Doctors in India: Villains or Victims?

"We have not lost faith, but we have transferred it from God to medical profession"

- George Bernard Shaw

The doctors community in India, both in public and private sectors, is in a state of unrest. Every few days there is news about brutal attacks on doctors and these are justified by patients’ family and friends as attributable to alleged medical negligence. Thanks to social media, copycat attacks are becoming frequent. The members of the medical fraternity very actively exchange news/ideas, devise strategies to overcome the problem, go on transient strikes, get assurances from the powers that be that concrete steps would be taken to contain such attacks; only for the cycle to restart after a short period. In a study that was conducted by IMA a few years ago three fourths of the doctors surveyed said that they were physically attacked at least once. In a study published in the national medical journal of India last year, not only significant number of doctors are getting attacked but it is also grossly under reported. The trend is getting worse.

Doctors were considered Gods at one time, when did the doctors become demons? From being the rakshak why did they become raakhshas in the public perception.

"Vaidhyaraja namasthubhyam, Yamaraja sahodara!! Yamasthu harathi praanaan, vaidhyah praanaan dhanaanicha!!"

(Meaning: Salute you doctor, brother of Yama, for Yama takes away only our lives, you take away our lives and wealth too) Sanskrit subhashitha.

The problem started when the health care started shifting from public sphere to private. Up to early 1980s patients were get treated in the private sector but when they had major ailments depended on government and teaching hospitals for their treatment. With the advent of corporate hospitals who were capable of providing care for an extended range major ailments, health care cost escalated and high end health care became inaccessible to a majority of people in India. In the absence of national health insurance scheme many citizens make out of pocket payment (OOP) which pushes 32 to 39 million people every year into Catastrophic Health Expenditure (CHE), which is defined as health expenditure which threatens a family's basic standard of living. The situation is only getting worse by the fact that the government's expenditure on health is just at 1% of GDP. (MOHFW2009).

Doctors who work in private hospitals in India know very well that one of the important triggers for irrational behaviour by patient and families is financial issues, especially when the patient outcome is not favourable. The potential for catastrophic health expenditure could cause psychological havoc.

"The huge gap between the rich and the poor, globally and within nations is not only morally wrong, it is also a source of practical problems"

Dalai Lama.

A patient who is at the risk of eliminating his/her financial resources to obtain healthcare, does not realise medical science has its limitations, every illness cannot be cured and there will be an outcome which is unacceptable in some cases. Good counselling of the exact nature of the problem and probable or definite poor outcome including mortality can mitigate this misunderstanding to some extent. Most of the doctors in India have realised the importance of this only in the recent years. As we are battling out issues like large volumes of patients, limited resources and poor infrastructure in almost all public sector providers and most of the private hospitals; effective communication and empathy could be one of the ways to keep situation under control at least partially and temporarily.

"To effectively communicate, we must realise that we are all different in the way we perceive the world and use this understanding as a guide to our communication with others"

Tony Robbins

Even as we doctors condemn unacceptable behaviour by patients and their relatives, can we absolve ourselves of wrong doings? Doctors say that there are some irregularities by a few individuals and a few hospitals and that should not be reason enough to portray the entire community adversely. True, that should not be the case but is it only a few individuals or hospitals? If we believe so, then we may need a reality check. Have we not heard of hospitals expecting their consultants to work to a target? Are we not aware of conversion rates, referral fees, unnecessary laboratory investigations by doctors and cross referrals, indicated or not?

"I am dying from treatment of too many physicians"

- Alexander the great.

This commercialisation and greed has become worse by the entry of unscrupulous businessmen, liquor barons and politicians into the ‘business’ of medical colleges and hospital ownership. Some/many, with their clout seem to flout every rule, manage accreditation yet unable to provide infrastructure or sufficient human resources.

