad vision of the super-specialists of yester–years, and developes a narrow and rigid attitude in his professional conduct. Barring his own (super) branch, his knowledge in other branches of medicine is almost as poor as that of a knowledgeable lay-man. In any case, he definitely refuses to accept any responsibility for any clinical problems for these ‘other’ fields – minor or major. No doubt, those who practise in small nursing homes and small institutions learn the hard-way through experience and come to terms with reality, but those who are attached to these High-tech institutions or ‘High – tech’ sections continue to live in their ivory towers. ‘(super) specialist is one who knows more and more about less and less’. But medical practice is not the treatment of one organ. It involves the treatment of the entire person, taking into consideration not only his clinical picture but also his social & economic circumstances. If an old lady developes an attack of paralysis, she will be treated by a neuro-physician. But what if she had high blood pressure or diabetes. Paralysis often affects, respiratory system or kindneys; who will treat these conditions? Who will do the dressings or operation, if she developes bed-sores due to prolonged stay in bed. Naturally for each of these ailments, separate super – specialists visit the patient separately. Sometimes the instructions are contradictory. Multiple doctors, multiple investigations, multiple medicines, and multiple procedures; naturally the expenses sky-rocket far beyond the capacity of the patient and the relatives. Even otherwise, high-tech treatment has to be costly. All hightech equipments are very costly ranging from a few lakhs to a few crores of rupees. One can not run such equipments with ordinary workers. Appointing skilled & trained technicians is a must. In our country of vast population, trained technicians are really scarce. Besides, they easily get lucrative jobs abroad after a few years of experience. Hence, they have to be paid high salaries, in an effort to retain them. Super specialist doctors, skilled technicians and costly equipments can not be managed except by ‘management experts’ who also must be well taken care of. Thus the whole set up is very costly; it can never be cheap. Politicians and social elites who continuously appeal from every conceivable platform that ‘modern medicine must be made
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affordable and should reach the poor masses’ are either fooling themselves or are hipocrats. Expense apart, are these facilities not really useful? Have they not revolutionized medical treatment and made impossible into possible? The answer is yes and no. Today many conditions can be diagnosed at a very early stage which was not possible before. Formerly cancer cases were cured only when detected in first stage, today patient even in third and fourth stage sometimes need not lose hope. Age and existence of major associated illnesses, made it impossible to operate on many patients, with a curable surgical disease. Today, almost anyone can be operated upon despite any other associated disease (from infants to 100 year-olds). Very major operations were needed for kidney stones and pancreatic diseases. But endoscopic surgery now cures them in less than a week, fit enough to join duties. Ultra-sonography and endoscopy have no doubt revolutionized management of many diseases. In short, when the disease or the patient was in a more advanced stage of morbidity and occasionally for early cure of unmanageable diseases, super-specialsit treatment and high technology is very useful and is inevitable. But its impact on health management of the entire general population is very negligible – almost nil – because the total number of such patients really needing such treatment is very low in the whole population. Hence these super-specialties, have not contributed to the increased lifespan of the population nor have they contributed to reduction in the incidence, severity or complications of various major killer diseases. This has been proved statistically not only in our country but even in the developed countries of the world. On the other hand, barring these few lucky patients perceptible harm can not be ruled out for many other unfortunate patients who happen to seek treatment in these high tech sections. Multiple high–tech investigation show up lots of ‘lesions’ which were never seen before. Many of them are aberrations of ‘normal’ but are now diagnosed as ‘diseases’. Thus overtreatment is very frequently indulged in, resulting in major hightech operations, like coronary angioplasty, bypass surgery or laparoscopic gall bladder surgery. Besides, complications arising out of these ‘modern interventional’ investigations or
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procedures are sometimes far more dangerous than the disease itself. Multiple super-specialists giving multiple advices at different times calls for a fine co-ordination among all of them, and that is not as easy as one may think. This often results in inordinate delays in instituting definitive treatments. But much worse, is the peculiar hostility the patients suffer in these ‘ivory tower’ institutions. With less social perspective and more pride-verging on arrogance – in their knowledge, the specialists are extremely intolerant to even suggestions for simpler alternatives, requested by patients and relatives. ‘This is my advice. Take it or leave it on your own responsibility’ is their attitude. So discussions are out of question. ‘The ivory-tower’ attitude soon percolates to all the staff in the hospital & they also become intolerant and arrogant. Soon the ‘Red-tape’ of public institutions tightens its hold even here and the patient or his relatives can not understand what is happening, why the delays, why the condition is not improving etc. Tension and panic, besides