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Dr. Soham D. Bhaduri is a Physician based in Mumbai and Editor of The Indian Practitioner (a peer reviewed monthly medical journal). He has been a healthcare commentator and columnist having published his articles in a number of esteemed publications including The Times of India, The Indian Express, The Hindu, The Telegraph, The Tribune, The British Medical Journal, and others. In recent conversation with IJLPP, he talks about challenges to India’s health policy, safeguards for medical professionals, The National Medical Commission Bill and condition of Primary Health Care (PHC).
It is criticized that the successive governments have taken the issue of health policy as an election issue whereby we see new schemes and development occurring as freebies or as a reaction to some wrong happening and image construction. In this context, where will you place the Indian Health Policy and the sector itself when compared to world health policies and practices?
Dr. Soham: In fact, schemes in health occurring as freebies and reactive developments itself signifies that health has NOT been an electoral issue of consequence in India – but has either been a last minute addition to the election agenda or a tool to secure short-term political mileage, through ad-hoc patchworks without pursuing thorough reform. One needs to look at examples of nations like Thailand and Turkey to understand what it actually means for health to be an electoral issue. In such nations, elections have been fought and won in the name of health. Yes, we indeed see and hear more of health emanating out of the political discourse lately, but we have to be careful about two things: firstly, that there has yet not been enough in the way of remarkable action; and secondly and most importantly, that this upsurge is not mainly due to pressure from the bottom-up i.e. public demand and pressure for better health. Unless the latter is met, chances of deep, enduring, and truly beneficial reforms shall remain slim.
In the preceding examples, either as a pre-requisite or a consequence, there was strong civic awareness and mobilization. You also have indigenous examples like Tamil Nadu and Kerala. The recent increase in attention to health is largely owing to a global climate that pushes for universal health coverage in countries like India. Political and industry interests are smooth to be represented in this arena, but the same cannot be said about the interests of the end beneficiary – which could have detrimental consequences.
As far as the health sector is concerned, examples of nations like Sri Lanka, Bangladesh, Ethiopia, and others clearly demonstrate how a lot more can come in the way of political commitment to health in India even at our present economic standing. The per capita GDP of India today is roughly the same at which Thailand achieved universal health coverage 17 years ago. Sure, we have our unique challenges, but that can’t be our alibi.
In June this year, a greater number of incidents of violence against doctors were reported and doctors went on to protest against inadequate security in the hospitals. The government has come up with draft Healthcare Service Personnel and Clinical Establishments (Prohibition of Violence and Damage to Property) Bill, 2019 which increases the punishment and fine for violence against doctors.
Do you feel the problem is merely limited to lack of punitive provisions? What else can be done to protect the fraternity?
Dr. Soham: Certainly not! The lack of effective punitive arrangements should be understood as a factor responsible for our inability to stop perpetuation of the problem of violence against health workers (a problem which has otherwise arisen) in the short run. The moorings of this problem lie in years of disillusionment with the health system and mistrust in the doctor-patient relationship.
The recent spate of doctor attacks have reinforced my conviction in the cascade effect, wherein each episode of violence unattended by strict punitive action inspires and provokes more such incidents more briskly than before. We have to understand the psychological (often subliminal) underpinnings of this: each violent attack by some makes a future attack look like a more justified and convincing course of action to some others. Unless each violent episode is quickly cracked down upon and the same is widely popularized, I am incredulous of any benefit arising simply on account of passing another new law with higher penalties. We already have such laws in some nineteen states in India, and look not just at the forlorn state of their implementation but also their awareness among people, and often among police themselves! In my opinion, this is the only practical measure that can deter violence with immediate effect. As I have elsewhere written, I don’t believe increasing security at hospitals, though needed, is entirely feasible given that even if you were to succeed in covering the major hospitals, a large number of small and medium establishments, which are equally prone to violence if not more, would still be uncovered.
In the long run, however, there is no real solution but to restore trust in the doctor-patient relationship. While the conventionally prescribed solution is to increase public health spending, I don’t think it is that simple. Increased spending and improved healthcare will need to go hand in hand with structural and systemic reforms to curb exploitative practices; streamlining the course of patient treatment and referral; addressing the inequitable distribution of personnel and services; and improving awareness and faith in the legal process of grievance redressal. Better communication between the healthcare provider and the patient can give substantial and sustained dividends only in such an atmosphere. In the absence of the above, short-term measures like increasing security may even prove to be counter-productive by way of aggravating mistrust, as has been found in China.
The Union Budget this year, increased the health budgetary allocation for tertiary sector and schemes by 60 per cent from the previous year’s revised estimates. This has been done despite Economic Survey mentioning that primary health care was struggling. Why is it that tertiary sector has received more attention than PHCs and how important do you think is the role of appropriate channeling of funds to PHC’s?