"I have always tried to avoid politics because most politicians I know are quite dirty in terms of human dignity, ethics and morals"

- Steven Seagal

The reality is, when an idealistic young doctor comes to practice with noble intentions he/she is caught in this web of helplessness because of the lack of the right conditions needed practice his/her profession. This is highlighted by Dr Arun Garde, from Pune, in his book in Marathi "Voices of conscience from the medical profession".

"Every truth has two sides; it is as well to look at both before we commit ourselves to either"

- Aesop

So who are the one who get attacked and is physical attack of doctors justified?

The ones who are attacked are residents, doctors who are on duty in high risk areas, especially in government  hospitals, charitable trust hospitals, small nursing homes and occasionally resident doctors on duty in bigger corporate hospitals though the vicarious responsibility of treating these patients rest with the consultants. The corporate hospital owners or senior consultants who are in many ways responsible for the impression (or truth) that hospitals are primarily profit seeking places, never get attacked. Like every battle, it is only the foot soldiers who get attacked. By doing this the patients further alienate the residents who are already overworked, under suboptimal working conditions which results in worsening of already acrimonious situations.

"Soldiers win battles, generals get credit for them."

Napoleon Bonaparte.

(In this case they get attacked!!)

Are patients justified in attacking the doctors, whatever the grievance? If money is an issue, why do such attacks take place in government hospitals where treatment is free? While there may be many reasons, here is mine. We are living in a society which is becoming increasingly uncivil and aggressive. There are many people who throw shoes and slippers at politicians; vandalise houses of cricketers when there is something as trivial as defeat in cricket match. So when a major tragedy like a loss of life of a dear one happens they indulge in violence. Further, many of them come to a government hospital after exhausting their financial resources they have, this results in their desperate but bad behaviour.

The health benefit schemes introduced by some of the state governments have benefited the private hospitals and insurance companies; that government money could have been better used to improve the infrastructure in major hospitals. In a recent survey by the citizen engagement platform more than 40% of the participants said that they don't trust the private hospitals but 80% visited private hospitals when there was an illness in the family.

"There are far too many silent sufferers.

Not because they don't yearn to reach out but because they have tried and found no one who cares"

- Richelle E Goodrich

The media do not play a constructive role. The police choose to stay away because they believe it is natural for the patients to be distressed and use that as a justification. In some cases the hospitals and doctors don't help their own cause by criticising the treatment given at another facility either because they are not thoughtful enough or they think it will help in their own defence, thereby indulging in medical jousting. The already vitiated atmosphere is made worse by this, making an irate mob, violent.

"We are all connected, when one arm or foot is poisoned the whole body is infected"

Suzy Kassem.

We doctors often become defensive or even play the victim and say we sacrifice everything to continue as a doctor. Every profession in this competitive world has its own difficulties. Because we deal with human lives we seem to run the additional risk of getting attacked immediately by a crowd which gets provoked when things happen contrary to their expectations. However, we can demand stringent laws and better security in the work place. This is more easily said than done.

"Doctors are only doing KRIYA, that is earning their livelihood through this profession, not doing KARMA, that is doing charity for betterment of mankind"

Dr Pankaj Chaturvedi, quoting Bhagavath Gita

The educated people rarely resort to this kind of physical violence against doctors. I know of instances where frank negligence on the part of  doctors resulted  in mortality and morbidity. I know how a middle aged executive became disabled because of inordinate delay and inappropriate treatment; an elderly surgeon who succumbed to negligent care following a surgery and another elderly gentleman never recovered from an easily treatable problem because it was identified late. All these hospitals are well equipped, high end hospitals and what happened there was definite provable negligence. The families of these patients because of their education and politeness did not indulge in unruly behaviour despite spending huge amounts of money for treatment.

"Human behavior flows from three main sources, desire, emotion and knowledge"

- Plato.

