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Tuesday, 22 November 2011

Nursing a critically ill state back to health
Nursing a critically ill state back to health
Indranill Basu Ray highlights the core problems that afflict Bengal’s health sector and suggests a few ways to improve the situation
Saktinagar hospital, Nadia, August 2011
Despite many technological and other achievements that have propelled India from being a developing nation to one of the top economies of the world, one field that India continues to lag behind in is health. This is why stories of babies dying in large numbers haunt newspaper headlines. India is behind Bangladesh and Sri Lanka in life expectancy at birth or under-five mortality level. India accounts for about 17 per cent of the world population, but it contribute to a fifth of the world’s share of diseases. A third of all diarrhoeal diseases in the world occurs in India. The country has the second largest number of HIV/AIDS cases after South Africa. It is home to one-fifth of the world’s population afflicted with diabetes and cardiovascular diseases.
A common excuse that I often hear is that we have limited resources to tackle the huge and burgeoning health problems. But even the richest country on earth, the United States of America, has failed to provide appropriate health services to a large section of the populace. The problem in India is quite different. Apart from being a poor nation with limited resources, it also has a sizeable population in need of basic health services. Furthermore, the lack of appropriate sanitary measures and education ensures an ever increasing presence of communicable disease that have been controlled and even eradicated in the developed nations.
India’s list of woes does not stop here. Lack of foresight on the part of successive governments and selective and fragmented strategies to counter daily problems without a definite public health goal have been the mainstay of India’s health policies. Resource allocation to this sector is influenced by the prevailing fiscal situation as well as by the priorities of the reigning government. Unfortunately, in Bengal — a state that faces a dismal fiscal situation — the government’s priorities have been skewed as a result of political necessities. Although we have a new government at the helm, it is important to realize that gross changes at the practical level cannot be initiated without having a team with experience and knowledge define a well-thought-out strategy. It is also essential to have a government that is willing to fulfil the financial needs necessary for the strategy to work.
It is difficult, if not impossible, to paint a picture of the present state of public health in West Bengal and to suggest measures to rectify the same in a short article like this. My intention is to highlight the core problems plaguing the system and to suggest solutions based on accepted principles of public health and healthcare management. The steps that need to be taken are as follows: reducing disease burden, including infectious diseases as well as non-communicable epidemics like diabetes mellitus and coronary heart disease; restructuring the existing primary healthcare system to make it more accountable; creating a skilled and professional workforce which is quality driven; financial planning to bring more investment to the health sector.
Reducing disease burden is the cornerstone of any good health policy. The factors that help reduce communicable diseases are clean drinking water, improved sanitation and an effective vaccination programme. A paradigm shift, from the prevalent curative approach to a preventive approach, including health promotion by inculcating behavioural changes, is imperative to reduce disease burden. West Bengal is one of four states that urgently needs high investment in safe drinking water and toilet facilities. It is estimated that Rs 18,000 crore is required to provide effective drinking water and sanitation facilities for the entire country. Kerala, Maharashtra, West Bengal and Odisha would account for more than 60 per cent of the total outlay.
Similarly, a huge investment is required to provide nutritional supplements to malnourished children and pregnant and lactating mothers living below the poverty line. According to a report by the national commission on macroeconomics and health, West Bengal would need to harness an additional resource requirement of rupees (in crore) 1,286, 2,459, 4,693, 13,811 and 8,485 in sectors such as health, water and sanitation, nutrition, primary schooling and roads. It has been projected that in the next five years West Bengal will spend a large portion of its revenues on wages and salaries, interest payments and pensions, leaving very little for discretionary expenditure in the field of health. It is imperative that the present government rethink and strategize in collaboration with the Centre to ensure the appropriate funding necessary to make the state healthy.
Restructuring the present healthcare delivery system is also equally important. Most primary healthcare centres are old, dilapidated buildings with few or no facilities. Some do not even have basic resources like healthcare workers or pharmacists. What is required is a radical overhaul of the existing system. There are differences in health systems of different countries. A State-run health system, such as the one in Canada, suffers from delayed medical care. A privately-run health system like the one in the US provides only limited health services to its poor. India’s healthcare should carve out the best of both systems. Private healthcare is thriving in India. It is uncontrolled and aimed at profit-making. Government-run hospitals are poorly managed, providing few or no facilities to those living below the poverty line.
Different models have been suggested to take care of this disparity. While private investment will always be geared towards profit-making, it is mandatory to rein in these bodies under well-defined rules. Large private hospitals in the US are non-profit bodies, which have to follow stringent rules in patient care. At the other end of the spectrum is the National Health Service in Britain in which small, medium and even a few large hospitals are making way for a more competent and accountable government-controlled health system with fewer hospitals.
