Clinical Establishment Act - Please respond

This is a post which I should have posted much before. I’m not sure about how many know about the Clinical Establishment Act 2010 which is being slowly implemented in the country. Couple of states like Assam and Orissa have already implemented it. There are many a hospital in both these states that have been closed down because of the regulations stipulated by the Act.

Recently, there was a notice from the the National Council forClinical Establishments under the Chairmanship of Director General of Health Services, Government of India inviting comments, suggestions, objections, including deletions /additions in the draft documents prepared by them from the public at large and concerned stakeholders.

I personally have much misgiving to the regulations of the Act in the present form.

1.      In a country like India which is very vast and the majority of the population (about 70%) lives in villages, it is going to be very difficult for anybody to set up hospitals in semi-urban and rural areas. The stipulations are going to be very hard to meet that setting up a hospital would hardly be a profitable venture. The other side is that even if hospitals are set up, the cost of care would be quite expensive. Almost all of us have mostly depended on small clinics or nursing homes which are run by a single doctor with the help of a nurse or by a doctor family. In fact, quite a lot of us may have knowingly or unknowingly gone to a unqualified practitioner or quack for our small medical problems. At present I live in a place where almost 95% of the population go to a quack first for treatment. They have bungled up cases where the patient ultimately died. However, nobody has been able to do anything. The only reason being that these guys are the only people who have some knowledge about medicine in remote settings. And they come very cheap. The regulations appear to be giving more importance for corporate multispecialty hospitals. This is quite protectionist in nature towards encouraging a corporate model which will ensure that healthcare is only available at a premium in the absence of an efficient public health care system.

2.      There is enough scientific evidence that family practice and nurse practioner based primary care is as efficient, and rather more people friendly than specialist doctors in full fledged hospital set ups.

3.      If you consider any of the complex clinical conditions one can think of, the primary level of care is much more important than high tech healthcare. We have examples of countries like Brazil and South Africa, where Family Medicine graduates have major role in healthcare. The present regulations would only increase costs. If you look at the regulations, the first level of treatment is going to be a Level 1 Hospital which needs to have a staffing of at least 6 for a place which do not have inpatient care.

4.      Most of our tertiary care centres are burdened with primary care. It is not uncommon for any faculty in our medical colleges who end up complaining that most of the patients that they see could have been easily managed at a Primary Health Centre or even by a Nurse Practioner. The ultimate result is that quite a many of our specialists are over-worked to the extent that they are not able to do justice to the specialised skills they’ve obtained.

If we can think of changes that can be proposed, I would propose the following –

1.      Legalising Nurse-Practioner Care: Nurses should be trained to treat simple illnesses allowed to prescribe medicines. A major need would be to allow a category of healthcentres which are entirely run by nurses who may or may not supervised by doctors. At least for populations who have poor access to healthcare, they would be a major boon. In fact, such nurse-led primary care centres have already been in existence in the country, mainly facilitated by various congregations of the Catholic Church.

2.      Provision for single doctor healthcare centres: We are all very familiar with such single doctor establishments. A 100 square feet room with a familiar friendly face to whom you ran when you had a toothache or a cold. You pay about 50 rupees and then you pay some more for the medicines and some basic investigations. The whole process took not more than half an hour. If the regulations in it's present form are accepted and finalised, the family doctor would be history.

May I encourage you to write back to the government, details of which can be found at http://clinicalestablishments.nic.in/WriteReadData/896.pdf.

Medical Education in India . . . A clarion call for Family Medicine as Specialty

The scenario of public healthcare in quite a large part of the country is in shambles. This is no secret. There are powerful lobbies within the country that are bent upon seeing off the remnants of public healthcare in whatever state they are in now. Healthcare as of now has become a commodity which is much beyond the reach of an average Indian in most of the states of the country.

There are questions being asked about the propriety of healthcare being put in as a basic right of each of the citizens of the country. The result has been quite gruesome.