the high cost, take the toll of the family members in terms of their own health. Yet the glamour persists and the conviction remains that the modern technology is very useful and life saving. So why should not the poor people get the same benefits? Thus superspecialty sections are established in all major public institutions. The up-gradation of J.J. hospital or the establishment of Renal Transplant Unit at Aurangabad at the cost of 2 crores, announced by the chief minister are but examples of this philosophy. The government spends only about 2 to 2 1/2 % of its buget expenditure on health-less but not more. But, now, a major share of this meagre expenditure is getting diverted to ‘modern super-specialty' sections. The Bombay Muncipal Corporation, for example, spends more than 60% of its health budget on the three medical college hospitals, and even there, more than 50% is spent on super-specialty section. Thus, it is not unusual to find that in the hospital which takes pride in doing many open heart surgeries, the general patient has to buy gloves and catgut for his simple operation. Are we justified in diverting the money meant for common needs of common people to the specialized needs of a few? Hygene, Nutrution and good drinking water along with
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preventive and primary health care are really what the common man needs. It is proved beyond doubt that the average life expectancy and general health of the society, as a whole, is improved by these measures, not only in our country but even in the developed countries. Hence, there is a real need to increase the expenditure on these, at least 5 fold. Diverting the funds, instead, from the present 2.1/2% expenditure is absolutely unjustifiable. As individuals can expect real life-saving benefits but the society, as a whole, does not get any benefits, it is but right that these modern facilities become available in private sector where the individuals pay for their services. If they were to go to the general specialists first through their general practitioners, to ascertain whether their ailments could be treated in a simpler way and at a lesser cost with the same degree of success before going to the super-specialists, it would help them a lot in avoiding the harmful consequences of ‘modern therapy’ as well as the high costs. It would have also encouraged a healthy competition between the specialists and super-specialists with great benefits to the society. But, the recent applicability of consumer protection act to doctors has greatly hampered this competition. Also, the present medical education system which teaches such a lot with almost no experience is resulting in less and less competent G.P.s and general specialists. The society is paying its price for ignoring these vital factors. It does not mean that there should be no super specialist sections in public hospitals for the poor and middle class. But, certainly, these should not be established or run by diverting the meagre funds allotted for general health services. These sections should be funded entirely through special insurance schemes, compulsory or optional, meant specifically for super specialities. Agreed that an individual can not spend a lakh of rupees for coronary bypass operation or for full cancer treatment. But, presuming that one in a thousand persons will need such treatment (actually it is much less) the cost per head would be only Rs. 100/- The centers thus raised are likely to be few but the returns can be even more costeffective, if no one was allowed a direct access to them. Everyone should be made to pass through dispensary to
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specialist and the super-specialisties would be involved only after the patient is refered to them by the specialists. If, however, any patient wishes to have a direct consultation and treatment from super-specialists, he will have to bear all the charges as in the private sector including the doctor’s charges. This way, maximum benefit will reach the deserving poor, there will no misuse of the facilities by those who can really afford and public sector super-specialist doctors would also benefit. The decision to open up health insurance to private sector is the most welcome step in this direction Marathi Article Published in Loksatta 2nd June 1997 QQ
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25
In Summary
1. In clinical practice, a doctor should be able to answer the allpurvading 3 questions scientifically. a) what is the diagnosis ? b) what is the management ? and c) what is the prognosis ? The approach to all social problems should preferably be on the same lines. 2. Health-Care is a complex subjectThough health is as important as food and clothing, health demands differ in intensity. They are vital, essential or desirable while some are luxuries. There are three tiers of health-care services primary, secondary and tertiary. There is a combination of art, science and commerce in varying proportion in all of these tiers of services. The health-care system in India is very haphazard. There are many systems of medicine – Allopathy, Homeopathy, Ayurvedic, Unani etc. in active practice simultaneously but their respective roles are not defined. In addition there are many spurious systems which, though not recognized, are still offering medical services to the public. 3. A Medical Council is established to control the standard of education and to maintain the standard of behaviour of the doctors at a high noble level. But... a) There is a Central Medical Council and a State Medical Council which are independent of each other. b) There are separate councils for different systems of medicine. c) They have very limited powers and there is no coordination between them. d) They cannot deal with quacks nor with anyone other than doctors - not even para-medical staff or erring patients.
