Category: healthcare system

Neuro and Spine

The torture of being “Just MBBS”

The average salary of a fresh medical graduate (MBBS) at private hospitals in sizzling cities like Bangalore,

Hyderabad, Chennai and Mumbai is much lower than an entry level call center employee. At most cities this income cannot support a lower middle class living.

Even when we talk about employability in small towns, rural setups and government setups, there is a big dearth of vacancies. In under-developed states like Bihar, for every available post for a salary of USD 400 per month public sector medical officer job there are hundreds of applicants for every district.

The health system clearly does not have necessary capacity to employ the existing workforce of fresh medical doctors passing out every year.

So where exactly the newly qualified doctors are disappearing to? Interestingly majority of the medical graduates are engaged in postgraduate entrance test for the first 5-10 years of their career and youthful lives instead of fruitful engagement with the health system.

I am sure that all of you who have been through the “Just MBBS” phase wouldn’t agree more.

While having an interesting discussion with one of my friends Dr Nitiraj Gandhi (Clinical Services Manager with a prominent Corporate hospital in Bangalore), on the pathetic conditions being faced by Junior doctors in India, one of his statements really gave me an insight on healthcare industry’s perception towards fresh MBBS graduates.

“Today’s MBBS has little to offer in addition to Web MD or such sites. They themselves (more than 90%),are apprehensive at making a diagnosis. In contrast MD and MS are extremely well equipped in terms of knowledge and expertise and at par with the best in world. Its a pity that post MBBS, few are equipped to practice while most are busy preparing for pg and memorizing stuff. The art of apprenticeship is a lost one today.”

Is it that something is wrong with the Medical education system or is it something else?

In India, most fresh graduates are involved in majority of nursing and clerical activities like giving injections, indenting medicines for the ward, doing dressings, putting IV fluids, drawing blood for investigations, transporting them to the lab and collecting results, carrying blood bags from the blood bank to the ward and collecting X rays. This work has to be done 365 days without a single leave, and duty hours extending upto 28-32 hours at a stretch!

This kind of work and work schedule will definitely suck out any left over knowledge, capability to analyze, capability to innovate and above all the capability to diagnose and prescribe medicines in a manner which is optimum for the patient.

There is a widespread resistance to change in the above situation because in a teaching hospital they are a cheap resource available with no prescribed rules on the nature of work, work hours, work days and holidays by the government.

Then you have our so called professional leaders in MCI and senior professors in Medical colleges who think that all of this is fine because that is what they have also been through. This notion that “You got to do it because we did it”, is what is taking the standard of Indian clinicians on a downward spiral.

For all categories of employees in India, we have some rules and laws laid down to prevent human resource exploitation. But to this date nobody bothers to take care of this under paid, over worked and underutilized brilliance we know as CRRIs, “Just MBBS”, “Junior doctors” or “Duty doctors”.  

Let’s Support Thiruvarur Interns:First batch interns in Thiruvarur medical college are threatened by the Dean that he…
Posted by SLAVE CRRI on Thursday, April 9, 2015

References

Kumar R. The leadership crisis of medical profession in India: ongoing impact on the health system. J Fam Med Primary Care [serial online] 2015 [cited 2015 Apr 10];4:159-61. Available from: http://www.jfmpc.com/text.asp?2015/4/2/159/154621

The Arogyada
www.arogyada.in
April 10, 2015 / by drsandeep.net

Family Medicine Clinics in India: The Next Big Thing for Indian Healthcare?


By Astha Gupta, MSc(BioMed) MHA PAHM

Healthcare in India has fast moved away from general practice to super specialised medicine. As a consequence the erstwhile family physician who had detailed knowledge of his patient’s lifestyle, family history and clinical history has somewhere gotten lost. Family Medicine is a branch of medical sciences which aims to provide comprehensive and continuing healthcare for individuals of all ages and genders. A popular branch of practised medicine across the globe, it provides for the first line of treatment and preventive care. In India, very recent times have seen a resurgence of this concept with a few private players stepping into this arena. The next few sections highlight the potential for this stream of healthcare in India and the challenges associated with it.

Models of Family Clinics 

1. Single Practitioner
A decades old model followed within the Indian market, it typically involves a single physician catering to a small local population. Services provided may range from only consultation to limited pharmacy, basic diagnostics and small procedures like suturing. Word of mouth is the most commonly employed tool for marketing. Mainstreaming and expansion of this model is extremely difficult since it is largely person dependent.

