Midwifing efficient healthcare

Guest article by Dr. (Prof.) Anand Krishnan
The writer is Professor of Community Medicine at the All India Institute of Medical Sciences, New Delhi
Devi Shetty has recently argued in these columns (September 10) how red tape is strangling the health system in India and is not allowing simple interventions which can transform healthcare to happen. Without belittling his argument, and while acknowledging his achievement as a cardiac surgeon and in running Narayana Hrudayala, let me offer a different viewpoint. I work with community health and my experience is in looking at the health care pyramid from the bottom.
He starts by saying that maternal and infant mortality rates in India will not come down because we do not have skilled manpower; he recommends creation of more skilled and specialist manpower like obstetricians. However, today more than 80% of all deliveries occur in health facilities due to the government creating an enabling environment and infrastructure. There is no need for obstetricians to conduct normal delivery. Nurses and auxiliaries can conduct them with supervision of a MBBS doctor.
He makes a case for two lakh anaesthetists and gynaecologists to do 5.2 million caesarean sections out of about 26 million births annually (or about 20%). Caesarean rates should ideally be around 10% of all deliveries. As per WHO norms any rate more than 15% indicates an overuse of caesarean sections by obstetricians. Even if we assume one caesarean a day by an obstetrician working 250 days a year, for 2.5 million surgeries (10%) we will need only 10,000 obstetricians.
We do not need more obstetricians. Caesarean rates in private sector are about twice that in public sector. Having more obstetricians would result in increased competition, and more caesareans would be done.
Devi Shetty advocates equalisation of undergraduate and postgraduate seats (14,000 versus 50,000) to cover the shortfall of specialists. Any health system is built as a pyramid with a large base, which gets narrower as you reach the top. The top is of the super-specialists (cardiologists, neurosurgeons, etc). Therefore, there has to be more MBBS seats than MD seats and still lower number of DM seats.
One could argue for some increase (say 50%) but the pyramid cannot be converted into a square, as by that logic all MD physicians should super-specialise into cardiology, gastroenterology, endocrinology, etc. We could, however, proportionately increase the seats for all levels, if it is desired after factoring in India’s high population.
He advocates making it easy to start a medical college and allow training in non-medical college settings. The quality of medical education, especially at undergraduate level, is an issue of grave concern to all health professionals in India. Just focussing on increasing quantity will be extremely detrimental to patients. The way medical college recognition occurs due to collusion between private medical colleges and Medical Council of India is to be seen to be believed. If at all, there is a case for stricter monitoring of quality of teaching.
To compensate for lack of doctors in the rural areas, he suggests creation of cadres of nurse practitioners or physician assistants and involving Ayush doctors by conducting bridge courses. I support this; it can be done.
Finally, he suggests micro-insurance schemes in the mould of ‘Yeshaswini’ started by him to address high cost of care. There has been strong advocacy for India to start a national health insurance scheme. While health insurance is something that needs to happen, we need more debate around this and design better schemes.
There are three major concerns with respect to health system in India – access, cost and quality of care. The ‘five-star’ hospitals have been cited as examples of excellent low cost (compared to international standards) and good quality care. Yet, there is no doubt in my mind as a doctor hailing from a middle-income group, that i would be very hesitant to get my near and dear ones treated in these ‘centres of excellence’ precisely because of cost and quality of care considerations.
While government needs to substantially increase the allocation to health to strengthen its health facilities in quantitative and qualitative terms, the private health sector is a major player which needs to be ‘reined’ in. In the private sector the need of the hour is accountability; both at the professional level as well as to patients.
Government has to establish regulatory mechanisms, set up benchmarks and monitor the cost and quality of care. It needs to define standard treatment guidelines or packages for different types of facilities. Consumers need to have a say in the monitoring of these facilities. We cannot depend on the charitable nature of the private sector because it does not exist. There is also great scope for professional self-regulation before government steps in.
Finally, all discourse in India on public health is restricted to health care provision. There is an enormous world outside it on which urgent actions are needed to improve health of Indians. This includes, to name a few, regulation of marketing of foods and beverages to children, working with food industry to reduce fat and salt content of processed foods and so on. Strengthening of disease surveillance systems linked to action is essential if we do not want to have our regular annual tamasha over swine flu or dengue related deaths.

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