Is it not an option to go to the consumer forum? According to a study, cases in the consumer forum has gone up by 400% in the last decade, the inordinate delay to get justice in Indian legal system adds to the frustration. Recently there was consumer forum ruling which was pronounced in 2017 for a case filed in 1998. More over the economically underprivileged ones are left with very little to fight a legal battle after they have spent their money in treatment, so they resort to their version of instant justice.

"Do not expect justice where might is right"

- Plato.

We are not Gods and cannot save all patients, we live at a time and age where practice of defensive medicine is almost a norm. We have not been able to address our issues of poor patient doctor ratio, infrastructure, abysmal working condition and inappropriate financial compensations.

Too many questions. Too few answers. The way forward.

We need a mechanism where we can make the patients our partners and communicate our difficulties to them. We have to spread awareness among public the factual and realistic capabilities and limitations of today's medical science.  We ought to stop advertising treatment modalities which may not be of benefit. We have to stop advertising treatment which could be inaccessible to many.

The doctor - patient trust and relationship is at its lowest point. Is the only way ‘up’?

While we demand a civil behaviour from our patients, it is important for us to do some soul searching and take that extra step and walk that extra mile to restore the trust and confidence of patients in doctors, medical profession and hospitals.

This in no way is a justification of violence against doctors. Every challenge is an opportunity and this is an opportunity for doctors for course correction where appropriate. The argument is advocatus diaboli.

"As doctors we generally don't tell outright lies. We don't speak the truth fully."

Dr.Allan Hamilton.

Are the patients ready for it? More importantly are we doctors ready for it?

Dr Usha

Physician

Hyderabad, India

All views in the above write up are the personal views of the author (and not that of this blog site)

©M HEMADRI

Follow me M HEMADRI on Twitter @HemadriTweets

M Hemadri’s mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 

Medical Education Reforms in India - Too Little Too Late?

Medical education reforms in India - Too little too late?

India is the second most populous country in the world with a population of 1.3 billion. The numbers are an issue, however, the diversity of our population is an important consideration as well.  This diversity is reflected in almost every aspect of our culture and policy including education; this often is worthy of celebration. However, when it comes to healthcare, this diversity results in fragmentation. Without a unified approach we cannot improve our performance in public health, which lags far behind other countries on nearly every health and human development indices.

Therefore, the need of the hour, is a robust system of medical education, which improves the quality of doctors it produces.

When we discuss health education we need to look at three important aspects:

a) the selection of students,

b) their training and

c) their evaluation when they complete the course. 

Till this year we had problems beginning in the very first step, the selection of students. In a country with multiple certification boards of school education and varying standards, we obviously did not have a single system of entrance examination. This meant every state conducted its own entrance examination. To add to the complexity some of the private medical colleges indulge in malpractices helping students slip through the cracks of such a fragmented system.  One of the most apparent manifestations of such malpractice was the concept of “capitation fee”. A student who had obtained a seat in one such medical college last year stated under anonymity that he “booked” his seat in advance and entrance test was a mere formality. The admission tests conducted by state funded colleges are not free from malpractices either. In the newly formed state of Telengana, the admission test was conducted thrice possibly because of similar issues in 2016, putting the students through a lot of inconvenience and extreme uncertainty.

The National Eligibility cum Entrance Test (NEET) was introduced in 2012/2013 for entry into postgraduate and graduate courses. With the NEET it is mandatory that a student should have a minimum qualifying mark to be in the merit list, which is applicable even to private medical colleges as they also come under NEET unlike earlier times when there were no such criteria. For political reasons some of the states and the private medical colleges appealed against it in the apex court. The court ultimately quashed the exam, calling it illegal. This verdict was unfortunately pronounced after students appeared for the test and exams had to be conducted again by the respective states for admission.

Again after three years it could be reintroduced for graduate entrance in 2016. This year too, plagued by confusions it was conducted twice. Later because of lack of clarity the states were given the option of accepting or rejecting the test. This resulted in windfall for private colleges which increased the fee steeply because parents of children who would have let them repeat the test in the normal course next year, if unsuccessful in the first attempt, crammed for the seats paying hefty donations.

