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.
