Dr Pingali Gopal and Dr Chodavarapu Ravikumar
Too many hospitals are coming up, but is health improving? Now, we have eICUs set up by big hospitals where remote monitoring using advanced software is helping patients getting immediate treatment. There is increasing specialized healthcare for those who can afford it. However, the gap between medical delivery for the rich and the poor is increasing. This, despite the country boasting of some of the best hospitals and the best doctors in the world. It just does not make sense. Where have we gone wrong in the delivery of the health system?
Most of medicine today targets at individual diseases making it an expensive venture and allowing a good amount of profiteering in the practice of medicine. This again has been at the levels of single doctors, groups of doctors, diagnostic evaluation, and the pharmaceutical industry. There is also increasing levels of defensive medicine as a secondary outcome of the onslaught of the legal machinery. The greater reliance on results of laboratory tests and radiological evaluation, ignoring the power of clinical medicine (symptoms and signs of patient), is an unfortunate precedence which increases the burden of modern medicine on patients.
Most of the doctors are aware of the 80-10-10 rule. History and clinical examination can diagnose 80% of all diseases, 10% require further investigations and the last 10% would never have a diagnosis. But many cannot implement that in clinical practice. The reasons may be many: undue faith on technology (lab tests, radiology); fear of litigation; confounding evidence-based medicine for laboratory-based medicine; insurance company demands for laboratory evidence; patients’ misplaced satisfaction in technology and investigations, and many other reasons. The commercial aspect is not the single factor, as is commonly alleged.
The parameters of health reflecting the status of health in the society like the infant mortality rate, the maternal mortality rate, life expectancy, Caesarean section rates have remained pathetic in most parts of the country. Government sponsored insurance schemes, mainly dealing with individual diseases, even after a decade, have hardly had an impact on the health numbers. Bangladesh, Sri Lanka, and even some African countries show better statistics.
We do not need many tertiary care medical centres, big hospitals in big cities doing big surgeries, to improve the nation’s health. They are no doubt needed for about 10% to 20% of complex health problems. They are a tribute to our hugely skilled professionals. Most of the health problems, 80% to 90% need primary to secondary level medical care and most importantly, preventive health services in the community. However, our country’s health pyramid should contain the big hospitals or ivory towers at the top of the pyramid. Unfortunately, they are now the base of the pyramid of the health system. The most important and vital factor in making our nation healthy is improvement at the grassroots level of health through strengthening of primary health centres.
BHORE COMMISSION RECOMMENDATIONS
The Bhore Commission to reformat the medical and health system of the country was set up in 1943; the report running into four volumes released in 1946; and the government finally accepted them in 1952. One of the great purposes of this commission was to fill the vacuum of trained doctors in the rural areas.
There was a licentiate system of medical practitioners which were doing yeoman and valuable services to rural India. Many of the older generation from the rural background remember the licentiate doctors, who were the LMPs (Licentiate Medical Practitioners). They underwent training in medical colleges and had an official degree to practice medicine, though in a limited manner. It allowed good medical services in the rural set ups.
Unfortunately, the committee rejected this system in its entirety though with a good amount of resistance from six of the committee members. These six members wanted the system to continue for some more time, who thought that they were very good in solving health needs in the villages. Apparently, this kind of system was a successful Russian model. The Bhore committee appeared more tuned towards Western medicine, as it allowed the possibility of American and British co-operation in the training of Indian doctors.
The argument was that inferiorly trained doctors would lose their way and become a burden eventually; and a properly trained ‘basic doctor’ would be the best person, given adequate ancillary staff, who can impact the health improvement scenario of the country. It was unfortunate because the philosophy has failed. It made some solid recommendations to improve the overall health delivery system of the country in terms of medical education, Primary Health Centres, Nursing training, etc. The recommendations have remained Utopian as we are still struggling with the health parameters of the country after six decades.
