HEALTHCARE IN INDIA: IS THE GOVERNMENT EVEN BOTHERED??

Political parties often pitch intensively against a few individuals for maximum media bites. There is, however, no real discussion of the issues which affect the lives of scores of Indians. “Development” has recently become the buzzword of all the political parties. Development does not only mean economic and social transformation, health also has to be seen as an essential component. A country’s future is determined by the investment the government makes in health and education for its human resources.

The most one hears from politicians about health is on the subject of reducing infant and maternal deaths. These are issues that matter, but it is a shame that the government has realized this so late. For the last sixty eight years, it has been largely silent on the issue of India’s poor infant and maternal mortality indicators. With more voter friendly issues to be discussed, such as roads, trains, and buildings, more fundamental societal issues such as health does not seem to appear at the forefront of political discourse.

Although the government routinely announces grand health schemes, India does not use credible evidence to guide health expenditure. Evidence based public health policy, which determines planning and spending, is virtually non-existent. There is a need for state funded and autonomous research funding organizations. Many countries have institutions that collect information on the burden of diseases. These institutions have statutory and economic powers to enable them to plan and implement integrated surveillance for diseases, and to guide policy to determine priorities, which could prove to be a crucial step for India.

Barring the pulse polio programme, having a world class surveillance network, there have been ambitious intents but futile implementations of disease surveillance and response in the country. There are no standard operating guidelines regarding reporting diseases, and health hazards, which should be implemented throughout the country. The ministry of health and family welfare needs just not the right intent but also coordinate with state governments to implement evidence based public health in India.

The government health departments need to be autonomous with minimal political interference. Currently, the majority of health expenditure is from people’s own pockets. Middle class families are not invulnerable to major illness or the likely subsequent impoverishment. Insufficient funds and a lack of accountability in the public health sector have led to the flourishing of the private sector, triggering catastrophic health expenditure. No political party pledges to implement universal health coverage ahead of elections, given that it is not a burning issue for them.

The fact which is most astonishing is that no one talks about the importance of public health training and research; two important areas that require immediate attention. The autonomous public health institutes need to focus on the obligations of the local public health system.  These should include keeping the public informed about important general health matters, as well as conducting research in an area specific manner within each state, and reporting findings to the government so that changes can be implemented. It is critical that a well trained and professionally skilled workforce manages the public health system. A new “Indian Health Service” with power and financial autonomy equivalent to that of the Indian Administrative Service needs to be created. A detailed draft of such a service should be prepared and discussed in detail by public health experts. Professionals should be trained in addressing public health issues, and in educating the public on general health.

Private healthcare establishments are rarely accountable for any of the services they provide. It is important to recognize that the private health system in India is similar to any other profit making industry, with quality treatment coming at high cost, borne by the patient. The private sector in healthcare is unregulated. The need of the hour is to have regulations to ensure that the average person is able to afford healthcare. If one is not poor already, illness can make him poor. The only exception to this is for millionaires or politicians whose healthcare expenses are taken care of by others. Still, the middle class never demands more healthcare expenditure or considers this as an issue before deciding which party to vote for.

The current public health challenges are intense and complex, and cannot be addressed by the government’s department of health alone. There is much work to be done, if we want to claim to be one of the fastest growing and developed nations. It is time to focus on fixing the health system, and take steps that will improve public health. Most illness is preventable and early screening can minimize costs. Health is a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity, yet most health debates occur around sickness and diseases.

There is a need to implement universal health coverage and strengthen the comprehensive primary healthcare throughout the country. It is to be ensured that the control on providing healthcare services is decentralized. A school health programme needs to be implemented to ensure that every child is healthy. An integrated national health policy also needs to be developed, which would cover preventive, curative, and rehabilitative services, with the social determinants of health getting priority in planning and budget allocation.

The mainstream media airs debates on most trivial issues but do not have time to raise interest in health issues. With the common man not knowing the serious consequences, faced with the eternal neglect of politicians, and sidelined by private health interests and aiding policy makers, one is often left wondering who cares for the health of people.