Human resource management is very important in running an effective health system. One of the biggest lacunae of government health service is its poor human-resource management. Many physicians are not paid appropriate salaries or are posted in places that are not of their choice. Political intervention and favouritism play a big role in posting physicians. Consequently, dedicated physicians who want to serve the public or work in the academic setting found in government hospitals are forced to remain in private hospitals. To boost morale and efficacy, discipline needs to be instituted in the system and a transparent posting policy adopted. The doctor-population ratio needs to be improved by filling up vacancies in the West Bengal health service. It is important to free postings from the grip of bureaucrats to ensure the registration of quality candidates. Physicians failing to report to duty or indulging in indiscipline must be punished. Doctors who do sign up need to provide relevant and quality medical care. This can only be done if some form of recertification of doctors is made mandatory once every 10 years. Physicians’ salaries in the state health service must be made on a par with those of the Central government to make sure that it remains a lucrative option. Senior physicians providing exemplary public service must be rewarded for the same. A commonly-held notion is that most physicians run after the lucrative salaries that are offered in private hospitals. Hence it is difficult to retain them in the government sector. This, however, is true of a minority. The majority of physicians are willing to work in a healthy, progressive and academic environment if there are appropriate non-financial incentives. Let us take the example of Christian Medical College, Vellore. Most of the faculty there are paid salaries that are much lower than those of the private sector. However, physicians are provided with other facilities such as good housing, free schools, free-to-highly-subsidized college education and, most importantly, a progressive and research oriented work environment.
West Bengal lags behind many other states when it comes to medical education. There is an urgent need to increase the number of medical colleges in the state. Private investment for the same should be welcomed but appropriate laws must be instituted so that huge capitation fees are not charged for seats. Furthermore, selection should be made through competitive examinations. A certain percentage of seats can be reserved for the economically weaker sections. Students passing out of such medical colleges must be given postings in rural hospitals. This has been true on paper for many decades now, but the rule has been poorly implemented even in government-run medical colleges.
Innovative schemes ought to be thought of to involve the cash-rich private sector to service the medical needs of the state. Private institutions using government money or land must be asked to provide free service to 20 per cent of their capacity. Appropriate punitive measures — such as temporarily withholding or cancelling licences — can be taken when a private institution fails to honour this commitment. Institutions willing to set up large hospitals, particularly around Calcutta, must be helped through the provision of low-cost land. But in return, promises to set up satellite hospitals in far-flung district headquarters have to be met.
The biggest challenge to the rejuvenation of the healthcare system is the garnering of funds. West Bengal is financially broke, thanks to the misrule of the communists. Unlike most other communist rulers, our home-grown variants failed to provide basic sanitation, good roads, a working healthcare system and appropriate nutritional supplements to women and children. The lack of social services resulted in poor health and in increased mortality among the vulnerable sections of society. Government efforts to improve basic health services must fund programmes that provide sanitation, nutritional supplements, and daily meals for school-going children. Substantial investments in these sectors can reduce mortality in children. It is popular to blame doctors for not being able to save severely ill, malnourished children. But things won’t change unless determined steps are taken to root out the problems, such as poor funds, minimal resources and an incompetent workforce, that affect the West Bengal health service.
In the next five years, in collaboration with the Centre and the non-government organizations involved in public health, the state government must chalk out a definitive strategy to improve the supply of clean drinking water, provide better sanitation and one full meal to school-going children and arrange for nutritional supplements to pregnant women. Private investment should be wooed in the health sector to set up hospitals in large metropolitan areas as well as in small district towns. While government land is needed at an appropriate price to help investors build hospitals, steps must be taken to bring about the inclusion of the deprived sections in their service plans. Strong regulatory bodies that can monitor private hospitals and nursing homes must be instituted. Many of the profiteering health institutions do not provide basic facilities, lack trained nurses and paramedical staff, and some are even run by quacks without medical degrees. It is of utmost importance that a regulatory body conducts surprise checks on these institutions, registers complaints and takes remedial steps.
Many NGOs have been able to set up large projects benefiting thousands of people. They have also succeeded in bringing foreign aid to tackle malaria and HIV. The state government should help these NGOs achieve their goals while exercising control to prevent financial irregularities. Their services ought to be applauded and single-window processing of applications instituted to help them tackle bureaucratic delays. Health is a service industry and not a lucrative business. Unfortunately, in Bengal, most large hospitals are owned by corporates. Only a few are owned or run by doctors. There is thus a sustained effort to make profit. Poor consumer protection makes the man on the street vulnerable to substandard service at high prices.
These are trying times for Bengal, after years of mismanagement in the health sector. It is important for the present rulers to rectify the situation by laying down the stepping stones for a better tomorrow.
The author is with the Ochsner Medical Foundation

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