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

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In Summary

1. In clinical practice, a doctor should be able to answer the allpurvading 3 questions scientifically.

a) what is the diagnosis ?
b) what is the management ? and
c) what is the prognosis ? The approach to all social problems should preferably be on the same lines.

2. Health-Care is a complex subject- Though health is as important as food and clothing, health demands differ in intensity. They are vital, essential or desirable while some are luxuries. There are three tiers of health-care services primary, secondary and tertiary. There is a combination of art, science and commerce in varying proportion in all of these tiers of services.

The health-care system in India is very haphazard. There are many systems of medicine – Allopathy, Homeopathy, Ayurvedic, Unani etc. in active practice simultaneously but their respective roles are not defined. In addition there are many spurious systems which, though not recognized, are still offering medical services to the public.

3. A Medical Council is established to control the standard of education and to maintain the standard of behaviour of the doctors at a high noble level. But...

a) There is a Central Medical Council and a State Medical Council which are independent of each other.
b) There are separate councils for different systems of medicine.
c) They have very limited powers and there is no coordination between them.
d) They cannot deal with quacks nor with anyone other than doctors - not even para-medical staff or erring patients.
e) There is a need for central (and state) Health Council with wide powers and superior to all above bodies.

4. a) Health – care is an Industry, and Industrial principles must apply here too.
b) Health-care is productive and hence must be paid for.
c) There is nothing like ‘Free’ medical service. Somebody else pays for it.
d) Money must come in – in a cognizable way – so that it can be spent and the correlation should be easy for a common man to understand.
e) There are too many disadvantages of ‘Free’ treatment – It is the costliest method with poorest returns.

Government supported or company supported medical insurance could be one of the remedies.

5. The need for a pyramidal structure of Health–care system. Primary Care Centres - Secondary Care Hospitals - Tertiary Care Hopitals.

6. a) High-tech modern medical service is very costly and cannot ever become cheaper.
b) It does contribute to the health of formerly incurable or difficult disease but it also increases the cost of healthcare unnecessarily for majority of the people.
c) It has contributed very little (or non-at-all) to the overall survival of the community.
d) Hence it is almost a crime to spend public money heavily on this high-tech medical service.
e) However, these services can be available in private sector for full costs to be borne by individuals, and in public sector only after proper reference from the lowest to the medium to the high speciality hospitals.

7. a) Considering the need of doctors in a ratio of 1: 1000 the country needs 10 lacs doctors.
b) In cities, specialization has increased, so the ratio could become 1:500.
c) Selection for M.B.B.S. course is not strictly by merit – at least 49% seats are filled through reservations based on caste/creed.
d) The minimum qualifying marks were 45% aggregate in 12th standard in 1950 when the Republic was founded, it is still 45% - in P.C.B. (not aggregate).
e) Full advantage of this was taken and is still being taken even to day by private colleges and deemed universities for malpractice and corruption.
f) There are multiple C.E.T. for the aspiring students – which is totally unnecessary and again a source of corruption.
g) Confusion is created by central CET and 15% reservation for admission on an all India basis.
h) Caste-based reservation should be abolished but regionbased or community based colleges with 33% reservation should be encouraged, to be managed by the region or the community.
i) Minimum qualifying marks in 12th standard examination must be raised to 60% of aggregate marks (not PCB). and/or 75% in P.C.B.
j) Only one C.E.T. at the state level – one central.

8. Charging of fees-Fee structure is irrational.
a) Fees in government colleges are too low and in private colleges too exorbitant.
b) Wrong students are getting subsidy and poor students are denied subsidy.
c) The criterion for subsidy should be purely economical and not merit-based, and subsidy should be available in gradation to students both in government and private colleges.
d) The fees in government colleges should be raised to nonsubsidy level at par with the private colleges.
e) For others soft loan facility should be made available.
f) Students getting subsidy must serve in public sector for 10 years.

9. a) The number of patients in private medical college hospitals is very poor due to various reasons – but this number forms the main source of education for them. It is here that the student gets 70% of his knowledge.
b) The M.C.I. only cares for the total number of beds provided – not the total number of patients on them.
c) Full occupation of beds is equally the need of the people to get good doctors.
d) therefore, in the private college hospital, the charges of patient–care should be subsidized by the government equivalent to the expenses incurred in district hospitals.
e) Research grants must be created and utilized fully, and the main research officer be paid.
f) An optimum of 25% of the beds in each unit should be ‘paying’ beds. There are several advantages educationaly, administratively and financially.
g) This is so important that the issue should be bitterly contested, if M.C.I. opposes it.
h) The medical teachers should be prohibited from doing private practice outside the premises, but offered incentive practice within the premises.

10. a) Thus, the fees to be charged will be minimized.
b) Paying patients, research grants and subsidy from government will substantially reduce the deficit of income over expenditure. The salary expense of the practicing teachers will be reduced.
c) So the students will have to bear only the remaining expenses of the college and hospital.
d) Additional training courses can bring additional income.
e) The system of professionals on ‘fixed salary’ cannot work, unless there is an extremely intelligent and efficient management system with M.I.S., both of which we simply do not have.

