The problem of access in Healthcare:

Before we delve in the bigger question of access, let’s pause and think about the how and why of people choosing professions. How does one choose or decide what to become?

I feel there are certain professions which are primary – agriculture, teaching, defense and police services, medicine and so on. And then, here are some which are secondary, i.e., those that strengthen or optimise the primary ones, say, IT, press and TV, the civil services and so on. Primary ones, broadly speaking, are the ones essential for survival of civilisations. This division is arbitrary and please feel free to disagree.

Traditionally, the primary services always held sway and were respected. However, now, the primary ones in general, are considered less glamorous and are, in many cases, paid less than the secondary career choices. An average teacher or a farmer earns way less than say an average IT sector worker.

Now coming to the how and why we choose our professions. I, personally, think that the primary driving cause is money. The passion and purpose people attribute to their jobs are secondary, and in most cases, invented to assuage the ego. An average youth wants to join the army for the sake of job security and decent pay and not out of a sense of patriotism or wanting to die for the country defending her borders. That does not mean that the average youth is not patriotic. But you will never see the MP or the MLA pushing his or her child in to the armed forces. I can bet that the percentage of children of our patriotic hyper nationalist elected representatives (across party lines) in the army would be negligible (if not zero). 

The same holds true for a Doctor. Most of them want to specialise and then super specialise so that they can be experts in their sub-sub speciality and rule the roost in corporate hospitals. Is there anything wrong in that?? – NO – not at all. Not by far. Do we honestly think that a super specialist, who spends anywhere between 10-14 years to reach that level, really did that so that he can serve the poor and under privileged in remote districts?  

The need of the vast majority of patients attending our public health facilities (or even the private facilities) are mundane illnesses- ones that require a basic knowledge of medicine and not super specialised skills. An intervention cardiologist would be worse than useless in a PHC set up.

So, let’s think of an MBBS doctor in a PHC. He is one who could not manage a PG seat (so far) or one who is still trying for one and sees this as a stop gap arrangement. I have been in the exact same situation in a remote PC in the tribal Keonjhar district (2000 to 2003). Leave aside the salary structure for a moment - so what does a doctor do there – I mean other than see patients? Who does he talk to, socialise with? Which school do his kids attend? Roads? Electricity? Living quarters?  You have to see the conditions to believe it (and I am not exaggerating here). I am not even alluding to basic health infrastructure, patient transport facilities medication and equipment, nursing support etc. Why would he want to stay there? Trust me - philanthropy wears away pretty fast!

So, you have a situation where the doctors don’t want to stay or make alternate arrangements so that they (unofficially) manage the PHC in shifts. Patients too, naturally, start losing faith and tend to go to higher centres – district hospitals and medical colleges, for their medical problems. This leads to over crowding of tertiary care centres (which are equally short staffed) and a lethargic primary care set up.  

Now here is one solution that can be considered:

Algorithm based syndromic management: This sounds fancy but is a fairly simple and tested principle. Patients, generally, present with symptoms. So, we have standard algorithms for investigations and management of symptoms. Let me explain. If a patient presents with cough of les than 7 days. The treating physician prescribes anti cough medications, anti allergy tablets and if there is fever, a course of antibiotics. Majority of patients get well. The ones who don’t, report back. Now the physician orders a sputum smear Microscopy to diagnose or rule out TB. If the smear results are positive for AFB (TB) at the quality assured Lab, the physician treats for TB. The treatment, under the National TB Control Programme, is fairly simple. Patient is subjected to other investigations as required and is given a set of medicines depending on his or her weight followed by ensuring treatment adherence.

 

So, the advantages of Algorithm based syndromic management are:

1. Chances of human errors are minimised. 
2. The investigations and management are standardised. 
3. Referral criteria are pre-decided. Which means, a vast majority won’t be entertained at the higher centres without proper referral from a lower centre. This frees up the capacity of the tertiary care centres to cater to genuinely serious cases. 
4. And most important (and a bit radical): Do you really need MBBS doctors or specialists for management of these cases?? Think about this. Why can’t a trained para medic (pharmacist, staff nurse and so on) follow the set algorithms and manage cases. They refer to a doctor at a higher centre only when certain criteria are fulfilled.

 There are scores of other suggestions – but that’s for a later day