Crisis in Health Sector

This article is based on editorial “Missing remedies: on West Bengal doctors' strike” which appeared in The Hindu on 17th June 2019. It talks about, inadequacies in India’s healthcare system and suggests a way forward in this context.

The nationwide strike by doctors, which has been triggered by a brutal assault on a resident doctor in West Bengal, indicates a widespread problem of violence against doctors that requires urgent redressal.

Such violence is invariably the result of systemic problems in the healthcare sector in the form of expensive and unaffordable treatment, poor infrastructure, overburdened doctors and poor doctor patient ratio that adversely affects optimal attention to patients which in turn creates trust deficit in doctor patient relationship and paves the way for violence against doctors.

Inadequacies in India’s Healthcare System

• Ailing Public health sector: meagre healthcare budget, overcrowding, long waiting time and the need for multiple visits for investigations and consultations frustrate patients on a daily basis.
• Paucity of Resources: Doctors work in extreme conditions ranging from overcrowded out-patient departments, inadequate staff, medicines and infrastructure.
• Expensive Private Medical Education: increasingly high cost of medical education in the private sector is forcing many students in India to look for cheaper destinations abroad.
  
  • Countries such as China, Russia, Ukraine, Philippines and Nepal have become popular destinations for aspiring doctors as the cost can be less than half of what private institutes charge in India.
  • Expensive medical studies are responsible for dearth of doctors in India as after acquiring studies from abroad they do not prefer to practice their profession in India because of the necessity to clear the exam conducted by the Medical Council of India.
• Overburdened Doctors: Owing to disproportionate Doctor Patient ratio, limited number of doctors, nurses and medical staff have to cater to a large number of patients.

Doctor Patient Ratio

• Studies and Survey reveal that in India, there is one government doctor for every 10,189 people (the World Health Organisation recommends a ratio of 1:1,000) implying a deficit of 6,00,000 doctors.
• The nurse:patient ratio is 1:483, implying a shortage of two million nurses.
• India today needs twice as many doctors as are available, three times as many nurses and four times as many paramedics.

• Unaffordable Treatments: More than 17% of Indian population spends at least 10% of household budgets for health services.
  
  • Catastrophic healthcare related expenditure pushes families into debt, more than 24% households in rural India and 18% of the population in urban areas have met their healthcare expenses through some sort of borrowings.
  • Competition Commission of India report on affordability stated that 50 to 65% of Indians did not have regular access to essential medicines.
• Doctor Patient Relation: The highlighting of errors by doctors, medical staff, and hospitals, as well as corruption among doctors, has further eroded the trust patients have in the medical facilities.
  
  • Trust deficit between doctors and patients is also gradually becoming a concern, with rising violence against doctors.
  • According to the Indian Medical Association (IMA) nearly 75% of doctors in India have faced some form of violence or threat at some point in their careers.

Indian Medical Association

• Indian Medical Association is the only representative, national voluntary organisation of Doctors of Modern Scientific System of Medicine, which looks after the interest of doctors as well as the well being of the community at large.
• Indian Medical Association is founding member of World Medical Association.
• IMA hosted the III World Conference on Medical Education under the joint auspices of W.M.A. and I.M.A. in New Delhi in 1966.

• Ineffective Implementation of Laws: Inspite of having the laws that envisage imprisonment besides recovery of compensation from perpetrators for loss or damage to Medical professionals and property, states are lacking in its effective implementation.
  
  • For example West Bengal has also enacted a law for protection of doctors but due to its poor implementation it has failed to curb the ongoing doctor-patient crisis.

Doctors’ Protection Act in India

At least 19 states — including West Bengal, the epicentre of the protests — have passed what is called the Protection Of Medicare Service Persons And Medicare Service Institutions (Prevention Of Violence And Damage To Property) Act, also known as the Medical Protection Act (MPA).

• Any damage or act of violence against Medicare professionals is an act punishable by law.
• Any damage to the property or the Institution of Medicare service is prohibited.
  
  • Destruction of hospital beds, burning of ambulances, smashing medical stores is punishable by law
• Imprisonment to lawbreakers for a minimum period of 3 years and fine amount of INR 50,000 to be imposed if found guilty.
• Offenders of medical professionals/medical colleges can be cognizable or non cognizable crime depending upon the offences committed.
• Damage to any medical devices and equipment is a punishable offence and offenders are liable to pay twice the amount of the damaged equipment’s cost.

The Act, however, fails to really protect doctors because it features neither in the Indian Penal Code (IPC) nor in the Code of Criminal Procedure (CrPC). This makes it difficult for victims to approach the police for help or the latter to file a complaint against suspects.

Way forward

• Legal protection: Protection provided by the state to doctors needs to be strictly implemented and a Central law to enforce protection should be enacted at the earliest.
  
  • There must be a comprehensive law to deal with violence against healthcare personnel.
• Security Deployment: Medical establishments need to deploy security at their clinics and hospitals.
  
  • Deploy CCTV cameras mandatorily in all emergency areas and record all conversation between doctors and relatives in high-risk medical areas.
• Ethics and Morality: Medical colleges also need to redefine their teaching in terms of knowledge, skill and behaviour by incorporating modules on humanitarian conduct, including etiquette and ethics.
• Unreasonable Expectations: As per an IMA study:
  
  • 90% of patients want doctors to listen to them in great detail during the first consultation.
  • 80.4% patients want the doctor to explain in detail about the drugs, investigations and the treatment.
• The Indian Medical Association (IMA) should help arrive at a solution that can address the concerns of both doctors and patients by instituting better systems to counsel patients and remove unreasonable expectations about treatment outcomes.
• Structural Change: National Health Policy, which commits to raise public expenditure on health to 2.5% of GDP, must pay as much attention to scaling up infrastructure and the capabilities of government hospitals.
• Training and Standard operating procedure: Training resident doctors in effective communication and alternative methods of resolving conflicts and institutionalising standard operating procedure in medical establishments (explaining do’s and don’ts in cases of violence) can help in addressing the issue of violence.
• Destressing Sessions: must be conducted on regular basis in the form of meditation and spiritual activities. As these can help medical staff in coping up with the situations of extreme stress.

What hospitals can do

A standard operating procedure may be developed for such situations like Code Purple, used worldwide to alert medical staff to potential violence. It includes the following measures:

• An announcement on the hospital’s public address system, giving the exact location of violence to disseminate information.
• Security staff to respond immediately and assist, if needed.
  
  • All staff, except that of ICU and OTs, to come to aid and form a human chain around professional under threat.
• Senior member of staff not involved in treatment may try to communicate with the patient’s relatives and try de-escalating the situation.
• Drill should be done every month in all medical establishments.

While providing better safety and security is important, we should also address the underlying factors such as overcrowding, lack of resources, behaviour of frontline service providers and how they should handle cases sympathetically.

Drishti Input

Nationwide strike by doctors over the issue of violence against doctors reflects inadequacies in health care system. Comment