Healing a sick healthcare system

1

1 Introduction

There is a well known story in mythology of Bali Raja andBatu Waman. Bali Raja was a noble king but Asur-a lower cast-ruling part of the country which is now known as ‘Kerala’. He was agreat, wise king and with his strength and intelligence not onlyconquered the earth round his kingdom but even invaded thekingdom of god. The king of gods, Lord Indra, was frightened thatone day Bali Raja will conquer the entire kingdom of gods i.e.‘swarga’. Therefore, he went to Lord Vishnu with an appeal toprotect the gods from the might of Bali Raja. Lord Vishnu agreeingto protect the gods, took the form of a Batu Waman. i.e. smallbrahmin priest and went to Bali Raja. Bali Raja asked him what hewanted and Batu Waman requested him to give him merely threesteps worth of land. Even though Bali Raja knew the trap, hereadily agreed and Batu Waman grew into a huge giant figure andwith his one step conquered the whole earth and swarga. The nextstep he kept on ‘narak’ and asked Bali Raja where to keep his thirdstep. Bali Raja promptly asked him to step on his head and thusBatu waman pushed Bali Raja into the ‘narak’. But because he wasa really benevolent king. he was allowed to revisit his Praja once ayear. To this date the people of Kerala celebrate ‘Onam’ towelcome their king and show him that they are happy.

I do not particularly like the philosophy underlying this storybecause Bali Raja was not an evil king. His only fault, if it can becalled so, was that he was not from higher caste or from amonggods. Today we cannot easily accept this philosophy of protectingthe haves, even if the have nots are capable of rising above the‘haves’. But I have been narrating this story for another reason tomany of my students, to compare the three steps of Batu Wamanto the three questions in clinical practice which encompass theentire field of medicine. The practicing doctor needs to answer onlythree questions.

2 Management of the Sick Health-Care System 3

Health–care-system is a very complex system. It is asystem in which any person with any perceived illness seeksmedical assistance to get rid of his illness, even if the perceivedillness is false, in the sense that it may not be a true organicillness. The primary needs of the individual are food, clothing andshelter. Health and education come next in order. Food, clothingand shelter are considered most essential for the survival of anindividual. Yet every need under these heads cannot beconsidered as essential. While rice, chapatti and dal maybeconsidered most essential, the same cannot be said about‘pickles’, ‘papad’ and ‘pista’, ‘badam’ and such dry fruits couldlegitimately be considered as luxuries. Kashmiri chicken in fivestar hotel certainly cannot be called a necessity. Same is trueabout clothing. While shirt and pant or ‘saree’ can be consideredas most essential, designer shirt or silk saree would come underitems of luxuries. Most people do not realize that all the health-care needs are not necessarily essential or vital for the survivalof an individual. There are some essential services but there areother services which can be called desirable but not absolutelyessential and yet other services accepted by the society couldeasily come under the term of luxuries. Most of the cosmeticsurgeries belong to this last category. Even many of the so calledpreventive measures for long life such as use of a particular oilin food could also be considered as not essential, if not luxuries.Therefore, one has to realize that in health–care–system, thereare essential services, there are desirable services and there aremedical services which can be termed as luxuries.

In actual clinical practice the health professional is not justa man of science. There is an admixture of art and science andcommerce in the actual clinical practice. Also there are three tiersin the services provided under health-care system. Primary

2 The PresentScenario

1) what is the diagnosis?2) what is the management? (includes investigations and

treatment) and3) what is the prognosis?

Prognosis means the ability to predict what may happen infuture if the disease is allowed to progress without treatment oreven if it is treated as per his advice what are the consequencesthat the patient may face in future. In short, he should be able toclarify all the doubts and questions that a patient has in mind aboutthe course of disease. This prediction is not based on conjecture orastrology but has to be based on sound knowledge about thecourse of disease and the effectiveness of the treatment. Theentire medical practice thus depends on the ability of the doctor toanswer these three simple questions – simple questions whichassume gigantic proportions, like the gigantic steps of BatuWaman. In the same way when I look at any social problem, I liketo know what is the diagnosis i.e. what exactly is the societysuffering from? Therefore, what will be the steps required toimprove the condition of the society and actually whether it willhave any long lasting positive effects or will it prove to be a shortterm remedy and the sufferings will return in the same form or insome other form to trouble the society? Before we look at theproblems in health-care system and how to solve them, it isnecessary to know the present situation in this system. Therefore,let us first look at structure and functions of the medical system asis prevalent at present. I am not a historian nor a great scholar togo through the system of medical practice through the ages. Dr.Udwadia has written a beautiful book on how the medical practicehas evolved in every part of the word from about 5000 years backreaching to the present–day–system of medical practice. I haveonly observed and given thought to the medical system as I saw itfrom the first day of my entry in the medical college in 1951 tilltoday for the last 60 years and I propose to restrict myself to theseyears and propose to suggest some remedial measures which Ithink are necessary to improve the medical practice in the country,so that every one from the poorest to the richest can get thetreatment he or she deserves.

4 Management of the Sick Health-Care System 5The Present Scenario

health care service which is offered in the dispensaries andprimary health centres usually by a single doctor. These doctorstreat the patients who come to the dispensary for theirelementary diseases. The patients are not admitted in theseprimary health-care centres. These doctors also treat the peopleto prevent diseases. Preventive medicine has become a veryimportant aspect of the management at the primary health level.Immunization, Vaccination, Counselling during the pregnancy,Advice on diet and Hygiene for the family are all essential partsof the primary health care of the society. Thus, primary healthcare is one of the most essential health care services needed bythe society. Yet this is the most elementary aspect of the healthcare and needs very simple equipments, investigations andsimple medicines. The doctors in these primary centres need tohave patience, a lot of sympathy and a great ability to discernbetween simple and major illness. Thus, there is a lot of art andsome science at this level. ‘Medicine is an art’ applies particularlyto this primary health-care system.

At the other end of the spectrum are extremely seriouspatients who are at a risk of losing their lives or at the risk ofbeing crippled. The medical science has progressed a lot andmany of such illnesses can be treated effectively now-a-days.Some patients can be cured and life of many others can beprolonged or made comfortable. But all this cannot be donewithout profound knowledge of the science of medicine and manyhigh-tech equipments and sometimes use of newer drugs whichcould be quite costly. In short, the management of seriousorganic disease requires use of modern equipments andmedicines and the profound scientific knowledge of the body–systems involved in the disease. Science plays a very major roleand the art of medicine is often sacrificed by the specialists whooffer these services. These medical services are offered only attertiary medical centres. They cost a lot and can be managedonly by expert consultants / specialists and super specialists.

All the intermediate groups of diseases i.e. those whichcannot be treated in dispensary or at home and yet are not soserious as mentioned above are all treated at the secondary levelof the health-care-system. Nursing homes, private hospitals orTaluka and District level hospitals in the public sector offer theseservices. Standard equipments and standard drugs are mostly

sufficient and the medical professionals are specialists of basiclevel or general specialists. A good admixture of art and scienceis needed at these centres to satisfy the patients.

Apart from these, there are plenty of ailments for which thepatients seek the medical advice. Due to the modern pace in lifethere is an immense increase in the psycho-somatic disorders.The real ailment is 'tension or stress' but this emotionalimbalance is manifested in bodily illness. Some of these psycho-somatic illnesses turn into organic diseases but many of themremain non-organic in nature. Headache, backache, inability towork, flatulence (gases) and many such vague symptoms areinstances of psycho-somatic diseases without any organicchanges in the body. Diabetes, hyper tension, heart disease etc.are also phycho-somatic diseases but they cause organicchanges in the body and, therefore, become organic diseasesrequiring major treatment. The first type i.e. non organic type ofpsycho-somatic illness needs more of psychological treatmentwhile even in the second type, psychological treatment couldhelp a lot. In addition there are many ‘imagined’ illnesses. Allthese except the organic diseases mentioned above could becalled as ‘non essential’ health care needs. Lot of art is requiredin treating these diseases. But a lot of commerce also enters intothis field and even the patients are willing to spend exorbitantlyfor getting rid of their ‘non-essential’ diseases.

Medical professionals are not saints and they have enteredthe profession specifically to earn. They belong to a relativelymore intelligent strata of society and are highly educated.Therefore, their expectation of earning is also legitimately high.This legitimate demand of the medical professionals cannot betermed as commercialization and the society must learn toaccept it as due compensation for the service rendered.Therefore, commerce enters into the field of medicine at alllevels. Commerce enters in the medical field from the primarylevel to the tertiary level and is most conspicuous in themanagement of the psychosomatic illnesses mentioned above.For the clinical practitioners, at any level, a fine balance has tobe achieved between art, science and commerce so that thehealth professionals are not denied their legitimate dues while atthe same time, they are not allowed to commercially exploit thepatients who are too anxious to get well. There is no doubt,


illegitimate demands are raised by some doctors and suchdemands must be termed as ‘over commercialization’. This over-commercialization needs to be curbed.

There are many systems of medicine practicedsimultaneously in every part of our country. Ayurvedic system ofmedicine is the most ancient system in the country and isrespected by the masses even today. Hence, it is recognized bystate as well as central government and plenty of Ayurvedicmedical colleges churn out a lot of Ayurvedic practitioners. Evenin this system there are general practioners and specialists.Same is true about Unani system. Started nearly 1500 years agoin the middle east, it is more popular among Muslims and isrecognized by the governments. Homeopathy came in muchlater. First founded in Germany, Homeopathy became rapidlypopular all over the world, as also in India and is now recognizedas a system of medicine like the other two faculties. Each of themis governed by their own medical council and each separatelyregister their practitioners. Knowing the importance of Allopathyas a more scientific system or, at any rate, the presently mostpracticed system, all the above faculties have incorporated someelements of allopathy in their training course. Even if it happensto be very inadequate, it offers their practitioners a legal right topractice allopathy simultaneously though they are not registerednor governed by allopathy State or Indian Medical Council.

Indian Medical Council was established at the centre inorder to establish a standard of education in the allopathicsystem. The council is expected not only to prescribe andmaintain the standard of medical education but is also expectedto oversee and regulate the functioning of the practitioners ofallopathy in India. In order to do so, the council had to firstprescribe the standard of education and prepare the curriculumfor various courses for graduation and post-graduation. Thecouncil then had to define the exact role, the health-careprofessionals are expected to play. Every practitioner, therefore,must register under the Indain Medical Council.

But the council has the most insufficient infrastructureamounting to almost nil to actually supervise the conduct of theirhealth-care-workers. Broadly the council depends on complaintsby their associates or by the public at large individually or throughgovernment channels and then decides whether the person

actually is maintaining the standard or not. Even if the councilfinds the behavior of the doctor sub-standard, it has very limitedpowers. It can either warn the doctor or de-register him. Once aperson is de-registered, he or she cannot practice in theallopathic system of medicine. But the legal system of the countryis so peculiar that once de-registered that person no longer is aqualified doctor coming under the ambit of the medical council.Therefore, for any malpractice, if he continues to do so, thecouncil cannot deal with him as he is no longer a member of itsbody! Only the department of law and the police under them candeal with such culprits and take necessary action against them.The council is helpless. With meager knowledge of theregulations under which the doctor is supposed to practice andwith such over-burden of duties to maintain the law and order inthe society, it is no wonder that the police also take no action andvarious doctors who are de-registered by the council or spurious(unqualified) doctors are practicing in the country in abundance.The results for the society are obviously disastrous.

