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.

Cont'd - Dangerous Obstetrics

Yesterday, we had quite a crowd in our Labour Room. Over the last 5-6 months, we've had a fall in our Labour Room statistics. We presume that the fall has been due to the opening of multiple nursing homes and hospitals in the small towns from where patients usually came to NJH. Most of these hospitals are manned by nurses or junior doctors, but has names of consultants from the nearby cities on their rolls. 

Of course, we still continue to have our share of eclampsia and rupture uteri. Yes, I've sort of stopping writing about them for some time. You can read the following posts which I had put up some time back about our high risk obstetric patients. 

1. Dangerous obstetrics. 

2. Maternal health care . . . quo vadis.

3. Obstetric Care stories . . . cont'd

4. Weekend diaries

5. Best posts on RCH

We continue to have such patients regularly, although I've not written about them of late.

However, I was quite surprised by yesterday's rush. We had 6 labour patients coming in of which we ended up managing 5 of them. 

The first to arrive was SabD, a 32 year old G6P5L3D2 who had a Cesarian section to deliver her last child. She was in labour and had been trying to deliver at home. By God's grace, she had progressed to quite an extent. But her hemoglobin was only 8 gm%. Considering the prolonged labour, I offered to do an emergency Cesarian section if blood was arranged. The family went to arrive blood. However, the lady progressed well and delivered vaginally by late morning. 

We were glad, but the family was downcast. The reason - - the baby was a girl and the family already had 3 girls, and no boy. They were expecting a male baby. I counselled them to do off a tubectomy, but the family nor the patient would have nothing of it. 

The second patient was PrD, a 20 year old who was pregnant the third time. She had lost one baby earlier due to premature delivery and one was spontaneously aborted in the 2nd trimester. 

To our horror, PrD was leaking for more than 2 days. She was being managed elsewhere, was told that everything is fine and was discharged. Soon after discharge, she started to have fever. The family thought of a second opinion. PrD had a hemoglobin of 9 gm% and she was in full blown sepsis - -  a total count of 40,000/cu mm. She was only 136 cms tall and on per vaginal examination, there was hardly any space along the pelvic outlet. We had to do a Cesarian. 

Per operatively, on opening the uterus, the entire endometrium and the baby was stinking. It was hard to believe that the baby was still alive. So far, the mother and the baby have done well. 

The third patient was SanD, a 23 year old primi who had an uneventful labour and delivered normally. 

The fourth patient was AnwD, a 20 year old G2P1D1, who had a previous LSCS, but no live issues. She had been trying to deliver at home since evening and had ended up with a rupture uterus. The rupture was quite a bad one and very uncharacteristic of previous Cesarian ruptures which usually occur only along the suture line. 

Below is the snap of the rupture after the suturing was done. Since she has no issues, we have not done tubectomy. We pray that she will conceive and deliver a healthy baby later. 

The fifth patient was RekD, a 25 year old, G2P1L1 with previous Cesarian section who came in with labour pains as we were doing surgery on PrD. According to her dates, she was only of 32 weeks gestation. The baby looked quite small and I thought of suppressing her labour. However, the pains just increased. We had told the relatives of the non-availability of specialist facilities should she deliver. 

She did not respond to any of our treatment, but, almost after 6 hours of good pains, she was not progressing. There was a danger of going into rupture uterus. The doctor on duty thought of screening her by ultrasound and found that the baby was in fact term. Yes, the baby appeared to have low birth weight. 

Off went RekD for Cesarian and she delivered a Low Birth Weight baby. RekD had a hemoglobin of only 7.8 gm%. She is yet to receive a blood transfusion.

There was one more patient - the sixth one who did not stay on with us. IikD, a 26 year old wife of a army jawan. The poor lady was leaking since the last 2 days. They were trying for a normal delivery at home. She was G3P2L2 with the first delivery done by Cesarian and the second one a home delivery !!!. Her husband wanted an assurance that we would ensure that she has a normal vaginal delivery. 

I told him that that assurance cannot be given. The family went off in a huff with the jawan shouting all obscenities about the staff and the hospital. It was sad to see that an army jawan just not understand my reasoning and wanted to rather have his way without looking at the possible adverse outcomes. 

Now, all except one patient were very very high risk obstetric patients. 

In fact the 5 of the ladies who delivered yesterday, had lost a total of 4 babies earlier (5 if you include the present rupture uterus too).

5 families . . . 14 pregnancies . . . 5 dead babies . . . one more could have died if we had not intervened on time (PrD).

As I mentioned in one of my previous posts, the status of obstetric care in the region is so bad that we've not still got into the process of looking at neonatal outcomes. 

I'm proud that we've been entrusted by the UNICEF with the responsibility of supervising obstetric care in the district. 

However, to do justice to this responsibility, I need more help. One of the major challenges we have is the unavailability of an obstetrician and pediatrician. And there is always the dangling sword of the Clinical Establishment Act and non-understanding officers who could stop us managing such patients in the near future. 

Please spread word about the urgent need for consultants in the specialities of Obstetrics, Pediatrics and Anesthesia without which quite a number of hospitals such as ours would not be able to be the sort of blessing we are now to many a families. 

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.