2. Practice Association
Continue reading this post…

The Arogyada
www.arogyada.in
April 2, 2014 / by drsandeep.net

Differences between Healthcare Systems of India and the UK

Continuing with our series on comparison of Indian healthcare system with various healthcare systems across the  globe, here are some gross differences.

The Indian healthcare system, though evolved from its colonial roots of the British empire, started with many similarities but has not been able to maintain the strength of its public arm and consequently the private arm has far overtaken and established deep roots in the Indian healthcare scenario.

——–
UK:
A healthy proportion of 9.6% of the GDP is spent towards healthcare expenditure.Public spending contributes to 81.7 percent of overall healthcare expenditure.

India:
4.1% of the GDP is spent on healthcare expenditure while the public spending is as low as 1.2% of the GDP or 26.2% of the total expenditure(2010).

——–
UK:
Healthcare is publicly funded from general taxation, and is free to all permanent residents.There is also a thriving private healthcare sector which is considerably smaller than its public equivalent. The cost of private healthcare is mainly covered via private health insurance.

India:
Majority of healthcare expenses are out of pocket with private sector playing a major role. There is no single universal scheme covering the entire population. Though there are a multitude of health benefit schemes at central and state level for specific sections within the population.


———
UK:
Fifteenth best in Europe and eighteenth in the world (amongst 191 member states in the World Health Report, 2000)

India:
Ranked at 112 in the world (amongst 191 member states in the World Health Report, 2000)

———
UK:
Coordinated care is a norm. For elective care, patient has to visit a General Practitioners (GPs) first who acts as a referral authority for referral to specialists and super-specialists as necessary.

India:
Coordination of care is weak, almost non existent. Anybody can directly approach any specialist or super-specialist without proper referral system in place.

———
UK:
Single holistic health services under National Health Services(NHS) England cover entire spectrum of primary to tertiary healthcare, acute to chronic services and vaccination to adult screening programs.

India:
Multiple centre and state level programs which cover same issues amongst the same set of beneficiaries on one end. For instance, maternal health has schemes such as Janani Shishu Suraksha Karyakram (JSSK), Janani Suraksha Yojna (JSY)  and Indira Gandhi Matritva Sahyog Yojna (IGMSY) running in parallel apart from innumerable schemes in every state. On the other hand there is no focus on other set of health issues like geriatric health.

———
UK:
Pharmacies (other than those within hospitals) are privately owned but have contracts with the NHS to supply prescription drugs. Systematic and only on prescription sale of drugs is the standard practice.

India:
Pharmacies are predominantly privately owned by single owners with no affiliation to public health systems except for licensing
formalities. There is indiscriminate sale of drugs over the counter including antibiotics leading to a very imminent risk of widespread bacterial resistance

The Arogyada
www.arogyada.in
January 17, 2014 / by drsandeep.net

Five Key Challenges for Indian Health Insurance Industry

In the current scenarios Indian health insurance industry can be considered to still be in its infancy. The next few years posit a plethora of challenges. Have highlighted key five areas of concern.

1. Lack of standardised transactions between the insurer and hospitals or the insurer and insured. This often results in individual interpretation and methodology for processes like claims and pre-authorization

2. Use of non-standard terminologies with regards to treatment protocols and care plans. In fact absence or minimal documentation and implementation of standard care pathways become a cause of conflict with regards to services covered/not covered for payment via the insurer. This gets further aggravated with extremely poor usage and implementation of ICD codes

3. Skewed penetration (much higher in urban India than rural) of private health insurers within the Indian population leading to asymmetric distribution of risk. This ultimately on one hand bleeds the insurer, on other hand hits the insured due to higher premiums and finally also the hospitals due to higher rejection rates

4. Non SLA based transactions between hospitals and insurers. Response time and request closure time for crucial transactions like pre-auth filling, pre-auth approval, claim filling, and claim approval is still not a strictly followed dimension.

5. Both hospital and insurer hold sensitive patient data but we are still far from having any form of implementable India specific law or guidelines to protect and securely exchange patient data between two major pillars of healthcare industry

The Arogyada
www.arogyada.in
January 8, 2014 / by drsandeep.net

Can Indian ‘healthcare’ survive a business focused hospital set up?