11. Choice of medical teachers leaves much to be desired.
a) There is a lack of incentive and of job satisfaction for medical teachers.
b) There are three desirable qualities for teachers, Every teacher must possess at least one, preferably two of them in very good measure. i) professional skill; ii) art of teaching and iii) research attitude and skill.
c) i) incentive practice within the premises will satisfy the first type which is 80%.
ii) Academic incentives are needed for 2nd and 3rd type, and a good compensation for not going into practice. They deserve non practising allowance, and other perquisites.
Iii) Having defined job specifications, accurate performance records must be maintained, shown to them, corrected if necessary and then firmly used, for pay-rise, promotion.etc.
iv) The present method of promotion or selection is extremely faulty and leaves wide much to be desired.
v) M.P.S.C. is most incompetent and slow and must be replaced by a better expert commission, specifically for selection of medical personel. The performance record must be submitted and used. vi) If the work load is more than can be managed by the mandatory number of medical teachers, additional part time consultants can be appointed from amongst the practising faculty- the best amongst them should be chosen. They are not medical teachers, but will gain teaching experience over years.

12. The patter college – applicable (in principle) to other secondary, tertiary hospitals also.
a) Too many doctors in one unit to manage 32 to 40% patients – 1 professor, 1 Associate Professor, 2 lecturers and at least 6 residents.
b) Only one O.P.D. day in a week for non-admitted patients.
c) Multiple duties on the O.P.D. day – O.P.D. patients, routine admission, emergency admission, emergency management /operations, routine and semi urgent minor operations on O.P.D. patients, etc. – other days are relatively free.
d) Extreme mal-distribution of work and total lack of answerability.

13. A better system of administration is absolutely essential.
a) In India, individuals are easily blamed, the system is rarely blamed-in fact it is hardly even discussed.
b) i) The unit should be divided into 2 sub-units, working independently.
ii) There should be at least 3 O.P.D. for each unit, more if possible. c) O.P.D. and emergency duties should be on separate days and all other duties should be evenly spread over
the week. That will increase answerability. Nine morning to twelve noon to be strictly reserved for patients and under graduate students.

14. a) Curriculum – 1st M.B.B.S. should be extended back to 1½ year (instead of 1
b) The stipulated period of posting must be strictly followed. No exemptions or concessions should be permitted for deficiencies on any ground.
c) There should be an exposure to allopathy for at least 2 years in the courses of all other systems of medicines.
d) The C.E.T. for post-graduate selection, should be held within 3 months of final M.B.B.S. exam, almost at the beginning of internship and
e) The interns should get mandatory training in management, social studies, logic, psychology etc. during the remaining 6 to 9 months of internship.
f) There is a specific need to start post graduation in general practice.

15. a) Any patient enters any centre or hospital. There is no referal system in existance.
b) Medical Collage Hospitals see 50% trash in O.P.D. and that lowers the quality of treatment.
c) Patients must be seen at primary care centres and refered as per criteria laid down.
d) Secondary care hospitals will see only patients seen earlier at primary care centre–refered or dissatisfied. They will be entitled to highly subsidised or free treatment.
e) Patients coming directly to secondary or tertiary care hopitals will have separate O.P.D. timing and will pay 50% of charges, as paid by paying patients, even in general O. P. D.
f) Paying patients will have a separate O. P. D. in the evenings. their investigations and operation will also be done in the evenings only. They will pay full hospital charges.
g) Same system of referal must be advocated for private sector also. Consultants must see cases first seen by General Mactioners refered or dissatisfied.

16. a) Charges to be collected from patients – two components;
i) hospital expenses
ii) professional charges of consultants/doctors.
b) There cannot be ‘free’ service from the consultant.
c) As public hospitals see a lot more patients, the professional fee for consultants works out to be 5% to
e) The patients must have some protection in a different way, if this act was to be repealed.
f) Criminal negligence was and is always punishable in the court of law, but the doctor should not be held guilty for adopting cheaper methods, at low cost, if he has explained the patient why and how?
g) or the C.P.A. should be made optional. The patient should be given a right to opt out of the act and give the doctor a free hand.
h) Substantial statistital evidence with good records should be acceptable.
i) For unexpected complications and loss of earning member, there can be a system of some compensation, irrespective of who is at fault.

21. Accreditation :- a) Any doctor can treat or perform any operation anywhere. There are no rules and regulations, defining the role of each category of doctors. This is dangerous.
b) Accreditation of hospitals is one of the answers. Each health-centre, nursing home, hospital should be graded officially, as per the equipments, and staff and systems in that place.
c) The health-care centre can under-take only what it can manage and send more serious patients to a higher grade centre.
d) Most professionals will be happy and feel secure. Only unscrupulous or greedy professionals will be worried.

22. The role of different doctors must also be defined.
a) Basic doctors cannot advise high-tech investigation nor prescribe the costly or latest drugs introduced in the previous 1-2 years.
b) Non-Allopathic doctors can practice only in rural and semi rural areas or in slums, if they do allopathy.
c) The specialist should see only cases referred by the ‘basic’ doctor or at least treated earlier by him, except in serious cases.
d) The patient should be referred back to the basic doctor for further treatment.
e) The line between specialist and super specialist must be drawn, even if vaguely.

21. a) Rules and regulations must be strictly followed and action taken.
b) Full-time doctors should not be allowed private practice except incentive practice within the premises.
c) Same with medical teachers, as already discussed.
d) They should be adequately compensated, but theycannot have a cake and eat it too.
e) This will reduce over-crowding in the field of private practice and that will help in reducing malpractices, overtreatments etc.
f) Patients, in public health service, must go through the established hierarchy to entitle them for (nearly) free treatment or pay from their own pocket.

 
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