“THE PAPER  IN MY WALLET”:THE PROBLEM STATEMENT

Nobody knows the value of those crumbled tokens of labour more than me. Physically dry, they may be, but apparently soaked in drams of my metabolic excreta called sweat. Each of them represents a canvas of exorbitantly painful events of exploitation. Each of them to be extracted for a plate of rice and a piece of cloth. These crumbled tokens are my world, my means of surviving. Yet the black hooded carnivores snatch them from me , with a knife on my stomach: literally. Shall I call them healers?  - a Farmer

Disease is omnipresent in this mortal world. It is something like an integral part of human life. It has been an unavoidable phenomenon of life ever since that mortal bite by Adam. Therefore healthcare becomes a basic need along with “roti, kapra, makan” (food, clothing, shelter). It has been recently regarded as one, at a time when man was compelled to look beyond the extraordinary greediness of commodity accumulation. Interestingly, none of these basic needs have been included in our fundamental rights. Were the makers of the constitution, ignorant of it or avoided it purposefully or thought it is not feasible for the government to provide these basic needs to the people. The point to be noted is that these basic needs of life have been included in the directive principles of state. So the needs which are fundamental for living are not included in the fundamental rights but in the list of objectives which the state do not guarantee a citizen but should strive to achieve.

The state is presently in a tug of war. On one hand there are the international markets, organizations, MNCs, hungry bureaucrats pressurising the government to let healthcare be treated as commodity that has to be bought from the market, and on the other hand , the media and social scientists demanding for free healthcare. However, the former group has won because of their stronger "holding" on the government. Theresult:“the paper in my wallet has been stolen". Indeed there are thieves in the health system of the country(the huge NRHM scam is a small example).

Off late, we have had a battery of scams, rather a battery of identified scams. This might just be the tip of the ice berg. Take for example, the much hyped 2G scam, which has said to have resulted in a loss of crores of rupees. Many intellectuals have been crying how much good could have been done with that money. But even if the money had been present, there would be multiple mini-scams, each may be on an individual basis to absorb the money and the picture perhaps wouldn’t have been a rosy one. The trickle down theory doesn’t work anyway, whereas it needs to work on a grand scale to ensure these "papers in the wallets" (fruits of economic growth), trickledown to the poorest of the poor.The social and health programs of the government have failed to trickle down and raise the living standards of the poor. According to Rahul Gandhi, only 5 per cent of development funds reached their intended recipients due to hierarchical corruption in the country! However this failure of the trickle down theory has received little attention as compared to the 2G scam.

Let us now look at some “unhealthy” Indian statistics:

Ä      World bank says, 40% of the hospitalised Indians has to borrow or sell their assets to meet the healthcare costs and of these 35% fall below the poverty line and the world bank thinks that public interventions are a barrier to removal of poverty. [NSSO]

Ä      Coming to public spending on health, it has changed drastically over the years. With the beginning of post colonial era, it gradually increased till 1980s and 1990s after which the SAPs prescribed a decreased public spending on health. According to United Nations calculations, India’s spending on public health as a share of GDP is the 18th lowest in the world.

Ä      The low public spending continues till NRHM when the public spending increased and now we are looking at further increase with the 12th 5yr plan. However, with 1.2% of GDP dedicated to health, there has been 1 NRHM scam;                                                Now, with 2.4% of GDP, there might be 2 NRHM scams.                                            More focus on efficient mobilization of existing resourcesrather than injecting more funds into the system was/is painfully absent.

Ä      Heart disease, strokes and diabetes cost India an estimated $9 billion in lost productivity in 2005. The losses could grow to a staggering $200 billion over the next 10 years if corrective action is not taken quickly, says a study by the New Delhi-based Indian Council for Research on International Economic Relations.

Ä      India is the TB capital of the world:India accounts for one-fifth of the global TB incident cases. Each year about 1.8 million people in India develop TB, of which 0.8 million are infectious cases. It is estimated that annually around 330,000 Indians die due to TB. [WHO India]

Ä      India is the diabetes capital of the world [India Today]. India has very high mortality rate from malaria & HIV/AIDS.