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e) There is a need for central (and state) Health Council with wide powers and superior to all above bodies. a) Health – care is an Industry, and Industrial principles must apply here too. b) Health-care is productive and hence must be paid for. c) There is nothing like ‘Free’ medical service. Somebody else pays for it. d) Money must come in – in a cognizable way – so that it can be spent and the correlation should be easy for a common man to understand. e) There are too many disadvantages of ‘Free’ treatment – It is the costliest method with poorest returns. Government supported or company supported medical insurance could be one of the remedies. The need for a pyramidal structure of Health–care system. Primary Care Centres - Secondary Care Hospitals - Tertiary Care Hopitals. a) High-tech modern medical service is very costly and cannot ever become cheaper. b) It does contribute to the health of formerly incurable or difficult disease but it also increases the cost of healthcare unnecessarily for majority of the people. c) It has contributed very little (or non-at-all) to the overall survival of the community. d) Hence it is almost a crime to spend public money heavily on this high-tech medical service. e) However, these services can be available in private sector for full costs to be borne by individuals, and in public sector only after proper reference from the lowest to the medium to the high speciality hospitals. a) Considering the need of doctors in a ratio of 1: 1000 the country needs 10 lacs doctors. b) In cities, specialization has increased, so the ratio could become 1:500. c) Selection for M.B.B.S. course is not strictly by merit – at least 49% seats are filled through reservations based on caste/creed. d) The minimum qualifying marks were 45% aggregate in 12th standard in 1950 when the Republic was founded, it is still 45% - in P.C.B. (not aggregate).
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e) Full advantage of this was taken and is still being taken even to day by private colleges and deemed universities for malpractice and corruption. f) There are multiple C.E.T. for the aspiring students – which is totally unnecessary and again a source of corruption. g) Confusion is created by central CET and 15% reservation for admission on an all India basis. h) Caste-based reservation should be abolished but regionbased or community based colleges with 33% reservation should be encouraged, to be managed by the region or the community. i) Minimum qualifying marks in 12th standard examination must be raised to 60% of aggregate marks (not PCB). and/or 75% in P.C.B. j) Only one C.E.T. at the state level – one central. 8. Charging of fees-Fee structure is irrational. a) Fees in government colleges are too low and in private colleges too exorbitant. b) Wrong students are getting subsidy and poor students are denied subsidy. c) The criterion for subsidy should be purely economical and not merit-based, and subsidy should be available in gradation to students both in government and private colleges. d) The fees in government colleges should be raised to nonsubsidy level at par with the private colleges. e) For others soft loan facility should be made available. f) Students getting subsidy must serve in public sector for 10 years. 9. a) The number of patients in private medical college hospitals is very poor due to various reasons – but this number forms the main source of education for them. It is here that the student gets 70% of his knowledge. b) The M.C.I. only cares for the total number of beds provided – not the total number of patients on them. c) Full occupation of beds is equally the need of the people to get good doctors. d) therefore, in the private college hospital, the charges of patient–care should be subsidized by the government equivalent to the expenses incurred in district hospitals.