THE NMC BILL AND ITS CONTROVERSIES
There is a recent move to introduce the LMP kind of system, which allows untrained people like compounders, health assistants, ophthalmic assistants to become trained as ‘community health providers’ and who can practice preventive and primary medical care. Under the supervision of a trained doctor, they can practice even secondary and tertiary level treatments. This is one of the most dangerous and ill-conceived moves of the government in their desperate drive to increase the pathetic doctor-patient ratio in our country.
The Indian Medical Association (IMA) is naturally aghast at such a proposition, as the requirements to become an MBBS doctor through the more stringent system becomes rather strange. This concern to some extent is right, as the health delivery to the rural segment will further compromise. It is very important at this point of time to have a scientific debate and devise a method of training a group of ‘middle level doctors’ who would be useful and at the same time non-dangerous, addressing thus the biggest fear of the IMA. It would be a far better idea to look at well trained nurses to fill this need of primary health care, since their numbers are better than doctors. Also, they are part of a structured curriculum and accepted as an inherent part of the medical delivery system without any ambiguity or controversy. Their scope and limitations can have a very clear definition.
HOW DID THE INVERSION OF PYRAMID HAPPEN?
MBBS doctors of previous decades were very effective in delivering cost-effective primary to secondary level treatment to the people, nearer to the people’s living places-villages and towns. A few decades ago, primary health care centres (PHCs) were functioning well with dedicated MBBS doctors. The previous generation of MBBS doctors had training in all round competencies needed by people at community level. Though the MBBS training previously was predominantly in medical colleges with tertiary care hospitals, unlike now, the focus and thrust of training MBBS graduates previously was on primary to secondary level care.
Later, with the evolution of modern medicine, under intellectual control and domination by western thought and technology, rapid growth in specialisation and sub-specialisation beyond the requirements of the society happened, at the cost of primary health care, needed by most people. It increased the cost of therapy. Specialisation started receiving more glamour and income.
The practice of medicine has become a source of decent money which is apart from the fees paid by the patients. The equations held in prescriptions and ordering tests can prove very profitable for some. We are certainly in a big fix. The young generation are more attracted to specialisation and sub-specialisation. Medical college training and continuous medical education programs of various medical associations, government policies, medical technological industry, and market forces all have advertently or inadvertently shifted to specialisation and tertiary care.
Specialisation and tertiary care are very costly and perhaps needed to about 10% or less of health problems. People also developed undue faith in technology and tertiary care. Patients are directly consulting specialists and subspecialists, without first seeking medical care from primary care doctors and centres, even for common primary health care problems. It has led to increased health care cost for families.
Specialists have very little to do in primary and preventive care which are mostly a need for society in villages and towns. Specialists are ill-equipped to cater to the all-round primary health care needs of people in villages and towns; and hence try to find a job only in cities. Young doctors are so enamoured by the tertiary care that almost every student who joins medical school wishes to undergo training in some specialisation and none wants to be an effective all round MBBS doctor. All this resulted in inverted pyramid of health care providers. When MBBS doctors are becoming scarce in villages and towns, the healthcare shifted unfortunately to the quacks.
PHCs IN DOLDRUMS
The biggest backbone of the medical delivery system as conceived by the Bhore Commission were the Primary Health Centres staffed by a ‘basic doctor’, supported by an ancillary staff, and maintaining a certain PHC to population ratio. Primary Health Centers, the district level hospitals, and the tertiary teaching level hospitals formed a good hierarchical system with an adequate transport mechanism. It was a beautiful pyramid which remained on paper. The following decades after 1952 saw a complete collapse of the base, even as the health pyramid has undergone an inversion as we saw before. The load is now on tertiary level hospitals which are simply not able to cope. The PHCs which were the backbone simply crumpled to the present degenerate state.
A typical PHC would be on an acre land and staffed by 2 qualified doctors, 4 nurses, 2 pharmacists, 2 laboratory personnel, 3 sweepers, and 2 security staff. But on a typical day, one can see probably 2 or 3 people coming and signing in the register for everyone. The doctors also would have some sort of internal arrangement for the days to attend. It is an irony of sorts in some places, that the doctor would have a private clinic very near to the PHC.