Ä      Women to men ratio were feared to reach 20:80 by the year 2020 as female fetus killing is rampant. Ten million girls have been killed by their parents in India in the past 20 years, either before they were born or immediately after. [India Fact Book]

Ä      Nearly 9 out of 10 pregnant women aged between 15 and 49 years suffer from malnutrition and about half of all children (47%) under-five suffer from underweight and 21 % of the populations are undernourished. [UNICEF]

Ä      India alone has more undernourished people (204 million) than all of sub-Saharan Africa combined.[WFP]

Ä      Nearly 20 % of women dying in childbirth around the globe are Indians. [WHO]

Ä      Six out of every 10 births take place at home and untrained people attend more than half of them. [WHO]

Ä      44 % of the Indian girls were married before they reached the age of 18. 16 % of girls in the age group 15-19 years were already mothers or expecting their first child and that pregnancy is the leading cause of mortality in this age group.[UN]

Ä      According to WFP, India accounts around 50% of the world’s hungry.  (more than in the whole of Africa) and its fiscal deficit is one of the highest in the world.  India’s Global Hunger Index (GHI) score is 23.7,  a rank of 66th out of 88 countries. 

Ä      India accounts for about 10 percent of road accident fatalities worldwide and the figures are the highest in the world. [World Bank]

Ä      We are not done with the ravages of the communicable diseases and the non-communicable diseases(NCDs) have already started to plague us in a big way. the role of NCDs in the health system has become so much significant of late, that for the first time a UN summit was held in September, 2011 on the issue; the only UN summit on health after HIV/AIDS 2001.

With health, the cockpit of socio economic growth of the nation, in such dire straits, no wonder the hard earned “papers in wallet” of the poor men has been melting into thin air.

WHO IS LISTENING!! (pun intended)

Dr. Sugata Pyne

MHA-Hospital Administration

2012-2014 Batch

TISS,Mumbai

Hospitalists: Scope in Indian Hospitals and Healthcare Setting

Concept of Hospitalist: Hospitalist (practitioner of hospital medicine) ensures delivery of comprehensive medical care to hospitalized patient. Apart from performing the above mentioned core expertise, hospitalists work in coordination, communication and collaboration with all those who are part of care taking team of hospitalized patient. Hospitalist also ensures quality practice and effective use of hospital resources. Thus hospitalists can enhance the performance of hospital and healthcare setting.

Problem Statement: Do we have proper infrastructure and environment in hospitals and healthcare setting to deploy hospitalist? No, but we do need them in near future to provide quality of care with human touch apart from the sophisticated technological means of quality. Hospitalist can play huge role in improving the utilization of healthcare facility as compared to by other means, especially in the era of increasing literacy rate. More educated patient means higher needs of knowledgeable and qualified personnel to take care and answer the in-depth queries of patients. Basic concept of hospitalist was to have full time presence of physicians inside the healthcare setting to take care of patients round the clock. Consultants affiliated with hospital will need time to reach to hospital to tackle the case without hospitalist. But with the presence of qualified hospitalist, case management becomes more efficient and effective.

Indian Scenario: Even though NABH accredited District Hospital, Gandhinagar has latest and improved conditions, still educated population of well-doing capital of Gujarat, prefer tertiary care teaching hospital (Civil Hospital, Ahmedabad) which has one of the finest medical college in India (B.J.Medical College) affiliated with it. Round the clock availability of qualified PG residents along with frequent rounds of consultants (APs, HOUs and HODs) puts Civil Hospital, Ahmedabad in top position as preferred choice by educated people of the capital city and state. Patient outcome and patient satisfaction heavily depends on the presence of qualified person within the healthcare facility. Though government is putting stress on improving infrastructure of the district hospitals (DHs) across the nation, healthcare personnel management becomes equally decisive with regard to its utilization. The same scenario is there in private setup, where patient chooses the hospital based upon presence of qualified person to answer them immediately. With increasing trend of literacy rate, concept of hospitalist will become essential in Indian hospital and healthcare setting. Currently tertiary care teaching hospital is the only facility that has inbuilt advantage of post graduate residents, whose work is more or less similar to that of the hospitalist’s work.

Relevance of Hospitalist: Hospitalist work is not limited to family medicine or internal medicine, but any department with large OPDs and small indoor admissions are suitable for hospitalist. Hospitalists are hired by hospitals and they usually do not have office-based practice. Hospitalist concept was criticized heavily by experts in late 1990s. But now as the concept of hospitalist has already proved its worth in western world during past one and half decades, it is now growing and expanding its span from non-specialist hospitalist to specialty based hospitalists. Hospitalist program covers emergency department, orthopedic, pediatrics, neurology and many more specialties today in USA. For instance, there are nearly 35,000 hospitalists are working in USA in 2012. The growth of hospitalist is incredible. By seeing and sensing the need and usefulness of the hospitalist, currently fellowship programs are being offered in hospital medicine, pediatric hospitalist, Obstetrics and Gynecology hospitalist and so on. This suggests the importance of hospitalist in healthcare setting to improve quality and add value to the service delivery.