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e) Research grants must be created and utilized fully, and the main research officer be paid. f) An optimum of 25% of the beds in each unit should be ‘paying’ beds. There are several advantages educationaly, administratively and financially. g) This is so important that the issue should be bitterly contested, if M.C.I. opposes it. h) The medical teachers should be prohibited from doing private practice outside the premises, but offered incentive practice within the premises. 10. a) Thus, the fees to be charged will be minimized. b) Paying patients, research grants and subsidy from government will substantially reduce the deficit of income over expenditure. The salary expense of the practising teachers will be reduced. c) So the students will have to bear only the remaining expenses of the college and hospital. d) Additional training courses can bring additional income. e) The system of professionals on ‘fixed salary’ cannot work, unless there is an extremely intelligent and efficient management system with M.I.S., both of which we simply do not have. 11. Choice of medical teachers leaves much to be desired. a) There is a lack of incentive and of job satisfaction for medical teachers. b) There are three desirable qualities for teachers, Every teacher must possess at least one, preferably two of them in very good measure. i) professional skill; ii) art of teaching and iii) research attitude and skill. c) i) incentive practice within the premises will satisfy the first type which is 80%. ii) Academic incentives are needed for 2nd and 3rd type, and a good compensation for not going into practice. They deserve non practising allowance, and other perquisites. iii) Having defined job specifications, accurate performance records must be maintained, shown to them, corrected if necessary and then firmly used, for pay-rise, promotion.etc.
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iv) The present method of promotion or selection is extremely faulty and leaves wide much to be desired. v) M.P.S.C. is most incompetent and slow and must be replaced by a better expert commission, specifically for selection of medical personel. The performance record must be submitted and used. vi) If the work load is more than can be managed by the mandatory number of medical teachers, additional part time consultants can be appointed from amongst the practising faculty- the best amongst them should be chosen. They are not medical teachers, but will gain teaching experience over years. 12. The pattern of working of a clinical unit in the medical college – applicable (in principle) to other secondary, tertiary hospitals also. a) Too many doctors in one unit to manage 32 to 40% patients – 1 professor, 1 Associate Professor, 2 lecturers and at least 6 residents. b) Only one O.P.D. day in a week for non-admitted patients. c) Multiple duties on the O.P.D. day – O.P.D. patients, routine admission, emergency admission, emergency management /operations, routine and semi urgent minor operations on O.P.D. patients, etc. – other days are relatively free. d) Extreme mal-distribution of work and total lack of answerability. 13. A better system of administration is absolutely essential. a) In India, individuals are easily blamed, the system is rarely blamed-in fact it is hardly even discussed. b) i) The unit should be divided into 2 sub-units, working independently. ii) There should be at least 3 O.P.D. for each unit, more if possible. c) O.P.D. and emergency duties should be on separate days and all other duties should be evenly spread over the week. That will increase answerability. Nine morning to twelve noon to be strictly reserved for patients and under graduate students. 14. a) Curriculum – 1st M.B.B.S. should be extended back to 1½ year (instead of 1).
