Why is Mumbai abandoning its civic hospitals? #Healthcare


 

 – Rediff.com India News

By deserting public hospitals we are dismantling our public health-care system, says Dr Sanjay Nagral. | Why is Mumbai abandoning its civic hospitals?

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Why is Mumbai abandoning its civic hospitals?

May 09, 2013 10:56 IST

By deserting public hospitals we are dismantling our public health-care system, says Dr Sanjay Nagral.

The recent story of babies with heart defects dying in Mumbai’s [ Images ] civic hospitals while the procurement of a heart-lung machine was delayed is tragic and shocking.

The heart defects in these toddlers were eminently correctable by timely surgery, which not only would have saved lives but also lead to a normal quality of life.

Unlike bypass surgery, which may add a few years to life, surgery for repairing congenital heart defects can translate into a normal healthy life span. Many readers are likely to have dismissed it as yet another chapter in the now familiar media exposes on the crumbling systems in Mumbai’s public hospitals. And we will all soon if we already haven’t forgotten about these babies and their cruel fate.

Mumbai’s civic hospitals boast of some of the oldest and finest cardiac surgery departments in the country. A lot of the early pioneering works in cardiac surgery in India [ Images ] –including the earliest successful heart operations — were performed at KEM Hospital‘s cardiac surgery department. Many of us who have trained in KEM’s surgery department have been beneficiaries of this great legacy.

Even today Mumbai’s civic medical colleges and hospitals are considered amongst the best in the country, both for undergraduate and postgraduate studies. Mumbai’s civic budget for health is one of the highest in the country and the teaching hospitals get a lion’s share of this.

So why is it that the purchase of a lifesaving heart-lung machine gets delayed for so long and it takes a newspaper expose for the authorities to respond?

Is it all about bureaucracy, red tape and indifference of some officials?

It is indeed tempting to think so for this is an easy, simplistic explanation. We can then momentarily feel sad, perhaps a little outraged, rationalise it and go back to the comfort zones of our daily lives. But there is more to it.

And that bit is not about some inefficient civic official, it is about you and me.

Public hospitals in Mumbai were once the heart of health-care in the city. Except for the few super rich who would seek services in a fringe private sector a large majority of the population including the middle class were treated in these hospitals.

Check with your parents and grandparents, and they will tell you this. Over the years a burgeoning private sector started attracting larger and larger sections of the population.

Today most people including the poor seek health care in the private sector which is perceived as ‘efficient’ and of ‘better’ quality. The middle classes have largely abandoned these hospitals and even the poor seek their services only for major illnesses often after being bankrupted in the private sector. Thus, these hospitals have essentially moved out of the imagination of those who shape public opinion.

A majority of the doctors trained in these institutions seek careers abroad or in the private sector. They have largely become training grounds for nourishing the private health- care industry. And finally no bureaucrat or politician now seeks treatment in these institutions, preferring to get their treatment funded at private institutions.

At the Bhabha hospital in Bandra — one of the largest civic peripheral hospitals where I work part time as a surgeon — there is a predictable pattern to patients brought to our casualty with accidents. Those who are well to do will often be whisked away by their family and friends to nearby private hospitals, whereas the poor will continue to be treated with us.

Thus in the bomb blasts of 2006 most of the victims including those with serious injuries were transferred to private hospitals since they were from the first class compartment. In the previous year’s riots and floods we managed the victims.

Many years ago when I was at KEM I would treat a large number of friends and their family; people like you and me. Now I treat a large number of maids and drivers of friends at Bhabha, whilst I treat their employers in the private hospitals I work with.

A few years ago when a senior journalist friend chose to get himself operated at Bhabha a large number of common friends expressed surprise and even admiration for his act of ‘courage’.

In a subconscious collective act we have abandoned these institutions to those ‘others’ who inhabit a different space, who have no voice, clout or energy to fight the battle for decent health-care.

The parents of the kids fortunate to have their hearts fixed may thank the newspaper and the journalist who broke, and followed up the story. The act of getting a few private hospitals to do the pending cases is but only a temporary solution.

Even worse, it strengthens the belief that such care can only be provided in the private sector. Some of the private hospitals will seize the moment to actually market themselves.

The specific reason for the delay in sanctioning the heart-lung machines could have been a slowly moving file, an indifferent official or even a lack of follow-up from the departments concerned. But each time a life-saving ventilator doesn’t work, a CT scan is not available for a young man who has fallen off a train and a young pregnant woman dies, as she is transported from hospital to hospital in ramshackle ambulances, a media story cannot correct the problem.

Unless we realise that by abandoning these hospitals we are complicit in the process of dismantling our public health-care system. Whether we like it or not, at some stage in our lives we need the services of public hospitals; what if you are knocked down on the road and carried by passersby to the nearest public facility?