When a corporate hospital conducts a camp in the PHC and screens patients to get them treated at their hospital, with the money coming from a government insurance scheme, it is a shameful mirror of the public health system. The PHC is the main pillar of our nation’s health care system. Planning a strong and effective PHC with a good transport system can go a very long way in improving nation’s health.
Rural population must have immediate access to health care so that many illnesses have treatment at a primary level without allowing the disease to become so advanced as to need secondary or tertiary care in cities. With such pragmatic thought, the government planned the system of the Primary Health Centres. The idea was commendable, but the implementation remains deplorable.
In some places, the location of the PHC itself is not ideal for the service area. Many do not have the basic amenities for the doctors and its staff. It is dubious planning when staff quarters do not adjoin the PHC building. In several PHCs, the posts are vacant despite attractive salaries. PHC doctors, staff and their families must have encouragement by the government and society by providing them basic amenities, and providing proper educational facilities for their children. It is also a fact that some doctors and staff do not attend to their duties too. It needs correction in a scientific way by the government. The usual approach is the whip and the rod by the administrative system which only leads to hardening of the stances.
PHCs are primarily meant for preventive services, but in remote areas, drugs, and instruments to deliver emergency services need stocking too. Unfortunately, even the present quality of drugs and equipment in many health centres makes the job of the doctor difficult. And unfortunately, the doctor is engaged in administrative activities, something untaught in medical school. But the bureaucratic-political controllers expect them in a big way to answer all administrative and logistic problems which are not basically medical issues the doctors are trained in. This can be disheartening for a serious and conscientious doctor.
Unfortunately, population control, though important, takes a priority over all other strategies to improve the health of the community. Health does not stand only on the availability of doctors, drugs, and equipment. It depends greatly on the provision of clean water, good roads for transport, elimination of garbage, closed drainage systems, and improvement of food and educational opportunities. These are far more important than the PHCs, specialists and tertiary care centres. But the governments have failed on most of these counts. The reasons are mainly faulty planning and corruption at the political-bureaucratic level, even as truant or even sincere doctors take the blame for an entirely inefficient system.
Inadequate facilities plague the doctor, but when combined with many doctors avoiding their duties despite heavy salaries, it is a recipe for collapse again. Private practice lures many of the government doctors. The para-medical staff is sometimes involved in the same kind of truancy and massive ego issues with the doctors too, not very conducive to the proper running of the Primary Health Centres.
At a higher level, in Taluka and district civil hospitals, things are no better. Lack of professional facilities, inadequate staff, lack of unity amongst the staff members, gross negligence of duty, and corruption exist on a bigger scale.
RMP’S AND ‘QUACKS’
The transport systems in villages and towns need a lot of planning and strengthening to take care of the health of the country. The rural India is far too detached from the main hospitals in most instances. With a weakened primary health care system and a poor transport facility, health delivery in the villages has gone into the hands of quacks. They have different names and, in some areas, called RMPs, an acronym for Registered Medical Practitioner. Thy are obviously not scientifically trained health care personnel.
The fact is that they are neither registered nor practitioners of medicine. They are smart people in the villages who have exploited a very fluid medical system of the country to make money. For most part, they are uneducated and illiterate. They act mainly as immediate health delivery points in the villages; act as transporters to the sick and not so sick patients; and finally, as brokers to individual doctors, hospitals, diagnostic centres, and pharmacy shops. The villagers who have no access to health care depend on these RMP’s and no amount of persuasion on the part of the conscientious doctor helps them to stave off the dependency. The dependency and the fear are very easy to understand with a little application of thought.
There is a very good need of doctors to go to the remote areas. It is an irony that 70% of Indian doctors stay in urban areas catering to an overcrowded urban population which forms only 20% of Indian population. In countries like UK, there is a desperate attempt to get jobs in small District General Hospitals which are almost equal to our PHCs. If we cannot encourage our doctors to go to the villages, the alternative doctors may be prepared in a bigger way.
