SEPTEMBER-OCTOBER 2007 Edition

 

 

DOES the phrase ‘inclusive health care’ sound like jargon? Several slogans like ‘health for all by 2000’, ‘comprehensive healthcare’,‘total healthcare,’ and some political ones such as ‘primary healthcare,’ have been coined earlier. Are all these slogans attempts to assuage the ‘middle class guilt ’ of politicians, bureaucrats and ‘yes minister’ health professionals who draw up health policies? The health status of the country has changed only marginally in the past 60 years. Unreliable government statistics try to show the brighter side by quoting improved health indicators. But nobody does a cost benefit analysis of the money that has gone down the drain. Several health ministers, deputy ministers, secretaries, directors of health services and other officers in the states and the Centre have drawn salaries during this time. But none of the targets fixed in the eleven Five Year Plans have ever been achieved.

Vertical programmes starting from population control, leprosy eradication, malaria eradication, tuberculosis control and child health have failed as planning was done with a view that healthcare was disaster management. So vertical programmes replaced planning for radical, comprehensive change. The late Dr PC Bhatla, past president of the Indian Medical Association (IMA) and the initiator of the National Institute of Primary Healthcare said: “It is not health for all, but hell for all by 2000.” But he was only partly correct. While rich Indians and foreigners are buying hi-tech healthcare including kidneys to survive, the poor sell theirs in a desperate effort to survive. The story of blood transfusion is similar. A large number of prestigious institutions called ‘corporate hospitals’ where lifestyle diseases are treated efficiently with the latest technology have sprung up in the country. Children from foreign countries are operated for congenital heart disease with wide media publicity while children of the poor die of rheumatic heart disease while in the waiting list of heart care institutions.

Thus, Dr Bhatla`s prediction is applicable in the right context. According to a survey by the Voluntary Health Association of India, 400 million people in our country have no access to modern health care. Also, 26 per cent of the population which is just above the poverty line, gets pushed below the poverty line when they spend their hard earned money on medical care. While 80 per cent of our population lives in rural areas and peri-urban slums, 80 per cent of hospital beds are in large cities. For ‘inclusive health care’ to materialise, what is the way out? Starting with the Bhore Committee Plan immediately after Independence, the government today seems to have given up in despair. Privatisation is being promoted, much in the pattern practised in the US. The government sector is taking a backseat. Corruption is rampant - starting from admission to a medical college, passing the examinations, post graduation and practice. And unfortunately, we have come to accept it as a way of life. We fail to realise that unlike medicine, other professions do not have a direct bearing on human life. In days of yore, the Charakas and Sushrutas of Bharat realised this. At that time, knowledge of medicine had to be acquired more by preceptorship than by reading ‘MCQ’s like today. And admission to a course in Ayurveda was restricted to those who showed an aptitude for service rather than high intelligence or the strength of their family money.

For inclusive healthcare to succeed, this spirit has to be revived in the profession, both at the educational and the practical level. The professional has to lead from in front. Whether we Indian doctors can do this is the million dollar question. The country is churning out more then 20,000 doctors a year. They end up in large cities or going abroad. The role model for them is the corporate superspecialist or the NRI consultant. This attitude of the professional has to change if inclusive health care has to succeed. In March this year, the prestigious Journal of the American Medical Association (JAMA) dedicated a whole issue to the breakdown of the health care system in the US. While costs are at an all-time high, 60 million people have no health insurance. After some discussion they came to the conclusion that a radical change could be brought about only if doctors took the lead. The profession must unite in driving reforms away from cost-cutting and short-term fiscal competitions to catering to the patient’s need. Can we import this attitude along with the import of technology? In Europe, the European Society of Medical Decision- Making (ESMDM) has been playing this role since the 1980s. Equitable access to high-cost technology and prioritisation for appropriateness was slowly being pushed down in the services. Prof. Wilfried Lorenz, a past president of this society, mentions in his chapter in the book Surgical Research, “The role of the scientist today is no longer that of a precise methodologist or a sophisticated thinker but also of the provider, a person whose primary concern reflects the needs of the individual and of the society.” Several innovative changes are being introduced in the medical education systems of these developed countries to suit the needs of their changing societies. Meanwhile the Indian Medical Council functions with primitive policiesand an outdated constitution. It is not willing to live up to the needs of the people. To bring about a radical change and provide inclusive healthcare, the professional in India will have to reject the glamour of its industry-based high-tech orientation. The spirit of national service has to replace the greed of personal profit.

The professor has to induce the younger generation to serve humanity and not become a slave to technology. The established rural practitioner has to be eulogised. We cannot have a corporate hospital in every village. It is our responsibility to provide health care for the people. The best way forward is to train a generation of doctors who can perform multidisciplinary service and train village boys and girls to run a small hospital and sustain it with voluntary effort. When such a move comes from the profession, the government will support it.This is the only way of providing ‘inclusive healthcare’ for India in the 21st century

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