Aaditya has shot off another angry email to the health minister…knowing fully well that just like the last time, this one would most likely be ignored too. Both times he actually put in an enormous amount of research, expertise and perspective - formulating clear plans and suggesting ways and means to remedy the particular problems he’s been perturbed about. These weren’t a means to rant at the establishment. I suspect the powers that be lost no time in brushing his emails off to the trash bin in one clean sweep without so much as a curious glance. At least that seems the most likely scenario as he has never heard back.
It’s true that the Indian healthcare system inspires dread and frustration in a by and large susceptible population struggling with every bend and curve of the system, unable to find any alternative. Some of the obscene statistics that have now become the hallmark of Indian healthcare system around the globe include the 900,000 Indians that die every year from drinking contaminated water and the more gruesome “5.6 million child deaths” in India every year, making up more than half of the world’s total. In the age of ‘India shining’ and words such as ‘corporate superpower’ being bandied about, this almost seems like an anachronism, doesn’t it? I won’t harp on about more of these ‘numbers’ as generations have sat on these statistics with nothing changing except the hospital walls which now look more beige than red, with successive generations of patients, their relatives and ward boys having spat that ubiquitous ‘paan ki peek’ that is as much a part of the hospital as the flies that buzz above.
As with everything else, Indians of a few thousand years ago seem to have been a lot more proficient and systematic at managing health care problems as well. We all cram lessons in school about Charaka, the ancient physician and Sushruta, the ancient surgeon who were both pioneers in their respective fields. Even before their time, there is some evidence that Agnivesh wrote an encyclopedic treatise under the guidance of the ancient physician Atreya in the eighth century BC. There is some evidence that Emperor Ashoka Maurya (third century BC) was the first leader in world history to attempt to give health care to all of his citizens. Thus it was the India of antiquity which was the first state to give its citizens national health care.
What seems to have gone wrong? The modern Indian system of health care is loosely based on the tiered British system, the National Health Service or NHS. We have Primary health care centres at village/small town levels and district hospitals/referral centres at the district or city level to manage the greater numbers in the city and more complicated problems referred from the PHC’s. But here the similarity ends. The PHC’s, though ideally suited to the needs of a country like India, are hardly functional. In actual effect, the system works with major input from the private sector through corporate hospitals and what are called ‘polyclinics’ where money making takes precedence over all else. The ‘sarkari haspatal’ experience is nothing short of purgatory for most of its users.
The system as it works in the UK (and yes, they have had their own share of problems with a fully state funded system of health care recently) caters to ALL citizens irrespective of their paying capacity. From the most basic level of preventative care to highest level of surgical /interventional care, everything is offered free of cost. This is what the planners in India envisaged. Except that they forgot to make provision for the basic needs of such a system. In India, health care comes under the remit of state Governments with central government providing overall direction and recognizing areas of impetus through the five year plans. The Seventh Five-Year Plan (FY 1985-89) budgeted Rs 33.9 billion for health, an amount roughly double the outlay of the sixth plan. However, the catch is that health spending as a portion of total plan outlays, had declined over the years since the first plan in 1951, from a high of 3.3% of the total plan spending in FY 1951-55 to 1.9% of the total for the seventh plan.
But financial resourcing is only part of the problem. Health care professionals – their attitudes, ethics and respect for self and profession seem to be the major players in what ails this system. In 2005 the World Bank conducted a study and reported that "a detailed survey of the knowledge of medical practitioners for treating five common conditions in Delhi found that the average doctor in a public primary health center has around a 50-50 chance of recommending a harmful treatment". This is the more shameful aspect of how a country of over one billion and a so called emerging economic superpower manages the health of the nation. Note the setting here- the public primary health center. Something about that rankles. It’s as if the country’s polity has decided that the poor/lower middle class Indian can make do with second grade health care. How else do you explain the fetid, non-resourced environs of a primary health care center? A rickety chair and desk, plaster falling off walls, no medical equipment to speak of and no support system in place should a difficulty arise. So by logical extension, the only people you find populating these centres are ones who would rather be elsewhere but find themselves unable to.