Thus, it will be realized that the structure of the health-caresystem in India is haphazard. There is no clear-cut pattern in thehealth care system in the country. Different categories of doctorspracticing their own systems of medicines-allopathy,homeopathy, ayurvedic, unani and what not-all practice in theirown way without the control of the government and without anyco-ordination among them. The government has formed bodiesto control the practice of the doctors in each of their specialsystems separately, Thus, just as the Medical Council of Indiawas formed to regulate and control the behavior and standard ofallopathic doctors. similar bodies were formed for homeopathy,ayurvedic, unani etc., But there is no central body to have anoverall control over the health-care professionals in the wholecountry. Each of there bodies supposedly try to maintain thestandard in their own system of medicine. The role of respectivecouncils of other systems of medicine was to regulate theprofessional conduct of the health-care doctors in their respectivesystems. But what is true of Indian Medical Council, issubstantially true for every other council like Ayurvedic,Homeopathic, Unani ect. The role of the council is thus limited toprescribing the curriculum for the courses of their respectivesystems and to prescribing rules and regulations for the college

The Present Scenario


management to see that good standard is maintained in themedical education. Here again the maximum the council can dois to de-recognize a particular college or university. Political andmoney pressure. coupled with incompetence of the inspectingteams of the council, sufficiently dilute even this power of de-recognition and sub-standard colleges continue to produce sub-standard doctors.

But health is a concurrent subject and the stategovernment has a bigger role to play in the health-care than thecentral government. Therefore, the state governments haveformed their own Medical Councils like say Maharashtra MedicalCouncil for the state of Maharashtra. Strangely these statecouncils are not subordinate to the Indian Medical Council butare completely independent bodies formed and regulated by thestate governments. Therefore, even if the medical course ormedical college is not recognized by Indian Medical Councilbecause it is not maintaining the standard expected by it, thestate medical council has its own right to recognize such adifferent course or such a college and the graduates coming outfrom such institutions are eligible to practice in that particularstate. They can not practice outside their own state, if notrecognized by Indian Medical Council nor can they go abroadbecause other countries recognise only Indian Medical Council.In a way it is not an altogether undesirable situation for a vastcountry like India with a population of more than hundred crores.It is not justifiable to have only one standard of health caresystem for the whole country as social and economic conditionsin various parts of the country or in different states can beextremely dfferent. A particular standard which can bemaintained by very wealthy states may be an impossibility foranother state which is comparatively very poor. It may be notedthat western Europe with a population of about thirty five croresis divided into several independent sovereign countries and eachcountry has its own standard of medical education and its ownrules. Similarly in U.S.A. with the population of about thirty fivecrores there are 48 states and under their constitution each statenot only has its own medical council to define the system in itsown state but such a medical council is also entitled not torecognize the qualifications of the medical professionals fromother states. Such ‘outsiders’ are made to appear for their own

test before they can practice in that particular state. Therefore, itis absurd to think of one universal system for a country ofhundred crores of people whose social and economic conditionsdiffer as widely as between different countries in Europe ordifferent states in U.S.A.. I, therefore, said that the independenceof such medical councils of each state is not so undesirable.However, it may be noted that there is no regulatory or co-ordinating mechanism between Indian Medical Council and StateMedical Councils, which is the matter for worry.

Even besides the medical professionals working in theserecognized systems of medicines, there are any number offaculties of medicines which are practiced by the so calleddoctors of these unrecognized faculties. They are bone healers,acupuncturists, electro Magnetic Medical system and what not.Unfortunately the political leadership in various regionsencourages these systems and the present government virtuallytakes no action against these 'doctors'. The people at large donot clearly know whether they are recognized professionals ornot.

Even within the allopathic system the role of eachprofessional ought to be properly defined and regulated. Thereare M.B.B.S. doctors who are supposed to be ‘basic’ doctors.They were the backbone of the society in the form of generalphysicians or family physicians. They treated the patientsprimarily irrespective of which part of the body was affected andirrespective of the age/sex of the patients and refered thepatients to a particular specialist only when the disease appearedto be more serious. Now there are not only specialists (M.D. &M.S.) but there is a plethora of super specialists. (D.M. & M.Ch.)Specialist is defined as a person who knows more and moreabout less and less. The recent advances in medical technologyhave undoubtedly contributed to the development of the superspecialists. For example, in an organ as small as an ‘eye’ wherean ophthalmologist is a specialist of eye disease, there are nowsuper specialists who look at ‘retina and posterior segment’ of theeye, super specialists to look at the ‘cornea’ only and superspecialists who deal with the tumors of the eye only. While therole of super specialist is becoming clearer and clearer, therespective roles of a basic doctor and a specialist are becominghazier and hazier. Even the distinction between the various

The Present Scenario


The Health Care Delivery System is equally complex. Themain method of health care delivery was through private medicalpractice. The patient directly went to the doctor. He, in turn,established his own clinic or nursing home or hospital. Therelationship between the doctor and the patient was direct. Thefees charged by the doctor, therefore, were also totallyunregulated and depended on the whims and fancies of thepractising doctors or on general market value. Slowly institutionalsystem of health care got established. The government bothcentral and state as well as some public sector organizations likerailways started establishing their own health care services. Thiswas the beginning of secondary health-care service. Most ofthese health care services in public sectors treated the patientsfree of charge and the doctors working there were paid somefixed remuneration as per the quality of service they gave.Similarly hospitals or health-care systems were established alsoby many big corporates like Tata Streel, They also employed themedical practitioners at a fixed salary and treated the patientsfrom their own institution free of charge. The growth of privatesector in many other fields made entrepreneurs realize thathealth-care is also an industry and this resulted in establishmentof many corporate hospitals and many trust hospitals. These arerun more professionally. The hospitals provide more and morefacilities in the form of modern equipments and employ thedoctors to serve the patients coming to the hospital. However,the treatment is not free and the patients have to pay for everyservice they get. In order to strike a balance between thecapacity of the patient to pay and actual charges, the patients inthese hospitals are classified as per their financial status and thecharges are graded accordingly. The doctors working in suchhospitals are not on fixed salary but get their charges as per the

systems of medicine is getting obliterated. Eighty percent of thegeneral practitioners now hold non-allopathic degrees likeAyurvedic or Homeopathic or Unani. But all of them, withouthesitation, prescribe allopathic medicines and treat their patientsallopathically. Similarly many allopathic pharmaceuticalcompanies are manufacturing Ayurvedic drugs and theirrepresentatives are freely canvassing these drugs to theallopathic doctors. In short, their practice goes far beyond whatwas officially taught in their respective courses. In a way,therefore, 80 percent of the patients are being treated by 80percent of non-qualified doctors. I emphasize that even qualifieddoctors become ‘non-qualified’ when they transgress the limits ofthe systems they were taught.

3 Health CareDelivery System


allopathic doctors, who nevertheless practise allopathy. Theprimary health-care-remains neglected, even in the privatesector.

A vast majority of rurual and semi-urban populationdepends on public sector for their primary health-care needs. Itleast 60% of the total population of the country could be servedby the state i.e. central & state governments, municipalities, jilha-parishads and gram-panchayats. For them, the state has createda network of primary health-centres with their subsidiaries whilemunicipalities have created their dispensaries in the cities. Thetreatment in all these centres is supposedly free; but inefficientand corrupt administration makes most of the patients to spendhuge amount for their treatment. In additions the facilitiesprovided are very meagre and the pay-structure of the employedhealth-care professionals is also very poor. Unattractive pay andunattractive service conditions can not attract good talents, andthose who serve in these places constantly look for betteropportunities and leave the job within a few years or becomecorrupt or are of hopelessly low calibre. Thus, the vast majorityof the population in the country have a poor primary health-careservice available to them both in public and private sector. Forfurther care, the state has also established secondary carehospitals at Taluka and District places, while Medical Collegehospitals are probably the only centres offering tertiary care inthe public sector, barring a few exceptions.

Another system was introduced in the form of EmployeesState Insurance Scheme, only for industrial labour with lowincome. The industrial labour contributed 1/3, the ownerscontributed 1/3 and the government contributed 1/3, to make thetotal budget. Services were established with the object of givingtotal health care to labourers and doctors were employed to workas general practioners or in the hospitals specially created underE.S.I. Scheme. For primary health care, the doctors wereemployed as general practitioners and the patients were entitledto choose their doctor and submit their health cards to the doctorof their choice. The doctors were thus entitled to a paymentproportionate to the number of cards each of them held. If he waspopular and many labourers chose him, naturally he would getmore payment and vice versa. These doctors were not supposedto practice in the private field. However, the renumeration given

patient they treat and the services they render, in the class thepatient has chosen. More the patients, more the income. Morethe patients in upper class, more the income. Though some ofthese new hospitals are now restristing their doctors frompracticing outside in the private fields, as yet majority of thesedoctors are free to practice privately in addition to theirattachment at these hospitals.

Religious institutions are playing a substantial role in thehealth-care delivery system. Christian missions have establishedmany secondary hospitals, but strangely they have contributedso little to primary health care. Nowadays plenty of Hindu andother religious bodies have entered in great numbers to establishsimilar secondary hospitals. The treatment offered here is free orhighly subsidized and there is an admixture of paid doctors onfixed salaries and honorary doctors who get paid, like in privateand private charitable hospitals, but usually on a lower scale. Asmentioned, very few of them have dared to enter the field ofprimary health-care. When a patient suffers a high-risk-illnessand therefore goes to a tertiary medical centre, he is treated bysuper-specialists but, strangely, he meets his doctor less andless. Higher the risk of his illness, more he loses contact with hisdoctor. He is seen by junior assistants appointed in the hospital.In fact, there could he another strata of junior specialists whomainly look after him. Thus, he is able to meet his super-specialist only briefly and if would not be surferising, if the patientmeets his super-specialist at the time of the procedure only. Thishappens too frequently in public sector but it is also theexperience of those who enter major tertiary care charitable orprivate hospitals. The only exception is small, secondary careprivate hospitals and nursing homes where the patients mostoften meet and deal directly with the specialists. That is whythese hospitals are most popular among the middle-classpopulation.

Thus, though the private sector has entered the field ofhealth-care in a big way now a days, the entry is restricted tosecondary health-care and even more significantly in the tertiaryhealth care. General physicians in private practice form the bulkof the private sector participation in primary health–care, but withthe majority of qualified allopathic doctors chosing to go forspecialization this private sector has fallen into the hands of non-

Health Care Delivery System


was so low and the administrative set up was also so poor thatmost of these doctors freely practiced as private practitioners andmost of the labourers went to the doctor not so much for thetreatment but for getting certificate of illness to take maximumadvantage of the personal benefits offered by the company.Despite huge amount of money lying with the scheme, theemployees state Insurance has become a great flop.

I have tried to point out that the health-care delivery systemis also not well defined and different systems are working at thesame time in the same city or district. The rules governing therole of each doctor in each of the systems is extremely ill definedor even if the role is defined by the rules, these rules are notfollowed at all and any doctor from any system or any specialtyfreely wanders into the territory of others in order to make moneyand yet goes scot free. No action is possible as company /government rules are so flimsy, and medical councils haveframed no rules in this matter.