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b) The stipulated period of posting must be strictly followed. No exemptions or concessions should be permitted for deficiencies on any ground. c) There should be an exposure to allopathy for at least 2 years in the courses of all other systems of medicines. d) The C.E.T. for post-graduate selection, should be held within 3 months of final M.B.B.S. exam, almost at the beginning of internship and e) The interns should get mandatory training in management, social studies, logic, psychology etc. during the remaining 6 to 9 months of internship. f) There is a specific need to start post graduation in general practice. 15. a) Any patient enters any centre or hospital. There is no referal system in existance. b) Medical Collage Hospitals see 50% trash in O.P.D. and that lowers the quality of treatment. c) Patients must be seen at primary care centres and refered as per criteria laid down. d) Secondary care hospitals will see only patients seen earlier at primary care centre–refered or dissatisfied. They will be entitled to highly subsidised or free treatment. e) Patients coming directly to secondary or tertiary care hopitals will have separate O.P.D. timing and will pay 50% of charges, as paid by paying patients, even in general O. P. D. f) Paying patients will have a separate O. P. D. in the evenings. their investigations and operation will also be done in the evenings only. They will pay full hospital charges. g) Same system of referal must be advocated for private sector also. Consultants must see cases first seen by General Mactioners refered or dissatisfied. 16. a) Charges to be collected from patients – two components; i) hospital expenses ii) professional charges of consultants/doctors. b) There cannot be ‘free’ service from the consultant. c) As public hospitals see a lot more patients, the professional fee for consultants works out to be 5% to
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15% of the charges in private. d) Free Medical camps should not be allowed by medical associations. e) Even the hospitals charges should not be free nor should they be ‘nominal’ ‘arbitrary’. They could be subsidized even to the extent of 90%, and only 10% could be charged, for poor patients, if they come through established proper channels. f) Costing and way to decide subsidies can be easily worked out – a method has been worked out here. g) Even in the medical colleges, charge must be collected. These patients are already subsidized by students, research and the government to some extent. 17. a) Despite criticisms, tender system for purchase of medicines is good. b) The cost price to government and muncipalities is 2/3 or even half of what companies sell to others due to bulk orders and competition. c) But instead of single lowest item, 3, 4 or more comparable brands should be approved. Hospitals can purchase any brand, it likes. d) Purchase system should be decentralised to district level, if not taluka level. e) Drug should be sold at 10% market price at primary health care and to those properly refered to the higher centres. at cost price to those attending hospitals directly or after referal from private sector & at 90% market price to paying patients. 18. a) Salaries (or income) of the doctors should be comparable to his counter parts of equivalent talents in other fields – horizontal parity. b) It is easy to be strict, if remuneration is adequate. c) The post-graduate students in medical colleges should receive ‘contract-payment’ proportionate to salary and Not ‘stipend’. They should not be considered ‘students’ they are employed workers – on contract/apprentices d) Public service doctors must also be paid adequately. e) The E.M.I. for study-loan works out to be Rs. 10,000/p.m. and that must be added to what they deserve for the first 10 years. Subsidized students will re-pay the subsidy
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in this period. f) Additional expense will be recovered from patients, if they are charged Rs.3 to 5, respectively, in villages and towns, and fixed cost of medicine 2 to 5 = a total of 5 in rural area & 10 in towns. g) Consultants about Rs.50,000/- (including E.M.I.) of Rs.20,000/- p.m.) h) The quality of service has parabolic ratio to the remuneration. i) Govt. can spend at least 4 to 5% of G.D.P. instead of 1.1% as at present. 19. Health Insurance Scheme :a) health care is becoming costly and it will continue to be costlier. b) Health Insurance scheme is the best available answer but it is not as simple as it looks. c) There is an exclusion clause, worst among these, is pre– existent disease. d) The patients become relaxed and allow inflated billscompanies react. e) Over-investigation and over treatment result in mounting costs, resulting in mounting annual premium. f) Charges are not displayed, in spite of M.C.I. instructions. charges must be displayed. g remedy – the patient must bear at least 20% of the cost and he/she can be insured only for upto 80% of the expenses, with the usual ceiling. h) Senior Citizens and the poor are not covered. Companies refuse. Therefore, only the government can and should cover both of these under a special insurance scheme with health-cess for all. 20. a) There are many doctors who would like to treat the patients in simpler ways with greatly reduced costs. b) But they are impeded by consumer protection act made applicable to doctors. c) Doctors insure themselves against damages, that increases the costs of health-care but relieve the doctor's tension only partially. d) There are serious disadvantages of this Consumer Protection Act, for general public.