In context to India, educated patients of urban and rural India seek for quality healthcare and hurdles like distance and cost have lesser effect on choice being made by them. Thus it is high time to implement new brigade of hospitalists in hospital and healthcare setting to improve quality of healthcare.

Challenges and Scope for India: Hospitalist can play pivotal role in functioning of both public and private setup. The current challenge would be to have effective policy for the same. Not targeted, but integrated and broad approach is needed to make it happen at each level of healthcare service delivery setup. As MCI gave green signal for MD in Family Medicine, Medical education and MCI along with ministry of health and family welfare should pursue preliminary research for the possible scope of implementation of hospitalists (MD in Hospital Medicine) in phased manner with enough regulations to ensure quality of care being offered. Initially MCI and medical education division needs to carry out evidence based planning for the same. In early transition phase, 3rd & 4th year residents of tertiary care hospitals could be deployed for about 3 months to various District Hospitals and CHCs of the vicinity as a specialist hospitalist. In parallel to this, intern doctor could be posted in DHs (just like current rural SC/PHC/CHC postings), where they could work as non-specialist hospitalists. Just like MD in Family Medicine as post-graduate branch, MCI could offer degree and diploma course like MD in Hospital Medicine (hospitalist).

This will definitely help to build the cadre of hospitalist for nation in a phased manner. Also there should be enough provisions to be made for them to become specialist hospitalist as super-specialist branch to pursue. Major proportion of super-specialty branches offered should be for pediatrics, geriatrics, psychiatry and emergency hospitalist to address the future burden of these types of illness and diseases.

This kind of strategic increase in numbers of healthcare personnel could ensure better patient management in healthcare setting. Great challenges lie in terms of economic and political commitment. But evidence based research could assure favorable cost-benefit ratio for building healthy nation with quality of care at each level of health service delivery system.

In PHCs and CHCs, Medical Officer and AYUSH practitioner along with qualified physician (MD in Family Medicine) would be best approach to cater the needs of community. At district and tertiary care hospital level, along with consultants, posts like hospitalist (MD in Hospital Medicine) is much needed to address the patient needs and narrow down the gap in health personnel in healthcare settings. This in-house approach of hospitalists can also work effectively in private setup and can offer quality of care. Thus within the scope of public and private setup, hospitalists can be the center point to exercise patient centered care approach. They can form effective teams for patient care and can provide leadership skills. They can ensure best use of hospital resources and can perform vital role in real time monitoring the functions of hospital. Finally hospitalists can offer comprehensive and complete healthcare to the hospitalized. Hospitalists can be seen as transforming hands of Indian healthcare system if deployed with great commitment across the nation.

Dr. Biren Chauhan

MHA-Hospital Administration

2012-2014 Batch

TISS, Mumbai

HOME DELIVERY OF HEALTH SERVICES

              While rushing through the paperwork in order to meet the submission deadline, when one feels hungry and not in a position to go out to dine, innumerable food outlets are at your service to deliver your meal at your doorstep. For Instance, this same person while relishing his meal gets an Angina pectoris. Will he be in a position to call for some immediate medical help (physician) at his doorstep, being in India? Why is it that today Indian Public is in a position to book a ticket in Tatkal, buy any commodity on Flipkart, order any food just by a call or a click, but when it comes to medical services in an emergency situation, it is still “out of coverage area” ?

                Telecommunication has made a miraculous advancement in every aspect of development in terms of trade, commerce, education, transportation, entertainment, finance, marketing, science, research & technology etc. but has failed to bring about any major improvement in the field of health services in the country. And when a person from a fairly well-to-do family is still stuck in an uncertainty about his plan of action during his illness, how can we guarantee a sound health to the rural and backward and not so well-to-do strata of the society that builds the majority of the country.

Every healthcare initiative by the government of the country bears in mind the key motives namely accessibility, quality, affordability and equality of healthcare in all respects. But unfortunately one or the other motive always remains unmet. The greater chunk of the population dwelling in the backward rural areas and the slum areas are still struggling to gain access to a quality healthcare.

Leap for Mankind to cover the gaps

Given that there are still huge and unmet demands for healthcare in the rural backwoods, making it available as well as affordable to the needy and attractive for the providers at the same time is a challenge. In such a scenario, we ought to think beyond the boundaries of a conventional brick and mortar hospitals and “Telemedicine” is a great strategy to channelize and strengthen the existing human resources in healthcare delivery.