4Health CareSystem is

An Industry

The medical practice or the health–care delivery system isalso an industry and rules of industry must apply to the health-care system. This is not realized by most of the people. Neitherthe patient nor the political and social leadership of the citizensis willing to accept this fact. If at all, they accept this fact mostreluctantly. ‘Every life is precious and cannot be counted in termsof rupees', is the common statement which is still accepted byalmost all sections of the society. But it is not true. This is borneout by the compensations given by courts or compensationboards in various cases of loss of limb or life. Every life is valueddifferently and that is a fact. As in every industry, money must bespent to create the infrastructure and employ professionals to runthe services and the services must bring returns enough tocontinue the services and, if possible, to expand the services.The service renedered in this case is health service i.e. theservice that makes a person disease free. Can this be calculatedin terms of money? The answer is both ‘Yes’ and ‘No’ Eventhough the exact quantum in terms of money gained by a patientwhen he is cured of his disease cannot be measured easily, theoverall effect on the society and its productivity can be measured.A person made healthy certainly can work better and this resultsin increase in his productvity and increase in the generaldomestic product – G.D.P. of the country. That addition to thesociety, quantitively or qualitatively, defines the total returns tothe society by the actual treatment given under the health–caredelivery system. Even in the case of children the health andeducation produce better citizens and therefore, better


productivity when they become adults. This is the generalizationof the value of health delivery system. It does not help to definethe exact quantum of charges to be levied to each patient for thedifferent sevices he or she gets, but surely can define the totalbudget to be spent on health. Also this itself proves the fact thatno treatment can be free. It has to be paid for by somebody. Inthe so called 'free' hospitals run by government or by publicorganizations or by large private corporate industries, thepayment is done not by the patient himself but is paid by theorganization which creates the health care facility. In the case ofpublic or private sector industries, the workers under them arecontributing a great deal to the wealth created in their respectiveindustries and the management merely takes out a chunk of thatmoney to provide them good health care services. Therefore,indirectly, it is the worker who pays for his health care service. Inthe case of government and muncipal hospitals, the patients getfree treatment but as I said earlier no treatment can be free.Therefore, the money required for creating such a health serviceis collected from the whole mass of people living in that particularstate or city in the form of some taxation or the other. It is the taxmoney paid by entire population, a part of which goes for thehealth care system created by government / municipality butnobody knows the inter-relationship between the money collectedand money spent. Thus the money spent on health becomes un–correlatable to the money collected through taxes. For example,a major bulk taxation Mumbai Municipal Corporation collectscomes from octroi which is the tax collected for every kind ofgoods brought into city. This has no correlation to the health caresystem and yet a lot of that money is spent on the health careservice by Mumbai Muncipal Corporation. It is not realized that ahuge structure has been established for collecting the money,accounting for it and then planning the redistribution of thatmoney to the various services / schemes of the municipality /government. This infrastructure itself eats away nearly 60 percent of the money collected. Part of the remaining 40 per cent isallotted to the health care system but it is a well known fact that,out of this, a large percentage is lost in corruption. Thepercentage of such a loss could be anything from 20 per cent to50 per cent. Thus, out of the total money, the population hascontributed in the form of taxation, hardly 20 percent reaches

them in the form of the health care service. None other than ourformer prime minister Shir Rajiv Gandhi stated in one of hisspeeches that the citizen gets only 11 paise worth service out ofa rupee that he pays in tax. However the poor common manthinks that these taxes are paid by the rich and he gets freetreatment and, therefore, there is nothing wrong about it. This isthe most fallacious concept the common man has. In fact, 80percent of the taxation comes from indirect taxation and,therefore, ultimately he alone pays all these taxes. When he buysvegetables or rice or cereal, it is he who pays the tax on the truckand lorry that brings these articles. It is he who pays the taxesthat are levied on the merchant for his grain shop. The ultimateprice of the vegetable could have risen three times or four timesfrom what its price was in the village. It is surprising that socialand political leaders are not bringing this to light to all the peopleat large. I can understand politicians-they have too many stakesin the present system. But I am deeply surprised that none of theN.G.O. and social workers / journalists sincerely interested in thewelfare of the poor hardworking common man are not high-lighting this aspect and not warning them against ‘FreeGovernment Schemes.’ The politicians of the country continue totax more and more, after promising the common citizen more andmore ‘free’ services. There are other disadvantages to which I willallude to later. For the time being what I am emphasizing is thatthe health care system, in fact, is an industry and money mustcome in from some source to be spent on the infrastructure, theprofessionals and the consumables to be used in the health caresystem. The way it is coming, in the present ‘free health care ingovernment hospitals’ is the costliest way. The people are payingthrough their noses, in return for very poor service.

In the private sector the patient directly pays for the service hegets. As mentioned earlier the charges are not regulated butdepend on the whims and fancies of the doctors and thehospitals. The charges vary depending on the economic status ofthe patient and the reputation of the health professional orhospital. So far, the hospitals and the doctors have not made anyworthwhile efforts to regulate the charges. The principles adoptedby most of the hospitals is what was termed in U.S.A. as 'costplus'-which means whatever the costs incurred by the hospital orthe doctor, additional profits are added as per their own

Health Care System is An Industry


calculation and this amount is what the patient has to pay. Therewere no efforts to find out whether the cost can be reduced bybetter administrative system or by the use of more appropriateequipments at lesser cost. Thus, here too, the patients have topay through the nose for the services that they get. With moreand more equipments used in the modern days and with highsalaries to the professionals working on these equipments, theprice of health care is mounting steeply and is now going nearlyout of hands of the common man or even a upper middle classfamily. Secondly it is extremely difficult for a common man tosuddenly collect and pay the sum in thousands and lakhs and hehas to either sell family jewellery or some property`or take a hugeloan to fulfil the health-care obligations. In a recent study abouttwo years back in U.P. a social Institute of Science observed thatif any patient got admitted and treated for any serious illness inany hospital private or public in U.P., 40% of them went belowthe poverty line due to the expenses incurred during the fullcourse of his treatment. Though no such study has appeared inthe state of Maharashtra, some authors believed that the figurefor Maharashtra could not be less that 35% However, the systemof unregulated private practice continues and in fact coversnearly 60% of the total urban health care system in the state. Afew are lucky that their employers take care of their healthexpenses as mentioned earlier. About 25% of the total populationis thus protected against the financial burden of the health carein these organized sectors. The bulk of them are governmentemployees or corporate industrial workers.

A new system is coming up of late i.e. the scheme of healthinsurance. Just like a person can insure for life, he can nowinsure for his health and the health of his family. Not everyperson falls ill. Presuming that one out of 250 falls ill in a givenyear and, therefore, needs to pay for the health service, it can beclearly calculated that he will have to pay hardly 1/250 of the totalbill, if all the 250 persons have insured for their health. If the costand profit of the company which provides such service was alsotaken into account, it could be 1 / 150 or 1 / 200 of the total cost.Therefore, on this presumption, if the total bill of a patient whorequires the hospital service is Rs. 1,00,000/- (One lac), he willbe paying only about Rs. 650/- or Rs. 500/- annually for suchservice. (Rs. 1,00,000/- divided by 150 or 200)]. Undoubtedly this

is an excellent scheme and the government and healthcareInstitutions must make maximum efforts to encourage maximumnumber of people to adopt the Health Insurance Scheme. InEurope and in U.S.A. there is hardly a citizen who is not coveredby health insurance scheme. However, in actual practice. thehealth insurance scheme is not as rosy as is pictured above. Thisaspect of insured health-care service will be dealt with in detaillater. But basically it is a good concept to pay collectively for thehealth service and reap the benefit individually as and whenrequired. Hence, the same thing was sought to be achievedthrough taxes (as health cess) in a completely nationalized healthcare system. This has been tried in England and Sweden. Eventhough the common man is guaranteed free treatment with thehelp of minimum health cess in England, the system is extremelyfaulty. It has become a white elephant for the government andthe public at large are not very happy. Appointment for anoperation could be after a year or more–if you live. Obviouslycoming to the other extreme of nationalized health servicethrough taxation money does not seem to help. The nationalizedhealth service scheme seems to be working very well in a fewvery advanced socialistic states like sweden. In sweden thehealth–care-system covers from ‘womb to Tomb’. In Sweden, awoman gets a special allowance from the government as soon asshe becomes pregnant, and when a person dies, he / she (i.e.the relatives) gets special allowance for the final disposal of thebody. Every thing is taken care of. But it must br rememberedthat swedish citizens pay extremely heavy taxes amounting tomore than 40% of their income (I am told). It is relatively a smallstate and it is almost totally non-corrupt. Both the community atlarge and the government machinery have an extremely highdegree of honesty and integrity. That is why, the scheme ofnationalized health services seems to be working satisfactorily

All these patterns of expenditures and incomes have beendiscussed merely to show that while considering the mostsuitable health care systems for our country, we will have torealize that money must come in for being spent on health care.

Money in = Money outModern Health Care System

The advanced system of health–care has created two foldeffects. Today the medical professional knows much more about



exact physiology of the body. He has an extremely minuteknowledge of the chemical processes that occur in each andevery organ during its functioning. With equipments like C.T.scan, Ultra Sound or M.R.I. he can penetrate into the deepestpart of the body and see the structural changes, if any, that couldhave distorted any organ in the body. There are umpteen numberof tests like P.C.R. or enezyme studies or tumour markers bywhich minutest amount of pathological substance can bedetected and thereby early diagnosis can be made - sometimeseven before any symptoms have troubled the patient. Thus, thereis no doubt that the disease can be diagnosed at an extremelyearly stage and can be treated much more accurately, thus givingpatients maximum cure rate. However, most of theseinvestigations need high technology and sophisticatedequipments and the cost of investigations and the treatmentbecomes formidably high. These equipments cannot be operatedby an ordinary worker and therefore, the workers need to beproperly educated and need further specific training to operatethese equipments. Naturally all of them have to be paid muchhigher salary than the average worker. This being an expandingfield of science, the need of such skilled workers is equally highin the developed countries and therefore many of these trainedworkers easily migrate to the developed countries, leaving behinda great shortfall of such workers in our own conuntry. That in turnmakes it imperative for the hospital to give them increased payscale. Costly equipments, costly workers and specially traineddoctors (super specialists); naturally the treatment cannot be butexpensive. It is a common practice of our political leaders toinstall such machines in some big hospitals and profess that thehospital must find ways of making these treatments cheaper andaffording for the common man and/or that such treatmentsshould become available in the villages. The fallacy is apparent.This treatment can never be less expensive and can never reachthe villages. Luckily such high cost treatment is not needed formany diseases and it has been proved by statistics that thetreatment by such sophisticated equipments has notcontributed much to the increase in average span of life ofa common man. Much more has been achieved by hygiene,better living standard and primary health care. Thesesophisticated equipments have undoubtedly been selectively

useful to some individuals who suffer from previously incurablediseases and to whom the modern management has given amuch longer span of active life. In short, modern high-tech healthcare system is definitely very useful for a select few individualswho were previously incurable, but has very little impact on thesociety as a whole whose longivity has been only marginallyincreased by its modern techniques.



5 The need forQualified Doctors

When we plan to improve our present health-care-system, wewill have to look at each and every aspect of this system and thinkof improvement in every one of them. The discussion about how toimprove the system becomes all the more important because ourpolitical leadership is far too ignorant about the administrative ororganizational aspects involved in improving the present system.They work as if they are feudal lords and offer special benefits tothose who approach them with their grievance-right or wrong. Theyare, in general, incapable of looking at the problems of the peopleas system failure. Yet I would like to remain optimist and try tosuggest long term remedies in the coming chapters that may go along way to improve the health–care-system in the country.

So let us look at each fact of the health–care system in details.First let us give a thought to medical education. At the time ofindependence we had about 105 medical colleges churning outabout 10,000 doctors every year. The need for the Health CareProfessionals and the required organizational set up for thecountry was discussed in great detail by Bhore committee andMudliar Committee. In fact, the pattern of primary health centre isbased on the recommendations of the above committees. Thecommittees recommended that there should be at least one doctorper 3000 population. This proportion was too low and it is nowbelieved that the country needs one doctor per 1000 population. Inbigger cities and wherever the specialization has advanced verymuch, the proportion of the doctors should be even higher-may beabout 1 per 500 population But considering the need of one doctorper 1000 population India with population of 100 crores will need10 lacs doctors. A doctor is supposed to practise for 35 to 40 yearsfrom the age of 25 to 60/65 which means 25000 to 30,000 doctorsmust come out every year from the various medical colleges. Asthere was such a great need, the number of medical colleges

increased very rapidly. Whereas earlier all medical colleges werein the public sector – owned by government or municipality-nowthe private medical colleges owned by private trust sprang up inmuch greater numbers basically because the government couldnot afford to create so many new colleges and the privateenterprises found this a very lucrative business. There was nothingwrong in medical education being taken up by private medicalcolleges, except for the fact that the private entrepreneurs thoughtof medical colleges only as a profitable business. The main aim ofmaintaining and improving the medical standards was completelysidelined. Thus the standard of medical education has suffered alot. The ambition of the parents to send their children to the medicalprofession was so great that the fees for the medical colleges roseexorbitantly and the government had to step in to control the feesto some extent. Today there are 273 medical colleges turning outabout 31,000 graduates in allopathy alone. The number of medicalcolleges of Homeopathy, Ayurvedic and Unani Medical colleges is167 Homeopathy, 169 Ayurvedic and 9 Unani respectively. It goesto prove that there is no real shortage of doctors in the country.There is a gross maldistribution.