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e) The patients must have some protection in a different way, if this act was to be repealed. f) Criminal negligence was and is always punishable in the court of law, but the doctor should not be held guilty for adopting cheaper methods, at low cost, if he has explained the patient why and how? g) or the C.P.A. should be made optional. The patient should be given a right to opt out of the act and give the doctor a free hand. h) Substantial statistital evidence with good records should be acceptable. i) For unexpected complications and loss of earning member, there can be a system of some compensation, irrespective of who is at fault. 21. Accreditation :a) Any doctor can treat or perform any operation anywhere. There are no rules and regulations, defining the role of each category of doctors. This is dangerous. b) Accreditation of hospitals is one of the answers. Each health-centre, nursing home, hospital should be graded officially, as per the equipments, and staff and systems in that place. c) The health-care centre can under-take only what it can manage and send more serious patients to a higher grade centre. d) Most professionals will be happy and feel secure. Only unscrupulous or greedy professionals will be worried. 22. The role of different doctors must also be defined. a) Basic doctors cannot advise high-tech investigation nor prescribe the costly or latest drugs introduced in the previous 1-2 years. b) Non-Allopathic doctors can practice only in rural and semi rural areas or in slums, if they do allopathy. c) The specialist should see only cases referred by the ‘basic’ doctor or at least treated earlier by him, except in serious cases. d) The patient should be referred back to the basic doctor for further treatment. e) The line between specialist and super specialist must be drawn, even if vaguely.
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21. a) Rules and regulations must be strictly followed and action taken. b) Full-time doctors should not be allowed private practice except incentive practice within the premises. c) Same with medical teachers, as already discussed. d) They should be adequately compensated, but they cannot have a cake and eat it too. e) This will reduce over-crowding in the field of private practice and that will help in reducing malpractices, overtreatments etc. f) Patients, in public health service, must go through the established hierarchy to entitle them for (nearly) free treatment or pay from their own pocket. QQ
MANAGEMENT OF THE SICK HEALTH-CARE SYSTEM (WHAT IS WRONG WHAT CAN BE DONE) Dr. S. V. Nadkarni,
M.S.
Formerly, Professor of Surgery & Dean L.T.M. Medical College & Hospital Medical Director Bhatia General Hospital, Jaslok Hospital
Report Prepared between March & August 2009 MANAGEMENT OF THE SICK HEALTH-CARE SYSTEM
Š Publisher First Edition 2010
Price : Rs. 100/ISBN 81-8406-015-7
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Printed & Published by : Ratilal K. Vora Vora Medical Publications 6, Princess Building, E. R. Road, Near J. J. Hospital Traffic Signal, Mumbai - 400 003. (India)
Dr. Sadanand Vinayak Nadkarni - M. S. - (Gen Surgery) Born
- Mumbai 3rd May 1932
Education
- in Pune - Open merit scholar of Fergusson College, M.B.B.S. & M. S.
Extra curricular
- 12 years with a socialist organization - Kabbadi, Drama - won university and state awards.
DEDICATED TO ALL PATIENTS FOR ALL THEIR PATIENCE. I PRAY THEY BECOME KNOWLEDGEABLY IMPATIENT.
Medical teacher
- Education, research, organization & administration.
Reader in Surgery
- Manipal and Mangalore - Private Trust Institution. 5 years (Private Medical College).
Associate Professor
- Goa - Central Govt. college 6 years (Full Time System)
Professor of Surgery & 13 yrs
- L.T.M. Medical College, Sion, Mumbai Muncipal Medical College
Dean 5 years
}
- 18 year (Partly Honarary & Partly Full Time System)
Medical Director
- Bhatia Hospital - Middle Class Trust Hospital 2 years
Jaslok Hospital Pikale Nursing Home
- Elite 5 Star Trust Hospital 1 year - Private Nursing Home Owned By Son in Law & Daughter
Advisor to Govt. of Goa - 2 years - Organized Trauma Care Service in Goa Medical College. Established Trauma Care Unit at L. T. M. M. C. which is the first of its kind, well Organised Unit in India in the civilian sector. Specialised in offering extremely low cost, high quality surgical treatment in a public hospital. Thus, wide experience in Private, Central govt. & municipal hospitals and private hospitals for all strata of society. Greatly concerned with the appalling deterioration, in the standerd of medical education, public health services as also private, medical services in the country.