Basic health indices like Maternal Mortality Rate, Infant Mortality Rate etc. are so dismal in quite a many parts of the country that both the care-givers and the cared are well versed in sweeping adverse health events under the carpet. Latest reports say that we're in for real trouble with tuberculosis.

States like Kerala, Tamilnadu etc. have made major strides in healthcare whereas states earlier known as the BIMARU states, and presently designated as the Empowered Action Group states are a major blot for the healthcare prestige of the nation.

The question remains on how serious we are about this?

One aspect to look at is the healthcare manpower of states in general. I would like to start off with the availability of doctors in various regions of the nation. I do not have numbers from the respective State Medical Councils. However, there is readily available information about the number of seats for MBBS in the different states of the country.

Of course, I would have critics tell me that the presence of doctors alone is not enough to ensure that the nation is healthy. There are countries like Sri Lanka who depend more on nurses for primary care than doctors, thereby ensuring that healthcare indices are much better than even places like Kerala or Tamil Nadu.

Going back to availability of medical graduate seats in various states, I would like to draw your attention to the table below . .. …

Take a look at the below facts . . .

a. Kerala and Tamil Nadu which has got a combined population which approximately totals the population of Bihar has 70 medical colleges with a total of about 9000 MBBS seats whereas Bihar has a measly 13 medical colleges with a total of 1200 seats.

b. I thought of looking at Gujarat as we have NaMo, the present Chief Minister claiming all qualities to don the mantle of Prime Minister after the next parliamentary elections. With a population which is almost double that of Kerala, Gujarat does neither have the number of Medical Colleges nor the MBBS seats that Kerala has. Poor marks for that, Mr. Modi!

c. You may be wondering on how I arrived on the calculation of doctor per 100,000 population. I made the supposition that each medical graduate would serve the nation for at least 40 years after graduation. However, there is a problem here too. For India, the calculation says that there would be about 160 doctors per 100,000 population. However, on the ground, we have only 62 doctors per 100,000 population. For comparison, Cuba has 672 doctors per 100,000 population. I have not taken into account the major brain drain in the field of healthcare which continues in the country.

d. I’ve not taken also into account doctors who are graduating from other countries and coming back to India. Experience says that the numbers of such doctors are also more from the better off states rather than the EAG states. And of course, doctors who would have spent quite a lot for their studies abroad will never be much inclined to serve the rural areas. However, I’m sure that there is no point blaming them as our graduates too do not prefer serving Bharat and instead preferring the shining India. 

Now, I’m going to give another twist to this whole issue. Recently, there was a major statement from a leading healthcare professional about the need for more specialists in the country especially for the specialities of cardiology, diabetes etc.

Of course, with only measly group of medical graduates passing out each year in terms of requirement of the country, it becomes all the more tough to make them specialists in various fields of medicine. And the biggest question is whether we require specialists for each branch of medicine.

In one of my previous posts, I had explained quite in detail about the realities about availability of specialists in remote areas of the country, such as ours.

Here, I would like to look at how we would end faring if the situation remains status quo.

One major concern is poor obstetric care. Why don’t we look at the speciality of obstetrics?

Below is a very similar table to the one above. The only difference being that, we’re looking at the number of obstetricians that colleges in the same states churn out every year.

The number of obstetricians who pass out each year in Tamil Nadu is more than twice that of Kerala. There is no point in looking at numbers from the other states. Uttar Pradesh, which has almost 3 times the population of Gujarat has almost the same number of obstetricians passing out each year. The maximum overall conversion rate from graduates to obstetricians is a measly 4%. For comparison, almost all developed countries has more than 10 obstetricians per 100,000 population.

In a hospital setting where we have a sick baby, a mother for antenatal care, an elderly man for diabetic control, a mother in labour room who needs an emergency Cesarian section, we expect to have a Pediatrician, Obstetrician, Internal Medicine Specialist, and an Anesthetist.

I was trying to do some calculations.