Health care in India gets limited due to the affordability and time factor most of the time. Thus, Telemedicine has a major role to play. It‟s a method of remote diagnosis, monitoring and treatment of the patients via videoconferencing or Internet. It may be as simple as two health professionals discussing medical problems of a patient and seeking advice over a simple telephone to as complex as transmission of electronic medical records of clinical information, diagnostic tests such as E.C.G., radiological images etc. and carrying out real time interactive medical video conference with the help of IT based hardware and software, video-conference using broadband telecommunication media provided by satellite and terrestrial network.

Telemedicine and mHealth- Untapped potential

Being started just a decade ago, Telemedicine is at a fairly inchoate stage presently, but undoubtedly with its emerging trend, has the potential to address medical needs of the masses and taking a doctor to people having no doctor before. The large scale application of this innovation will however be possible by effective government intervention.

Presently, some of the major players in telemedicine in India include Narayana Hrudayalaya (earliest and largest program with ISRO), Apollo Telemedicine Enterprises, Asia Heart Foundation, Escorts Heart Institute and Aravind Eye Care. Though, there are no clear numbers regarding the size of the telemedicine market in India but it has been estimated that it is around US $7.5 million which is estimated to grow at a compound annual growth rate of 20% in the next five years which would make it around US $ 18.7 million by 2017(M. Rao, Technopak Advisors, 2012).Also, if it is believed that it calls for a huge investment then it‟s a myth. The basic system requires hardware, software and a telecommunication link. The costs are well within the reach of the hospitals and can easily be recovered by charging nominal amount from the patients which would be much less than the physical travelling.

Indians attach multiple cultural beliefs especially to medical care hence, difficult to convince them about the credibility of such technology .Getting personally examined by the doctor will always be preferred by the people of hinterlands than adopting any technology of such kind. Moreover, the medical facility and staff available in the vicinity may not be well tuned with the hi-tech equipments. A major limitation seems to be the poor bandwidth in the remote areas and the problems of power supply. Thus, these technologies will make no sense if the required facilities are not intact. In such situation, it is inevitable for the government to make sure that connectivity is established (e.g. via ISRO) to all the districts and village level hospitals and required facilities (power supply) is provided round the clock. Low cost, easy to install and use technologies capable of operating at not so good bandwidth should be encouraged. Educating and updating the masses about the benefits of these technologies and at the same time training the manpower in the vicinity to handle the technology is inevitable. The newer technologies – telemedicine boxes and software rather than just a video conferencing link and its „tools. e.g. digital stethoscopes and otoscopes, oxygen saturation probes (to assess the oxygen level in the patient), blood pressure monitors etc. have made the telemedicine consultation more scientific and data based.

A brief mention about the scope of mHealth (mobile health) in healthcare delivery. Mobiles have been able to penetrate more deeply into the masses than the internet with more than 800 million mobile users. Presently, entertainment and financial services have only been able to reach out to the public via mobiles.

Though mhealth has been successful in other countries, it has just managed to scratch the surface in India largely due to the lack of awareness among the public and the doctors about its benefits. One such initiative “mHealth ventures in India” was started in 2010 with the first product “mera doctor” i.e. “call-a-doctor” service, a medical call centre involving licensed doctors and medical protocols for consultation on phone 24/7 at a nominal charge per consultation.

But frankly, in my view, mHealth should be largely directed towards education and awareness generation, training for healthcare workers, tracking an epidemic outbreak and remote monitoring than diagnostic and treatment support. It is my personal opinion that it would be more helpful in an acute emergency, to provide some life sustaining tips until medical help arrives in person or in very common diseases/epidemics where just prescribing the medicine sis sufficient. As, diagnosis made just on the basis of symptoms (call a doctor) without considering the clinical signs might not be helpful in complicated cases where one can always be referred for further consultations. This too remains a nascent field yet to be developed which will answer many of such queries in the near future.

Thus, today India needs an effective collaboration of these innovations in a well planned manner to reach out to the needs of unprivileged masses in order to ensure that everyone gets the equal opportunity to attain a sound health status. Moreover, all these initiatives will help in establishing internet enabled health centres and usage of point-of-care devices will enhance the quality of services and bring health services within coverage of ALL.

Dr. Anindita Banerjee

MHA-Hospital Administration

2012-2014 Batch

TISS, Mumbai