PREFACE I have spent nearly 55 years in the clinical field-first 5 years as a graduate M.B.B.S., doing resident posts and later anaesthesia in Pune till I passed M.S. in general surgery. For the last 50 years, I am in the medical field doing varied functions like surgical practice, teaching, research, administration and development of hospitals.Initially I worked in a private trust medical college; thereby I developed an insight into the pros & cons of a private teaching institution. later I worked in the central government run medical college with a 100% faculty of full time consultant teachers who were not allowed any private practice, while in Mumbai I worked in the muncipal medical collage which showly transformed from Honorary consultant system to the full time consultant teachers who were not allowed to practice outside the premises. However till do day it has remained a mixed system. I headed the college and hospital as a Dean and got a wide experience in administration and development. After retiring from the college, as a medical derector, I managed a middle class charitable trust hospital as well as an elite hospital like Jaslok Hospital and spent the last 20 years in running a proprietory nursing home owned by my daughter and son-in-law. Thus, I had the widest experience ever for any medical professional-cum-administrator, having seen from the poorest to the richest class of patients and all kinds systems of administration from full time to Honarary to only private practice and intimately experienced the working in muncipal corporation, State and Central Government. In a way I was fortunate that I was not contaminated by "Foreign education or experience" but observed their working only late in my life. In addition during my cllage days, I had a 12 years’ association with a social organisation, which brought me in close contact with the poor to the poorest strata of society and which gave me a lot of training in sociology and politics. Though, I never entered political field, this helped me in understanding the real problems of the common-man in getting proper care and in understanding the anamolies in the health care system. To-day, health care is going beyond reach for even the middle class people and the costs are likely to soar higher & higher. The
glamorous high technology is blinding the people's vision and the ever increasing demands for such equipments is only helping to make the situation worse. It is not realised that what the people need is good primary health care and a reasonably priced secondary care. Unfortunately, "Free Treatment" is not only considered the right of every citizen but has become an accepted slogan for politicians as well as public health doctors and all the citizens. They take immense pride in advocating "free treatment", despite the fact that people are spending more & more and getting worse and worse treatment in these "free hospitals". I also realised that the main problem in our system is an extremely faulty medical education and an equally faulty primary health care system. These are the root-causes of the chaotic health care system. Hence it is necessory to give a body blow to the concept of "free treatment" and earn revenues from every one capable of paying for medical services, whether in private or public sector. It is also essential to radically improve the medical education system. The society benefits or suffers for the next 35-40 years, depending on whether the doctors brought out are good or bad. It must also be realised that a poor ineffecient public health care system results in a highly exploitative, costly private health care system; it has no fear of any competition from the former. In addition people have wrong concepts about the medical insurance schemes, consumer protection act and its consequences etc. All this prompted me to write this book. I have explained where things are going wrong and what needs to be done. I would be the happiest person, if the book leads to a wide discussion on all the points I have raised, irrespective of whether my ideas are accepted or not. I feel convinced that many of them will be accepted, if only widely discussed.
– Dr. S. V. Nadkarni
CONTENTS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.
Introduction The Present Scenario Health Care Delivery System Health care system is an industry The need for qualified Doctors Selection pattern for admission to Medical College Fee for Medical Education Subsidising Private Medical Colleges Paying Patients in Med. College Hospitals Effective fees for Medical Education Selection of Medical Teachers Working pattern in (Med. College) Hospital The Dean Medical Curriculum Referal System & Charging Pattern Service charges for patients Supply of Medicines Adequate Emoluments for Medical personnel Nursing Homes Health Insurance Accreditation Miscellaneous Bill for the patient in Public Hospitals For Teaching Economics of Healing 24. High-Tech Modern Hospitals - Are they Really Useful? 25. In summary
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