Alternative medicine is also useful to people. Time tested alternate medicine practiced by appropriately trained alternate medicine doctors is not quackery. The government must support scientific research in alternate systems of medicine too like in modern medicine. All systems of medicine have their strengths and limitations. People have a right to the benefits of any system of medicine. Doctors of modern system of medicine and alternate systems of medicine must accept that all are complementary to each other in strengthening health care of our nation.
AYURVEDIC DOCTORS
In this present scenario one option is to look at Ayurveda doctors who fit the bill very nicely. The Ayurveda doctors study medicine systematically, can diagnose the health conditions effectively by use of tests, can manage the emergencies if trained well and can very usefully complement allopathic medicine. They are an equally important group of people who have a secondary status to the allopathic practitioners. In many places of the country, the success of many individuals and hospitals literally stands on their shoulders. They have compromised in an unfortunate manner to become the best duty doctors and the best theatre assistants. There are thousands of such symbiotic relationships in flourishing medical careers and thriving hospitals.
Most of these doctors do not get credit for their work. The important thing is they are readily available for the delivery of health and we have not given them their due status in society even though Ayurveda is a systematic study of medicine predating our modern systems by thousands of years. It is certainly not controversial like some other alternative forms of medicine. There is a strong need to integrate the Ayurvedic doctors in the primary health delivery systems. But there is a certain amount of confusion and ambiguity about accepting and integrating the Ayurvedic doctors. They can very well integrate into detection strategies of the country like for chronic diseases like hypertension and diabetes.
GOVERNMENT TEACHING HOSPITALS
There is a huge amount of work going in the overloaded, understaffed government hospitals, both teaching and non-teaching by dedicated, underpaid, and under acknowledged doctors and nurses. There is no doubt about some of the greatest teachers in the public sector who are responsible for giving quality education to thousands of doctors in training. The government institutions can however become stronger and more effective. Private practice takes a more important role in the life of many government doctors who just do not attend to their duties.
In government colleges and attached hospitals, additionally problems of nepotism, chauvinism, and casteism come to the fore. Many teachers and academics lack the aptitude for teaching and show a disinterest in keeping the highest possible medical standards with enthusiasm. Both the emerging future medical professionals and the patients stand to lose in this scheme of affairs.
Adaptability and not dogmatism towards newer studies and advances should be the norm in the teaching institutes and this is hardly the story in most of the institutes across the country. Islands do not make for paradise. It is a fact that the responsibility of a doctor in a teaching institute doubles as they must not only treat the needy but also prepare the future generations of doctors. It is a sad irony that most students of medicine want to study in government medical colleges as a matter of prestige and ‘to learn more’; and the same doctors after completion of the education run to private hospitals for employment!
RESTRUCTURING THE MEDICAL CURRICULUM
It is another matter that the medical graduate nowadays is not confident enough in his job as soon as he comes out of the alma mater, many times the onus lying on the teachers rather than the institute. There may be an argument to increase the internship period from the present one year to two years and perhaps cutting down on the course duration itself of four and a half years. Internship period can fill the PHC posts and the period used for intensive training in managing the daily emergencies.
In the Western world, a doctor after internship would be able to handle most emergencies, but would be rather weak on the theoretical aspects. Contrast to that in India, where a fresh intern can reel off all the answers to the most difficult questions, but would be inept to handle a case of an asthmatic attack. Most students nowadays spend the post MBBS internship training program to either prepare for their post-graduate exams or fly abroad in search of greener pastures. Another possible solution to make internees or house surgeons to work sincerely in clinical care is holding Final MBBS theory examination at the end of MBBS programme and conducting Final MBBS clinical-oral examination at the end of compulsory rotating internship.
Our teaching institutes need modification in the sense that it should be completely non-practicing- with good incentives, of course. That would go a long way in elevating the teaching standards, because today the teachers and especially those on the clinical side, split considerably between their roaring private practices and teaching schedules in the institutes. This does not augur well for the future of the students as there is always a compromise of time for such teachers and professors.
