MANAGEMENT OF THE SICK HEALTHCARE SYSTEM
( By Dr.S.V.Nadkarni, M.S. )

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The Present Scenario

Health–care-system is a very complex system. It is a system in which any person with any perceived illness seeks medical assistance to get rid of his illness, even if the perceived illness is false, in the sense that it may not be a true organic illness. The primary needs of the individual are food, clothing and shelter. Health and education come next in order. Food, clothing and shelter are considered ost essential for the survival of an individual. Yet every need under these heads cannot be considered as essential. While rice, chapatti and dal maybe considered most essential, the same cannot be said about ‘pickles’, ‘papad’ and ‘pista’, ‘badam’ and such dry fruits could legitimately be considered as luxuries. Kashmiri chicken in five star hotel certainly cannot be called a necessity. Same is true about clothing. While shirt and pant or ‘saree’ can be considered as most essential, designer shirt or silk saree would come under items of luxuries. Most people do not realize that all the healthcare needs are not necessarily essential or vital for the survival of an individual. There are some essential services but there are other services which can be called desirable but not absolutely essential and yet other services accepted by the society could easily come under the term of luxuries. Most of the cosmetic surgeries belong to this last category. Even many of the so called preventive measures for long life such as use of a particular oil in food could also be considered as not essential, if not uxuries. Therefore, one has to realize that in health–care–system, there are essential services, there are desirable services and there are medical services which can be termed as luxuries.

In actual clinical practice the health professional is not just a man of science. There is an admixture of art and science and commerce in the actual clinical practice. Also there are three tiers in the services provided under health-care system. Primary health care service which is offered in the dispensaries and primary health centres usually by a single doctor. These doctors treat the patients who come to the dispensary for their elementary diseases. The patients are not admitted in these primary health-care centres. These doctors also treat the people to prevent diseases. Preventive medicine has become a very important aspect of the management at the primary health level. Immunization, Vaccination, Counselling during the pregnancy, Advice on diet and Hygiene for the family are all essential parts of the primary health care of the society. Thus, primary health care is one of the most essential health care services needed by the society. Yet this is the most elementary aspect of the health are and needs very simple equipments, investigations and simple medicines. The doctors in these primary centres need to have patience, a lot of sympathy and a great ability to discern between simple and major illness. Thus, there is a lot of art and some science at this level. ‘Medicine is an art’ applies particularly to this primary health-care system.

At the other end of the spectrum are extremely serious patients who are at a risk of losing their lives or at the risk of being crippled. The medical science has progressed a lot and many of such illnesses can be treated effectively now-a-days. Some patients can be cured and life of many others can be prolonged or made comfortable. But all this cannot be done without profound knowledge of the science of medicine and many high-tech equipments and sometimes use of newer drugs which could be quite costly. In short, the management of serious organic disease requires use of modern equipments and medicines and the profound scientific knowledge of the body– systems involved in the disease. Science plays a very major role and the art of medicine is often sacrificed by the specialists who offer these services. These medical services are offered only at tertiary medical centres. They cost a lot and can be managed only by expert consultants / specialists and super specialists.

All the intermediate groups of diseases i.e. those which cannot be treated in dispensary or at home and yet are not so serious as mentioned above are all treated at the secondary level of the health-care-system. Nursing homes, private hospitals or Taluka and District level hospitals in the public sector offer these services. Standard equipments and standard drugs are mostly sufficient and the medical professionals are specialists of basic level or general specialists. A good admixture of art and science is needed at these centres to satisfy the patients.

Apart from these, there are plenty of ailments for which the patients seek the medical advice. Due to the modern pace in life there is an immense increase in the psycho-somatic disorders. The real ailment is 'tension or stress' but this emotional imbalance is manifested in bodily illness. Some of these psychosomatic illnesses turn into organic diseases but many of them remain non-organic in nature. Headache, backache, inability to work, flatulence (gases) and many such vague symptoms are instances of psycho-somatic diseases without any organic changes in the body. Diabetes, hyper tension, heart disease etc.are also phycho-somatic diseases but they cause organic changes in the body and, therefore, become organic diseases requiring major treatment. The first type i.e. non organic type of psycho-somatic illness needs more of psychological treatment while even in the second type, psychological treatment could help a lot. In addition there are many ‘imagined’ illnesses. All these except the organic diseases mentioned above could be called as ‘non essential’ health care needs. Lot of art is required in treating these diseases. But a lot of commerce also enters into this field and even the patients are willing to spend exorbitantly for getting rid of their ‘non-essential’ diseases.