The heart-lung machines have probably been temporarily procured and unlike the unfortunate ones who died, some of the kids will now live to tell the tale of the holes in their hearts. Many years later when they grow up will there still be a long queue for poor kids born with heart defects?

Their fate is inextricably linked with the value we give to the development of an efficient public health system. And that in turn will be determined by whether we relate to our civic hospitals as our own and are outraged by its inadequacies and indifference.

The holes in the babies’s hearts is currently a gap in our collective minds.

Dr Sanjay Nagral is a consultant surgeon, department of surgical gastroenterology, Jaslok Hospital and Research Centre, Mumbai. Photograph: Sahil Salvi

Dr Sanjay Nagral in Mumbai

 

Private health providers are NOT more efficient, accountable or medically effective #healthcare


POSTED BY ANNA MARRIOTT ON MAR 28TH, 2013 globalhealthcheck.com
 
 

In 2009 Oxfam published “Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries,” to help redress what we saw as an international health discourse increasingly dominated by unchallenged private sector advocates.  Some of those same advocates accused Oxfam of being purposefully selective with the evidence.

The health team at Oxfam were therefore very pleased to see the recent publication of a thorough and balanced independent appraisal of peer-reviewed evidence on this topic in PloS Medicine. The study supports many (not all) of our conclusions about both the public and private sector.

In their research Basu et al. assess the comparative performance of the private and public sectors in health across a range of health system performance areas. They are clear that comparative evidence is often lacking and that distinctions between what is public and private are often difficult (for example when public facilities act more like commercial operators by charging fees). With these limitations acknowledged, the authors’ own conclusion states:

‘Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients’.   

Like Oxfam, the authors of this comparative study make special note of the World Bank as an influential advocate of public-private partnerships in health, but one whose claims are often unsubstantiated by their own data. The authors raise concerns about a conflict of interest for the World Bank that may undermine the validity of their research and analysis on this topic.

Some highlights from the paper are listed below (though I recommend reading this important article in full – especially for interesting country examples):

Access and responsiveness

  • A significant proportion of services in some developing countries are provided by the private sector but figures vary enormously by country and by income level. When informal or unlicensed providers are excluded, the public sector provided the majority of care in 19 out of 22 low- and middle-income countries for which World Bank data is available.  
  • Studies that measured utilization by income levels tended to find the private sector predominately serves the more affluent. In Colombo, Sri Lanka, where a universal public health service exists, the private sector provided 72% of childhood immunisations for the wealthiest, but only 3% for the poorest.
  • Waiting times are consistently reported to be shorter in private facilities and a number of studies found better hospitality, cleanliness and courtesy and availability of staff in the private sector.

Quality

  • Available studies find diagnostic accuracy, adherence to medical management standards and prescription practices are worse in the private sector.
  • Prescribing subtherapeutic doses, failure to provide oral rehydration salts, and prescribing of unnecessary antibiotics were more likely in the private sector, although there were exceptions.
  • Higher rates of potentially unnecessary procedures, particularly C-sections, were reported at private facilities. In South Africa for example, 62% of women delivering in the private sector had C-sections, compared with 18% in the public sector.
  • Two country studies found a lack of drug availability and service provision at public facilities, while surveys of patients’ perceptions on care quality in the public and private sector provided mixed results.

Patient outcomes

  • Public sector provision was associated with higher rates of treatment success for tuberculosis and HIV as well as vaccination. In South Korea for example, TB treatment success rates were 52% in private and 80% in public clinics. Similar figures were found for HIV treatment in Botswana.

Accountability, transparency and regulation

  • While national statistics collected from public sector clinics vary considerably in quality, private healthcare systems tended to lack published data on outcomes altogether. Public-private partnerships also lacked data.
  • Several reports observed significant public spending being used to regulate the private sector in order to improve patient care quality, and with limited effectiveness.

Fairness and equity

  • Financial barriers to care exist in the public and private sector.
  • Private sector services tend to cater for higher income groups with studies showing exclusion and discrimination against poorer patients and women.
  • Several studies suggested the process of privatizing existing public services increased inequalities in the distribution of services.
  • Private contracting and social franchises showed potential for reaching impoverished groups, though findings are tentative because comparisons to the public sector are unavailable.

Efficiency

  • Contrary to prevailing assumptions, the private sector appeared to have lower efficiency than the public sector, resulting from higher drug costs, perverse incentives for unnecessary testing and treatment, greater risks of complications, and weak regulation.
  • The evidence is mixed (and often weak) on the cost of contracting to private providers – increasing expenditure in some countries whilst reducing it in others.

Other important findings

  • Rather than adding resources, several studies reported that growth of the private healthcare sector, whether independently or via public-private partnerships, directly reduced public funds and staff available for public provision.

And on the World Bank….

