Clinical Establishment Act . . .

Well, I’m sure quite a lot of Indians would have some sort of idea of what this is. Well, for the dummies, this act would lay down basic criteria for operationalising clinics, hospitals, laboratories etc.

For the uninitiated person, who has no idea about the masala of Indian healthcare, the natural response would be - ‘Great, this is something each citizen would definitely benefit from. Access to quality healthcare at your beck and call’. Well, appearances can be very deceptive.

Now, let me come to something which we at NJH do on a regular basis. Obstetrics . . . I’m yet to see the CEA (Clinical Establishment Act) of Jharkhand. But, the CEA made up by another state, Assam states that for a Maternity Home (Hospital with Obstetrics Department) you need the following -

1. Full time qualified gynecologist with PG Degree/Diploma in Obstetrics

2. Full time qualified paediatrician with PG Degree/Diploma in Paediatrics

3. Full time qualified anesthesiologist with PG Degree/Diploma in Anesthesia

4. Part time/Full time Physician with PG Degree/Diploma in Medicine

Well, the rules are not quite difficult to follow in maybe the metropolitan cities of the country and many of the towns of better off states like Kerala, Tamil Nadu or Gujarat . . . The rest of the country? ? ?

I thought of doing a small exercise yesterday. NJH caters to complicated obstetric cases of almost the whole of 3 districts in West Jharkhand. Only those who can afford to pay well go all the way to Ranchi which is 135 kms away.

I called up one of my acquaintances and requested names of obstetricians with either a Degree (MD) or Diploma (DGO) in the speciality of Obstetrics in these 3 districts. Below is what I got.

Palamu district – 1 MD, 5 DGOs

Latehar district – 1 MD, 2-3 DGOs (not certain)

Garhwa district - 1 MD, 2-3 DGOs (not certain)

Well, anybody interested in the population of the 3 districts . . . Approximately 4,000,000. Which means at a birth rate of approximately 25 per 1000, we would have about 100,000 births to be overseen by 15 obstetricians every year. Even after calculating a 50% institutional delivery rate, this would mean that each obstetrician would end up overseeing about 3500 deliveries every year.

The scenario which I’ve shown is the same rather worse for almost all the other specialities.

What would the CEA lead to in most of the regions of the country -

1. Healthcare which is already expensive would become more expensive.

2. Healthcare would become inaccessible to most of the Indian poor unless they live in a state which has good public healthcare.

3. Specialists would become more in demand. Their salaries would rocket sky-high

4. Most of the small nursing homes and hospitals especially mission hospitals would have to be closed down.

5. Healthcare would become an industry rather than a service.

One among the multiple thoughts I had about the CEA was the fact that in spite of quite stringent rules, all through these years quacks and allied health professionals have been practicing medicine in almost the whole of our country. I wonder why the government should insist on specialists alone handling the clinical work.

Please do note that in many of our medical schools, we’ve had non-specialists doing excellent work in various departments. So far, we did not have any problem. In fact, no patients have any problem going first to a quack before he tries to access a qualified doctor.

I wonder if the state would have problems if I wanted to show my child to a non-specialist with whom I’ve developed a good rapport throughout the years. Some of the best hands I’ve seen dealing in specialities are those with no specialist qualifications. I’m well aware that it would be ideal to have specialists. But, what worries me are the following factors -

1. Lack of adequate training facilities for specialists, both in terms of quality and quantity. Recently, I met a senior obstetrician who is in the faculty of a Medical School and she mentioned to me that her MD Obstetrics students do not do more than 10 independent Cesarian Sections during the entire course of their study. I remember going to one Medical School where the postgraduate students in Surgery told me that their course is more like an MD Surgery rather than MS Surgery. The reason, they read more theory and hardly get to do any practical work. Post-graduate medical training in India is at the cross-roads. 