Medical professionals are not saints and they have entered the profession specifically to earn. They belong to relatively more intelligent strata of society and are highly educated. Therefore, their expectation of earning is also legitimately high.This legitimate demand of the medical professionals cannot be termed as commercialization and the society must learn to accept it as due compensation for the service rendered. Therefore, commerce enters into the field of medicine at all levels. Commerce enters in the medical field from the primary level to the tertiary level and is most conspicuous in the management of the psychosomatic illnesses mentioned above. For the clinical practitioners, at any level, a fine balance has to be achieved between art, science and commerce so that the health professionals are not denied their legitimate dues while at the same time, they are not allowed to commercially exploit the patients who are too anxious to get well. There is no doubt, illegitimate demands are raised by some doctors and such demands must be termed as ‘over commercialization’. This over commercialization needs to be curbed.

There are many systems of medicine practiced simultaneously in every part of our country. Ayurvedic system of medicine is the most ancient system in the country and is respected by the masses even today. Hence, it is recognized by state as well as central government and plenty of Ayurvedic medical colleges churn out a lot of Ayurvedic practitioners. Even in this system there are general practioners and specialists. Same is true about Unani system. Started nearly 1500 years ago in the middle east, it is more popular among Muslims and is recognized by the governments. Homeopathy came in much later. First founded in Germany, Homeopathy became rapidly popular all over the world, as also in India and is now recognized as a system of medicine like the other two faculties. Each of them is governed by their own medical council and each separately register their practitioners. Knowing the importance of Allopathy as a more scientific system or, at any rate, the presently most practiced system, all the above faculties have incorporated some elements of allopathy in their training course. Even if it happens to be very inadequate, it offers their practitioners a legal right to practice allopathy simultaneously though they are not registered nor governed by allopathy State or Indian Medical Council.

Indian Medical Council was established at the centre in order to establish a standard of education in the allopathic system. The council is expected not only to prescribe and maintain the standard of medical education but is also expected to oversee and regulate the functioning of the practitioners of all pathy in India. In order to do so, the council had to first prescribe the standard of education and prepare the curriculum for various courses for graduation and post-graduation. The council then had to define the exact role, the health-care professionals are expected to play. Every practitioner, therefore, must register under the Indian Medical Council.

But the council has the most insufficient infrastructure amounting to almost nil to actually supervise the conduct of their health-care-workers. Broadly the council depends on complaints by their associates or by the public at large individually or through government channels and then decides whether the person actually is maintaining the standard or not. Even if the council finds the behavior of the doctor sub-standard, it has very limited powers. It can either warn the doctor or de-register him. Once a person is de-registered, he or she cannot practice in the allopathic system of medicine. But the legal system of the country is so peculiar that once de-registered that person no longer is a qualified doctor coming under the ambit of the medical council. Therefore, for any malpractice, if he continues to do so, the council cannot deal with him as he is no longer a member of its body! Only the department of law and the police under them can deal with such culprits and take necessary action against them. The council is helpless. With meager knowledge of the regulations under which the doctor is supposed to practice and with such over-burden of duties to maintain the law and order in the society, it is no wonder that the police also take no action and various doctors who are de-registered by the council or spurious (unqualified) doctors are practicing in the country in abundance. The results for the society are obviously disastrous.

Thus, it will be realized that the structure of the health-care system in India is haphazard. There is no clear-cut pattern in the health care system in the country. Different categories of doctors practicing their own systems of medicines-allopathy, homeopathy, ayurvedic, unani and what not-all practice in their own way without the control of the government and without any co-ordination among them. The government has formed bodies to control the practice of the doctors in each of their special systems separately, Thus, just as the Medical Council of India was formed to regulate and control the behavior and standard of allopathic doctors. Similar bodies were formed for homeopathy, ayurvedic, unani etc., But there is no central body to have an overall control over the health-care professionals in the whole country. Each of there bodies supposedly try to maintain the standard in their own system of medicine. The role of respective councils of other systems of medicine was to regulate the professional conduct of the health-care doctors in their respective systems. But what is true of Indian Medical Council, is substantially true for every other council like Ayurvedic, Homeopathic, Unani ect. The role of the council is thus limited to prescribing the curriculum for the courses of their respective systems and management to see that good standard is maintained in the medical education. Here again the maximum the council can do is to de-recognize a particular college or university. Political and money pressure. coupled with incompetence of the inspecting teams of the council, sufficiently dilute even this power of derecognition and sub-standard colleges continue to produce substandard doctors.