Working for a hospital I thought it was my karmic duty to insist on price revision as per current industry norms, to impress on consultants to promote utilization of our pharmacy and diagnostics (for better drugs and accurate results for the patients!!) and off course maximum conversion to inpatient services. After all, EBITDA had to be above the red mark to keep the institution viable.

This was until yesterday, when a leading specialist at another leading hospital refused to even go through the previous case sheets of one of my relatives until a costly scan he was suggesting was done at the facility suggested by him. Another revelation in this tryst was that some hospitals now have stop watches in the cabins of consultants so as to double up consultation fee as soon as the management accepted time is up.

I always had a perception that consultants are treated as the final authority in majority of hospitals today. However, this experience of a hospital where consultants are understandably under strict instructions from the management was repellent from a patient perspective.


The same day had more experiences in store. Another famous consultant working for a mid – sized hospital (read mismanaged and unpleasant) attended to my relative with patience, appropriate clinical concern and had no bearing upon where the drugs and investigation came from as long as they were from an authentic source. However I had no answers when I was faced with a question from my relative that why this famous doctor has moved from a five star hospital to this one and not a ladder up may be a seven star hospital?

Contradictions galore, questions remain constant.

Are we headed towards a commercialized Indian Healthcare where patient is at the bottom of the food chain?

How to bring patient in focus for business minded managements?

A questionable change in the patient perception that a star hospital will house best of the consultants and a small hospital will not.

I leave you with this final question to ponder upon:

Can ‘healthcare’ survive a business focused hospital set up?

The Arogyada
www.arogyada.in
August 25, 2013 / by drsandeep.net

Public Private Partnerships in Healthcare : A Win-Win Strategy for all Stakeholders

For developing countries, PPPs can be utilized as a strategic tool to  strengthen healthcare delivery system  and accelerate achievement of healthcare development  goals. Though some critics consider PPP as another catalyst in increasing privatization, but we don’t have paucity of examples to demonstrate the positive impacts of PPPs. Following are some of the points why PPPs are considered as a Win-Win strategy for all the stakeholders.
For the Public: Focused healthcare development initiatives utilizing PPP can result in provision of healthcare services in a better way improving the affordability and accessibility for those sections of society which are in acute need. Outcomes can be expected in a defined span of time.
For the Government: A PPP can enable the government to deliver best value for taxpayer’s money by utilizing the private party’s skills which add to the scope for innovation in the project. In addition to this the private parties bring with them the potential to operate efficiently and effectively. The effects of interventions can be visible in a time bound manner. There is also an added risk control in the project as the private party is an experienced player in handling similar assignments.
For the Private Party: For companies/civil organizations aiming to contribute to the society, this can be one of the channels through which they can help in improving the key development indices which as a result can generate a long drawn impact on future healthcare outcomes of the society. Another incentive for big corporation/companies to enter this kind of engagement is building business at the bottom of the pyramid which can give them competitive edge in terms of knowledge and experience. The base of the pyramid also has some big numbers on it- 4 billion people with per capita income of less than $1500 (Commission on Private Sector and Development, 2004). (India alone has 700 million people in rural markets; whereas China has a billion)

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The Arogyada
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January 3, 2012 / by drsandeep.net

Public Private Partnership – The Roadmap to Equity?

Introduction
According to Asian Development Bank, the term “public-private partnership” describes a range of possible relationships among public and private entities in the context of infrastructure and other services. The public partners in a PPP are government entities, including ministries, departments, municipalities, or state-owned enterprises. The private partners can be local or international and may include businesses or investors with technical or financial expertise relevant to the project. Increasingly, PPPs may also include nongovernment organizations (NGOs) and/or community-based organizations (CBOs) who represent stakeholders directly affected by the project.

The notion of Public Private Partnerships forms an inseparable component of myriad of policies on healthcare delivery at local, national and international levels. The probable reason for the popularity of this category of strategic partnership is its potential to deliver fast results by utilizing the efficiency and accountability of private domain to produce an impact in the public domain.