ATTACKS ON DOCTORS: SAVIOURS NEED TO BE DEFENDED

No physician, however conscientious or careful, can tell what day or hour he may be the object of some undeserved attack, malicious accusation, blackmail or a lawsuit for damages. It’s happening more and more- doctors being assaulted by patients or their relatives. A hospital is supposed to be a sanctuary, a place where people come for care at the most troubling times, where we seek safety and reassurance. Those needing such care greatly depend on the doctor and his support staff. Doctors strive to be impartial caregivers for everybody, to be the shining examples of humanitarian service and self-sacrifice. Doctors have traditionally enjoyed an unassailable halo, a mixture of healer, advisor and confessor. Doctors have been appropriately bestowed with a higher degree of trust than most members of society. These senseless acts of vandalism serve as a metaphor for the potential decay of a profession.

Today’s health care system is being transformed into a chaotic one because people tend to view the system as too expensive, dysfunctional, and at times, irrational. The regulatory and financial burdens placed on doctors can result in long wait times and short “face times” with patients. The high expectations raised by the latest medical technology can be shattered in individual cases.  Frustrations can reach the boiling point for some people, and the doctors or their clinics offices are not immune to them.

A doctor is often an object of strong feelings, both positive and negative. A patient may view him as a saviour, God or a magician.  Yet to some, he may be the symbol of a system gone wrong, if not the tool of one’s particular suffering. Violence stems from the complex dynamics of a given individual’s specific situation. Violence can be a flash reaction to frustrating helplessness, fear or humiliation. A doctor’s unique role may make him an iconic, visible scapegoat for health care’s failings, particularly now as his stature is being eroded by a combination of external forces and some of his own making.

The traditionally autonomous doctors, once independent operators of medical service, are becoming line workers in large systems. Majority of freshly passed ones choose employment, as opposed to private practice, given the daunting regulations and financial pressures. Though valued and trained members of the health care team, in many cases these doctors lack the privileges of performing high skill procedures, thus limiting their competence.

Additionally, the internet has turned everyone into a doctor.  Patients come to doctors armed with downloaded material targeting their condition, challenging the value of the doctor’s knowledge.  Lawyers also tend to do so regularly, to find a loophole in the procedure performed by the doctor so as to nail them, even if it was an exception made by the doctor, seeing the patient’s condition.

This devaluation of the profession of medicine is of some societal concern. Physicians are professionals not simply because they get paid.  Sociology, the social science that studies human interactions, organization, and institutions, defines a profession as an occupation which regulates itself through systematic, required training, and collegial discipline. A profession’s validated knowledge and competence is continually validated by the community of peers, and its continuing education standards. Perhaps most importantly, that professional knowledge results in judgment, advice, and actions oriented towards a set of substantive societal values, which is health and well-being in the case of medicine.  Service rather than profit is enshrined in its code of ethics.

Hence the profession is cognitive, collegial, and moral.  Because of this process of legitimization, doctors achieve a coveted status of professional authority, which is a valuable asset.  It increases the probability that people will obey a legitimate command or call to action and that a particular definition of reality and judgment of meaning and value will prevail as valid and true.  For example, a person heeds a doctor’s warnings about smoking, taking needed medication, vaccinations for personal and societal benefit.  A doctor’s authority also creates a dependency condition. Patients acknowledge the professional’s superior competence within a deep context of emotional and physical needs in the doctor-patient relationship. A component of this dependency condition actually promotes therapeutic success.  Therefore, professional authority is worth preserving and nurturing.

When a doctor abuses his professional authority, he contributes to the profession’s devaluation.  Medical education is expensive, with the doctors training for years, sacrificing early paychecks, and missing family time to attain and maintain the ideals of their calling.  A false sense of entitlement in some is understandable. Some may define themselves as professional simply as being paid for their service, and define professional success in financial terms. Clearly, the transformation of health care poses challenges for most doctors, and threatens to commercialize their specialized core assets.   Sensing an increasing loss of control, a growing frustration with their redefined industrialized role, it is easy for doctors striving to maintain the true ideals of their profession to become disillusioned, if not downright cynical. Cynicism can corrode all human values and can also corrode the values of a profession.

One cannot prevent precious loss of life of a patient in all the situations, and no doctor actually wants to do harm to his patient, or bring himself disrepute. Doctors, as well as policy makers and patients, should strive to sensibly prevent a noble profession’s pernicious loss of its cognitive, collegial and moral value system, a thing that is precious to one and all.