But health is a concurrent subject and the state government has a bigger role to play in the health-care than the central government. Therefore, the state governments have formed their own Medical Councils like say Maharashtra Medical Council for the state of Maharashtra. Strangely these state councils are not subordinate to the Indian Medical Council but are completely independent bodies formed and regulated by the state governments. Therefore, even if the medical course or medical college is not recognized by Indian Medical Council because it is not maintaining the standard expected by it, the state medical council has its own right to recognize such a different course or such a college and the graduates coming out from such institutions are eligible to practice in that particular state. They cannot practice outside their own state, if not recognized by Indian Medical Council nor can they go abroad because other countries recognise only Indian Medical Council. In a way it is not an altogether undesirablesituation for a vast country like India with a population of more than hundred crores. It is not justifiable to have only one standard of health care system for the whole country as social and economic conditions in various parts of the country or in different states can be extremely dfferent. A particular standard which can be maintained by very wealthy states may be an impossibility for another state which is comparatively very poor. It may be noted that western Europe with a population of about thirty five crores is divided into several independent sovereign countries and each country has its own standard of medical education and its own rules. Similarly in U.S.A. with the population of about thirty five crores there are 48 states and under their constitution each state not only has its own medical council to define the system in its own state but such a medical council is also entitled not to recognize the qualifications of the medical professionals from other states. Such ‘outsiders’ are made to appear for their own test before they can practice in that particular state. Therefore, it is absurd to think of one universal system for a country of hundred crores of people whose social and economic conditions differ as widely as between different countries in Europe or different states in U.S.A.. I, therefore, said that theindependence of such medical councils of each state is not so undesirable. However, it may be noted that there is no regulatory or coordinating mechanism between Indian Medical Council and State Medical Councils, which is the matter for worry.

Even besides the medical professionals working in these recognized systems of medicines, there are any number of faculties of medicines which are practiced by the so called doctors of these unrecognized faculties. They are bone healers, acupuncturists, electro Magnetic Medical system and what not. Unfortunately the political leadership in various regions encourages these systems and the present government virtually takes no action against these 'doctors'. The people at large do not clearly know whether they are recognized professionals or not.

Even within the allopathic system the role of each professional ought to be properly defined and regulated. There are M.B.B.S. doctors who are supposed to be ‘basic’ doctors. They were the backbone of the society in the form of general physicians or family physicians. They treated the patients primarily irrespective of which part of the body was affected and irrespective of the age/sex of the patients and refered the patients to a particular specialist only when the disease appeared to be more serious. Now there are not only specialists (M.D. & M.S.) but there is a lethora of super specialists. (D.M. & M.Ch.) Specialist is defined as a person who knows more and more about less and less. The recent advances in medical technology have undoubtedly contributed to the development of the super specialists. For example, in an organ as small as an ‘eye’ where an ophthalmologist is a specialist of eye disease, there are now super specialists who look at ‘retina and posterior segment’ of the eye, super specialists to look at the ‘cornea’ only and super specialists who deal with the tumors of the eye only. While the role of super specialist is becoming clearer and clearer, the respective roles of a basic doctor and a specialist are becoming hazier and hazier. Even the distinction between the various systems of medicine is getting obliterated. Eighty percent of the general practitioners now hold non-allopathic degrees like Ayurvedic or Homeopathic or Unani. But all of them, without hesitation, prescribe allopathic medicines and treat their patients allopathically. Similarly many allopathic pharmaceutical companies are manufacturing Ayurvedic drugs and their representatives are freely canvassing these drugs to the allopathic doctors. In short, their practice goes far beyond what was officially taught in their respective courses. In a way, therefore, 80 percent of the patients are being treated by 80 percent of non-qualified doctors. I emphasize that even qualified doctors become ‘non-qualified’ when they transgress the limits of the systems they were taught.
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