  • The World Bank has made strong claims that investing in public-private partnerships will improve efficiency and effectiveness in the health sector, yet several of its publications revealed that these assertions were either unsupported by data or the data was not provided in sufficient detail to pass minimal inclusion criteria for this review’.
  • Despite the lack of data about private sector performance, recent initiatives by the World Bank’s International Finance Committee (IFC) are underwriting the expansion of private sector services among low- and middle-income countries. For example in sub-Saharan Africa, the IFC has created a private equity fund to make 30 long-term investments in private health companies. These conflicts of interest pose a potential threat to the validity of World Bank-sponsored studies and raise the need for independent scrutiny.

The evidence from this study shows that while public health systems are often weak and under-resourced they still deliver better quality of care, more equitably and with greater efficiency than the private sector.  The study highlights the tendencies of private providers to serve higher socio-economic groups, have higher risk of low-quality care, create perverse incentives for unnecessary testing and treatment, and suffer from weak regulation. It also suggests there are a number of ways public health systems can do better.  They must be more responsive to patients and more accountable to citizens, improve systems for distributing essential inputs like medicines, and address financial barriers to accessing care (such as formal and informal fees).

These are legitimate challenges that deserve thoughtful attention and action, but they should not be used as evidence of the superiority of private sector approaches. Instead, the policy response to these findings should be very clear: far more effort and resources must be mobilized to maximize the clear advantages of public health systems, rather than further starving them of the resources and support they need to deliver equitable and quality health care for all.

 

Jan Swasthya Abhiyan (JSA) campaigns against outsourcing of diagnostic centres #Chhattisgarh


TNN | Feb 1, 2013, 03.04 AM IST

RAIPUR: Jan Swasthya Abhiyan,  today started a campaign against the proposed move of the government to outsource diagnostic centres at 379 public health facilities in the state. A public meeting was also held to show discontent with the decision.Talking to TOI, Sulakshna, member of JSA, said that instead of improving and expanding services in the existing system, the government is replacing it with private service providers. “What is disheartening is that the Raman Singh government has taken no lessons from other states where privatisation in this sector flopped,” she added.

Some senior officials in the state also agree that the government seems to be in a haste to privatise the service. They admit that flaws do exist in the system, the biggest being that privatisation would not solve the problem of understaffing. “How will the private sector get qualified staff in Bastar when the government cannot get it on their own,” one of them said.Experts say that unless and until checks and balances are put in place and they are implemented in letter and spirit, the move is bound to backfire. Moreover quality and not the quantity of the tests conducted should be the criteria and the same has to be monitored on day to day basis, a difficult proposition in the present scenario.A senior official commented that merely putting tough conditions on the contract paper will not resolve the problem. “What is required is monitoring, which is a difficult task”, he said.

 

#India- Acute shortage of mental health care staff #humanresources


      SPECIAL CORRESPONDENT, The Hindu Jan 14, 2013

India faces an acute shortage of mental health care professionals, including psychiatrists, considering the high prevalence of mental health disorders.

Studies suggest that approximately 13 per cent of the entire population may actually be suffering from some kind of mental disorder — 10 per cent with minor ailments such as stress, anxiety and depression while the remaining with serious disorders such as schizophrenia. Alcoholism and psychotropic addiction are also included in this.

According to a Mental Health Survey carried out by the Directorate General of Health Services in 2002, there were only about 2,219 psychiatrists in the country, against the required 9,696. The number of clinical psychologists was 343, against the desired 13,259. Similarly, psycho-social workers available were only 290, against the required 19,064, while the number of psychiatric nurses was not available, though over 4,000 such trained nurses were required then. Also, while there were about 21,000 beds for mental health patients in the government sector, the number was just about 5,100 in the private sector.

The country has 43 government mental health facilities, though a huge number of private facilities, known as psychiatric nursing homes, have come up. Delhi alone has 16 such facilities. The State governments are authorised to register these private facilities.

The number of psychiatrists and nurses may have marginally gone up since then and the number of patients too would have gone up substantially.

“I think we need to address mental health issues, both by addressing demand for and supply of services, and by services I mean evidence-based medical and psycho-social interventions that can address a wide range of mental health problems, including their prevention,” said Dr. Vikram Patel, eminent mental health expert and Professor, London School of Hygiene and Tropical Medicine.

This required multiple actions, from awareness building in communities and in the health workforce, to the creation of new community-based human resources skilled in providing psycho-social interventions and building capacity of primary health workers for delivery of medical interventions, he told The Hindu.

There is a huge debate going on in the country over the nature of treatment that must be provided to people with mental disorders. While a majority believes it should be home and community based — considering the condition of mental homes and public facilities — there are others who believe institutional care is also required, particularly for women, as people with mental health issues are often disowned by families and hence vulnerable to exploitation.

 

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