The need for Qualified Doctors


6Selection Patternfor Admission toMedical College

The pattern of selection for entry into medical colleges wassupposed to be only by merits. But this principle of admissiononly on merit was diluted by the political decision of givingreservation for the scheduled cast and scheduled tribe to theextent of 16%. Initially the constitution accepted this specialreservation only for 20 years to be replaced later by criterion ofpure merits. However, the politicians thought it fit to extend thisreservation perpetually. Not only that, on the recommendation ofMandal Commission, another 33% of other backward class weregiven reservation based on their castes. Constitution prohibitedthe ratio of reservation not to extend beyond 49%. However,there was a lacuna. The percentage of reservation could beincreased even beyond 50% by any state provided such anextended reservation could be approved constitutionally byCentral Government. Thus, the states like Tamilnadu increasedthe percentage of reservation well beyond 49%. The admissionsin the respective reserved category however, must be only onmerits. However, a minimum of 45% marks had to be obtained in12th standard examination in physics, chemistry, & biology(P.C.B.) to be eligible for admission. It was reduced further byanother 5% for reserved categories. Naturally, the studentsgetting admission under reserved categories scored much lowerthan in open merit category students, and in the category ofscheduled tribes & nomadic tribes students are admitted eventoday with marks as low as 40%. Immediately afterindependence, the number of students getting first class i.e. 60%marks was very small and the last student getting admission onmerits would have secured as less as 52% marks. The minimum

qualifying marks of 45% was justified in those days. Pattern ofexamination for S.S.C. and H.S.C. changed and students startedscoring very high marks. Later, only the marks obtained in P.C.B.only (Physics, Chemistry, Biology) were considered and lowscoring subjects like languages and maths were excluded whileconsidering merits, and the percentage sored --- higher. Patternsof examination for S.S.C. and H.S.C. changed further andobjective assessment was introduced, so that the studentsnowadays secure more than 80% in aggregate & above 90%marks in P.C.B. and yet some of them are unable to getadmission on merits in the public sector medical colleges. Eventhen minimum qualifying marks remained at 45% in H.S.C. (i.e.12 th standard)-that too in P.C.B. only-not the grand total. Fulladvantage was taken of this lacuna by the private medicalcolleges. They kept some reservation quota for foreign students,local students, trust students etc. and charged exorbitantadditional amount as donation from students seeking admissionunder such categories, as long as they secured 45% or moremarks in P.C.B. at 12th standard. Fortunately the Court’sintervention stopped all such so-called 'quotas' and the courtdirected the private colleges to admit all students purely onmerits. Donations / Capitation fees were prohibited. However,now a new problem propped up. The marks obtained in the verysame state as in maharashtra in different zones like Marathwada,Vidarbha, Pune and Mumbai differed a great deal, andcomparison became difficult. So this difficulty was overcome byrestricting the admission of the students of a particular zone tothe medical colleges in the same zone.

But meritorious students from other regions who wanted toenter into the medical colleges of Pune and Mumbai protestedand the Courts had to accept their grievances. Court ordered thatatleast 25% of the students from other regions must be acceptedin the medical colleges anywhere within the state. In additionsimilar applications were made by the students from other statesand again the Supreme Court ordered that an additionalminimum of 15 % admission must be reserved on an all Indiacompetitive basis. Looking into all these aspects of comparisonof merit between different zones in the same state and betweenstudents from all states of country, the Common Entrance Test(CET) had to be started in all states. CET was also justifiable

Selection Pattern for Admission to Medical College


because of another reason. The question papers for H.S.C. i.e.12th standard were set up taking into consideration the averageintelligence and capacity of all the students taken together.Passing percentage of H.S.C. is usually 70% or more and keptat that level all the while. Hence, the bright students get 90 to 95percentage marks without much difficulty with this set of simplequestions. Therefore, it was necessary to test the differentialmerit of these bright students for their selection in professionalcolleges and a relatively difficult question paper was in order. Inaddition there are several boards like I.C.S.E., C.B.S.E. whichconduct their own 12th standard examination. Thus, taking intoconsideration all these aspects, CET was perfectly justified. Nowthe students passing H.S.C. have to appear yet again forCommon Entrance Test for Medical or Engineering or any otherbranches of professional studies. It was presumed that there willbe only one common test for one state and may be yet anotherone by Central Government for an all India selection. But privatemedical colleges took advantage of this new criterion anddecided that they will have a separate CET for private colleges.The University Grant Commission has in addition created anotherextremely fallacious entity called ‘deemed University’. Originallythe principle for considering any institution as 'deemed university'was that the institution has such a high standard far above thestandard in the University of the area that they could examinetheir own students as per their own high standard and confer itsown could not degrees. University which in any case had only anaverage standard could not interfere. But the rules governingdeemed University are so fallacious that many new institutionswith hardly any standard or reputation could fill in the forms andsubmit some data as required by the University GrantCommission and could obtain the status of ‘deemed university’.Thus, there are many medical institutions which have obtainedthe status of deemed university. They can decide the meritcriteria and decide the pattern of admissions on their own. Thedeemed universities conduct their own CETs. Therefore, astudent today has to appear for not less than 5 to 6 CETs andrun from pillar to post to seek admission in one or the othercollege, if he wants to enter the medical profession. Needless tosay that there have been number of complaints, with solid proofs,about partiality and corruption in these CETs conducted by

private medical colleges or by deemed universities. Professionalcolleagues have authentically mentioned the cash they paid fortheir ward to secure adequate marks in C.E.T. and getadmission. Actually there is no reason why the result of CETconducted by the state and/or CET conducted centrally on an allIndia basis, should not be acceptable to each and every medicalinstitution, whether it be private medical college or deemeduniversity or for that matter even Armed Forces Medical College.

That would obviate the need of multiple CETs that thestudents face today. Ordinarily such one common CET wouldeffectively curb the corruption and malpractices practiced bythese private bodies.

The question of admitting 15% students on an all India basiscould also be resolved suitably. After all, health is a concurrentsubject. The central government as well as the state governmenthave a role to play in creating the health care structure. Thedesire of students from any part of our country to seek admissionto any medical college anywhere is also fully justified. But whyreserve 15% seats in every college as per the present supremeCourt’s order? It would be much simpler for the centralgovernment to create 15% of centrally administered medicalcolleges in all states, and admit all students in these collegesonly, on the basis of All India Common Entrance Test. There isno need even to create more colleges. Central Government cantake over 15% i.e. one out of seven colleges in all the states andrun them through central government funds. In case themunicipal corporation as in Mumbai or Pune decide to havemedical colleges from its own budget without the assistance ofthe state government or central government, such institutesdefinitely have a right to have certain percentage of seatsreserved for the students of the city, say about 25% to 33% of thetotal seats. Similarly if any region / district decides to have amedical college and is willing to support such a collegefinancially, if would be able entitled to have 25% to 33% regionalreservation. Instead of reservation based on caste and tribes orreligions, the regional reservation as mentioned above would goa long way in creating balanced growth of medical facilities invarious parts of the country.

The same principle could be applied even to the differentcommunities. The reservation on the basis of religion, caste and



creed is not only strictly against our constitution but it hasadditionally created a lot of resentment and animosity amongstdifferent castes. The recent examples of Mina Vs. Gujjar inRajasthan and the agitation for Maratha reservation which iscreating apprehension amongst the other backward classes inMaharashtra, are the latest examples. It is ironical that during theperiod of independence movement, our leaders blamed theBritish rulers of adopting a policy of 'divide and rule' by creatingelectorates on the basis of religions. Gandhiji had to fight and useall his power of pursuation to oppose separate reservation forscheduled castes and persuade Dr. Ambedkar against such amove by the British. Pune agreement between them is veryfamous. Yet it is ironical that our present leaders are increasinglysupporting such reservations on the basis of caste and our newpoliticians are willing to extend them even to Muslims andChristians, thus creating severe resentment and conflictsbetween various castes and religions. The reservation on thebasis of castes has not given any advantage to the poor. On theother hand, only a few privileged people in these various castesare reaping the maximum advantage out of it.

Even in U.S.A. Dr. Martin Luther King Junior and many otherprotagonists, the uplifters of the blacks in America, did not ask forreservation but instead created opportunity in education andother infrastructure facilities for the blacks and thus brought themup to the level of the whites. Those who have already beenbenefited by policy of reservation can contribute along with thestate or central government or along with N.G.O.s to createeducational and other infrastructural facilities including themedical educational and service facilities, with percentage ofseats reserved for their own communities (again say 33%).These efforts by community itself to uplift the other members oftheir own community will not cause any animosity and are likelyto benefit the poor much more than the ever expandingreservation system prevalent at present. It may be noted thatminority colleges created by minority religions like Christian, Jain,Muslims etc. do have such a facility of reserving the seats for themembers of their own religions and they have not caused muchresentment in the society. It would be the golden day when thereservations based on castes are totally abolished and replacedby such efforts by various communities and N.G.O.s to uplift the

members of backward communities. However, such reservationsshould not exceed 25% to 33%.

Admissions are now based on marks obtained in the C.E.T.provided the student gets a minimum of 45% in P.C.B. in his 12th

standard examination. One adverse effect of this system is thatthe students totally or near–totally ignore their 12th standardexamination and remain satisfied with obtaining the minimum of45% marks in P.C.B. in that examination. It is also illogical thatlanguages and mathematics are totally ignored. Obviously thisomission was done as demanded by the parents who have nowdeveloped a habit of complaining of ‘stress’ or ‘tension’ for theirwards. Language is a means of communication and those whocannot communicate well can never become good medicalprofessionals. Similarly the modern advances in the medicalknowledge have made it more a science, less an art and thestudents have to be mathematically precise in their clinicalpractice after they graduate and start practising. Modernequipments are now mathematically derived and the student whodoes not have a mathematical attitude is likely to fail in treatingproperly, the complexities in cardiac, renal and such otherdiseases. Besides, examination is a test to know how much thestudents have absorbed out of what is taught to them. Therefore,if languages and mathematics are taught, his ability to absorbthese subjects also must be a part of examination to decide hismerits compared to the others. Therefore, marks obtained inlanguages and mathematics must also be considered whiledeciding the merit at 12th std. and CET must include questions inthese subjects too.

To keep the minimum qualifying marks at 45% in the presentdays is ridiculous. This is one of the reasons why undeservingstudents are able to manipulate and get admission in privatemedical colleges or under reservation category as long as theycan obtain more than 45% marks in PCB in the 12th standard. Itis tragic that many of these students are not able to complete thecourse at all and I have seen many parents suffering hugefinancial loss-despite their poverty-in trying to make their-ward adoctor and getting frustrated after 7 to 8 long years. Such atragedy among scheduled tribes and such a corruption amongthe among influential and wealthy parents in CETs would beavoided, if the minimum qualifying marks are made 55% in



aggregate and 70% in physics, Chemistry and Biology. As atpresent, the minimum percentage could be 5% less for allcatagories having reserved seats. So, the minimum would become 55% in aggregate and 70% in P.C.B. It could be safelypresumed that candidates getting less than these percentagesare not safe to be entrusted the task of caring for the sick.

Also merit need not be decided only on the basis of CET.Merit can be best decided by taking into consideration

a) the performance in 10th standard;b) the performance in the 12th standard andc) the performance in the common Entrance TestIf all the three examinations were taken into consideration, a

chance freak lower performance by a particular student in CETwould affect him less, as his average performance would proveto be better. Similarly the corruption is likely to reduce, as it is notso easy to use the corrupt methods in all the three examinations.The comparision of 10th and 12th standard marks could be doneon percentile basis. Properly re-calculated percentile basisremoves most discrepancies. It is the best method universallyadopted by developed nations.

In short, having considered the present pattern of selection ofstudents for medical education from the 12th standard, I wouldsuggest the following important steps.

