Policy Health Integration Tops

Sarla Bhargava, a gynecologist with the Madhya Pradesh health services recently quit her job at a community health centre (CHC) in Madhya Pradesh’s Morena district. She had been working at the rural health centre for the last seven years. Now she wants to begin her private practice at the divisional headquarters in Gwalior. She is not the only one to make this career switch; thousands are joining her in this pursuit every year. The mass migration of qualified doctors would, no doubt, boost their personal careers, but if allowed to continue, would deal a serious blow to the National Rural Health Mission (NRHM).

The government needs to fix this high attrition rate, and do it fast. Adding a few thousand MBBS seats is not the answer. The key is to provide reasonably good working conditions to those who are still willing to serve in rural areas. Long festering grievances such as low salary, lack of accommodation, poor safety, and more importantly children’s education and entertainment, need to be addressed. Unfortunately, it has never been sufficiently recognized that the optimal availability of medical personnel, such as doctors, staff nurses, auxiliary mid wives (ANM), operation theatre (OT) technicians and radiographers is pivotal for universal health coverage (UHC). The solution is ‘integration’. UHC will remain a pipedream without sufficient integration of health, both vertically and horizontally. Horizontally it means sanitation, health education to children and adults, nutrition and environment; vertically, it includes primary health centres (PHCs), CHCs, and district hospitals with tertiary care facilities.

Cynicism put aside, the truth is that India can provide for better health to its 1.2 billion children, 85 percent of who do not have med claims. Additional funds will definitely transform health and sanitation infrastructure but first we need to take a hard look at the system which is inept, inefficient and compartmentalizes the whole health scene.

The country today has 380 medical colleges compared to 144 in 1991 churning out 5,000 doctors every year; there is a 650 per cent increase in the number of dentists and nursing colleges have gone up to 3,000 from 200 in 1991. But a proportional increase of skilled man power in rural areas is not visible . The Ambah CHC, where Sarla Bhargava worked, had six doctors against 10 posts, and one staff nurse against five. That’s why ANM (which is basically field staff) is used for labour room and OT work. No doubt, quality suffers. The block is 32 km from district Morena and majority of the villagers are not even aware of the patient transportation ambulance facility provided by NRHM, let alone any existence of referral system .Health for all by 2000 was declared way back in 1977. The goalpost was later shifted to 2020. How prepared we are to meet the future deadline is anyone’s guess. The sight of attendants and out patients packed like sardines in the toilet area of New Delhi’s All India Institute of Medical Sciences (AIIMS) is certainly not a reassuring sign but reflects, instead, on the pain and suffering of millions specially at tertiary care centres.

Here are certain clear cut ideas to improve the mess-

•   Pay substantial rural allowance to doctors and nurses, which would make their take-home salary on better than their urban counterparts.
•   Have a well-laid out and transparent transfer policy for medical personnel working in rural areas so that no doctor/nurse will serve more than seven years of total service tenure in PHC/CHC. Presently, there is no rule, and transfers are driven by bribes and favours. The going rate for a doctor is said to be around Rs three to four lakhs, for a nurse Rs 1 to 1.5 lakhs. The political class is united in making megabucks out of this transfer industry
•   In villages, identify pockets where trained medical personnel have high attrition or absence rate by authorizing panchayats and janpads to hire doctors/ nurses at higher salaries and perks. This market strategy has been successfully tried by China under NRCMCS (new rural cooperation medical care system).
•   Introduce E–health at CHC / DH level and integrate them with higher centres. Telemedicine will not only improve the level of treatment but also boost the confidence of patients. Certainly this step will reduce the avoidable crowding of tertiary centres by rural folk for less serious ailments.
•   Generic medicine introduction (Tamil Nadu model) remains a favorite with the other states, but except Rajasthan and couple of others, no one has tried to emulate the experiment in its true spirit. The vested interests in the purchase departments do everything possible to block the model’s implementation. The quest clearly should be for people who cannot afford private hospitals in India and there are many.