Increasing importance of Public Private Partnerships in healthcare delivery

Blame it on the lower per capita expenditure on healthcare by the government or preferential access of bigger fraction of population to private healthcare setups, the private healthcare sector is definitely gaining importance in the healthcare delivery system. In monetary terms, the Private Sector contribution to the healthcare sector at ~75 percent is amongst the highest in the world in percentage. Public spending, on the other hand, is amongst the lowest in the world and is ~23 percentage points lower than the global average (KPMG ASSOCHAM, 2011). In quantitative terms, 80 percent of households prefer to use private sector treatment in India for minor illnesses, and 75 percent of households prefer to go to private sector for major illness (Uplekar, Pathania, & Raviglione)

In this prevailing situation, private sector cannot be kept aloof while formulating any public policy on healthcare delivery if you are aiming for a successful policy. The partnership with private sector can be done using different instruments whereby each partner is liable to deliver the terms by legally binding contract(s).

• service contracts
• management contracts
• affermage or lease contracts
• build-operate-transfer (BOT) and similar arrangements
• concessions
• joint ventures

Under the 10th Five Year Plan (2002-2007), initiatives have been taken to define the role of the government, private and voluntary organizations in meeting the growing needs for healthcare services and meeting the goals of National Health Programmes. The National Health Policy of India (2002) and the National Rural Health Mission (NRHM) formulated for the period 2005-2012, takes into consideration the important role played by private players and civil society organizations in meeting the health goals of the country.

Few successful PPP projects are mentioned below (Technopak, 2010):

• Karnataka Karuna Trust; Yashaswini Scheme
• Tamil Nadu Mobile health services
• Andhra Pradesh Aarogyasri
• Andhra Pradesh Diagnostic Services for 4 Medical Colleges
• West Bengal Mobile health services
• Madhya Pradesh Community outreach program
• Rajasthan Contracting in public hospitals
• Gujarat Chiranjeevi Project

Areas where Public Private Partnerships have delivered for achieving Public Health goals 
In the value chain of healthcare, public private partnerships can be used for almost any week link in the chain. Following are some of the areas where public private partnerships have been used (KPMG):

1. Utilizing the Private infrastructure for meeting the objectives of a public health program eg: Gujarat Chiranjeevi Project
2. Strengthening a particular aspect of health service, e.g. Contracting for drug store operation in Sawai Man Singh hospital, Jaipur
3. Providing Insurance in collaboration with Private Insurers, e.g: Rajiv Aarogyasri Health Insurance Scheme in AP between the Government and the New India Assurance Company.
4. Collaboration to develop a technological expertise for public welfare eg: ‘Karnataka Integrated Tele-Medicine and Tele-Health Project (KITTH) by Government of Karnataka, the Naryana Hrudalaya Hospital in Bangalore and the Indian Space Research Organization
5. Management of a Healthcare facility by a civil society organization eg: Karnataka Government and Karuna trust for management of PHCs to serve tribal communities in Gumballi and Sugganahalli
6. Community Outreach eg: Uttaranchal Mobile Hospital and Research Center(UMHRC) between Government of Uttaranchal, Birla Institute of Scientific Research (BISR) and the Technology Information, Forecasting and Assessment Council(TIFAC)
7. Product Development eg: Path Malaria Vaccine Initiative(MVI, 1999), Drugs for Neglected Disease Initiative (DNDi, 2003)

Some Concerns with Public Private Partnerships

Following are some of the pragmatic issues and concerns that are important for the success of Public Private Partnerships

Defining partnerships: The definition of contracts and agreements should be done keeping Public interest and Private stake on an equal platform such that there is no skewing of the agreement for the benefit of any specific party involved. There may be cases of undervaluing an asset to be divested, thereby skewing the deal in favor of the private party.

Conflicts of Interests: A careful attention should be paid to any conflict of interests, both apparent and unapparent. Such personal biases in public decision making are very common. This may lead to preferential choice of one private partner over another, leading to an inferior deal for the government.

Failure to monitor Partnership performance: There can be pitfalls in monitoring the partnerships’ performance from the government’s side which could lead to failure of the scheme or substandard outcomes.

Conclusion
With many examples available in hand, where Public Private Partnerships have performed successfully to fill the gaps in healthcare delivery system to promote equitable delivery of services. Public Private Partnership may not be a sole dependable premise, but it is surely an effective and efficient one.