(1) Admission should be purely on merits. The merit isdecided based on CET examination, provided the candidate getsa minimum 55% marks in 12th standard overall, and/or 70% inP.C.B. The merits need not be decided only by the performancein CET. It would be better to consider the performance of thestudents at various levels from his 10th standard to 12th standard.At least overall marks in 12th standard, corrected by percentilemethod should be considered to 50% extent & CET would makeup the other 50%

(2) The omission of certain subjects like languages andmathematics while considering the candidate for medicaladmission is faulty. The performance in all the subjects must beconsidered and therefore these subjects ought to be part of theCET also, if overall marks of 12th standard are not to be takeninto account.

(3) The minimum qualifying percentage of marks foreligibility to enter the (medical) professional colleges must be

raised from the present 45% in PCB to a minimum of 70% in PCBor 55% marks overall. (5% less for all 'reserved' catagories.)

(4) Despite some criticism and adverse publicity, I stillbelieve that S.S.C., H.S.C. and CET or equivalent examinationconducted by different Government Boards are still the mostimpartial examinations conducted in the state. Hence, thereshould not be multiple CETs. Only one common entrance testconducted by the boards appointed by the government is notonly sufficient but be made absolutely compulsory for all collegeswhether government, private or colleges of the deemeduniversity. Central government would be the only other body toconduct their CET on an all India basis. As stated above, if thecentral government takes over 15% of the colleges from all thestates and itself administers them, these students will getadmitted to the Central Government Medical Colleges. Thus,admission to the rest of the colleges in the state will not behampered, delayed or interfered with because of the so called'central quota' as is happening today.

(5) Reservation on the basis of caste should be totallyabolished. However, regions or communities willing to conducttheir own medical colleges with their own expenses shouldcertainly be allowed to reserve some percentage of seats but notmore than 33% to the students of their regions or the students oftheir particular community. In short, reservation should be basedon region or community, provided the region or community takesthe responsibility of running their own medical colleges andhospitals.



7 FEE for MedicalEducation

Now let us look into the pattern of charging fees to the medicalstudents during their entire curriculum. When I joined the medicalcollege in 1951 just one year after India became Republic ofIndia, we paid Rs. 175/- per term i.e. Rs. 350/- per annum as ourtuition fees. There were, of course, other ancilliary fees so thateffectively our term fee was about Rs. 250/- per term. Thebrochure then mentioned that the government subsidized themedical education to the extent of nearly 50% of the actualexpenses. When my son and daughter entered the medicaleducation somewhere in the early eighties i.e. more than 30years later, the fees levied were exactly the same. But now theyformed hardly 10% of the actual expenses incurred on medicaleducation. Subsequently the fees were raised but the fees weremost appreciably raised only after the private colleges came up.While medical colleges run by public sector are subsidized soheavily by the government, the private colleges have to bear theentire expenses as they do not get any government aid / subsidy.It is but natural that the students/parents must bear all theexpenses in these colleges.

The private medical colleges took advantage of this logic andstarted to charge exorbitant fees and the Court had to interveneagain to regulate the fees for the medical students. Now acommittee is supposed to supervise and determine the legitimacyof fees to be charged to the students. It is not clear whatprinciples are used to determine the legitimacy of the expensesand, therefore, the legitimacy of exact fees charged but theformula appears to be obviously faulty.

The medical colleges continue to charge very heavy fees, inthese colleges. A medical student pays anywhere between Rs.1.5 lac to Rs. 3.5 lac per year at present. The government toohas raised the fees because of the financial pressure; yet the

fees are around Rs. 18,000/- to Rs. 20,000/- per year. Thestudents prefer government or public sector medical collegesbecause the training in these is qualitatively much better and notnon-affording because the training is so cheap, except in thecase of a few minority of the students. Naturally the students whoget highest marks enter the government medical colleges whilethe students getting a little less marks are forced to takeadmission in the private medical colleges and medical colleges ofdeemed universities. The paradox of the present situation is thatstudents getting very high marks get subsidized education and,therefore, in a way are supposed to be economicallyhandicapped whereas those students who have secured marksless by a few percentage have to pay exorbitant fees and,therefore, in a way they are supposed to be belonging to the richor economically affording class. Between students of equalcaliber of intelligence, it is the rich or affording class who canprovide better facilities-special tuition class and internet facilityetc. to his ward, whereas it is the middle class parent who maynot be able to provide such facilities and may depend on ordinarytuition classes at the most for his ward. Between them, therefore,it is the affording student who is likely to secure more marks thanthe unaffording student. Yet as mentioned above, it is the studentwho gets less marks who has to pay very high fees and thestudent who gets more marks pays lesser fees irrespective of theaffordability of their parents and, in all probability, the affordabilitybeing quite the reverse. During my time in 1951-56, 15% ofstudents were given partial freeship i.e. they paid only 50% of thestipulated fees, while another 10% were given full freeship; Itmeans that they did not pay any tuition fees at all, except theancilliary fees. The criterioa for giving partial or full freeship werepurely economical. The parents had to submit a form anddocumentary proof to confirm their income and only thedeserving candidates got such relief of not paying part or fullfees. I myself might not have been able to complete my medicaleducation but for the partial freeship which I obtained during thecourse of my education. It is ironical, therefore, that now whenthe fees have been raised so high, there is not a single seat withpartial or full freeship in anyf of the colleges – government orprivate. Even in the government medical colleges, the feestructure, though reasonable, may not be quite so reasonable for

FEE for Medical Education


many of the very poor students and, therefore, today, they areforced to give up the ambition of becoming medicalprofessionals. The situation would be even worse for those whoaspire to get admission in the private colleges. Thus, it can beseen easily that more and more percentage of students inmedical colleges both in government & in private colleges arenow belonging to the higher income group and the percentage ofstudents from lower income group in medical colleges is steadilydecreasing. Apart from the fact that deserving students are beingdenied the opportunity despite their merits, this has even morerepercussions on the very pattern of healthcare. Both thestudents and teachers belonging to the rich class cannot easilythink of simpler or cheaper substitutes in healthcare for the poor.They easily accept the costly modern technology as but naturaland as a sign of real progress in medical management; thuscontributing to the medical expenses rising by leaps and bounds.

Should the expenses for medical education be subsidized atall? The subsidy in medical education is justified, if the doctorscoming out from the colleges are sure to be absorbed in thenational health services and that the people at large are servedby them and in return they are given a reasonable remuneration.In countries like England and Sweden, highly subsidized medicaleducation may be fully justified as their entire health care systemis nationalized. But in our contry, where the student has a totalfreedom to select his field of practice-even go out of the countryto the greener pastures in the foreign countries-the subsidycoming from the tax payer's money cannot be justified.Alternatively some provision has to be made to recover the entiresubsidized fund with interest, if and when, the doctor leaves thecountry or enters into private business (I have deliberately usedthe word business instead of practice). Therefore the question ofsubsidy in medical education has to be very carefully looked into.The best solution for this is easy availability of educational loanat fairly low interest rate, say 6% which can be repaid by thestudent after he enters into regular professional field. Certainlysome students-to the extent of 15% and 10%, from the poorersections of the society-deserve partial and total freeship-respectively as was the practice in the fifties and the sixties. Thegovernment would be fully justified in compelling these studentsto serve in the public sector for a stipulated period-say 10 years-

on a subsidized salary. On the other hand, the insistence of thegovernment of compulsory service in the public sector by eachand every student does not appear to be justifiable, if he/she ispaying fully for his/her education. Similarly the fee of onlyRs.18,000/- to Rs. 20.000/- in government medical collegesversus average fees of Rs. 2,00,000/- in the private colleges istoo weird as explained above. Atleast 50% of the students gettingadmission in government/municipal colleges belong to high/veryhigh income families. A few of them could buy the hospital. Forexample if the son of Ambani or Godrej or Kirloskar secures 98%of marks and gets admission in G.S. Medical College (K.E.M.) inMumbai or B.J. Medical College in Pune, he pays the fee of onlyRs. 18,000/- but the son of the poor accountant or head clerkworking in his own office who secures 92% marks pays a fee ofRs. 2 lacs, if at all he aspires to become a doctor. The questionof proper subsidy to proper students will be correctly approachedand this paradox will be totally abolished, if the fees in thegovernment colleges are also raised on par with the privatecolleges and, therefore, the subsidy is totally abolished. Nowsubsidy should be given only on the basis of the economic statusof the family in two or three grades ot students in all colleges,government or private. The students with family income of Rs.75,000/- per month or more will pay full fees. those whosemonthly income ranges from Rs. 60,000/- to Rs. 75,000/- permonth may get 25% subsidy. The families with income between40,000 to 60,000 will get 50% subsidy. Those below this incomeupto Rs. 25,000/- per month may get 75% subsidy. and thosebelow Rs. 25,000/- p.m. will get full freeship. These figures arementioned somewhat arbitrarily but the actual figures could beworked out very easily taking into consideration family liabilityand their capacity to pay for the education OF THEIR TWOCHILDREN ONLY. The government need not consider evenremotely the financial burden of the family beyond two childrenas in Singapore. In short the pattern of subsidy would ensure thatthe poor should get 100% subsidy, lower middle class may get75% and the middle class may get 50% For the highest strate,there is no need to give any subsidy irrespective of which collegehe joins, government or private. Such subsidy, therefore, will beavailable to the students whether he joins a government collegeor private college or a deemed university college. The subsidy

FEE for Medical Education


8Subsidising

Private MedicalColleges

As pointed out earlier the government has appointed a boardto determine the fee structure in private colleges and to see thatthe fees charged are legitimate. It is not clear what principles theyuse but it appears that the board merely verifies the expensesincurred during the previous year and sanctions the fee patternto meet those expenses. There are no criteria to judge thelegitimacy of those expenses. Therefore, the fees are as high astwo to three lacs per annum as mentioned earlier. Even afterpaying such high fees, the students in private colleges are greatlyhandicapped because their attached hospitals have very lowoccupancy. The patients in these hospitals have to pay for theirhospital expenses. The treatment cannot be totally free. Around50% of the burden of the expenses incurred on the patients isborne by the students and forms part of their fees. Even then, thepatient himself has to pay a fair amount towards his treatmentcompared to the fact that they get free treatment in governmenthospitals. Coupled with the fact that these institutions may behaving relatively poor investigative and operative facilities andless experienced teachers, the result is a great reduction innumber of patients coming in these hospitals. Therefore, thenumber of students admitted in these colleges is very highcompared to the patients available in the hospitals and thepatients feel more harassed by a large number of studentsexamining each of them. Thus, a vicious circle is established.Ultimately this results in proportionately small number of patientsavailable to the students to observe and learn his clinicalmedicine. In all technical colleges, the laboratory or workshopwith all equipments suffices to give the students adequate

means that an equivalent amount will be paid to the respectivecolleges by the government so that their budget is not disturbed.Every student who gets subsidy will have an obligation to servein government service or in public sector for a reasonablenumber of years as per the subsidy he has received or else hewill have to return the amount of subsidy with interest to thegovernment. A large number of doctors will then becomeavailable to serve the poor at various primary health centres orother public sector health care organizations. Otherwise thegovernment will receive back the money they had spent on thesestudents-money which can be now re-used for future students.


training but not so in the medical college. For medical students,a large number of patients in the attached hospital is mostessential for getting their clinical experience. The lay peopleshould realize that a medical student does not interfere with themanagement of the patient. But he is constantly with the teachingstaff & other seniors and observes every step in the process ofclinical management and even assists them as directed. Thisactual observation and participation in the management of thepatient forms a major part of his clinical studies; I would saynearly 75% of the education in clinical methods. Therefore, themost important need of the medical students is the hospital filledwith numerous patients of different kinds of diseases. TheMedical Council had recommended a ratio of 1 to 10 initially i.e.10 patients per student admitted every year. That means if 100students were admitted per year in the college, the attachedhospital must have the facility to admit at least 1000 patients. Inorder words, there ought to be at least 1000 patients in thehospital on an average every day. Tha ratio was diluted later andnow stands at 1 to 7, 700 bedded attached hospital for 100admissions per year in the medical college. Many private collegehospitals do have the number of beds but not the occupantswhereas the government hospitals are full or even overburdened.The total number of patients in private college hospitals could beas low as 150 to 200. it must be realized again that the hospitalfully occupied is not only the need for the students but it is abigger need for the society because the student who passes withinadequate experience because of lack of availability of patientsand has only book-knowledge will obtain the same degree andwill be fully entitled to treat the people at large as a student whogets adequate clinical experience. Thus the effects of bad /immature doctors coming out of the medical college are borne forthe next 35 years by public at large. So also the benefits ofmature doctors coming out of the medical colleges will be reapedby the public at large only. Another factor needs to be consideredi.e. the government hospitals/ medical college hospitals as wellas district hospitals are too overcrowded and there is a vital needto reduce this overcrowding in these hospitals so that each of thepatients gets adequate attention and treatment. Besides, over-crowding hampers medical education as much as scantypatients. The best way to disperse the patients to these private

medical college hospitals would be to subsidize the cost of thetreatment in private hospitals equally as in government ownedmedical college hospitals. What I am suggesting is that theexpenses of the poor patients coming to these medical collegehospitals should be subsidized by the government. The subsidycan be calculated as per what is spent for a similar patient AT ADISTRICT HOSPITAL. This amount could be safely consideredas the most minimum amount essential for the treatment of thepatients, with no other components added. The expensesincurred by patient in a medical college hospital have addedcomponents and could be broadly divided into three parts

(1) the expenses required essentially for his treatment. I havetaken it to be equal to the expense incurred by the governmenton similar patients in a district hospital and, therefore, suggestedthe abovementioned level of subsidy.