PRIVATE PRACTICE
Private practitioners in the cut-throat world of competition go down the road of ethics and morals many times. For most pharmaceutical companies, their investments into their business are the doctors and prescribers of medicine. An unqualified quack would attract the company with its immense schemes if he (there are rarely any ‘she’) is generating enough prescriptions. The consequence of all this becomes a complete absence of research output in both private and the public sectors despite the most voluminous clinical material.
In the Western world, with less than a tenth of our patient load, they end up with all the papers and the textbooks- which we in turn read and apply to our world ironically! The medicine we teach and practice is mostly from observations made in developed countries. Creation of clinical research departments in teaching institutions and supporting them helps develop our observations and data. There may be even an argument for periodic evaluation of the doctors in both private and medical sectors to assess their competency to deliver health.
The public sector and government bureaucratic agents look at private practitioners with a good amount of suspicion, dislike, and apathy. In our country, more than 75% of doctors are engaged in private practice probably; and it would do well if the private-public partnerships are manged more effectively and with more trust.
INSURANCE AND ITS PROBLEMS
Legal or defensive medicine is bad enough, and now insurance type medicine is making it more peculiar. The overriding rule of any insurance at the time of claim settlement is the claimant is a fraud until proved otherwise and this system is no different. Strange and unscientific protocols for diagnosis and treatment come into being which defy logic.
Many doctors are uncomfortable with the protocols. Medicine is a science and an art as we all know and insurance degrades it to business. Sometimes, the design of the protocols is so nonsensical and funny that a definite fudging of reports becomes necessary just to benefit the patient. And when this cannot happen, there is a denial of treatment. Some of the tests required in insurance protocols are scientifically not essential in managing a patient; and strangely, these protocols, if quoted in a medical college examination, would be a cause for an immediate failure!
Insurance entering into medicine destroys the system. Our country cannot take the insurance route to medicine. Under the assault of insurance and the lawyers in the USA, medical care has become very expensive, very defensive, and very bizarre. There is an interesting story. During a recession in USA, apparently employment went down in all sectors except the health insurance sector. The job of most of the employees would be to find reasons to deny insurance! The reasons can be as varied as possible.
Private insurance is, at the end of the day, a return on investment for the company. The insurance controls are so heavy that sometimes, the decision making in treatment and investigations is as per the guidelines of the company rather than clinical evidence-based guidelines. In textbooks, statements like, ‘we wanted to do this investigation on follow-up, but the insurance company did not allow us to do so!’ are no longer surprising.
GOVERNMENT BACKED INSURANCE SCHEMES
There are state backed insurance schemes like the Arogyasri in the two Telugu speaking states. The same kind of government sponsored insurance schemes with low, impractical packages have started at the central level, but it is bound to be unsustainable. The doling out huge amounts of money, by the Government supported health insurance schemes, to the private hospitals amounts to accepting the fact that the government is unable to take care of the health of the citizens which is its primary duty. It is disheartening to note the unhappiness with which the hospitals are running the scheme. Many are opting out because the reimbursement is grossly inadequate to cover even the overheads. This, combined with a grossly delayed payment and that too after slashing the rates randomly at the time of payment causes dissatisfaction. Sometimes, after the surgery is over, despite all the legal and society pressures in case of a failure, there a complete denial of the payment on the flimsiest of grounds. Certainly, there is plenty of heartburn as the hospital’s costs keep increasing and the pending bills accumulate.
Fixed packages irrespective of the classification of the towns and cities, and the costs of living, is a case of bad economics. A few questionable practices have come into vogue, like generic medicines. Generic medicines are drugs with unchecked standards, with no brand name, and not surprisingly, cheap. A normal doctor would not use generics, but now with fixed packages, generics have become an accepted policy to tweak the returns a little more. The corporate hospitals end up accepting the straightforward cases, turning away the complicated ones requiring long and intensive treatment because the economics simply do not work out. With plenty of overheads to worry about, it is like asking a 5-star hotel to supply ‘idlies’ at twenty rupees for humanitarian reasons! The whole purpose of the scheme loses when this happens.