From this academic year we are going to have NEET on regular basis for graduate, postgraduate and specialty courses. This would at least curb manipulations in the conduct of the test because it is an online test. This also ensures the students get a qualifying mark to be in the merit list.

Dealing a double blow to  merit is the system of reservations which being  primarily caste based instead of income based, results in quality medical education being put even further out of reach of meritorious but economically backward students. Even with NEET, this system of caste based reservation has not been done away with.

Moving past the testing process, we find issues with testing methodology too. We still persist with methods which tests only memorized knowledge and not the student’s analytical skill. Likewise ,there is a gap in testing the student’s aptitude. There is no method at the time of admission to check if a given student has what it takes to become a doctor. The Charaka Samhitha, an ancient medical treatise which dates back to 2^nd century BC candidly describes the attribute of a medical student. It states: ”The ideal medical student should be of  mild disposition, noble by nature, never mean in his acts, free from pride, strong of memory, liberal minded, devoted to truth, likes solitude, of thoughtful disposition, free from anger, of excellent character, compassionate, one fond of study, devoted to both theory and practice, and seeks the good of all creatures”. No one could have put down more succinctly what is required of a medical student. Not paying heed to these words of wisdom over the years has resulted in generations of doctors who are poorly informed and unprofessional.

The problems, unfortunately, do not end with selection process and continue into training. There has been no major change in the curriculum, which continues to encourage rote learning. It is not formulated according to requirements of the population which the doctor under training would be catering to, but focuses on a learning a lot of theory. Such a curriculum fails to inspire students, whose studies are getting so diluted that they would choose to read study guides instead of text books. None of these augur well for the training of good doctors. This issue was addressed in the Vision 2015 document, which was drafted by a Board of Governors who took over from the MCI. The blueprint, which covered both graduate and postgraduate education, detailed an entry level exam which is common, a curriculum which has both horizontal and vertical integration where the students are trained in basic sciences, lab sciences and clinical sciences from first year onwards and a nationwide common exit level exam before the degree is awarded. The whole process is yet to be effectively implemented though the document was drafted in 2013.

The infrastructure in government funded colleges leaves a lot to be desired, due to the inadequate budget allotment to health and education. A mere 4.05% of the GDP is spent on health, which funds government hospitals which are supposed to be training the medical graduates. Even what is allocated is not fully spent, due to the leakage of funds at all levels. Added to this is the shortage of faculty who, because of better remuneration choose to work in private hospitals. The private institutions also do not spend their revenue on upgrading the infrastructure after their approval and do not most often have required staff.

Realising the need for the long awaited reforms in medical education, a three member committee of the NITI Aayog drafted the National Medical Commission Bill 2016 which would replace the Indian Medical Act, 1956.This in itself is a topic for discussion. The draft bill, aimed at bringing about a complete reformation has flaws which require immediate correction. The most important one is the issue of fee capping in private colleges, which is not clearly spelt out, which means deserving students inspite of a good rank in NEET, may not have access to most of the seats due to non affordability.

The next major feature of the bill which may be self defeating the purpose of improving the quality is the proposal of allowing “for profit” medical colleges. Though the rationale for this may be the need for increasing the number of colleges to meet the demand, this would once again bring in the private players whose intention of starting a college would be commerce. We have now 426 colleges, nearly half of which are private. One proposal that frequently comes up to overcome this problem is to upgrade large district headquarters hospitals to teaching hospitals.

If we need to have a medical education system that would be comparable to the rest of the world, we need to pay attention to student selection which should be purely merit based, infrastructure, training and their evaluation. This is the only way to produce doctors who would be able to face the unique challenge s faced by the society and health care industry.