(2) But the expenses of the patient in medical college hospitalwould rise appreciably because he is a material for the medicalstudent to learn. The stay of the patient is necessarily increasedto some extent and some of the investigations are done merelyfor academic purposes. As this part of expenses is entirely dueto the presence of students in that hospital, it is legitimate thatthese expenses be borne by students.

(3) But in good medical colleges research is an essentialactivity. Without research there will be no progress in the scienceof medicine. Since certain investigations or modalities oftreatment are carried out purely for the research, it is clearlyunderstood that this component of the expenses must be giveneither from the institution or recovered from the research grantsprovided by the private industries like pharmaceuticals or byautonomous government agencies like University GrantsCommission (U.G.C.) and Indian Council of Medical Research(ICMR). The interests of the patients / volunteers aresafeguarded by Research Council in that the patient must gainadvantage or at least must not be harmed at all and that thepatient is properly informed that these investigations andtreatment are being done as part of research

Today the government refuses to give a single paisa to theprivate medical colleges as a subsidy. "Why should we spend for‘rich’ private trusts and the ‘rich’ medical students who, in anycase, want to make money?" Strangely all experts are

Subsidising Private Medical Colleges


9Paying Patientsin Med. College

Hospitals

Indian Medical Council is very ambiguous about recognizingthe affording class of patient as clinical material for the students.If the hospital keeps a section where patients pay for thetreatment, that section is not recognized by the Medical Councilas teaching beds. One reason given by the Council is that thesebeds form a section like a Nursing Home and the same bed maybe occupied by a medical case under a physician one day, by asurgical case for the few days and a pediatric case at yet anothertime. Therefore, such beds cannot be allotted to any specificbranch. The argument is quite valid but if the hospital was tohave paying beds in each of the wards which are allotted to thespecific teacher, then these beds ought to be considered asteaching beds. In U.S.A. almost all patients do pay for theirtreatment and yet form part of teaching material for the medicalstudents. Even in attached hospital of Kasturba Medical College,Manipal, all patients pay. If 25% of the beds of each teaching unitwere allotted to paying patients, it would have many advantages.First, obviously the hospital will have a source of income to runthe hospital and thus will indirectly help the institution to reducethe fees for the medical students. But a bigger advantage is forthe students in their medical education.

A paying patient is more health conscious and more aware ofhis rights. His expectations of treatment are higher and in generalhe is well–informed and more easily available for follow-up.Besides he often comes with an early and possibly curabledisease. Therefore, he is an excellent clinical material for themedical students. In addition and most importantly the students

emphasizing the role of private public partnership in various otherfields, for example in road and bridge construction. Similarlygovernment factories are constructed on the basis of BOT i.e.build, operate and transfer policy. Therefore, there is no reasonwhy there can not be a private public partnership in the field ofmedical education. It is not being done to benefit the private trustor agency which is running the college. The government and thepublic would get tremendous advantages by such subsidy. Whenthe poor patient gets treatment at the same cost as in a districthospital but by more qualified medical teachers, the number ofpatients in the hospital is bound to increase and the experiencegained by the students because of availability of wide varieties ofpatients would go a long way to make him a better doctor. It isin the interest of the society, therefore, that the medical collegehospitals are filled with patients by giving them adequate subsidyto cover the treatment expense of the poor patients.

Paying Patients in Med. College Hospitals


learn good bedside manners almost automatically. The patientbeing educated, health–conscious, affording, he or she isautomatically treated with due respect by the student. Thestudents do not pounce upon him or examine him roughly as theyalmost always do in the case of poor general ward patients. Incontrast the general ward patients suffer from more advanceddisease and often do not turn up for long term follow up. Theyform, at best, experimental material like animals. It is regrettableto say so but it is the common experience of each and sundrywho have observed the plight of these patients in our country.

Every clinical unit in a medical college hospital must haveabout 40 beds with a recognized team of medical teachers /consultants in charge as per the medical council rules. Usuallyeach such unit has a separate ward; sometimes two units sharea ward. It is suggested that all such wards should have atleast25% of these patient-beds for paying class patients. That meansout of 40 beds atleast 10 beds should be paying beds where thepatient pays for his / her treatment. One part of the ward couldbe converted into rooms with extra facilities like separate toilet, aseparate access and a few facilities for relatives while remaining30 beds would be either free or partially subsidized-generallycalled the general ward beds. The medical students willnecessarily be allowed to examine and observe the treatment ofall these paying class patients and as stated above I expect thestudents to learn proper bedside manners and also observe thesigns, symptoms and clinical picture of a relatively early diseasein the special rooms in contrast to what he observes in thegeneral ward, namely signs symptoms and clinical picture of arelatively advanced disease in a patient whom he may not beable to observe in the follow-up period. As these beds arespecifically allotted to the teaching unit, there is no reason whythe Indian Medical Council should have any objection to considerthem as part of the teaching beds. Such a system has an addedadvantage of assessing the capability of the teacher to attractpatients. The patients in the general ward have no choice but tocome to these ‘free’ hospitals and their number does not reflectthe clinical ability of the teacher. It is only a competent teacherwho can attract patients in the paying class. The incompetentteacher will thus be easily exposed. There are many moreadditional advantages in having this system. The out-patients-

department, laboratory and the operation theatre, all remainclosed after the morning shift. The whole hospital works only inone shift from 8.00 a.m. till 3.00. p.m. Hospital services areclosed after 3.00 p.m. except for emergencies during the rest ofthe day and night. If paying class of patients are to be treated.in this same hospital as mentioned, it will become necessary touse the evening hours to have such pay-clinics for the payingpatients. The O.P.D. the laboratory and investigative facilities willalso naturally remain open during these evening hours and inorder not to disturb the treatment of the poor class, theoperations and procedures for these paying class patients willalso have to be performed in the evening. In short, the wholehospital will have morning hours reserved for the general class ofpatients while the whole infrastructure will be put to full use againin the evening hours for the paying class of patients. Doubleutilization of the available infrastructure, and therefore thestanding expenses, will be better utilized. In addition, of course,the hospital will earn a very large income from these beds andthat will cover a major part of the hospital expenses. That thesepatients may refuse to allow the students to examine them is acommon objection raised by those who are against it or havefixed ideas. But it must be remembered that it is obligatory forevery patient who goes to a teaching hospital to allow thestudents to examine him. As per the rules of the council, a noticehas to be put up prominently and even signatures can beobtained from the patients before they are admitted and anytreatment is initiated. This is the practice in the western world.This has a further advantage in that medical teachers or seniorsremain available in the premises right upto evening time evenupto 8.00 p.m. or 9.00 p.m. At present the seniors leave thehospital by 4.00 p.m. maximum and they are approachable onlyon phones thereafter. If and when private practice is allowed tothese teachers outside the premises (legal or illegal) as is oftenthe case to-day, they are busy elsewhere in their private practiceand are reluctant to come to the hospital even when the situationso demands. They manage the situation by giving telephoningadvice or telling the junior to go ahead and perform or advice thejuniors to keep the case pending till morning. Such negligencewill also be minimized by having the paying class in the hospital(a) because the senior doctors are readily available within the



premises even upto late evening and (b) they have no externalinterest in terms of private patients elsewhere and, therefore, arenecessarily and truyly available for the patients within thepremises-whether general ward or paying class. After someyears almost every doctor develops a certain philosophy andethics of practice. Therefore, it is unthinkable that such a seniormedical teacher will attend only to the paying class patients andignore the general class patients, when both these classes ofpatients are in the same premises and the consultant is availablethere. Therefore, the general ward patients also will get betterattention in this system. Even otherwise, the attention to thegeneral ward patients i.e. poor class of patients will improveautomatically, even in the out patients department because of yetanother factor. At present, if the medical teacher is competent, heattracts many patients who are either very influential or affording.They seek treatment here, for various other reasons apart fromcheap or free treatment, mainly because of the competance ofthe consultant teacher. In the present system, these affordingpatients attend the same O.P.D. during the same morning hoursas the poor general class patients. Inevitably this influential oraffording class of patients get preference over the poor and if themedical teacher is very popular, it may happen that he hardlygets time to see any general class patient. They are all seen byresident doctors or juniors and the senior teacher is consultedonly if the juniors consider it necessary to show him such a case.The same thing happens in the investigation department and inthe operation theatre. The rich or influential patients easilysupercede the poor and the investigations and/or operations ofthe poor general class patients keep getting postponed for wantof time to accommodate the rich or the affording. Everyone is aloser except this crooked class, which exploits the facilities meantfor the poor. The senior medical teachers in the unit do not objectmuch because their own share of influence in the societyincreases by treating these people. On the other hand, he hasnothing to loose, as his salaries are fixed. There are a fewexceptional techers who do object on moral ground to suchentries of privileged class. But they are far and few between.They lose their sphere of influence in the society and remainstatic, irritable and generally not appreciated by anyone.

All this would be prevented if the scheme of 25% paying beds

is properly implemented. As the medical teacher will gain inactual terms as and when he treats paying class patient, he willnow be more reluctant to adjust him in the morning hours and willinsist on him coming during the hours of paying clinic. Therefore,the general ward patients will have the full attention of themedical teachers during the morning hours. The investigationtime and the operation time being so reserved specifically for thegeneral ward patients till 3.00 p.m. and for the paying class in theevening, there is no interference between the two classes, thus,giving indirect benefit to the general class patients. The morecompetent medical teacher will earn more than the teacher whois relatively incompetent. Thus, the need of 25% paying beds ina teaching hospital is so important that, in my opinion, thestudents, the university and or the state government should bewilling to fight for it in the court of law, if the Indian MedicalCouncil raises any objection to such a system on any ground.

Free medical treatment should be abolishedAs I emphasized earlier there is nothing free. When a patient

gets treatment free of charge, it only means that somebody elsehas borne these expenses directly or indirectly. In the case ofgovt. hospitals, it means that every citizen is paying for thetreatment of that patient through direct or indirect taxes. Besidesneither the patient nor the student nor the senior medical teacherbecomes aware of the expenses incurred in the treatment of thepatient and thus, does not even think whether the expensescould be minimized. Therefore, it is my firm opinion that thepatient must pay at least some percentage of the expensesincurred for his treatment.



10Effective Fees

for MedicalEducation

When we consider the fees to be charged to the medicalstudent, two important aspects must be taken into consideration.

