So what’s the diagnosis doc?

Public health choices between providing medical care for all and ensuring health for all remain clouded in hazy twilight zones

Parsa Venkateshwar Rao Jr Delhi

The hospitals are always overcrowded. The doctors are overwhelmed. The nurses are stretched to the limit. The government hospitals are bursting at the seams as it were. A general hospital is a picture of a bit of mayhem and a bit of bedlam. Yet, some of the best doctors in the world handle some of the most difficult cases ever in the most confused theatres of action. But the anarchy seems sustainable. Millions of people pass through the hospitals. Some of them are cured. Others die. Doctors go through the stress and strain, and then look back at it all with fond memories.

Private hospitals are also getting crowded. There, too, the poor and the rich jostle with each other. The rich pay it out nonchalantly. The poor borrow money to save the lives of their loved ones, and sink into greater poverty. Here, too, there are never enough doctors. And it looks like we need hundreds more of these posh, private hospitals to complement the civil and general hospitals.

As an official in the union ministry of health and family welfare admits, there are not enough doctors in the country. India has about 44,000 doctors, and there is need for more than double number. There are not enough nurses either. He says, "Even private hospital administrators say they are unable to hire even trained ward boys, who are so crucial in the running of a hospital. And even as they are trained, they move out."

The public health system in India presents a paradoxical picture. On the one side, Indian doctors are winning plaudits in Europe and America for offering world-class treatment at nearly half of what it would cost in the western world, and which is giving rise to the temptingly lucrative vista of medical tourism. And a sense of smugness is palpable in the public sphere dominated by media, big businesses and the aspirating middle class. On the other side is a bleak, stark picture of a tottering system, plagued with myriad problems.

The paradox is well summed up in a World Bank paper of 2004, authored by Monica Dasgupta and Manju Rani: "India has relatively poor health outcomes, despite having a well-developed administrative system, good technical skills in many fields, and an extensive network of public health institutions for research, training and diagnostics. This suggests that the health system may be misdirecting its efforts, or be poorly designed."

The problems facing the public health system is spelled out candidly in the National Rural Health Vision document of the ministry. And the facts are bleak enough to dampen the spirit of the most sanguine optimist. (See box)

Of course, the strategies to improve the situation are laid out as clearly, and with all good intentions. The strategies indicate that the government would want to devolve the health care system to the village level, through the Panchayat Raj institutions. It is an ideal strategy on paper, but there are hidden problems.

The ministry official points out that the elected representatives in the Panchayat Raj are not equipped to monitor, assess and manage the health care system and they would not be in a position to allocate funds. What is needed is an army of public health officials to make the system work smoothly. And there are too many around.

Dr Piyush Jain, a medical expert from Old Delhi, agrees. He points out that there is a real dilemma whether qualified doctors should go into administration or whether it should be left to trained personnel. He does feel it is better if a qualified doctor is in charge of the public health system. He says that to maintain a good sanitation system, there is need for an engineer and a microbiologist, and not exactly a doctor.

In western countries, it is usually the doctors who oversee the public health system. In India, however, the administrative system, created by the British, has entrusted the privileged position of power to the civil servant or the Indian Administrative Service (IAS) cadre officer. "Why should there not be an Indian Health Service as there is an Indian Economic Service? Qualified people need to be in charge of technical aspects of administration."

Of course, there are problems. Although public health as a course is offered at the post-graduate level, very few, who have done their six-year MBBS degree course, opt for it. Only those who fail to get into the post-graduate course for other specialisations, go in for this course. So, there is shortage of qualified public health officials who are grounded in medicine.

Jain has an ingenuous explanation for the crowded hospitals issue. Citing the example of the All India Institute of Medical Sciences (AIIMS), in New Delhi, he says AIIMS caters to more than 1,00,000 patients, most of whom should be treated at the primary health centre level by a general physician, in the basic referral scheme of the health system. So, most of the senior doctors in these specialised hospitals are attending to minor ailments like cold and cough, influenza and blood pressure. So, there is not enough time for the genuinely serious cases. But the social perception in India is such that every sick person feels assured only when a specialist doctor treats him. Indeed, because the village, local and district level health systems are not functional patients are compelled to go straight to the big city hospital for reference, diagnosis and treatment.

Jain is all for the government’s AYUSH strategy. That is, including the other systems of medicine — Ayurveda, Unani, Siddha and Homeopathy. He says it is perhaps better to get Ayurvedic medication

for cough, which has no side-effects, rather than take an Allopathic pill. But when there is a complication that requires surgery, then it should be treated under the Allopathic system. He cautions that a Homeopath should not take up the task of transfusion of blood for which he or she is not trained.

Is there a way out? The ministry official says that government can provide the money, but it will not be able to operate the system. That should be outsourced. Public-private partnership is an option. Yes. It is possible to try out the experiment done by the Tony Blair government in Britain. There, hospitals in the National Health Service (NHS) were handed over to private operators. This could possibly work, but there is the lurking danger that private owners might turn hospitals into a lucrative profit-making institution, that just can’t be accessed by the majority in India.

Besides, are private sector players interested in going to the villages to set up a network of medical facilities where they are most needed? As the anonymous official observes cryptically, doctors are nor willing to go to villages and that’s where majority of people who need healthcare are.

Radical solutions are attractive, but impracticable. Can doctors be made to serve compulsorily in rural areas? The ‘barefoot doctors’ programme of Maoist China, like backyard steel plants, sounds hip enough. But it misses the point altogether.

Most doctors are willing to set up shop in district headquarters, where people from surrounding villages flock. The doctors find it lucrative. The villagers are willing to spend. This development took place more than 30 years ago in the southern states. It was common to hear doctors say that villagers have taken to modern medicine in a big way, so much so, many of them are not satisfied unless they get an injection, whatever be their complaint!

It is not certain whether this shift has helped in improving health standards among the majority of people. But their dependence on medical remedies has grown exponentially. It is a point of debate whether this access to medical care is good. Social scientist Ivan Illich had questioned this assumption in his book, Medical Nemesis, written in 1974.

The alternative vision is to make a society healthy enough and less dependent on medical care. And that is indeed one of the important aspects of public health. Public hygiene achieved through proper sanitation, clean water supply, nourishment and hygienic conditions are its key components. Governments are mandated to provide a healthy environment through the tax-payers’ money. But most debates on public health centre around making medical care accessible to all. That may not be the right answer.

"In sum, the system has many strengths, above all good skills and infrastructure. It functions relatively well for services, such as responding to disasters, which attract much political and media attention, suggesting that with greater public demand other parts of the system could function equally well. We conclude that with some re-assessment of priorities and revised ways of functioning, health outcomes could be substantially improved. Better public health outcomes are a "win-win" on many fronts: they are good for poor people, who are the most exposed to high disease burdens; for improving productivity and growth; and for politicians who support the process…"