-Ibrahim Hafeezur Rehman
‘Health is wealth’ is getting converted to ‘health is for wealthy’ wherein in this era of corporatisation of everything the approach to dealing with illness and disease is benchmarked more on amount of money you can spend and less on cost effective reach and delivery. The reach and cost factors are particularly important for developing countries and even transition economies such as India where the low priced health facilities range from rudimentary at the village level to grossly inadequate at the city and metro level. In such a scenario the wider availability of health facilities at an affordable cost to the masses especially the poor becomes critical. Of course, affordability varies hugely but a large section of India is in no position to bear the cost of private or corporate hospitals that have sprung up in every nook and corner of big cities. Consequently, the poor are dependent on the heavily crowded and scantily provided government hospitals which against all odds often render services that go well beyond their mandate, infrastructure and institutional strength. For instance, in Delhi the three major hospitals, Safdarjung, All India Institute of Medical Sciences and Ram Manohar Lohia together cater to over 60 Lakh (6 million) people every year in their OPDs.
The renowned All India Institute of Medical Sciences (AIIMS), Delhi, is recognised not only in the country but globally for its cutting edge research and expertise matching the best in the world. “The rich history, legacy, strive for academic excellence coupled with the immense satisfaction of tending to the poor keeps the motivation levels high of the entire AIIMS family of health service providers”, says Prof. Randeep Guleria globally renowned pulmonologist and Director of the Institute. Over 10000 people visit AIIMS OPD everyday. While at any given point AIIMS admits close to 2000 patients the waiting periods in the hospital for admittance, tests and procedures can still range from a few days to three or four years. The AIIMS Causality is a ‘War Zone’ with almost 400 critical patients visiting it daily. On a first glance the ‘Emergency Ward’ appears highly chaotic but once you observe closely you realise it is a hugely efficient and a phenomenally result oriented unit. Tests are done in a matter of minutes, diagnostics from X-rays, Ultra Sound to Scans are delivered and doctors materialise quickly to resuscitate and save a life. It is an amazing place comparable to the best in the world in terms of delivery that can truly be a case study for dealing in ‘Emergency Medicine’. The experts in AIIMS are in the league of the best in the world and need to be applauded and saluted for sacrificing big corporate money to serve the needy. These experts work at least 12-14 hours a day and perform all kinds of interventions to save people having achieved many firsts both in surgery and medicine. With a handful of super specialists path breaking and modern health service delivery to millions per year is made possible by the ever alert residents and students of the hospital who constitute the backbone of this ever alive institution. An affiliated institution the AIIMS Trauma Centre is also one of its kind in the country. The Centre and its orthopaedics unit perform all kinds of complicated surgeries to restore to good health the limbs and mobility of people who have met with serious life threatening accidents. The Centre handles about 60000 in a year and admits over 20000 annually. “In spite of augmenting bed strength by more than 25% we are ever fighting a losing battle because the beds are filled up before you can literally blink! The high quality trauma care being provided by us attracts patients from unbelievable distances. So unless we strengthen trauma care at the grassroots tertiary care centres will keep bursting at the seam,” says Prof Rajesh Malhotra, world class surgeon, Head of Orthopaedics and Chief of Trauma Centre.
Safdarjung Hospital was founded during the Second World War in 1942 as a base hospital for the allied forces and was taken over by the Government of India in 1954. Until the setting up of AIIMS in 1956, it was the only tertiary care hospital in Delhi. The Doctors in Safdarjung perform about 200000 major and minor operations every year. Nearly 7000 patients visit Safdarjung OPD everyday and the hospital has an accept all policy meaning nobody can be turned back for admission. The patients pay almost nothing for the health facilities and the hospital has many acknowledged experts, efficient residents and students who work round the clock. Unfortunately, the hospital has seldom been in the news for treating and servicing such a large number so cost effectively but is more often criticised just for failures.
Even lesser known hospitals such as Ram Manohar Lohia in Delhi are providing fantastic service to the deprived by catering to close to 5000 OPD patients on a daily basis. The efficiency levels in these hospitals are also relatively high considering the volume that they serve. For instance, a young lawyer arguing before his Lordship who found his heart fluttering and spluttering was attended to in a matter of minutes and it took less than two hours to get a stent placed while having a massive heart attack thereby avoiding major damage to the heart muscle. Such cases are routine in these government supported hospitals but often get overshadowed or buried.
It is easy to criticise the government facilities and the hospitals but considering the volumes they handle, low delivery to cost ratio and the wide coverage provided by these centres their contribution to keeping the nation healthy is immense. The ones who are fortunate enough to get health services through insurance and corporate system also need to appreciate the other system which is so essential to the overall well-being of the country. Hence, instead of being negative we should look at these institutions with the respect that they deserve and applaud them for the wonderful work that they are doing. It is also important to remember that major immunisation efforts and drives in the country are through the non corporate hospital sector which primarily results in saving millions of lives.
In order to prevent crass commercialisation of the health sector it is also desirable that we find innovative and additional ways to strengthen and support these government run health institutions. One possibility is to set up alternative funding mechanisms involving individual and corporate donations routed through a health trust that could provide much needed finance particularly for enhancing capacity and infrastructure in these institutions. The trust could insulate the institutions from direct donations which could be a cause for conflict of interest or any other unscrupulous practice. The other more important element is to provide more salaries, incentives and recognition to the experts who should remain motivated to serve the poor without feeling the sacrifice of missing out on the commercial or monetary side. For the purpose the system of rewards and appreciation needs to be strengthened wherein such experts can be duly facilitated for the services rendered.
Of course, the intent here is not to say that private sector is not rendering health services as one can easily find enough examples of dedicated individuals and private institutions who are serving the ill in an efficient manner. In particular the burgeoning middle class in this country is now served well by the private sector hospitals as is evident from the fact that most of them are bursting at their seams. Some of the private sector Doctors also unhesitatingly serve the poor without worrying too much about the economics of the service rendered.
One further needs to be cautious of insurance led health services delivery which now controls the health system in the West. It is important that we derive learnings from the Western system and not just ape and replicate it as we have been doing till now. The case in point is the rampant misuse of stents and implants aided and abetted by the insurance sector. It was only when the government intervened and regulated that the cost of the stents came to a fraction of what was being charged.
Provisioning for health cannot primarily be a charitable exercise but in a civilised and humane society it is equally important that nobody is denied proper health support just because one cannot afford it. It is in this context that government, private sector and social or voluntary institutions need to put their heads together so that quality health services can be provided to one and all. The last word to health care providers in the kind thought and language of Mother Teresa, “It is not how much you do, but how much love you put into the doing that matters.”