Suppose one obstetrician can supervise approximately 200 deliveries in a month, which amounts to about 2400 deliveries in a year. In Jharkhand we have an approximate birth rate of 24 per 1000 population. Therefore, we would do well with one obstetrician for 100,000 population. Unfortunately, although this looks good when we calculate availability according to the number of post-graduate seats in obstetrics, it does not work well. For example, the region of Palamu, Garhwa and Latehar districts which has a total population of approximately 4 million has only about 10 obstetricians on paper. It should have had 40 obstetricians. I understand that practically, there are only 3-4 obstetricians in the region.

Now, according to rules, we need to have an anesthetist wherever there is an obstetrician. Below is a table showing status of anesthetists in the same states.

But, do remember that anaesthetists are not only required by obstetricians, they are needed to work alongside any of the different surgical specialities. So, the anaesthetists need to be much more than the number of obstetricians.

Now, if we apply the same rule to other conditions, we shall soon find out the enormous challenge that we have in our hands.

I’m sure that this is the case scenario for almost all specialities. All of us know quite well that the number of post-graduate training opportunities available to MBBS graduates is on the lower side. The National Board has tried to offset this shortcoming by arranging DipNB courses in private hospitals. There are challenges here which are beyond the scope of this article. 

To complicate issues, on the healthcare side, the burden of non-communicable diseases is on the increase. There are calls for more specialists in the areas of diabetes, cardiology, oncologists etc. However, do remember that we still grapple with basic healthcare issues such as maternal and child health care, infectious diseases such as malaria and tuberculosis. For completion sake below is a table which shows the number of Internal Medicine consultants and cardiologists who pass out from the same set of states.

Availability of clinical care in rural areas of the country is a major issue. Of course, there needs to be major inputs into infrastructure development of public health facilities in all tiers of clinical care. States such as Tamil Nadu and Kerala has already shown us the way in this realm.

If one closely looks into the Kerala model of healthcare, one can very easily find out that the availability of graduate doctors in grass-root public health facilities, namely the Primary Health Centre and Community Health Centres has been one of the key reasons for healthcare equity. The challenge is to replicate this model in this era of specialisation.

And in Kerala, I find the justification about equipping PHCs and CHCs adequately. Because till about 5-10 years back, the total medical graduate seats in Kerala was not more than 800 seats. And still with that number, Kerala was successful in bringing to quite a certain extent in bringing about healthcare equity.

In the present era, considering into fact the reality that post-graduation is the norm in the field of healthcare, we are in a quandary. In addition, there is a fall in standards of medical education all over the country. It is not uncommon to find MBBS graduates who do not understand anything about clinical medicine and finds it difficult to practice. In such a scenario, a post-graduate speciality for training in general practice is very much necessary.

And this is exactly where a Masters course in Family Medicine would be of benefit.

For uncomplicated cases of pregnancy, do we need an obstetrician around to supervise delivery? For a routine care of diabetes, can we afford to have diabetologists all around the country? Even, for an acute cardiac event, are we entertaining the possibility of only a cardiologist managing the case? Of course, for the rich and the powerful, affording a specialist would not be an issue. The question remains of the common Indian citizen.

And this is where exactly a Family Physician would fit in.

In a situation where we can equip our Primary Health Centres with couple of Family Physicians, the workload on our referral centres would come down quite a lot. And the cost of healthcare would come down to quite a large extent.

Would like to have feedbacks for this post . . . 

Degrees, degrees everywhere . . . but . . .

Not an uncommon sight in many parts of India. 

Doctors with multiple degrees . . . however, none of them after MBBS could be googled.

And they flourish . . . at the expense of evidence based medicine and common sense.

To make matters worse, the government wants to have specialists all over the place . . . in fact, wants only obstetricians and paediatricians to be around when a mother delivers a baby . . .

But, they won't mind all such doctors who freely flaunt all these non nonsensical degrees. . .  

Another opportunity for a plea to take the speciality of Family Medicine seriously . . .