Sparktherise.comRURAL DEVELOPMENT AND SOCIAL ENTERPRENEURSHIPFor improvement inhealthcare delivery systems in India Dr Alok Vardhan Mathur, MS, Associate Professor, Dept of surgery, Shri Guru Ram Rai Insitute of Medical and Health Sciences, Patel Nagar Dehradun firstname.lastname@example.org
Nature and scale of the problem• About a third of all people below the poverty line have landed there because of unforeseen medical expenses• State run medical facilities are not trusted by the rural population , hence they rely on the private medical sector for their medical care, sometimes exposing them to exploitation by quacks.• Government funds , when they arrive, are largely being channeled off by the organized mafia, as evidenced by the recent murders in connection with NRHM funds.
Nature and scale of the problem• The condition of medical facities available in India is today largely dependent on the private sector. Though the metros today have some government presence in terms of hospitals and facilities offered, but even there the facilities offered are such that most people even from lower middle classes prefer to use private sector.• Facilities in rural villages are nonexistent to say the least.
The reasons for such a decline• Lack of government funding and low budgetary allocation• The absence of political will.• Unwillingness on the part of doctors to go to rural villages- due to absence of basic facilities like electricity, water, education for children and monetary considerations.• The failure of the government setup means that the sytem is often directing patients to the private establishment
Some opportunities that the current medical set up has• Infrastructure resource• Finance resource• Manpower resource• Transport resources
Infrastructure resource• Medical education is today being catered to by as as many as 150 private medical colleges.• A large number of them are situated in relatively far flung areas and grade B and grade C towns.• These colleges need to have an average of 500 beds under medical council of India guidelines.• However since these hospitals have facilities at near market rates, and because the management of these colleges is dependant more on the income from admissions in these colleges rather than the hospital revenue, most such medical colleges have low bed utilization from the affiliated hospitals.• This is the infrastructure resource that needs to be tapped
Finance resource• Insurance sector has become the mainstay of funding of medical care in the west.• However Indian government has not used the insurance sector to fund medical facilities other than CGHS and ESI and a few similar organizations.• Today a few states have begun to purchase medical insurance for people below the poverty line to the tune of about Rs 30,000 per annum.• Even the United States depends on the Insurance sector to fund government spending in the medical sector, so, developing nations will need to utilize it more efficiently.• The rural Indian will need to know more about medical insurance and either the state or the individual himself will need to purchase the insurance. Funding of medical care will need to be from this financial resource for the porposed scheme.
Manpower resource• A large number of medical graduates are been produced in India today, but only a small handful of them are able to make it to post graduate programs.• Many of them are setting up small private practices in grade B cities because they do find attractive employment opportunities, or because they feel that the employment offered does not match society’s image of a doctor’s lifestyle. This is the manpower resource we can tap.• Similarly there is a large pool of nurses, technicians etc being produced similarly, and they end up gaining employment in foreign countries, again because of poor salaries in India.• This manpower resource will need to to be offeredmotivation to offer quality primary health care in more peripheral areas instead of flocking to central areas.
Transport• A number of states now have begun to offer ambulance facilities which are run by private agencies on contract basis for the government.These services transport patients to the nearest health care providers, goernment or private, free of cost.The quality and reliability of these resources has been good.• They provide a fast means of transport for patients in urgent need of medical care.• They can be used as they are, but with additional inputs to b e able to transport patients over longer distances ,to secondary and tertiary care.
The proposal- Finance• Either the sate or the individual himself contributes to medical insurance for each member in the family to the tune of approximately Rs 50,000.• The annual premium for such insurance would be approximately Rs 1000 for most Indians whose age is less than 50 years.• State insurance companies like United India or Nationalinsurance could provide such insurance on a all India level.• The government could pay the premium for individuals below the poverty line.
The proposal - manpower• The existing infrastructure of primary health centers, extended health centers etc could be utilized and fresh medical and nursing graduates could be posted in these centers after a three month training course in family medicine.• The challenge would be to ensure that they feel motivated enough to stay there.• The proposal would be, either to build colonies at state capitals or district headquarters levels where the families could stay without a feeling of dissatisfaction or frustration.• For this they would have to be offered the benefits of – a handsome salary, – availability of power and water – facilities for their family to stay in bigger cities like state capitalsor district headquarters level, where their dependants’ needs like children’s education, and the need for an urban lifestyle exposure would be addressed.
The proposal - manpower• The team of doctors at the peripheral level will need to include one male and one female doctor. Together they would provide for primary health care for most problems.• They will in addition need a nurse and a lab technician and a Xray technician.• Most government Primary health centers already have these personnel• This team will provide basic medicines, pediatric and obstetric facilities.• In addition they will provide basic lab investigations and radiology facilities. The cost of the medication and investigations will be borne by the insurance of the individual where not provided by the existing Primary health centers.• They will supplement the existing system and not attempt to replace it.
The proposal- medicines• Primary health care medication will have to be procured at a central level to ensure its quality.• India is able to offer cheap, good quality generic medicines to many countries globally. Since there is little in terms of margins or commisions, that such quality and value for money products offer to government purchasers, these products are infrequently used by the existing sytem.• One big reason why the general public distrusts the government setup is that the medicines available are substandard.• The cost of such medicines, investigations and treatment would be borne by the insurance.
The proposal-secondary & tertiary care• Patients with problems that cannot be managed at the peripheral levels will be transported to the identified regional centers. The transport would be by means of the preexisting ambulance network provided for by the government in some states.• In areas where such a facility does not exist, it would need to be created.• The referral centers will be the 150 or so medical colleges which are currently available throughout the country. So most states today have about 5 to 10 medical colleges.• These colleges have unutilized bed capacities and pre existing manpower and medical infrastructure.• The proposal would be to foot the bill of the hospitalization through the insurance.• The medication or part of it for such hospitalization would be provided for by the insurance scheme so that the expense on medicines could be reduced.
• Initial the scheme would cater to primary, secondary and part of tertiary health care. Problems not managed at these medical colleges would be transferred to the regional AIIMS, six of which have been established throughout the country, Cost of treatment in these tertiary centers is and would continue to be the responsibity of the government.
the biggest hurdles will remain:• The unwillingness of the state machinery to divert funds at alternative schemes thereby accepting their failure• The inability of good medical manpower to work in the remote areas- this could be effectively addressed if the needs of their families are addressed at district headquarter and state capital levels and a family medicine is encouraged as a ttractive rewarding area of specialization. Brain drain will reverse when the financial aspect is effectively addressed in the country itself. Real estate developers could be asked to offer housing to the manpower employed for health care delivery at district head quarter level• Current governments do not have the time or the inclination to talk about health care and government expenditure on health care is way below the expected level considering that India will soon be the world’s third largest economy. How can the government be made to increase expenditure on this front in the presence of other problems will be a challenge.
Acknowledgements• This project proposal is for my patients whose lives were drastically changed, or wasted, for want of medical care ,which the state should have delivered, but did not, for want of a proper system, and which I delivered, but was inadequate or late, for want of money or information.
This is a common sight in India- because we have a system where rules are flouted because palms have been greased, the result proved disastrous for this 25year old farmer in UP, who, in a fraction of a second lost his hand to electrocution from an overhead low hanging high tension wire
This horror story was actually a young mother burned by her in laws and deprived furthertreatment for want of money, came to me when her child would not come to her, out of fear- a life destroyed by a lame system
This patient had cancer of the penis-He was advisedsurgery, but it took him two weeks to organize finances – just about 5000 Rs- by the time he came back, hisorgan was teeming with maggots-a shame story for our health care sytem