Doctors Under Scanner

Arjimand addresses the recent government intervention in curbing government hired doctors from engaging in a conflict-of-interest by pursuing private practice, and an editorial in the Rising Kashmir provides a word of caution

(Mr. Arjimand Hussain Talib, 34, was born in Srinagar. He is a columnist/writer and a development professional who matriculated from Tyndale Biscoe Memorial School in 1991. He subsequently graduated with a Bachelor's degree in Engineering from Bangalore University and has a diploma in journalism as well. He is an alumni of the International Academy for Leadership, Gummerbach, Germany and has worked with UNESCO, Oxfam and ActionAid International in some seven countries in Asia and Africa. Arjimand writes regular weekly columns for the Greater Kashmir and The Kashmir Times since 2000 on diverse issues of political economy, development, environment and social change and has over 450 published articles to his credit.)

Doctors in Dock
Our doctors are angry and sad this week. A video posted on Facebook has left feathers ruffled. The show of government raids on a few private clinics in Srinagar has ignited a big debate. People are bubbling with questions and counter questions.

So, the big question: did the video documentation and circulation of the raids constitute a breach of dignity and privacy? Can, by the way, we do away with the private practice of our doctors, well paid from public money, altogether?

In this age of openness, video documentation of the matter may not be wrong per se, but, yes, the raid could have been carried out in a more dignified manner. Such raids must also not intimidate the doctor being checked. In the video, the police obstruction of a gentleman doctor looked unnecessary and ugly. Why policemen be part of the exercise at all when the intention is not to arrest?

When it comes to the larger debate on banning of private practice of public-paid doctors, there are issues and issues.

It makes perfect sense for the government to ban private practice of the doctors of the institutions which are supposed to be institutions of excellence and research. The doctors there are handsomely paid. They have been provided the best possible living facilities to enable them discharge their duties. As such, banning their private practice is important because they have big responsibilities to fulfill.

There are some people who believe that if these senior doctors are not available to the people at their private clinics, many people would be deprived of quality medical advice. This is only partly true. Experiences show that if our specialist hospitals are professionally managed (not by doctors themselves but by trained management professionals) quality medical care to all is possible.

When it comes to private clinics, let us remember, specialized doctors’ are not that readily available. A patient, even with a critical illness, normally does not get an appointment within a week’s time from a specialist doctor. That is one reason why patients from Kashmir prefer moving to Delhi or elsewhere, where best of the doctors are normally available either on call or at a one or two days’ notice.

What also remains a burning issue in Kashmir is the non availability of specialist doctors in the emergency units. Normally, the first hour matters a lot in the game of life and death of a patient after arrival his or her at an emergency unit. Our emergency units are almost always manned by newly-recruited or on-training doctors who are generally not trained in performing specialist actions or take speedy decisions. Why can’t our senior doctors be available in emergency units for advice?

But there are other larger questions involved as well. We cannot ignore the fact that our governance dysfunction has made our specialist hospitals like SKIMS something of hybrid institutions – performing multiple roles of basic health care to specialist care. And that is what needs to be corrected.

What also needs to be corrected is the concentration of specialist doctors in Srinagar and also ensure a uniform distribution across districts. Non availability of specialist care outside Srinagar has crippled Srinagar’s specialist hospitals.

What we normally read as a lack of sensitivity among our doctors in government hospitals has also something to do with the massive number of patients they have to attend to. Quite naturally, if a doctor has to see a hundred patients in a span of two to three hours it is impossible for him to retain his humane touch. Large numbers desensitize.

Statistics are grim on that count. SKIMS’ official records say that 2000 patients on an average are received daily at the hospital’s Out Patient Department (OPD). What points to a systemic problem is the fact that at least 1200 patients among them are believed to be treatable at local hospitals, either at Primary Health Centres (PHCs) or district hospitals.

SMHS Hospital’s out-patient department had received around 1.30 lakh patients in 2008.

This also happens because J&K state is said not to have a patient referral policy. In the absence of a referral policy, Srinagar’s specialist hospitals get patients with illnesses which can even be attended to at PHC level.