The disparity between how core services such as health and education are delivered by the public sector and how things work in the economic/commercial hubs of the nation couldn’t be any wider. There has been a complete failure to integrate health with wider social and economic development. While money flows in certain sectors, health and education end up being the ‘poorer cousin.’ The attitude at the top is that of indifference and apathy. Obviously, people have been dying of poor health for decades and no political party has ever lost an election on this issue. So why bother? And here is where the story of downfall begins for a medical professional. A healthy and motivated workforce only exists where adequate support is available at the top. As with people in the financial sector, give these people proper working conditions, make resources available to them and they would work. At least a majority would.
The lowest rung of health care in the UK starts with the GP’s or General Practitioners, who also happen to be some of the best paid health professionals. They have a planned system of referral to the secondary level and a thoroughly self sufficient setup to cater to all health problems that can be managed at primary level. They work with immense pride in what they do and society recognizes them as the key player in improving community health. There is never any question of their being treated as inferior to a doctor in a tertiary hospital. The GP’s have support from well trained nursing and paramedical staff and work with a team rather than in isolation. They have an electronic medical records system and access to national guidelines and protocols for management of the plethora of non-serious conditions that they manage in the community. Above all, they are trained from an early stage to be ‘family physicians’ and are not therefore people who could not be specialists settling in for the compromise of general practice.
And that is precisely what we lack. An adequately paid ‘primary’ workforce that has access to at least basic infrastructure. No one is asking for an interventional radiologist at every PHC but basic medicines, syringes, gloves, antiseptics, wound dressing, local anesthetic in adequate quantities is elementary. Nobody can ever know all about all aspects of medicine and its futile to expect this from our overworked and underpaid band of community medics. In a country like India where roughly 700 million people have no access to specialist care, it is astonishing that there is no recognized training programme in community medicine! So what the world bank report failed to highlight perhaps was that these people who they found lacking in knowledge, were functioning not only without guidelines/protocols, knowledge resources and infrastructure to upgrade their learning but also without any semblance of training for the job they were expected to do. They carry out a job that no one else seems to want to do and morale, motivation, job satisfaction and pride in what they do is nonexistent. They need to be appreciated and recognized, not treated like second rate citizens in the medical fraternity.
Just about a quarter of a million trained doctors come out annually in our country and yet there is a perpetual shortage of medical staff in rural areas. The Government tried a policy of enforcing rural postings but why not invest in rural healthcare instead? If these doctors had a viable career option in the form of rural practice, why would they struggle in the cut throat competition in surplus areas?
While no one would dispute the fact that India has its own set of unique problems and no foreign model can be superimposed on it, the obvious lack of interest in improving grass root level healthcare is a disgrace. While we brag about an ever expanding ‘medical tourism’ industry and healthcare is set to become a $150 billion industry by 2017, this seems like a hollow victory in the absence of any sign of improvement in the health of those that need it most. It’s a slap in the faces of policymakers that less than 40% births in the country are attended by trained birth attendants and maternal mortality still sits at the same level as 60yrs ago. To get a sense of just how far behind we are from the rest of the world , maternal mortality rate i.e. a mother dying in childbirth, which is arguably the most sensitive index of the health of a nation, was still sitting at about 450/100,000 live births compared to about 14/100,000 in the UK. That is a staggering difference. What’s more poignant is that about 800,000 women each year die of the most easily preventable causes possible- anemia, infection and haemorrhage. If Mumtaz Mahal died of haemorrhage after childbirth in the 1600’s, more than three hundred years later, one of our most prominent and promising actresses of recent times, Smita Patil, dies of the same in 1986, telling us that nothing had changed in the interim. It requires the simplest measures to prevent so many unnecessary deaths each year- deaths that leave fragmented families and the spectre of infants without their mothers. We’re perpetually in a race to be as advanced as the developed countries of the west. Why then has no initiative been shown to be at par with these countries in terms of the most basic human necessity- efficient healthcare? The answer lies perhaps in freeing healthcare from corrupt political influence and putting people who really know, in charge of the system. Maybe then we’d be able to make a start towards becoming a healthy nation, which I presume comes before ‘superpower’ nation.
‘Death Becomes Her:’ 100 Years of Exquisite Mourning Dresses
14 minutes ago