Dr. Soham: The increase is due largely to the newly launched flagship health program of the govt. the Pradhan Mantri Jan Arogya Yojana (PMJAY), and the scheme will rightfully need incrementally higher investments in the coming years in order to live up to its stated commitments. Even the present level of allocation is inadequate and is less than what was initially asked for by the ministry. The problem is that the increase in investment in tertiary schemes is attended by stagnation of primary care schemes like NHM. But this is no surprising trend either. Our curative spending has traditionally overshot our preventive spending – government health insurance is a quite recent entrant in healthcare. And prioritizing tertiary over primary care is also a ubiquitous phenomenon – one would be hard-pressed to find a country, whether developed or developing, that has not witnessed it, albeit to varying extents. It is driven by the urge of governments and investors to achieve easy, visible, quick, and lucrative results – as also to appease the interests and aspirations of an array of powerful stakeholders including the gentry, the industry, and the medical profession itself. Negotiations and balancing at the political table is no easy job, but a strong political will can indeed tip the balance favorably. The importance of primary care is indisputable both in terms of achieving enduring positive outcomes, and an efficient, equitable and sustainable health system. This is more relevant than anywhere in the case of India, where each of the afore-mentioned elements – enduring outcomes, efficiency, equity, and sustainability – stand under severe challenge. Also, considering the Indian context of widespread unmet basic needs and compromised social determinants of health, the role of primary care becomes all the more indispensable.
In a recent article by you in The Hindu (September 07, 2019) you have questioned the Indian healthcare model of incentivising hospitals rather than general practitioners. Just few days back, the Cabinet has approved the establishment of 75 new government medical colleges by 2021-22 attached with existing district/referral hospitals. How do you assess this measure can help dilute what you call “ivory tower structures called ‘hospitals’”?
Dr. Soham: As much as hospitals have been the ivory towers of healthcare, medical colleges have been the ivory towers of medical education in our country. And the medical education system is equally culpable of disregarding primary healthcare as the healthcare system. A medical graduate that doesn’t study primary care as a separate subject/specialty as part of the curriculum, hardly undergoes any consequential training inside the community, and practically undertakes their entire academic journey surrounded with specialists and palatial multi-specialty hospitals cannot be expected to develop a primary healthcare orientation, let alone serve in underserved areas. The present day MBBS is practically a transit-lounge to specialization. Over the decades, a number of official pronouncements have expressed an intent to rectify this situation and build a ‘health and community’ emphasis in the curriculum, but they have remained largely on paper. The recent Graduate Medical Education Regulations, 2018 rightly underline the importance of a competency based MBBS curriculum, but substantive measures with respect to shifting more of medical training into community structures are still to be heard of.
Healthcare reforms and medical education reforms cannot but go hand-in-hand. Simply increasing the number of medical colleges will produce more doctors, but these doctors again shall share the same aspirations and want to cram into urban multi-specialty settings. Moving down from the ‘medical college-hospital’ level to the district hospital level is logically consistent move, but this alone can make little difference.
The National Medical Commission Bill aims for two major reforms: National Medical Commission and National Exit Test (NEXT). How do you think they will impact the primary health care (PHC) in India?
Dr. Soham: The NMC Act talks about training health personnel like compounders and lab technicians into a cadre of Community Health Providers, who shall practice “limited” medicine in underserved areas and deliver primary and preventive healthcare. The idea is fundamentally sound – in the Indian context, where needs perpetually outstrip capacity to deliver, having such a cadre of mid-level providers can prove beneficial in terms of increasing equitable access to primary care while promising of lesser strain on our budget. There are many a successful precedent of such models that have worked well worldwide. However, we need to remember that the key to the success of such a model is strong regulation of their practices, something at which we have a forlorn track record. The apprehension of today’s medical orthodoxy, that this step will promote quackery, is therefore partly justified. It remains to be seen how things unfold, as inclarity looms over the details of this proposed initiative. The NEXT is about standardizing the quality of emerging medical graduates, which in turn may improve the quality of care delivered by these graduates.
Apart from it, I am incredulous that the transformation of the highest statutory body of medicine from one dominated by elected representatives (MCI) to another dominated by a battery of ex-officio members and central govt. nominees (NMC) will usher into a fundamental transformation of primary care in India. Yes – the erstwhile MCI, being dominated by specialists and clearly partisan towards medical professional interests, was reproached with coldness towards primary healthcare. But so is likely to be the case with the NMC, as there is no precedent to prove that the government is or has been any more committed to improving primary care than the medical orthodoxy. Certainly, the term “family medicine” appears multiple times in the NMC document, but this too could very likely be only ritualistic. Also, primary care is more than just family medicine.
We must note here that the government, which initially set out with the motive of increasing multi-stakeholder representation from various sections in the highest statutory body of medicine i.e. NMC, has hardly achieved its purpose – as 29 of the 33 members of the NMC will still be doctors. Rather, in the garb of the above motive, the government has only spread its own tentacles far and deep into the regulatory body.
[This interview was drafted and edited by Consulting Team of IJLPP]