Dr Usha

Physician

Hyderabad, India

All views in the above write up are the personal views of the author (and not that of this blog site)

©M HEMADRI

Follow me M HEMADRI on Twitter @HemadriTweets

M Hemadri’s mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 

Evolution of professionalism and ethical medical practice in UK and some lessons for India

Indian background: personal view of my experience in India

The issue of ethicality for me, as for many doctors in India, started before joining medical college. In my time and until today, the issue of admission to higher education by merit as judged purely by school final examinations and entrance tests versus the need for social justice to correct the vestigial effects of historical wrongs remains a highly volatile, emotionally-charged ethical dilemma. Once we joined medical college, we saw that the professionalism was often tainted by the general corruption and laissez-fare attitude of which it is often accused.

We overcame these issues due to four main factors:

a) We were really passionate about being doctors;

b) the subjects were really tough, so there was not much time to think about anything else;

c) some highly ethical, professional teachers had a disproportionately positive impact on our thoughts; and

d) most of us were only passive players in any unethical and unprofessional behaviour (at that time, that made it okay).

My own brief period of post-graduate training in India was a mixed experience - for me because of where I worked, my training was directly related to my effort, with the occasional heartache when some VIP’s son (it was usually the son) forcefully robbed me of my opportunity. Many of my colleagues completed their post-graduate training with limited skills; some of them could afford (the time, money and connections) to gain it in the real world after they finished their training and become better doctors; the normal reality of life engulfed the rest and they entered a self- perpetuating cycle of talent deficit. In the years as a young doctor in India, and then later as an experienced surgeon who practised in India for a brief period, I saw repeated examples of unsupported doctors driven to displaying unprofessional and unethical behaviour which were adversely affecting the patient’s clinical care amidst a few individual islands and beacons of high moral behaviour. To avoid being misunderstood or misquoted, let me make it very clear - my view is that the doctors in India want to deliver the highest quality of clinical care and they want to apply ethical methods. The social construct and systems often try to push them away from ethicality; some doctors manage admirably to resist this.

Broad UK contextual principles

The UK is indeed a very ethical and professional atmosphere for doctors. Generally, expressed behaviours are a function of societal standards and expectations. The UK has a high degree of expression of the whole spectrum of the domains of human action - a high level of personal free choice which is tempered with a high level of societal ethics; and a high level of legal control should the personal free action cross ethical boundaries. To phrase it differently, people can do what they want, they do that with consideration for the rest of the society and when they cross boundaries there are laws and rules in abundance which are generally enforced effectively. This was not achieved easily.

Broad context for doctors

There are broader factors that act as the foundation for professionalism and ethicality. As soon as we begin working in the UK, we realise that the bulk of healthcare is delivered by the government through the NHS (though there is increasing privatisation at this time).We learn that the rich and poor can get the same access and treatment, which is more or less of the same standard, across the country. Healthcare has no relationship with the ability to pay – it is free at the point of care. An overwhelming majority of doctors are employed by the NHS on national contracts and there is no difference in pay, and thus earnings, for doctors from various specialties working in any part of the country. Private care exists for people with money or private health insurance; but it is usually to jump any queues and get some frills but the care quality is in substance the same. The system generally removes any financial or professional reasons that might trigger unprofessional or unethical behaviour.