Then is the development deficit and the petty vote bank politics parts of it, which generally get ignored. Let us understand that there has been a reckless horizontal expansion of health care facilities in our state without the necessary man power and systems in place.

The RHS Bulletin of March 2008, brought out by the Ministry of Health and Family Welfare, Government of India, has some interesting statistics. According to the document, J&K requires 1666 sub-centres; we have 1907 in place. While we need 271 PHCs, we have 375. Similarly, we have 85 Community Health Centres, for an actual requirement of 67.

In comparison, we have only six emergency hospitals for the entire state, for want of which most of our people actually die. We don’t have a dedicated cardiac emergency for 7 million people.

Then look at the manpower deficit. We need 340 specialist doctors at CHCs to have them functional, we have only 135. The number of pediatricians at CHCs is only 17, against a need of 85. We have only 44 physicians at CHCs against a need of 85. Obstetricians & gynecologists at CHCs are only 28 against a requirement of 85.

Disgracing Doctors

Private practice by doctors has always been a sensitive issue in the state more so in the backdrop of its ailing healthcare. The problem is not unique to J&K. Other states too have also grappled with the issue and evolved different means to discourage the practice.

Raiding the private clinics seems to be a universally acceptable method to set a deterrent. Even making a video of a doctor caught at his clinic is acceptable as long as it is just meant to act as evidence, but leaking it on social networking sites is unnecessary and pathetic to say the least. Some days back, the unedited videos of raids carried out on private clinics in Srinagar appeared on social networking sites. By doing so the authorities made a mockery of the exercise. With this ‘reality show approach’, it seems the officials are trying to make heroes out of themselves at the cost of the doctors. In the first place, there was no need to release the videos on internet and even if they deemed it necessary, they could have at least blurred the faces of the doctors. The way the videos were shot also raises questions on the intention of the raiding teams. They have emulated the methods of news channels which thrive on sheer sensationalism to catch the eyeballs. The ‘sting operation style’ used by the officials in the raids seems to have been aimed at getting instant internet fame even if it meant disgracing a doctor. Ironically, while all this tamasha was being shot, the Additional Commissioner Kashmir seemed to be watching as a mere spectator while his PA was calling the shots.

The act has not gone well with the medical fraternity and understandably so. It seems the government has run out of decent methods to tackle the issue of private practice. By parading the doctors as if they were hardcore criminals, the officials seemed to be making a needless publicity stunt. It is still not known whether the raiding teams acted on their own and released the unedited video on internet or was there any direction from the higher ups in this regard. It is also not clear whether there was a deliberate attempt to make some of the doctors scapegoat or was it just ‘first caught first disgraced’ thing. Whatever the case may be, the government is answerable for the whole drama. There is no doubt that people are not happy when doctors indulge in private practice at the cost of patient care in the hospitals.

But the way government has been dealing with the issue does not evoke much hope either. On one hand it wants the doctors serving in other countries to return to the state while on the other hand there is no policy in place to prevent the exodus of medicos. Now with the doctors being humiliated in public, there is prestige issue at stake more than the salary and other things. Furthermore, though a ban is in force, politicians and top government officials seek appointments in private, either for themselves or their relatives. While those who are well connected manage to avoid long queues, those without any connection have to turn to private hospitals in case of emergency. Since the government has been calling healthcare as its priority sector, one would expect it to work responsibly in this regard. However, the irresponsibility shown by the raiding teams runs contrary to this expectation.

Then look at the state of support staff. We require 2282 female multipurpose workers at Sub Centres & PHCs, while as only 1794 are in place. There is a basic requirement of 375 female Health Assistants at our PHCs, only 27 are there. Similarly, against a requirement of 375 male Health Assistants at PHCs only 89 are in place. Similarly, against a need of 970 Nurses/Midwives, only 403 are in place.

This makes it clear that our health sector needs an across-the-board reform. But without political will, that will not be possible.

But I am little cynical if all that can happen in our present political conditions. Our health sector cannot be an island of high efficiency in an overall environment of governance dysfunction. We need across-the-board administrative and political reform – which, first of all, demands our political uncertainty to end.