‘Young doctors don’t want to go to rural areas because they feel ill-equipped’
Every aspect of health care - prevention, diagnosis, therapy, rehabilitation, palliation – is unaffordable for a poor person. Even if some of these services are provided free under national or state health programmes, barriers to access and variable coverage of health services prevent the poor from benefitingUpdated: Sep 12, 2016 14:44 IST
Recently, there has been several reports on India’s comatose public health system: From a man in Orissa carrying his wife’s body because he was denied a mortuary van to a hospital in Rajasthan where patients are forced to sit outside the hospital and hang their IV bottles from nails hammered into tree trunks, the situation is dismal.
In an interview with HT, president of the Public Health Foundation of India Dr K Srinath Reddy speaks on what ails the public health system and what needs to be done to fix it.
HT: India’s public health system is in a shambles..
KSR: Media reports capture only a few tragedies. Several go unreported. Rural and urban poor as well as tribals are the worst victims of a health system that does not assure universal access, affordability and quality. Even the middle class is not assured of good quality care, even if they incur high out-of-pocket expenditure. The primary health care services are in a state of neglect. Apart from structural health system deficiencies, apathy and even dehumanisation among health care providers makes the poor voiceless victims of an uncaring system.
HT: How does the lack of a strong public health system impact a poor person economically?
Every aspect of health care - prevention, diagnosis, therapy, rehabilitation, palliation – is unaffordable for a poor person. Even if some of these services are provided free under national or state health programmes, barriers to access and variable coverage of health services prevent the poor from benefiting.
Many of the ailments are preventable or can be treated early in primary care. When that does not happen, costly advanced medical care becomes an economic burden. In addition, loss of wages of the ill person and family care givers compounds the financial strain.
The fact that over 50 million Indians are pushed in to poverty each year due to unaffordable health care costs is a grim reminder of the toll that an inequitable and inefficient health system extracts from the most vulnerable sections of our society.
HT: If the State is unable to handle the public health challenges, what is the solution? Involving private players?
KSR: In India, a mixed health system has evolved by default. This is loosely governed and inadequately regulated. We have to optimally engage all our societal resources - in public, private and voluntary sectors - to provide universally accessible, affordable and appropriate health services to all citizens. This can only be done when all categories of health care providers are methodically integrated in to a well designed and efficiently coordinated framework of Universal Health Coverage (UHC).
Primary health care has to be comprehensive, continuous and connected to referral services. It cannot be parcelled off as a separate piece in a laissez faire fashion.
The big question is will the designated provider deliver quality primary care without imposing a financial burden on any individual or family?
Such an assurance will only be derived when UHC defines the deliverables and sets terms of accountability for all categories of providers . We cannot afford fragmented responses driven by expediency. They will cost us heavily in the long run.
Building a strong and sustainable health system is an inescapable imperative for any enlightened government that is committed to promote, preserve and protect people’s health.
HT: Young doctors don’t want to go and serve in rural areas. How can this trend be reversed?
KSR: Young doctors are mostly trained in medically sophisticated, highly urban, tertiary care institutions. Both in terms of acquired skills and cultural affinity, they are alienated from the rural environment and feel ill-equipped to deal with the health challenges and resource constrained environment of basic health care facilities. We need to develop our district hospitals as major training centres for medical and nursing students, with both downstream exposure to primary health systems and upstream exposure to tertiary care.
The practical training has to be mostly location-based in district and sub-district health systems. Further, the government should provide free or heavily subsidised education to locally enrolled students from that state, with conditionality of service for four years after graduation.
During this service, they can be sponsored for distance education in public health degree or diploma programmes so that they have an academic incentive and will also gain knowledge that will be useful in implementation of national health programmes.
Local recruitment in to medical colleges aids local retention, as documented in many countries. Even in existing medical colleges, a larger portion of the practical training must move to primary and secondary care settings in the district of their location.
In addition, government should also consider offering rural re-employment for recently retired government doctors, many of who are still physically fit and have acquired the experience of working in challenging environments.