A huge amount of money rolls out to private hospitals to treat elective cases and regular emergencies which the government system can very well tackle with a good pyramidal set up and a transport system. Finally, the money runs out in the support of an essentially white elephant expenditure.
In Arogyasri, the most peculiar aspect of the scheme has to be the implementation in government hospitals. Most of the patients in these hospitals are BPL (Below Poverty Line) patients. But in this scheme applied strangely to public hospitals too, the patient is getting the same treatment as anybody else! Same ward, same doctors, same theatre time, and extraordinarily, the doctors get incentives and bonuses for doing their normal job.
One of the bad things which have happened with Arogyasri is the isolation of smaller nursing homes. There are hundreds of doctors in smaller set ups or in single specialty nursing homes who were doing yeoman service to society. Nothing can discount their immense contribution to the well-being of the society in the presence of an overloaded and sometimes ineffective public health services. The scheme severely affects these hospitals due to a migration of the patients to insurance company approved hospitals.
The disturbing aspect of Arogyasri scheme, like any insurance backed medical system, has been the brutal behavior of the company hierarchy against the doctors. The power equations to decide the nature and course of treatment causes an immense heartburn amongst the doctors. Most of the hospitals do not know how to deal with the onslaught. The practice of medicine has plenty of grey areas and this type of scheme has a lot of loopholes and a little deviation from what ought to be the correct procedure, everyone starts shouting thief. It is very demoralizing for the doctors to practice like this. To explain your treatment strategies to non-medical graduates at all levels is certainly a tough task.
On the other hand, the insurance approved hospitals start handling patient load beyond their capacity leading to a collapse of systems. The beds come closer, the toilets suffer, patient care gets compromised, nurses become overworked, and the complaints increase. Things become funny when these aspects are reasons to suddenly suspend the services of some hospitals leaving a lot of patients in the lurch. When a rejection comes on the flimsiest of grounds, today many hospitals heave a sigh of relief and show a disinclination to reapply. Ultimately, things are going back to square one with crowding of state-run hospitals, a disappointed private sector, and the patients suffering continuing.
It is not that doctors are greedy, but the overheads in running quality services in terms of infrastructure, equipment, workforce is so high, that even if the doctor waives off his charges, the official payments are grossly inadequate. The sustainability of such schemes come into question. As a first point, these schemes have no role to play in the public sector where everyone is already a salaried employee. Perhaps a good idea would be to cover only the emergency cases to the private sector, and could extend to all approved nursing homes. Of course, the documentation and approval process can be more stringent to avoid malpractice.
MEDICAL COLLEGES-MUSHROOMING GROWTH
In this whole scenario of modern medicine-based health system, there has arisen an acute need for doctors in the country in terms of the doctor-population ratio. We need a greater number of MBBS doctors well-trained in an adequate clinical training facility with enough patients. That happened really about a decade ago in government run medical colleges and attached teaching hospitals.
Later due to various reasons there is a meteoric rise of private medical colleges with huge fees, explaining it to meet this demand for doctors. In the government’s basic drive of achieving a better doctor-patient ratio, the recent controversial NMC bill again makes it favourable for these colleges to grow unchecked.
The high investment required to become specialists and super specialists are beyond the reach of most of the middle- and lower-class families. Most of the private medical colleges function very poorly, bereft of proper infrastructure, staff, and patient volume. They rarely provide quality education to the students in the practice of medicine. The doctors who come out are rather weak in their abilities and in most instances are not ready to take up the responsibility of treating patients. There are a few exceptions, of course. In the public hospitals though the patient load is good, unfortunately the teaching programmes are not up to the mark due to the irregularity of the teaching staff and the fascination for private practice and lack of real teaching aptitude.
All this becomes truly business like because the doctor who comes out of such colleges starts looking for ‘return on investments’ from the first day of practice. Most of the times, it starts with dowry for marriage in case of boys! The partnerships in marriage are most successful if the respective specialties happen to be profitable. So, even marriages are in the consideration of business transactions.