(1) expenses incurred by medical colleges and(2) the various means other than student fees that can bring

income to the Institution.If the medical college indulges in unnecessary expenditure,

such an extravagant expenditure need not be taken intoconsideration by the board. The Indian medical Council hasclearly stipulated the space, furniture and the infrastructure foreach department. Expenditure incurred on these is the mostessential expenditure. Additional expenditure can also be allowedonly if it can be proved to be important to qualitatively orquantitatively improve the standard of medical education.Generally I must accept that there is not much scope to reducethe expenditure on these grounds from the present level. But theexpenditure on the salaries and perquisites for the medicalteacher can be comfortably reduced by allowing the medicalteachers, private practice on the premises on the 25% bedsreserved for the paying class as discussed in details earlier.Medical teachers will get minimum salary for teaching as in otherfaculties, but he will earn more and more with his own skillthrough the private practice and the management need not payfor the perquisites such as non-practicing allowance, telephone,housing etc. In addition, there are possible sources of incomeother than the students fees. First major source is income frompaying class of patients. 25% percent paying class patients canbring enough income both to the senior medical teachers and to

the hospital. Even a hospital like Bombay Hospital can afford tohave about 25% beds free of charge or highly subsidized.Therefore, much of the hospital expenditure can be expected tobe recovered from the 25% paying class patients. Another sourceof income is Research Grant. One of the important functions ofa medical college is research and large sums of money areallotted by pharmaceutical companies and medical equipmentcompanies in private sector and the University GrantCommission(U.G.C.) and Indian Council of Medical research(ICMR) in the public sector but these are most scantily used.Used appropriately the medical college can earn lakhs of ruppesthrough research. I was told the Manipal University has morethan 80 research projects bringing in over 6 crores of ruppes tothe institute through research grants. Government hospitalsespecially are apathetic in utilizing these funds. Yet research iscarried out but the funds are exploited by vested interests byclandestine methods. The hospital earns nothing. Yet anothersource of income could be the training courses for all para-medical services. There is need to have nursing course,technician’s course and even training course for ward attendants.Even administrative courses like MBA, Cost–Accounting, recordkeeping etc. could be undertaken with the help of the respectivebodies in the various fields. There is no need either to extend theinfrastructure or teaching staff and the same premises and thesame staff can be used to conduct the training programmes fordifferent paramedical services. As will be discussed later, theconcept of absolutely free medical treatment must also becurbed; not so much for earning money but for many other vitalreasons. However, suffice it to say here that some income wouldbe added if general ward patients are also charged even 15% ofthe actual bill. I have already stated that the private medicalcolleges should also be entitled to a subsidy equivalent to theexpenditure incurred by government in a district general hospital.If all these sources of income are properly used, the burden offees on the medical students will be remarkably reduced and Ibelieve that medical education would not remain as costly as it istoday.

In summary, the following steps are needed to streamline thefees structure and bring the fees down to a reasonable limit.(1) there is no justification for very highly subsidized medical

Effective Fees for Medical Education


education in government medical colleges and exorbitantlyhigh fees in private medical colleges. The fees ingovernment medical colleges should be at par with theprivate medical college fees or based on expenditureincurred, as in the case of private medical colleges andapproved by the board appointed by the government.There should be no distinction between the two.

(2) No student with merit should be denied admission to themedical field because he/she cannot afford. Therefore,irrespective of whether the student joins government orprivate medical college, he will be entitled to a certainamount of subsidy depending on financial circumstances ofthe family. The families with income of Rs. 75,000/- permonth and above will pay full fees. But the families withincome between Rs. 60,000/- and Rs. 75,000/- will get 25%subsidy. The families with income between Rs. 40,000/-and Rs. 60,000/- will get 50% subsidy. The families withincome between Rs. 25,000/- and Rs. 40,000/- per monthwill get 75% subsidy and those below Rs. 25,000/- incomeper month will get full freeship i.e. 100% subsidy. Theadmissions, however, will be strictly on merit.

(3) While determining the fees, only the legitimate expenditureby the hospital for under-graduate and post-graduatestudies should be considered. The burden of unnecessaryextravagant expenditure cannot be put on the students.

(4) The hospital must keep atleast 25% of the total beds inevery clinical unit for paying patients. There is no need tocharge these patients exorbitantly to compensate thegeneral class patients. They will be charged appropriatelyas per costing. For the general ward patients, the hospital/ management will be entitled to a subsidy from thegovernment equivalent to the amount spent on an averageon patients in district hospital. In addition all general wardpatients will also be charged atleast 15% of theexpenditure actually incurred. Reserch grants willcontribute further to the income of the hospital. Theremaining excess expenditure will be borne by the studentsand will form part of their fees. It is expected to be not morethan 30-35 per cent of the actual expenditure on patients.

(5) As the hospital is going to have 25% paying beds the

consultant doctors / medical teachers will also earn directlyas per their skill. It is expected that this would reduce theexpenditure incurred on the remuneration for the medicalteachers; especially on perquisites. It should be noted thatthe salaries of the medical teachers form a major bulk ofthe total budget for the medical college and its hospital.

(6) Medical college must make efforts to have researchprojects and earn some specific added income through thegrant for research by the government, industries or otheragencies. The consultant medical teacher undertaking theproject must get paid appropriately. This aspect will hediscussed again later.

(7) The number of students getting subsidy are not expectedto rise above 40% to 50% In fact, those getting full freeshipand upto 50% subsidy are expected to number 25% of thetotal admissions. But it should be noted that even if thenumber exceeds this figure, the total expenditure of thegovernment on medical education is likely to be reducedand not increased from the present level of expenditure.However, if the situation demands the government, throughthe nationalized banks like State Bank of India should offereducation loans to the students which will be repaid fromone year after completion of education, over a period of 10years. (This factor will have to be taken into considerationwhile determining the salaries of the doctors in publicsector and will be discussed later.)

If legitimate principles of income and expenditure are strictlyfollowed, I expect that fees for the medical education may notexceed Rs. 1 lakh per month. In addition this financial regulationwill help a good deal to improve the standard of medicaleducation. It may also help in reducing the overcrowding ingovernment teaching institutions.

Free treatment is the Costliest treatment, with poorestreturns.

Free treatment is becoming the costliest treatment. Theresults of free treatment in public hospitals are disastrous.Neither the doctors nor the students nor the patients becomeaware of the cost involved in the management of the disease.This is the most disastrous effect of the so called free treatment.



Secondly as explained, earlier if the hospital budget is spentthrough tax money, hardly 13 to 15 paise remain available for theactual hospital expense from every rupee collected by taxation.If the money was collected in one form or the other more directly,the effective amount available for the health care system wouldbecome two to three times more than what is available now. Thethird adverse effect of the free treatment is that the wholemanagement is in the hands of bureaucrats who have very littleknowledge and expertise in this field. The allocation andutilization of the funds, therefore, is very haphazard. While C.Tscan and M.R.Is. are installed, the simple drungs like anti T.B.drugs, antibiotics etc. are not available for the patients. But theworst effect of free treatment is that the medical professionalswork on a fixed salary 'that too quite meagre, compared to thenumber of years they have spent and efforts they have made toqualify. So, many ethical and able doctors leave the paid jobsand enter the field of private practice which is considered bothlucrative and satisfying. Those who remain, work withoutenthusiasm or zeal. As long as the medical officer attends ontime, it makes no difference how much he works and howdifferent he is qualitatively from the others. The fixed salary, totallack of incentives and extremely poor administrative supervisionresult in totally demotivating the doctors. They get very poor jobsatisfaction and such demotivated doctors with fixed pay cannotserve the people properly. In fact, many develop a severeantagonism to the very patients they serve and this getstransmitted to their juniors and students. The laxity inadministration makes it very easy for the same doctor to look forthe greener pastures, start private practice (allowed or notallowed by rules of service) and earn directly. This again makeshim even less available in his primary field of governmenthospital or medical college hospital as the case may be. As theincome of the doctor is totally independent of the service herenders or the satisfaction of his patients, the most neededdoctor-patient relationship never develops. Thus, he becomesapathetic and oftentimes quite rude while treating his ownpatients. On the other hand as the patient himself never pays forhis treatment, his own (idle) expectations keep rising without hisown inputs. In our democratic set up, the number becomesimportant and the large population or their leadership keep

demanding more and more facilities. The medical 'market' isalways too eager to sell, keeps advertising more and more aboutthe newer equipments, drugs, prosthetic supports etc and thepoliticians and the beurocrats easily succumb to the pressurefrom both sides. Thus, the government hospitals keep addingcostly equipments without considering whether they are going tobe really useful to the people. The limited resources availablewith the government are thus spent on unnecessary modernequipments leaving no money for spending on the more essentialsimple drugs and equipments. While a free class patient may gethis C.T. scan or endoscopy free, he has to pay from his pocketfor the simple investigation of haemogram and blood sugar. Moreoften, the free C.T. Scan or Endoscopy is usefully exploited bythe influential or affording class, leaving the poor where they are.He has to buy medicines from his pocket for his diabetes, bloodpressure or antibiotics for his infections. This paradox is seenevery day in almost every hospital throughout the country. Yet itis not realized that the root cause for this paradox is the so calledfree treatment as explained in details above. Therefore, thissystem needs to be drastically changed.

It is not, as though the system of, doctors on a fixed salarybasis, can not work at all. But such a system of ‘paid’ doctors canwork only if the management is excellent. The management hasto define the role of each doctor, and each strata very preciselyand set up defined targets for every specific aspect of his work.It must have an excellent ‘feed-back’ system and must getmonthly reports (verifiable through good supervision) about theperformance of each item and work through is M.I.S.(management information services) as it is called such reportsmust be to give salary rise or promotion (or demotion ordismissal). An additional ingredient required is honesty andintegrity among the majority of the administrative andprofessional staff. With adequate salary structure along with suchsuperior management skills, the system of salaried workers(doctors) can certainly work. We are nowhere near this.



11 Selection ofMedical Techers

The choice of the medical teachers leaves much to bedesired. As per the Indian Medical Council rules, there arebroadly three categories of medical teachers – lecturer, reader(variously called Assistant professor, Reader, Associateprofessor etc. from time to time) and the professior. Postgraduation in the subject and the teaching experience of threeyears as a senior resident or equivalent are the minimumqualifications to become lecturer. Three years' experience as alecturer qualifies him to become a reader / Associate professorand after five years as Associate professor he can aspire to bea professor. Generally this appear to be on par with thestipulations in the western countries. There is always a big rushof qualified post graduates to become a lecturer, not becausethey like the teaching professon but because they wish to gainfurther experience in their own field of speciality. The applicationsfor the post of reader / associate professor are far less andsometimes it is difficult to get the post of a professor filled; theapplications are so few. Meagre salary, bureaucratic attitude,lack of incentive and poor job satisfaction are the main reasonswhy the consultant doctors are not attracted to the field ofeducation. I have also suggested that if these consultants fromthe level of Associate professor onwards, are allowed practicewithin the premises, that may be sufficient incentive for many ofthe consultants who are academically oriented or are not happywith the many gimmicks and marketing and unfair medods theyhave to adopt in private practice. But today it is a discredited fieldbecause of lack of incentive and inappropriate infrastructure. Butnot every one is inclined to practice and there are a few who aregenuinely interested in teaching and research and it is necessarythat the medical college hospitals-government or private – shouldencourage those who are truly interested in teaching and / or

research. The lure of private practice whitin the premises for suchconsultants is unproductive. For them some other incentivesmust be available.