Specific context for doctors

Doctors are held to higher standards of behaviour; these are regularly reviewed and set out in the UK regulator’s (General Medical Council’s) Good Medical Practice guide. Doctors’ annual appraisals are related closely to the domains defined in the GMC’s GMP guide. There is a specific area in annual appraisals titled ‘probity’ which is taken very seriously. Further, a doctor’s personal health problems have to be declared and their impact on effective functioning assessed. The GMC’s GMP is applicable not just within a doctors’ professional and clinical domains it is applicable to behaviour standards in a doctor’s personal life as well. If a UK doctor’s drunken behaviour during private holidays affected any member of the public the GMC wants to know about it and will investigate it to see if there were any patterns that might impinge on patient care. If a doctor attends a court of law on a completely private matter such as speeding on the road or a financial irregularity the GMC wants to know about it and is likely to sanction in parallel for any major convictions in court. A registered doctor is expected to have a higher standard of behaviour compared to the average member of the public and when it slips the regulator will not hesitate to act against that doctor. The GMC even has guidance on how doctors should interact in the social media even when doctors interact with social media on non-clinical matters. Voluntary compliance is the norm. Breaches are quite a few but these are resolved through either local or social pressure. A word from the senior, a call from the medical director or a well meaning assertive/aggressive warning from people in the social media is usually enough for doctors to pull back and fall in line. Doctors have to reflect on their developmental Continuing Medical Education/Continuing Professional Development (CME/CPD) activity, doctors have to reflect on the complaints they face. Currently, doctors are required to have regular 360 degree feedback administered by an independent party, funded usually by their employers - this feedback is obtained from randomly chosen colleagues including other doctors of various grades, nurses, managers and others. If this feedback shows a need for improvement that has to be undertaken. The UK regulator has recently introduced revalidation for doctors where annual appraisals form the core element of the decision to revalidate a doctor every five years and allow them to practise. All the above descriptions form a part of the appraisal revalidation process.

The evolution of current practices

This is an interesting exercise in conducting large scale change. It was a slow, incremental multi-channel process that took many years and many stages. CME/CPD requirements were defined by the Royal Colleges in the early 1990s. Clinical audits were introduced in a big way in the early 1990s, 360 degree appraisals were introduced as a part of progression for trainees in the early 2000s; reflective practice was introduced in medical schools in the early 2000s. Cross pollination of these practices between specialties and grades were encouraged. Formal annual appraisals were introduced with it being mandatory for trainees. Soon annual appraisals became an essential part of senior doctors’ career job planning and career progress with many elements already having been brought together. Now all these have been pulled together into a comprehensive appraisal-revalidation system which is mandatory.

In the late 1990s, the Bristol enquiry into paediatric cardiac surgery deaths on how a department’s poor performance went unrecognised over a period of time; in the early 2000s, the Shipman enquiry on how a doctor could escape any official scrutiny over many years of criminality; and currently the Francis report on how a whole local system focused on the wrong things causing patient harm without being challenged by clinicians were major national external stressors that have pushed the medical profession to re-focus on the patient and start taking responsibility.

Some counter points

Is the NHS system perfect? Certainly not. Will it catch the bad doctors? Probably not. The scientific evidence for many of these methods is arguable. Many doctors opposed it actively all along and resist it passively even now. Some use it as a purely tick box exercise so that they will have a licence to practise their jobs. No one can be sure if these improve clinical quality for the patient.

What it does seem to have done is to increase the professionalism and ethicality of doctors. When anyone suspects a breach of professionalism and ethicality by doctors anyone is entitled to report the doctor to the GMC. The GMC does a full investigation only for a small number of the cases reported to them. During the investigations the GMC looks for reflection, maintenance of clinical skills, and development of insight. If the GMC is satisfied with these then it decides on minimum sanctions or on no sanctions at all. If it is not satisfied, the sanctions can be very severe, including erasure. The GMC, backed by the law, is a powerful force for doctors to seek a higher degree of professionalism and ethicality.

In practice, a large number of doctors who are international medical graduates (IMG) and who are from black and minority ethnic (BME) origins believe the system may be broadly very fair for the UK local graduates, but for IMGs and BME doctors there is evidence of a higher rate of reporting to the GMC and a perception of a higher chance of sanctions and a higher severity of sanctions. This is seen by many IMG and BME doctors as somewhat defeating the otherwise worthy ideals that in general work well. It is not as though there are no other sub-radar ethical problems: defensive practice, higher levels of service utilisation with its implications of unnecessary interventions, racial divisions (in jobs, exams, pay grades, bonuses) and others.

