( By Dr.S.V.Nadkarni, M.S. )

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What is true of primary health care is almost equally true of secondary health care system. The glamour of complex knowledge and high technology of tertiary care system, coupled with aggressive marketing by the companies manufacturing these costly equipments, have easily diverted the attention of the socialites, the politicians and even the general educated population from the need to stabilise and improve secondary health care system. The very high cost of installing these high tech super speciality departments diverts the meagre funds available and thus creates shortage of fund for the much needed secondary health care. As mentioned earlier, in public sector, taluka and district hospitals in the state government and peripheral hospitals in muncipal corporations provide the secondary health care, while private nursing homes and medium hospitals and charitable medium hospitals help the affording class in the private sector. Nursing Homes cater to more than 60% of these paying class of patients.

Individual consultants opened their small nursing homes to treat their own patients who needed indoor treatment and/or operation. They provided a minimum of 4 - 5 beds to a maximum of around 30 beds. The facility is created by buying one or two flats in residential buildings. So far, the doctors have proved to be poor management experts. The owner consultant has to depend on other consultants to see that his beds are occupied. Generally at least 60% occupancy is considered essential for a nursing home to run profitably. This dependence on other consultants, who had no monetary stakes in the hospital, increased their greed and ambition and made the owner agree to whatever they do and whatever personal charges they asked for, thus increasing the costs for the patients while lowering the quality of management. The family physicians started demanding a a percentage of the fees charged by the consultants or by the hospital. Acturally, this tendency is seen far more in metropolitan cities but has spread even to the small towns. But, even worse, these nursing homes are having a huge standing expense and gross under utilisation of the manpower and equipments. In the O.P.D. whether there is one consultation room or four rooms, a servent, a nurse and a receptionist has to be appointed. The operation theatre, could be utilised for hardly 2 - 3 hours, instead of its capability of 12 hours in two shifts. Even if the ward is empty, the number of resident doctors, nurses and menial staff can not be reduced. Thus, the owner consultant is forced to compromise quality in lieu of quantity. Untrained nurses, incompetant semi- ualified resident doctors, cheap equipments be it suction machine, E. C. G. machine or X-ray or sonography machine are the order of the day in many nursing homes. Government is making rules and regulation which the nursing homes are unable to follow and the various inspectors are making hay while the sun shines. The whole burden of this mismanagement and bribes falls on the patients who are, thus, paying exorbitant charges for a poor quality of treatment.

The remedy is quite simple and very effective; if only 8, 10 or more consultants were to join together and create their facilities, the problems could be solved both for the owner as well as the patients. O. P. D. consulting rooms, investigative facilities, operation theatre(s) and intensive care unit can be established as a common property the expenses being shared equally by all. Naturally, the profit/earning will also be shared equally by all. All the space, equipments and manpower would now be fully utilized by their own patients. Hence they need not compromise on the quality of manpower or equipments which they can easily afford now. There is no dependence on 'other' consultants any more. Even the general productioners will be more sub-dued, as patients would always prefer a well equipped hospital with adequate facilities and trained staff, irrespective of what their G. P. s advise. The ward and the beds could be independent or shared as per what the owners prefer. Together they could buy 4 to 5 or more storied, one wing of a building, with a separate passage, stair-case and even a parking space for themeselves, as decreed by supreme court recently. Instead of begging for attachment in some major charitable or private institution, they would have created their own secondary care hospital, where they have a role in management too. The patients will get not only better quality of treatment but it will be cheeper too. Everyone gains and nobody is a loser.

Why is it no happening?

First is a techincal / legal sgag, at least in Mumbai. The municipal corporation allows the change of use, for nursing homes only on the ground and first floor but not above that level. It may not be difficult to convince the authorities, to allow a whole wing upto 6 th floor to be converted into a mini hospital, provided that their is not a single residential flat in that section. This change of rule is
absolutely essential.

But the consultants are reluctant because,

  • Natural inertia–people like to think and act as per existing tradition and are most reluctant to any new line of thinking. In fact, inertia is defined as 'a body remains static. unless forced to do otherwise', and 'force' is definied as the energy. 'that makes the body move.'
  • Consultant doctors are high intellectuals and are highly sceptical and suspicious of each other. They can not come together easily. There are a few sporadic cases in Pune, Bangaluru etc. where doctors have successfully combined to establish their own hospital but they are exceptionally few only to prove the law. Hence, they will have to be forced. Financial contraints and even increasing obligations of new regulation are making some of them to think. Stringent application of rules and insistant expectations of people for good standard of treatment would go a long way to make the doctors act faster. Mandatory display of hospital charges and a system of accreditation (topics which are discussed later) will surely force the doctors to abandon their present single owned nursing homes, in favour of joint venture of establishing a proper hospital. Suffice it to say here that STABILISING AND IMPROVING the secondary and primary Health Care System is the need of the hour not the glamorous high tech tertairy Health care 90% of the people do not need tertiay care.
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