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

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Adequate Emopuments for Medical Personnel

The problem of inadequate salary for the medical professionals is discussed several times but inadequately attended to. The salary structure of any professional must be considered in the light of what another person in another field with equal merits is likely to get. This is termed as horizontal parity. In short, the salary should be some what similar to what his counter part with equal merit in the field of computer, I.T., engineering is likely to get. In the case of doctors as well as the legal professionals, this rule does not seem to be followed. The result is obvious. Doctors with good merits or skill avoid joining the medical service especially in the government. If at all they join, they aspire to gain additional income through clandestine practice of one sort or the other.

This is not desirable, and everybody knows this. The government knows about these methods of clandestine practice but is unable to take strict and adequate action (a) because of its own laxity and (b) because it will be left with shortage of doctors if action is taken against them. Adequate salary and perquisites will not prevent all clandestine practice but will certainly minimize it. It will also enable the authorities to implement rules more effectively because there will be sufficient number of applicants waiting to take up the job, if a vacancy occurs. Doctors who choose to do post graduation and therefore join major hospitals as resident doctors are paid even much lower salary, as ‘they are learning’. They are considered as 'students' and, therefore, they get ‘stipend’ not salary. The government makes another spacious argument that it is spending so much money for their education. Both the arguments are very fallacious. A doctor who passes his M.B.B.S. examination and opens a dispensary right across the hospital and starts treating the patients without any supervision and guidance can collect far more in terms of fees from his patients, whereas the doctor who treats relatively more major illness in the medical college hospital and that too under supervision and guidance of senior consultant and therefore is likely to make less mistakes than his counterpart across the road, is considered a student. At best he is an apprentice. He spends his full hours of service in the hospital and that too for the kind of illness which is as grave as or graver than in general practice. Therefore, there is no justification to pay him salary far less than the doctor in regular service. Another dangerous argument is made and accepted by almost all without hesitation is that when he finishes his course and leaves the medical institution, ‘he is going to mint money’ – a most dangerous argument. The logic of this argument is, in fact, an open invitation for the doctors to exploit the patients as much as they like, after they become specialists. This argument should be thrashed even before it is uttered. Therefore, it would be in the interest of the society, if the resident doctors and the doctors in the public service are paid adequately and the residents are paid, if not equally, nearly comparable to the salaries of other doctors in service. Another factor to be considered is the amount of money spent for the education. If it is presumed that medical student spends Rs. 15 lakhs for his entire course of education and if that is considered as loan, the E.M.I. (Equal Monthly Instalment) on Rs. 15 lacs even at a soft loan interest of 6 to 8 per cent would be not less than Rs.1000/- per lac (i.e. Rs.15,000/- E.M.I.). If the fees are lowered, and he completes the education with Rs.8 to 10 lacs, the E.M.I. would become 10 thousand and if his education was subsidized as suggested earlier because of his economic condition, his repayment would be equivalent to this E.M.I. Therefore, they must be compensated, to an equivalent extent, while considering their salaries. One would realize that the salary given to M.B.B.S. doctors and the residents as well as junior specialists are too low.

I easily accepted the fact that the government cannot pay such high salary say Rs.35,000/- to 40,000/- to M.B.B.S. doctors and Rs.50,000/- and above for a junior specialist. But as I have emphasized again and again in my previous pages, the paucity of the funds with the government is due to their insistence on giving the so called 'free' treatment to every one. The government may give all other facilities free if it can afford but at least the fees for the doctors for their specialized services must be recovered and that should form part of the income the doctor could earn. In fact, repeated salary revisions (without adequate governance) have never helped. I have found again and again that services did not improve a bit, when fixed salaries were raised even to double or triple the original figure. In fact, if the salaries are raised beyond a reasonable limit, the professionals seem to slacken and become even more inefficient. The proportion of improvement in the quality and quantity of service to the salary paid is parabolic. When salary is low, services improve with better salary structure. But after the optimum is reached, the services decline when the pay is increased.It is, therefore, very essential that the professionals are given part of their income as fixed salary while the rest he will have to earn for himself, through properly devised incentives. The earnings of the doctor improve automatically, if and when he gives the better service.

The doctors in public service (M.B.B.S.) level, should get, at the present level of prices and living index, at least 20 thousand per month to spend. Therefore adding the E.M.I. of Rs.10,000/- for the first 10 years the salary cannot be less than Rs.30,000/- p.m. The E.M.I. can be deducted proportionately from those who got subsidy or loan during their education for the first 10 years. As mentioned again and again the professional charges should not be free. A private practitioner charges about Rs.20/- in small towns, going upto Rs.50/- in bigger towns/cities (Mumbai is an exception where charges are even higher-) Hence, every patient could be charged Rs.2/- for first visit and for follow-up every weak in all primary centres, dispensaries etc. as professional charges while the rate may be increased to Rs 5/- in bigger places. In hospitals, the same amount on an average could be added in hospital charges and it will contribute towards the junior doctors salary.

As mentioned, the resident doctors should also get an amount sufficiently close to their amount. I felt that the salary of 75% of that of service doctors would be justifiable, to be increased to 80% and 85% in the second and third year of their post graduate course. If they continue in service, these years should be considered for terminal benefits like gratuity, pension etc. The benefits of continuation of service should be granted to the resident doctors too. It must be borne in the mind that the government spends hardly 1.1% of G.D.P. on health while even small countries like Malasia seem to be spending 7 to 8% The suggested better payment to the doctors would not raise this percentage beyond 2 to 2.5% I expect. But that will give far better results than buying costly equipments at various hospitals, only to lie idle within a year or two due to bad management and inefficient doctors.

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