Transferable lessons

The principles underpinning UK medical practice are universal and hence transferable. The core principles are:

a) expecting a higher standard of behaviour from doctors in the practice of their profession and in their personal lives;

b) having a strong, progressive regulator backed by law; and

c) encouraging and supporting doctors at every opportunity to be ethical and professional, but with the clear

d) understanding that any breaches will involve facing the full impact of regulatory and legal enforcement without fear or favour.

The practice of these principles is not easily transferable since the context and environment is very different in India.

As very junior surgical trainees in India we used to ask patients to buy a variety of drugs, sutures and allied implements for their care - we would also make a judgement on the economic capacity of the patient, and on that basis ask them to buy a certain amount more than what would actually be needed for their care, sometimes upto double their actual requirement. We then used to store this in our individual cupboards and use the surplus for the care for other patients. Sometimes, we told the patients that this is what we were doing, sometimes we did not – either deliberately or simply due to lack of time. Essentially all of us were running our own individual small scale charity process. We saw this as completely ethical, moral and professional. We were saving lives, we were curing patients.

In the UK, this will be misrepresentation, lying, theft, financial misdemeanour, etc, all of which obviously are offences with the potential to end careers.

In India unnecessary investigations could have a financial motive (essentially fraud), in the UK it is mostly simply a matter of high utilisation (hence an issue of lack of operational standards). In India, talking to the next of kin of ill patients is normal accepted practice; in the UK, speaking to the next of kin without specific consent is sanctionable under the Data Protection Act and is a clear breach of right of privacy.

Creating an Indian system

A two-channelled approach may be needed in India. The first channel is to enable a higher standard of positive behaviours from doctors.

My personal suggestion is for doctors to create and maintain their own personal-professional portfolios. These portfolios could be reviewed by either employers or peers (individuals or professional bodies) every two years; and voluntarily submitted to the state medical councils every four years. In return these doctors could get the status of updated/enhanced registrations. Over a period of time, the medical councils and professional bodies can work together to make the portfolio very robust (perhaps in 20 years’ time the whole process can include a 5 yearly voluntary written knowledge test). A higher degree of respect, recognition and remuneration for doctors who have updated/enhanced registration could be an incentive to encourage the uptake.

The second channel would be to reduce the incidence and severity of negative behaviours in doctors. Pro-active, transparent, supportive intervention by the relevant professional society and the state medical council will be crucial. However, when those interventions fail a strict regulatory and legal approach will be needed.

A time defined, long term, incremental protocol, with specific measures that must be achieved, should be mandated with implementation commencing urgently.

I am hoping that these words make meaning and help thought in creating workable recommendations to enhance the ethics and professionalism of doctors in India. This will be essential for the future of the doctor-patient relationship and to enhance the reputation of doctors in/from India.

©M HEMADRI

Follow me on Twitter @HemadriTweets

Note:

This was originally written at the request of Prof Rajan Madhok as a part of background documentation for a conference in Kolkata in January 2014
The Global Indian Doctor: Workshop on promoting professionalism and ethics

http://leadershipforhealth.com/wp-content/uploads/2014/02/Event-report.pdf

The article was republished in Sushrutha (Volume 7 Issue 3), BAPIO's magazine published on the occasion of their annual conference 2015.

Indian Health: Money and Doctors Cannot Solve It - Get the Engineers Out There

India's recent mission to Mars seems to have provoked questions mainly from non-Indians on the need to prioritise development in other areas such as healthcare. Most Indians seem to be proud of the Mars mission and live on hope that the great successes seen in space exploration may somehow be replicated one day in other areas. Many non-Indian commentators and overarching international organisations have asked for India to raise healthcare spending.

The numbers seem to be all over the place. For the purpose of this blog discussion we will assume the following for Indian healthcare expenditure:

Percentage of GDP spent on healthcare 4%

Percentage of government expenditure on healthcare 8%

Per capita spending on healthcare $60 (if you believe wikipedia its $124)

Out of pocket expenses is around 60%

This is when the arm chair commentators, the ones who have never been bitten by a mosquito in an area where malaria is prevalent, should get out of the discussion and get a dose of reality.

