PART- 1
Why is our health care ailing amidst claims of improving economy and healthcare reforms? Is Healthcare optimum in India? Public health is a national investment, not a business. Here’s a question that’s been on my mind and perhaps yours: Is our healthcare system accessible, affordable, dysfunctional, or broken? The simple answer is ‘no’ to all. Below are some of the most convincing arguments I’ve heard that our system needs a major overhaul. And that’s just the tip of the iceberg.
If you’re one of the patients in low- and middle-income countries like India and you fall sick, you need to see a doctor. What do you do? Private hospital may not treat you free unless you are empanelled under PMJay, CS (MA)/ CGHS scheme. With affordability issues you go to a public hospital, crowded, overburdened with patient overload but there is a chance that the doctors themselves are missing to see you in timeline of triage you deserve, and you might have to wait for hours together in a queue or sitting on floor awaiting your turn, missing your day’s earnings. In these hospitals, your concerns will be addressed by the doctor in less than five and a half minutes, and your medical history is unlikely to be taken, leaving you with many unanswered inquiries about your care plan.
With a prescription, you can go to a hospital pharmacy, Jan Aushadhi Kendra, or private pharmacy. Your prescription may contain the generic name or the brand name of the medicine. If it’s a brand, then the pharmacy will give you the exact same expensive medicine as is prescribed. If it is a generic medicine, your pharmacist can choose the medicine for you. Depending upon your disease, these costs can be between manageable to monumental, and all borne by you. Indians pay more money out of their pockets than some of the poorest countries in the world for availing healthcare. As is infamously quoted, India’s Out-Of-Pocket-Expenditure (OOPE) for health is still one of the highest in the world though it declined from 62.6% in 2014-15 to 47.1% in 2019-20. The question, then, is, why a country lauded as the ‘Pharmacist of the World’ makes healthcare so unaffordable for its residents?
Is our healthcare system optimal?
Quality is -Doing the right thing right the first time, doing it better the next time in all time. Our health-care system definitely is not the envy of the world, as it faces serious challenges of accessibility, affordability, and accountability. Public dissatisfaction is steadily increasing and concerns regarding the safety environment and costs of care inside and outside Hospitals are rising rapidly. With the trending influx of visiting Non-resident practitioners and opening of branded Health care outlets in the valley, there are serious concerns regarding J&K’s credentialing and privileges policy on, who is doing what? And, how can such a system be made safer? How can we preserve the strengths of our current system while correcting its weaknesses”? World’s leading health-care scholars answer these questions in three words, ‘Healthy, Wealthy, and Wise’.
Healthcare at crossroads
We have excellent Specialists of International repute, hardworking paramedics and genuinely at some places we may be having shortage in machines and diagnostic aids of international standard but unfortunately when it comes to the ultimate goal of health care, “patient satisfaction”, and “quality” the shadow of accusation is there. We all know machines don’t give satisfaction and “standard output” as it is the man behind the machine who matters. Is it a bad manifestation of the existing system, or an individual’s attitude problem, or growing commercialization in the noble profession? Alas! Pending answers & solutions on this issue, a delicate mutual trust which existed in this noble profession has been lost. How early it can be reclaimed depends on how sooner we all realize our collective and individual responsibility in this hierarchy from “top to bottom” or behave as responsible citizens to resolve issues and misperceptions involved on both sides.
Errors in healthcare delivery were occurring long before and shall continue to occur everywhere in the world till medicine is practiced. We all agree that there are genuine pitfalls in the existing system of medical practice, as no system is ever perfect. When there is a problem, we are angry (which is often), by human nature we need to release our tension. Typically, we do so by blaming someone, generally picking on the most obvious person/s, and shame him or her/them by assigning blame. Where the real outcomes of the healthcare system must be achieved, Structural “quick fixes” of actions like the present model of quick enquiry with report awaited may be an administrative punitive step but in reality, does not change much on the front lines of health care delivery since basic flaws, deficiencies remain unaddressed.
Sadly, our focus has been mostly on managing the crisis “du jour” and we keep repeating the same old patterns. It may be not too late for the concerned authority to shift from their traditional damage control strategy of blaming the health care provider, but it is not too late to shift course when it comes to implementing or defining the word “accountability” as “Continuous Quality Improvement” – in the system. The truth is that our present health system is still addicted to the mental blinder “the illusion of control.” You can’t be accountable for anything over which you have no control. Accountability requires clarity about who is accountable to whom for what for their decisions and performance.
A best practice accountability is a written policy and must be a fair business bargain. It is a personal promise to achieve measurable results, it should be as a written policy procedure in every hospital, and every health care provider has to be well versed with it as is practiced outside. But health workers can’t keep their promises if circumstances beyond their control change. That makes sense, doesn’t it? If any officer is being held accountable for an outcome that can only be achieved if a certain barrier is removed – such as the lack of a skills development program, or the lack of manpower, equipment or technology, and nobody removes the barrier? How can an administrator possibly deliver on that promise if he or she is not given the support required to succeed?
If any administrator or HOD is being held accountable for improving the system, and the provincial government is engaged in bureaucratic notches, how can the administrative officers be held accountable for the results that such an atmosphere will produce? What is expected from a CEO, to improve outcomes with the mutual cooperation of his own organizations’ staff as an integrated team from the processes of KPIS (key performance indicators) they put in place to achieve measurable results.
Unfortunately the real focus of the existing system is on the rules, regulations and bureaucratic processes not on achieving improved KPIs. Though accountability and stewardship for the organization belongs to every healthcare employee, these KPIS must be understood and adjusted regularly to reflect new realities as they emerge in a constantly changing environment. The staff must also have the necessary resources, conditions, and skills to achieve the outcomes for which they are being held accountable. Is that not a reasonable “fair business bargain”?
We need to ensure that we all are working synergistically within our organizations and with all parts of the system and society, so that ultimate and real beneficiary of all this exercise is the patient himself and the onus is on public in making the hospital atmosphere conducive for delivery of quality and safe health care.
I haven’t met many patients or professionals who think our current healthcare system is great. The question going forward is whether there will be will, and vision necessary to build something better. It won’t be easy, but the alternative — continuing to complain while waiting for the system to implode — is unacceptable.
Our bottom-line message is to improvise on health care. The existing concept and the process of accountability in health care needs to be fundamentally redefined or restructured towards Continuous Quality Improvement. ‘A Call to Action’ is thought-provoking policy and ultimately a hopeful challenge to establish a true and sustainable health care system. I strongly recommend this to anyone interested in one of the biggest issues facing the UT both today and in the future.
(To be concluded….)
(The Author is a Healthcare policy planning & Quality Assurance expert, served as Chapter leader for Joint commission for Accreditation of hospitals, can be reached at [email protected])