Works Cited

KPMG ASSOCHAM. (2011). Emerging Trends in Healthcare: A Journey from Bench to Bedside.
KPMG. (n.d.). Public Private Partnerships in India.
Technopak. (2010). “A Peek into the Future of Healthcare: Trends for 2010”.
Uplekar, M., Pathania, V., & Raviglione, M. (n.d.). Private Practioners and Public Health: Week links in Tuberculosis control. The Lancet.
http://www.adb.org/India/PPP/about-definition.asp

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The Arogyada
www.arogyada.in
December 20, 2011 / by drsandeep.net

Five key differences between Indian and US healthcare systems

Just a FYI post to understand the basic differences between Indian and US healthcare system. This kind of comparative study can help us understand the good features and flaws in both the systems.



  1. In India the total expenditure as percentage of GDP is as low as 4-5 %. Whereas in US it is well beyond world standards, as high as 16.2 % of GDP. With highest per capita expenditure in the world US is ranked on 37th position, which indicates that increasing expenditure on healthcare is not the only solution to improve the health status of the citizens. On the other hand, India ranks quite low and stands at 112 which is well below countries like Sri Lanka(76) and Bangladesh (88). 
  2. The Indian Healthcare system can be considered as a Mixed Healthcare System where there is a government health infrastructure which provides healthcare at primary, secondary and tertiary levels. In addition to this there is a strong presence of private healthcare infrastructure which is growing stronger by the day with decline of trust of people in public hospitals. While in US the system is majorly privately funded where the employers are supposed to fund for the employees working with them. There is public funding is available only for unemployed people who cannot afford to purchase health insurance.
  3. Out of the pocket payments account for 70% of healthcare costs in India which warrants a work up on strengthening of financing mechanisms like insurance. On the other hand in US the out of pocket expenditure stands at around 10-12%.
  4. With the perspective of  outcomes, in India the Life expectancy at birth m/f (in years) is 63/66 while that for US is 76/81. Another important factor is Probability of dying under five (per 1000 live births) which indicates the load of infective diseases which affect children and the ability of the healthcare system to deal with them . In India the Probability of dying under five is as high as 66 per 1000 live births while that of US is 8 per 1000 live births.
  5. India has a universal health care system run by the local (state or territorial) governments. Government hospitals provide treatment at taxpayer expense. Most essential drugs are offered free of charge in these hospitals. However, the fact that the government sector is understaffed, underfinanced and that these hospitals maintain very poor standards of hygiene forces many people to visit private medical practitioners.. The United States does not have a universal health care system; it is a proposed reform. The Obama administration health care reform, the Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care and Education Reconciliation Act of 2010, seeks to have near-univesal healthcare insurance coverage to legal residents.
The Arogyada
www.arogyada.in
September 1, 2011 / by drsandeep.net

A Three Headed Monster

My last post was a product of immense frustration i am feeling these days while working as a resident in a trust hospital in Delhi which caters mostly to middle to lower income groups. And i have come across some 12-15 patients, in their middle ages with diabetic nephropathy with CKD stage IV to V in just a period of 2 months of my new job. And the element of surprise is that they were diagnosed to be diabetic only recently after coming in delayed contact with Healthcare. Adding to frustration was – some of them telling me “Sir jub se is hospital mein aaye hein tabhi se yeh sab kuch hua hai … nahi to mein kabhi beemar hee nahi hua !!!“.

I mean…How would you react to such kind of statement ??

Anyways, now that the problem has raised its ugly head, what are the ways available to fix it ?
The answer i get is : “Comprehensive conservative management and initiation of Renal Replacement Therapy”.
Renal Replacement Therapy !!! If i am right that implies :either a dialysis or a transplant.

As we all know Renal Transplant is a rare commodity available only to a lucky few (read lucky as rich).
So in short, how many dialysis can a lower to middle class family afford equates to the amount of life they can buy.

I also feel that each and every step of disease management is restricted by limiting resources especially in India with most of the healthcare bills being paid out of the pocket. Whether the treatment to a ailment is available or not, sometimes seems to be irrelevant.

I am clueless about whom to blame : The Naive attitude of People towards there own health or The Economic System or The Incapability of Medicine as a science !!
Or may be its like a three headed monster trying to eat you and you are trying to figure out which head is smaller…

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The Arogyada
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April 3, 2009 / by drsandeep.net