What can you get in western healthcare for $60? Not a lot. 

This $60 per person per year spent on Indian healthcare is mostly accounted for by the 20% of people who represent the middle class and above. Many of the middle class get much more than $60 spent on them leaving in theory and in practice, a large proportion of the population to have nothing spent on their healthcare $0 per year. A friend recently had a colonoscopy in a frightfully expensive hospital in India and spent Rs 70000 ($1111) this may mean this friend has used up 17 other Indians' annual healthcare spend. You get the picture.

70% of the Indian people live less than $2 per day (33% of people are below the official poverty definition of $1.25 per day). You get the bigger picture.

By how much should India raise its healthcare expenditure? Doubling it to $120? What would that get? Nothing in reality. Doubling that to $240? You would not even scratch the surface. If the entire per capita income of an Indian which averages $1100 is spent on healthcare India will still have a healthcare expenditure less than Lithuania. Even at that level no one can predict if healthcare benefits will be equitably distributed across the population. It may well be possible that the rich will get healthier and the rest may get unhealthier.

The US example is relevant here where 18% of GDP is spent on healthcare at nearly $9000 per person yet 40 million US citizens do not have healthcare cover and US has poor outcomes for many chronic conditions. Throwing money at problems does not necessarily solve problems. 

Ask for a better system. Ask for a different system. If that system costs a little more, then the money follows, do not ask for more money to be spent on the existing system - it just goes down the drain.

Copying the current western systems of the 21st century for healthcare delivery in India straightaway  is expensive. This means the benefits of any copied western systems will reach the small proportion of the wealthy population. Well worth remembering the Jaguar in India costs the same as in England and obviously the only wealthy get to use it.

Alternative medical systems (ayurveda, siddha, homeopathy, etc) are still unable to provide comprehensive answers at a population level.

So what is missing? What are the potential avenues to explore?

Cannot Escape Evolution

There can be no doubt health improvement at population level has evolved gradually over time from the early 1900s. Interestingly the earliest foundations of population level health improvement happened not by direct personal medical based interventions but by infrastructure based social living conditions improvement. I am talking about covering the drains, separating animals from human beings, providing clean drinking water and so on. Direct intervention based healthcare followed much later.

In India in 2013 there are still many areas even within all the cities greater boundaries where there are open sewers. In 2013 in one of the poshest areas of a very major city there are contaminated water supplies. The healthcare budget cannot not solve this; yet solving it will improve the health of the people.

A healthy population is the greatest boost to an economy but the population cannot be made healthy by primary, secondary or tertiary care based direct personal medical interventions - i.e. doctors, clinics, hospitals. Populations can be made healthy only by political will and civil engineers. That is the trick India is missing. Building more primary and secondary care centres with open drains around them is the opposite of a decent healthcare solution. India cannot hope to improve the health of the population by avoiding a well established evolutionary pathway.

It seems India and its well wishers may be looking for the magic injection that will solve major health problems. There may be magic injections for diseases but we will do well to remember that there are no magic injections for health.

Under the given current conditions, doctors cannot solve the healthcare problem of India. Get the engineers out there. Get them to cover the drain, clear the puddle, provide clean drinking water and keep the roads clean. You will find the population becomes healthier contributes effectively to the economy. Then and only then we can spend more on healthcare and expect to benefit from it.

©M HEMADRI 

Follow me on twitter @HemadriTweets

I have blogged previously about great areas of Indian healthcare which you may want to check out.

Dr Bang's remarkable achievement in rural India which gets the same results as cities  http://successinhealthcare.blogspot.in/2013/01/swadeshi-healthcare.html

My conversation with the Chairman of Aravind Eye Care a low cost superior quality system about their culture  http://successinhealthcare.blogspot.in/2013/04/my-conversation-with-dr-ravindran.html