Referral well made

It is quite common to see public healthcare facilities being given regular bashing in the media and our regular conversations. 

However, yesterday, I had a very encouraging experience when one patient was referred to us at the opportune time before she went into a complication. 

Although the indication for referral was a bit different, I was impressed that the person who wrote this referral letter timely identified that the patient needs to be referred. 

The staff at this PHC had diagnosed obstructed labour. However, on examination, we found out that there was third degree cephalopelvic disproportion although it had not into the stage of an obstructed labour. The delivery would have become badly obstructed if the delivery was allowed to progress. 

Please join me in acknowledging and applauding this unknown staff in a remote Primary Health Centre of Palamu district. 

Healthcare . . . Quo Vadis

I've been in Kerala for about 10 days. And one of the major thing I've noted is the explicit business that healthcare has become. 

I'm not sure about how much of what I heard is true . . . I would love to hear that all of this is mere gossip. 

One of my friends, who was working in the paramedical wing of a major hospital in the south of Kerala was narrating to me how expensive doctors have become. He was trying to facilitate a Internal Medicine consultant to shift from his previous place of work to the hospital he was presently working. 

The compensation the young doctor was demanding was a whopping 200,000 per month. It seems that he was making about 150,000 per month.

I wondered how the hospital made up this much of a money to pay the doctor. And I've been asking questions to anybody who has anything to do with healthcare whom I meet. The answers are very disturbing. 

It's easy. Every doctor is given a target of the number of blood investigations, ECGs, EEGs and CT Scans they are supposed to give. Obstetricians are given target of the number of Cesarian sections to be done in a month. Interventional cardiologists are given the target of the number of angioplasties for a month . . . The list goes on and on.

I could only feel sorry for all those of our teachers who were quite keen to drill into us the aspect of cost effective medical practice. Leave alone those who try to teach us evidence based medicine. 

The question is about how many of us doctors would take a stand against this sort of healthcare practice. 

Another side of this story is that almost every patient is happy to comply to any investigation or procedure that his/her doctor prescribes without a whimper questioning about the need of the test/procedure. The more complicated and latest the investigation or intervention, the lesser the chance of a patient not complying. 

And the pharmaceutical companies and their ploys to increase their sales make the scenario all the more enticing for unscrupulous business practices. 

Here also, I noticed that the patients also loved to have the latest antibiotic and the latest drug . . . many of which did not even have complete safety profiling. 

Sad . . . but true. No wonder, there is a big lobby against public healthcare all over the country. And with the rapidly increasing upper middle class with massive paying capabilities with a liking for all the latest, the future appears quite bleak.

Too Poor . . . Cont'd

As the story of the 4 day old baby dying in a hospital has made quite a headline in many of the country's newspapers and other media, I got more ammunition to strengthen my case for building up the public healthcare system of the country. Of course, I've been getting quite a lot of e-mails after my first post on healthcare for the poor. 

Yesterday, I came across a very good article in 'The Hindu'. I was flabbergasted to know that deliberations within the Planning Commission was leaning towards state funded insurance rather than efforts to rebuild public healthcare systems. 

It seems as if 'Corporate Healthcare' is well poised to hijack public healthcare. It is not without everybody's knowledge that private healthcare is always associated with profits. Therefore, the motives would remain profit making rather than public good. 

I remember going to a investment advisory meeting quite some time back. I was seriously thinking about going into share market, along side my medical studies. It was the first meeting of such a nature which I was attending. The guy on the podium was all dressed up. He communicated quite well . . . 

One part of the monologue went something like this . . . 'You know where you should invest if you don't have much money to play around with.' Hand went up . . . Someone told 'cement'. Others 'cars'. Someone else 'infrastructure'. Our friend gleefully negated all of them. 'There are two areas in which you can always be assured of profits - - petroleum and healthcare especially pharmaceuticals. The 2 Ps'. 'Of the 2 if you have to chose one, it is always pharmaceuticals', he blabbered on. I was stunned. 

I was just into medical school. And had very less knowledge about industries and business. This guy educated me that healthcare would always be profitable. There would always be customers come rain or shine.  

Today morning, I had 2 groups of medical representatives come in. They told me they only dealt with branded medicines. No dealings in generic cheap medicines. All this when there is a Central Government order on promoting generic cheap medicines. The bottom line was about the profits I could make.

So, the corporate world's involvement in healthcare is for profits. You know, how they can advertise one event of philanthropy and ensure that they have everybody's goodwill. I beg our guys in Planning Commission not to fall for the gimmicks being shown by private healthcare providers. They talk well . . . smoothly . . . and before long you'll be the main source of their profits. 