A consequence of the high fee structure of medical schools and the high cost of practice later makes medicine eventually a model of business rather than service. In such a scenario, the rural centres remain neglected. In these ever-increasing loops, the health delivery has remained rather ineffective in the country. We Indians are one of the best and most experienced doctors in the world. But our systems for health delivery have remained strangely weak.
CONCLUSIONS
Health consists of individual health and societal health (public health), with contrasting features. Societal health is initially cost ridden, but eventually improves the society and reduces health care cost eventually and improves our health indices. This requires a huge clean-up involving many levels starting from politicians and bureaucrats. The doctor is only a part of this flawed system today in the country, but is taking the entire blame. There is an interesting statistic. The very act of covering our drainage systems would eliminate 70% of our health problems. Instead of treating rare exotic disorders, it would be far better to put money in preventive strategies like potable water, healthy food, and good sanitation.
A better organization of the government set ups would serve the purpose well in the country. Regular attendance to duty the by public sector health care personnel, good transport, improving quality of medical training rather than quantity in medical colleges would go a long way, if combined with public health measures like closed drainage systems and immunisation programmes, Safe deliveries, immediate new-born care, giving priority to primary health care. The Polio programme is a huge example of the fact that our country can do it has will.
Individual health in terms of workforce, equipment and infrastructure is bound to be expensive. The business model of private sector mixes with the ‘humanitarian’ angle in the practice of medicine and along with failure of the governmental organizational strategies, leads to a tremendous bad-mouthing despite benefiting. A compulsion-driven seeking of the private sector unfortunately and paradoxically leads to the situation today of benefitting and yet abusing. The most affected are the doctors, of course, whose payment is not as much as people would like to believe.
People from abroad come to Indian cities and to corporate hospitals to avail the best medical and professional services from the most capable Indian doctors at extremely reasonable rates as compared to the rates in their respective countries. We take pride of individual competence, rightly so, but that does not fill the needs of the country. Medical tourism is popular in India; we should be proud of that but not at the expense of public health delivery. It is an irony that Sri Lanka has neonatal intensive care beds in a few hundreds, less than any typical town of India, and has a neonatal mortality rate in single digits. We are still struggling with high numbers comparable to some of the poorest countries in the World.
Our academic, moral, and ethical standards plummeted down despite the presence of well-meaning doctors and administrators. However, this is not exclusive to the medical profession, but reflects the general pattern of our society. But, the creeping of noxious influences in the medical professions has far more repercussions to society.
All this is not an isolated story. The story of greed, corruption, inefficiency, and exploitation is a story of our contemporary times. Our present times is a story of ‘Knowledge’ exploiting ‘ignorance’. This applies to any knowledge field: the mantras of the priests, the law of the police and the judiciary, the rules of the government officials, technical skill of the corporate companies, information of the media- every knowledge base has become a tool to exploit and make money. In such a time, it is wrong to blame only medicine and doctors of course. Medical systems reflect the society in which they embed. Unfortunately, every profession exploit but calls everybody else in the whole system as corrupt. But, being an important and a noble profession, there should be some urgent reforms the organization of the health system of the country.
The doctors have genuine grievances too which the governments, people, media, and the judiciary should understand. The rot in the medical system is a product of an innumerable number of factors coming together. This involves doctors, private players, judiciary, press, politicians, administrators, bureaucrats, medical companies, drug policies, the patients, and last but not the least, the laypeople. Greed, ambition, expectations, pressures, stresses, lethargy, inefficiency, and incompetency strikes each of the previous factors at varying levels making a complicated mess of the situation. We cannot degenerate into cynicism and say that there is no hope. We have some of the best brains as doctors, administrators, bureaucrats, politicians, and intellectuals. They can really make a difference to the health care aspects of the country in the days to come. If only they could come together.
Dr Pingali Gopal
Dr. Ravikumar Chodavarapu
RANDOM MUSINGS 