Dr Kamal Mahawar penned a very perceptive piece on his analysis of the Federal Budget and what we should extrapolate from it in terms of healthcare delivery in the country. He has made a careful analysis and I must compliment him for his efforts.
Broadly I agree with him when he identifies the assets and the pitfalls. Those who have followed my columns here would know the emphasis I place on primary healthcare delivery having observed and worked in 11 countries across the globe. Effective primary healthcare delivery is the bedrock on which the success and failure of the health of the population very largely depends.
In a previous column I have given my evaluations of the five best healthcare systems in the world and shared my reasons. Cuba, Switzerland, Sweden, Denmark and Norway – the five countries identified – rely primarily on the provision of primary health. And it is here that our country has failed miserably!
I agree one hundred percent with him (Dr Mahawar) that the improvement of primary healthcare would go a long way towards alleviating the abysmal healthcare provision in this nation. If one were only to peruse Cuba’s record, its healthcare difficulties in 1959 were identical to that of India and it has effected a turnaround by focussing entirely on the primary and preventive healthcare; the country, despite its remarkable healthcare statistics, is still woefully short of specialists and super-specialists.
I believe the improvement of healthcare in India cannot be brought about by injecting money alone. That is not to state that the healthcare sector does not need fiscal investment; it badly does! In fact I am all for having a separate healthcare budget every year. But in my opinion all the money injected would go waste unless we address some very vital variables that have a crucial bearing on the healthcare delivery.
The complete absence of emphasis on preventive healthcare is to be lamented! And what is more we do not observe any optimistic sign that this is going to change in the foreseeable future. Any healthcare system is doomed unless we make provisions in this regard. In Cuba, preventive healthcare is intertwined with primary healthcare and as it is based within the community it serves, it works well. At least I have not seen any eagerness within our legislative class to debate why we have not been able to curtail the tobacco menace despite the havoc it is creating. That is just one example. Preventive healthcare is a concept that is almost totally alien to the general Indian mindset! And for a functioning healthcare system, that is an absolute sine qua non. We have to bring about a change in our mindsets.
The other alteration that is needed in our mindsets is the complete devaluation of primary healthcare. It commences right from the policymakers both medical and non-medical. So unimaginative is our distrust of primary healthcare that its importance is never emphasized in medical schools. Indefatigable lugubriation by a few pioneers like Dr Raman Kumar has led to the commencement of postgraduate training in family medicine in about half a dozen centres but that is clearly insufficient. The government has to see merit in a two-tier system and institute it in its policy. Family practitioners are regarded as specialists in Sweden, Norway and Denmark plus many other European countries. Even the UK instituted the MRCGP (Membership of the Royal College of General Practitioners) exams but in all my interactions with the current generation of recently qualified medics, I have seen no motivation to seek a career in family medicine possibly because that is seen as a less glamorous branch of medicine with perhaps financial incentives that do not measure upto their expectations.
Not that long ago, when I had penned a column here stating that what my mofussil town needed was an institute to train primary healthcare practitioners rather than an AIIMS that was being planned by the political class (clearly for political reasons), I was subjected to intense criticism from some of my medical colleagues in the town. An owner of a very busy nursing home, himself an orthopaedic specialist, in a conversation mentioned that primary healthcare can be provided excellently by those holding an MD in Internal Medicine! The idea was so surreal that I started gaping in disbelief! Is it this gentleman’s contention that an MD in medicine would be able to competently handle obstetric emergencies, cope with minor surgeries and deal with neonatological problems which is what I would expect a family practitioner to be able to do!
A good preventive and primary healthcare provision automatically reduces the need for over representation of specialist centres that are mushrooming every day in every part of the country. It has become almost customary for a person with minor headache to undergo MRI and a person with minor hyperacidity to undergo endoscopy. To me that is the biggest evidence that our healthcare system has collapsed because of improper planning of which fiscal miserliness is only one part. The sad part is that we have inadvertently programmed our patients to accept this as legitimate; many of them vociferously demand MRI with the most elementary migraine and rush to the neurological clinic instead of consulting a family practitioner (non-existent at present) who would have all of the medical records and be able to provide a more personal touch. I believe that is one of the biggest disservice we have effected as medical practitioners.
More than a new medical college, what Gorakhpur really needs is an institute to train family practitioners
I spoke to a senior office bearer of the Medical Council of India and he lamented the lack of trainers for the proposed postgraduation in family medicine. I had to remind him that one of the reasons for this was the completely absurd ruling of the MCI affected by one of its less distinguished presidents viz B N Sinha that derecognized the British postgraduate medical qualifications purely on arbitrary and egocentric grounds. I personally know of at least a dozen physicians in the UK holding MRCGP who would be only too happy to relocate and function as trainers. The truth is there is nothing holding the MCI back from rescinding this ridiculous ruling, which only has had adverse effect on Indian citizens.
Those are a few problems that the government can take without any additional expenditure. But commitment to healthcare is a luxury among the political class who are in any case well insulated from the ravages of a deficient healthcare system.
But there is even a more fundamental problem, which needs to be urgently addressed before we can convince ourselves of the good faith of those in power. For that I would like to invite my colleagues to visit my part of the country and the region. They will find loads of primary health centres without any medic in attendance even during the working hours despite being posted and drawing their salaries. The truth is that many of them enter into a profane arrangement with their bosses whereby a certain percentage of the salary goes to them and they remain removed from the rural health centres. Many of them run full time clinics in the nearest district town and their ‘arrangement ‘ with their seniors both at the local or the state level insulates them from any penalties for this egregious misconduct, which in my view is also a crime. I refuse to believe that the administration and the government do not know about this. And yet there has been no credible effort to put an end to this malpractice. I tend to believe that this state of affairs is not peculiar to my state.
My point here is that before we even think of injecting more money, we have to make sure that there is no leakage and ensure its proper utilization.
by Dr Ashoka Jahnavi Prasad