With a poor global economy, healthcare is something the corporates are eyeing. They wait in the riverbanks like vultures eyeing a feast at the expense of the common man who has been let down by public healthcare of the country. 

At the end, what do we have to do . . . It goes without doubt that the government cannot shy away from the responsibility of ensuring public healthcare in a country like India. It is the worst crime against it's own citizens to outsource healthcare to private healthcare providers. 

Would the government ever think about outsourcing the security of country's borders to private security firms . . . Or call private armies to ensure law and order. Diseases occur due to as well as result in a breach in the health of a citizen. Outsourcing the business of proper healthcare to a motley group of 'cash rich but still hungry' healthcare businessmen is not we should be even discussing about. 

As mentioned in the article, we have enough research as well as global models to support a public funded healthcare system. Let's not allow healthcare to become an industry. Or if it has become an industry to at least some extent, let's prevent it from continuing as an industry. 

Of course, I'm sure that with a 1.2 billion and booming population, no private healthcare institute worth its salt would need to close down. I recently heard about small private hospitals in Kerala becoming non-viable. Of course, that's how it should be. Public healthcare should have prominence and should be the first choice for point of healthcare for any citizen of the country. 

I know that there is much more to be put in . . .which I would do in due course of time. I've enough cases which we got over the last 2 days . . .which all resulted because of a poor public healthcare system. 

Please share this post to build awareness about the need for strengthening public healthcare.

Moneylenders . . .

The rural Indian hinterland is not complete without the active presence of moneylenders. They usually belong to the business class. They are know by different names in different regions of the country.

Today I was reminded of the chaos that a moneylender can bring about in the life of a commoner. I was sitting in the cool air-conditioned environs of my office, when a shabby looking young lad of about 19 years walked in. It was obvious. He wanted a concession for the treatment of his wife. 

GD, his wife had come about a week back after having been in labour for more than a day. And she was terribly anemic. We operated after the relatives arranged one unit of blood. Per-operatively we found out that the uterus was already ruptured. The baby was lucky to have made it alive, although a bit sick. 

The total bill for both mother and baby came out to about 17,000 INR. He had brought 10,000 INR. The baby's bill was about 2000 INR for which we gave full charity from Grace Babies. That left 5000 INR. I haggled with him to at least pay 2000 INR more. He fell to my feet and told me that he has brought all that he could afford. 

I asked him how he managed 10,000 INR. It seems he had taken it from the local moneylender.

To all of you who know the moneylenders in the rural areas of India, this may not be new. 

I asked him about the interest he would have to pay back. The calculations are astronomical and unethical. Let me put it in simple terms. 

The interest he is being charged in 10% per month. And he is paid 10% less of what is taken. 

Which means, if I borrow 100 INR, I would get 90 INR. If I pay within one month, I would have to pay 110 INR. If I pay the next month, that would be 121 INR. So you can calculate how much I would have to pay if I take one year to pay the money off. 

If my mathematics is correct, if I pay a 100 INR loan after 1 year, I would end up paying 314 INR. Imagine, getting a loan for 90 INR and paying back 314 INR. Recently, someone told me that there are some fairer moneylenders who take 10 INR per month for 100 INR. So, if you calculate that way, that would still be 220 INR after one year.

Imagine, GD's husband getting 9000 INR. He would be having to pay anything between 22,000 to 31,000 INR if he manages to pay back within one year. And there is the spectre of bonded labour which continues without much notice in most of our villages . . .

Poor families in rural India take such loans for three major reasons - agriculture (for purchasing seeds and fertilizer), unexpected ill-health and marriage ceremonies. Unless the monsoon rains fail, he is able to repay for agriculture costs. The problem is with the next two. 

My prayer would be that public health facilities would improve so much so that patients like GD would get the best possible treatment such that they would not need to approach facilities such as ours. Until that happens, I pray that we would be able to write off bills for patients like GD. . .


However, the Rashtriya Swasthya Bima Yojana is the best option available before us to bypass the moneylenders at least when the issue of unexpected healthcare costs arises. Unfortunately GD's family did not have an RSBY card.


We are proud to say that till today morning, we've had 868 RSBY beneficiaries accessing outpatient facilities (free registration and consultation) and 141 accessing in-patient care. The total costs should be around 700,000 INR of which we have got about 380,000. I'm glad that we could be of service to these many RSBY card holders in a short duration of not more than 4 months.