2. Our huge population. For a 4 million population of the region, we calculated approximately 15 degree and diploma obstetricians. Now, I’ve read that in the US, during 1980s there were about 8 obstetricians per 100,000 population. Its 30 years now. If we used the same yardstick, we should have 320 obstetricians for the districts of Palamu, Garhwa and Latehar. I say, it would be a luxury to have 25% of that number, which is 80 obstetricians. Presently, the US has about 14 obstetricians for a 100,000 population and if you put that number for our region (Palamu, Garhwa and Latehar), that would be 560 obstetricians.

3. Inadequate medical graduates - There are quite a lot of medical schools in the country - the latest figures stating a total of 335 medical colleges churning out 40525 new doctors every year. The issues of emigration and non-practising doctors are quite a major factor. In addition, almost all of us prefer to work in urban areas, which ultimately results in a disproportionate distribution of doctors across the country. There has been news about the government trying to increase the number of seats.   

Taking the cause of obstetricians once again, according to the MCI website there should be 1214 OG Degree consultants and 637 OG Diploma consultants passing out every year. I thought of doing a small calculation to find out how many we need. If we use the standard we decided would be good enough which is 2 obstetricians per 100,000 population, for a population 1200 million we would need 24000 obstetricians; which means that 1800 odd obstetricians passing out each year would be well enough, provided we do not have the problems of urban flocking, migration and of those who decide to do 'armchair obstetrics'. 

But, mind you, there are major regional variations here. 

Let us take the example of Jharkhand. As per the MCI website, Jharkhand Medical Schools have a total of 9 MD seats and 2 DGO seats for Obstetrics and Gynecology every year. Which means that if the average practise period of a obstetrician is 25 years, there would be 275 obstetricians in the whole of Jharkhand at any point of time. And, we are dreaming of 320 obstetricians for Palamu, Garhwa and Latehar districts. 

The situation is entirely different in places like Andhra Pradesh Medical Colleges, which have a yearly total output capacity of 126 MD seats and 95 Diploma seats in Obstetrics and Gynecology.

Now, the total population of Jharkhand is approximately 33 million and Andhra Pradesh is 84 million, which means that to reach standards of Andhra Pradesh, we would need a total of about 70 Obstetricians passing out of Jharkhand Medical Schools every year. . .  

In the light of the factors, I would continue to trumpet the cause of 'Family Medicine' in the scheme of things in Indian healthcare. As of now, there has not been much of a support for the speciality of Family Medicine from almost the whole of the Indian healthcare fraternity. The issue of getting a team of specialists together at a given point of time in rural areas of the country such as ours. 

One needs to only ask any of the District Medical Officers on how practical are most of their First Referral Units are. I've been hearing those stories for some time now. It requires Anesthetist, Obstetrician, Pediatrician and Blood Bank Officer (Diploma in Clinical Pathology or MD General Pathology) at the same time together. One person's absence is enough to cripple the arrangement. And this is where the Family Medicine consultant steps in. With clear guidelines on when to refer, a group of Family Medicine consultants manning a Primary Health Centre or a Community Health Centre can make a world of difference to the healthcare in India. Unfortunately, I could not find any mention of a role for a Family Medicine Physician in CEA literatures of any of the states which are already implementing the law. 

The late Field Marshall Sam Manekshaw had made the following comment on lawmakers with regard to their knowledge of defence matters of the country. "I wonder whether those of our political masters who have been put in charge of the defence of the country can distinguish a mortar from a motor; a gun from a howitzer; a guerrilla from a gorilla, although a great many resemble the latter." I think the same applies to the healthcare sector. Could I paraphrase it this way. 'I wonder whether those of our political masters who have been put in charge of the healthcare of the country can distinguish labour pains from the labour department, an operation theatre from a cinema theatre, an obstetrician from an orthopedician, a consultant from a generalist, a quack from a quake . . . although a great many resemble the latter.

The CEA is a good step to standardise the quality of healthcare facilities in the country, but unfortunately appears to have been made by people who have no idea about grassroot level issues. There are umpteen number of pre-requisites to attain before we can plan to think of implementing the CEA. Almost all of the pre-requisites require a great amount of planning and willpower to operationalize with a long term vision. Otherwise the CEA would become another of the many Indian legislations which appear rosy on paper but has no use in bringing about the necessary changes.