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Let us rescue our healthcare from the sick bed

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By Dr. M. J. Kuruvilla


Health service in our country is in bad shape. It is impossible to conceal and ignore it any longer. The withdrawal of the government from the service sectors has created havoc. It has resulted in untold miseries to millions. It has left the healthcare sector high and dry. Private enterprises and corporate bodies have grabbed this sector. The hardest-hit in this game are the poor. The supreme challenge before us today is the provision of reasonable healthcare for one and all.


When the Chinese faced a shortage of medical personnel, they produced a large number of barefoot doctors. It did not work because the training imparted to them was inadequate and inappropriate. We are on the verge of committing the same mistake. The Central government plans short-term medical courses to produce half-baked doctors for our rural poor.


However, China has come up with a $124-billion plan. This is intended to correct the existing chaos over the next three years. There are additional steps to provide healthcare to all by 2020. They plan 29,000 new local medical centres and 2,000 new country-level hospitals; additional training for 1.37 million village-level and 160,000 community-level doctors; and caps on drug prices.


Obviously in India, there are not enough primary and secondary health centres. They are not distributed evenly through the length and breadth of the country. Further, the health centres are not equipped well, nor are they manned by adequately trained staff. We have to build more primary and secondary health centres, locate them in appropriate places and enhance the treatment facilities.


Then there is the question of management of these new health centres. The key person in charge has to be the doctor. Luckily, we have no dearth of doctors. One would be surprised to know that in Kerala, with a population of 3.33 crore, there are 43,260 MBBS qualified doctors registered with the Medical Council and practising, i.e., one doctor for less than 800 people (not patients). Kerala is not alone in this matter. The MBBS qualified apart, there are quite a number of doctors practising other well-established systems (ayurveda, unani, homoeopathy, etc). We have also to reckon with a number of quacks doing the healing art with impunity, disastrous to patients and detrimental to the public interest. Thus, the problem is not one of numbers, but of quality and their uneven distribution.


The present generation of doctors needs additional training. The Chinese are doing it. They give additional training for 1.37 million village-level and 160,000 community-level doctors. This has become all the more necessary because training has deteriorated in India over the years. This deterioration runs parallel to what is happening to primary education. The four Rs (reading, writing, arithmetic and reasoning) emphasised universally at the primary level are being neglected.


Likewise, the study of the structure and functioning of the human body and the derangements thereof (anatomy, physiology and pathology) has been put on the back burner. The net result is the production of doctors whose knowledge of the basic medical sciences is scanty. However, I will not subscribe entirely to Voltaire's view (1694-1779). He described doctors as men “who prescribe medicines of which they know little to cure diseases of which they know less, in human beings of whom they know nothing.” But Voltaire has a concealed cardinal message which we shall not miss. He exhorts doctors to learn pharmacology, pathology, biotechnology, anatomy and physiology.


Just as “the seed and the soil determine the yield” or “the quality of a product depends on the material and the workmanship in its makeup,” the quality of medical men we produce depends on choice of the right candidates as well as their proper training. Merit, aptitude, character and temperament should be the basis for selection.


A few simple substantial changes in the training programme are needed:


(1) Include mathematics as an additional mandatory subject for admission to the medical course.


(2) Extend the period of preclinical study to two years and cover the basic subjects viz. anatomy, physiology, biochemistry and pathology more thoroughly and comprehensively. Set apart two hours every day for dissection work. This will enable the doctor to have a first-hand knowledge about the structure and function of the human body.


(3) Clinical training should be for three years, of which the last year should be in general hospitals rather than in collegiate hospitals. This will enable the medical graduates to diagnose and treat patients based on the physical findings and clinical judgment with minimal support from sophisticated and invasive investigations and procedures. While the collegiate hospital training imparts skill in the management of rare and uncommon diseases and their tertiary care, the district and taluk hospital training will give them a good grounding in the primary and secondary patient care of common ailments. Doctors should be kept fit and proficient throughout their professional life. Recertification of the medical degrees and re-registration for continued practice are a sine qua non.


Improving infrastructure and their management by competent, committed staff are not enough. There should be a proper mechanism for healthcare delivery. The benefits should reach the needy. For guidance in this matter the best place to turn to is the U.K., where there is the National Health Service. Healthcare is open to everybody there, free of cost. (Contribution to national insurance is compulsory for all.)


Simply speaking, one does not contribute if one does not earn and yet will reap all the benefits of health service. But there is no freedom of choice for the patient. He does not choose his doctor, the hospital or the modality of treatment.


There is also the British National Institute for Health and Clinical Excellence. Some glorify it as the guardian angel, yet others (particularly, the Americans) have nicknamed it a brutal watchdog of British Health. This body ultimately decides which treatments the nation can afford to buy. In the decision-making process, the general practitioner and the bureaucracy have a big role. This looks fine! But a close examination reveals that the devil's in the detail. The value of life is calculated on the basis of its future utility. There is an undue emphasis on cost-effectiveness. For instance, resuscitation is not encouraged in case of cardiac arrest, if the victim is a cardiac cripple, a known cancer patient beyond cure or if the victim is overaged — so goes the list. However, it is difficult to find fault with some form of healthcare rationing.


We have to learn from the Americans too. They are not immune to healthcare problems particularly as regards their sick, old and poor citizens. That is the reason why three years ago Barack Obama lashed out at the health service. He outlined a plan in which it would be illegal for insurers to drop sick people or deny them coverage for pre-existing conditions. His concern was to ensure a uniform health coverage for all Americans. This he intended to do by making the health service work efficiently and at a minimum cost.


The President said his plan would provide ‘security and stability' to those who have insurance and in addition cover those who do not have it. He repeated his support for a government insurance plan to compete with the private sector (which is profit-oriented and not service-motivated). Still, the sheet anchor in his plan is contributory insurance. This will, however, siphon off a good chunk of money earmarked for healthcare to third parties.


We shall not fall into the insurance trap. What we need is uniform, universal free healthcare for everybody as in the U.K, and not insurance schemes for sections who contribute. In India, there are several health insurance schemes. There is a lot of misuse of these schemes by patients, doctors, hospitals and the insurance companies and their employees.


[Dr. M.J. Kuruvilla, FRCS (London and Edinburgh), has held faculty positions in the universities of Kerala; Pahalavi University, Shiraz, Iran; and Arab Medical University, Benghazi, Libya. His email id is kuruvilla_mj@bsnl.in]


(Courtesy: The Hindu)
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