There are three desirable types of medical teachers. The firstone is 'practice oriented'. They mix the art and science of clinicalpractice and render good medical service to the patients. Thiscategory is in the largest number. But as I mentioned earlier,many of them leave medical college hospital and enter intoprivate practice which is more lucrative and more satisfyingthough more intriguing. Actually these teachers would have beenan ideal example for the students to learn from and it is for thesake of retaining such consultants in the field of medicaleducation that I have suggested private practice within thepremises with 25% of the beds reserved for the paying class,Private practice allowed outside hospital premises isdisastrous not only because the medical teachers are out of thepremises for practice but, in addition, they develop too much ofcommercialization. In turn, they neglect their duties in the medicalcollege hospital and thus become the worst examples for thestudents to learn from. Unfortunately, such a system of allowingprivate practice outside the premises is advocated and allowed inmost of the government and private colleges due to the advice ofthe accountants and bureaucrats who are highly satisfied by thereduction of expenditure on the medical teachers. Besides, itrelieves them of a big administrative burden. In the municipalmedical colleges, for example, nearly Rs. 15,000/- to Rs. 20,000/-per month are saved per each consultant if he opts for privatepractice. Totally, in the eyes of the accountant, the corporationwould save around Rs. six to eight crores. But they forget that thesame teachers would have earned much more than these20.000/- rupees per month and further brought another two lakhsof income to the hospital, if practice was allowed within thepremises. In addition, the true benefit is the improvement in themedical education which will benefit the society for the next 2generations in the form of better doctors coming out from thehospitals. This has been discussed in great details earlier. Butthe administrative burden on the accountants and bereaucratswould rise five fold. The second type of teachers who are equallydesirable are teachers who read a lot and are truly interested inteaching. Every good teacher may not be a good practising

Selection of Medical Teachers


clinician, just as the best directors are not the best actors and thebest coaches are not the best players. Teaching is a different artaltogether and such teachers who are academically oriented andhave enough art of teaching must be sought after. Similarly someamongst them may be deeply interested in research work andshould become assets for the institution. The teachers who havetruly come for teaching or for research are very few in Mumbai.Hardly 20 percent of the teachers at the most can be expected tobelong to these two categories. They need different incentive. Asmentioned earlier research workers can be encouraged to utilizethe grants from the pharmaceuticals or I.C.M.R. funds and thecollege itself must have enough funds available for research.Foregin institutions are pouring funds for good research.Unfortunately in the present system, while every worker under himis paid adequate compensation, the consultant teacher, himself,who undertakes the project is not allowed a single rupee for thework he undertakes. This is most unfair and may be the root–cause why most of the teachers are reluctant to take researchprojects. This also leads to clandestine practice of thepharmaceutical companies paying in the form of gifts, foreign tourand so on to the Chief Investigator, thus inducing research workersto give favourable results for the company. The disastrous resultsof such corruption in research are obvious and drugs andmedicines which can be harmful are finding their way easily intothe market. Substantial payment to the research worker directlythrough the grant will help to make research more fruitful andhonest. Similarly a good teacher must get adequate facilities towrite books and monographs. Writing books and monographsseparately for students, nurses, technicians etc. is a task in itselfand apart from too much time consumed for it, it is also veryexpensive. Hence, he should be provided with adequate facilitiesto write such books. Such incentives would go a long way toimprove the standard of medical education in the medical college.Both these classes of teachers deserve non–practising allowanceand other perqisites, subject to performance. Therefore theperformance of the medical teachers must be assessed, as per thespecific expectations from each category.

Performance Assessment of TeachersUnfortunately today there is no assessment of the

performance of the medical teachers. It is only a confidential

report of each staff member. The confidential reports submittedevery year are a big farce. Basically the annual confidentialreport was meant to ensure at least the minimum output of workfrom every worker. If there were no adverse remarks, he / shewas considered satisfactory. There was no added credit if theperson worked more satisfactorily i.e. if he gave very good orexcellent performance. The next promotion usually went withseniority. Of late, competitive selection (for example by M.P.S.C.or U.P.S.C. interview) has been introduced and 50% of the postsare filled by promotion and 50 % are filled by competitiveselection. However, if one looks closely into the method of the socalled competitive selection, it would be realized that there are noperformance criteria and no performance records on which theselection is based as mentioned earlier. The ability of medicalteachers needs to be assessed (a) by his clinical ability i.e.record of number of patients treated, number of differentdiseases tackled with their ultimate results. or (b) by his ability ofteaching; the performance of the students in differentexaminations; under-graduates and post-graduates or (c) by theresearch work that the teacher has done. This last i.e. researchpapers read or published is no doubt considered during theassessment for competitive selection, but the quality of thesepublications is not analyzed at all. In fact, ‘The pepers read orpublished’ being an important column in the application form,everyone tries to write or read some paper or the other in somejournal or some regional conference. Most of them are trash.There is no distinction between the papers published in ordinaryjournals as compared to the papers published in well knownjournals or international journals. It is necessary, therefore, tosubstitute the system of confidential report by aperformance record. It is important that the performanceassessment must be done separately for each of the above threequalities required of a medical teacher. Administrativecompliance, complaints or compliments from students orpatients, ability to organize and conduct allied activities likeseminars, lay education, participation in socially importantevents. clinical programs etc. could be the other facetsconsidered in the assessment of the teacher. Unless suchrecords are maintained and submitted to the selection committein such a form with objective data, the competitive selection



would remain a farce and at best, lead to the selection of morevocal street–smart applicants. The recent cases of massivecorruption in these (MPSC) selection boards are eye-openerswhich have failed to open our eyes.

Selection ProcessThe M.P.S.C. is so slow in its selection process that the posts

are not filled for years together and thus the vacant posts areonce again occupied, by seniority alone on temporary basis fromthe junior cadre. These ‘temporary seniors’ are continued for adecade or more. It would be preferable if the M.P.S.C. issubstituted by another formal organization specifically appointedby government to enroll medical personnel and otherprofessionals in the government organization. The confidentialreports must definitely be replaced by the more objectiveperformance record in which the performance of each would begraded as excellent, very good, good, satisfactory andunsatisfactory. It would be an excellent idea to inform everyemployee his / her performance report. This will help him-if he isdissatisfied, to protest and to put forth the objective data to gethis report corrected. On the other hand, if he knows that hisperformance is good it will encourage him to do better. If hisunsatisfactory report is confirmed, he knows definitely that he hasto improve or perish. Such report once confirmed by the seniorauthority must be seriously considered at the time of competitiveselection. Thisway some junior teachers may supercede thesenior inactive teachers; and that will help to improve the medicalservice and medical education. It will create a fair competitionamongst the teachers. During my tenure as Dean, I had done asmall experiment and adopted this procedure. The then assistantcommissioner Mr. Karandikar was also very keen to promotemerit. Those employees whose work was declared just‘satisfactory’ but did not have a record of ‘good’ or ‘very good’ foratleast 2/3 rd of the period in their present post were deniedpromotion. The result was dramatic. Every lecturer and readerstepped up his/her performance and was keen to prove his/hermettle. Personally I conveyed the performance record to eachand every member of the medical faculty. Those reports werepersonally prepared by me and were given as confidential letterspersonally to each of them. Thus, the confidentiality was alsomaintained, as required under the present rules. It was only the

employee himself who could divulge his performance report toothers-otherwise it remained confidential. There was anotherunexpected but highly desirable result. Earlier when only theadverse remarks were conveyed to a few of the members, theyraised a lot of noise and complained bitterly about ‘partiality’‘corruption’ and so on in their conversation with other colleaguesin the common room. All other members of the staff, not knowingwhat their own report was, promptly sympathized and theassociation of the teachers jumped on the authorities concernednamely, the Dean or the Commissioner to get the reportsannulled. When I gave their performance reports stating clearlywhere they stand, a large majority, who now definitely knewabout their own good report, were totally reluctant to join thosefew who received adverse remarks. Thus, it was much easier todiscipline the teachers and make them perform their duties well.Unfortunately, after Mr. Karandikar left, as usual, seniorcommittee members raised many objections and the practicereversed back to promotion seniority-wise. The committeedoubted every adverse report. Yet this small experiment-even fora couple of years-has convinced me that if objective data arerecorded, performance reports are prepared and submitted toeach member separately (and confidentially if necessary) and ifthese reports are used seriously at the time of promotion, it hasa highly desirable effect. A competitive spirit develops andmedical services improve. Besides the whole process isextremely transparent as rightly demanded by the association ofthe employees. As discussed earlier every one need not to be agood clinician but every teacher must show proficiency aleast inone or two desirable qualities of a teacher namely, clinical workand / or teaching and / or research. This will also help in ensuringthe balance between academically oriented teachers andpractice oriented teachers.

Mandatory number of medical teachers required are clearlynotified by Indian Medical Council. In large cities where the workload in the hospital is high, the number of clinical teachers isshort of the real need in clinical subjects. At present oneprofessor, one associate professor and two lecturers, togetherform one unit and are allotted 30 to 40 beds for their clinical work.There are atleast 6 to 7 resident doctors who are doing theirpost-graduation; 2 students every year for a 3 years’ course.



They work and move around together all the while. Therefore, thetotal numbers in a unit are too many. Actually, they were notmeant to be flocking. It would be more advantageous to have oneprofessor, one lecturer along with 3 resident doctors to form acompact sub unit and the associate professor along with onelecturer and three residents to form another sub unit. This waythe role of each member will become more defined and all ofthem will have adequately defined work. Howeven, in general itcan be safely assumed that the number is too small to cater tothe large number of patients attending medical college hospitals.As the pay scales of the teachers are being raised from time totime and as the hospital earns zero revenue, managementsincluding those in the government become reluctant to appointeven one additional teacher than required by M.C.I. and if at allmore teachers are enrolled, the expenses rise. That results inhigher fees for medical students. This peculiar viscious cyclenaturally affects the quality of medical care given to the patientsin medical college hospitals. Regrettably no one is worried andthe authorities point their fingers to the Indian Medical Councilrules in justification of less number of teachers. The onlyexception appears to be the large reputed hospitals of medicalcolleges in Mumbai where number of teachers have gone upmuch above the stipulated numbers of Indian Medical Councildue to the public pressure. This inadequacy of qualifiedprofessionals in the medical college hospitals can be correctedby appointing part-time or honorary qualified professionals tohelp in the services in the hospitals. The Medical Council stronglyobjects to the appointment of part-time or honorary doctors asteachers. I, therefore, make amply clear that qualified doctorsthus appointed will not be called ‘Lecturer’, ‘Associated Professor’or ‘professor’. They will merely work as ‘Honorary Surgeon’ or‘Honorary Physician’. the appointment of the honorary or parttime consultant – one in each unit – will help a lot both inimproving the medical service as well as medical education.There are many successful consultants in the city doing goodmedical practice. They cannot be successful unless they haveproper grasp of the art and science of the branch in which theypractise. No doubt that there are some successful consultantswhose success depends only on their business acumen. Theseare ‘commercially successful’ doctors. It will not be difficult for a

good management to differentiate between the really competentdoctors and the commercially successful doctors. Experience ofthese competent doctors or the skill in their hands and theircapacity to observe and interprete the signs and symptoms of thepatients will make an excellent example for the medical studentsto watch and learn from. As mentioned earlier, good teachersmay not be skilled clinicians or surgeons but even their ownteaching ability will increase by observing such skilled colleaguesright in their own unit. Similarly retired or most eminentconsultants who have highly specialized knowledge could beinvited as emeritus professors. They will examine and treat suchpatients as are specifically referred to them by the concernedunit. The idea is to have the actual demonstration in theirrespective highly specialized field for the under-graduates andpost-graduate students. In fact, such a practice exits inengineering, law colleges and IITs. Many industrialists orprofessional experts are invited to give lectures, and many visitsto successful industries / institutions are arranged. There is noreason why similar practice could not be started in medicalcolleges. Today jealousy and the bureaucratic stiffness are theonly reasons why this is not practiced in medical colleges but itis high time we do so. The addition of honorary consultant in theunit will help to minimize the expenditure as well as to relieve theburden of increased workload in the hospital. Besides, they willbe able to claim teaching experience and become eligible to belecturers, associate professors or even professors at the end often years. The availability of such senior teachers will enable theteaching institution to overcome the acute shortage (of seniorqualified teachers). It will help to replace 'old dead-wood' by freshcompetent professors and associate professors. Thus, there willbe three consultants including three resident doctors, and anhonarary surgeon or physian in each sub-unit. Highly specializedemeritus professors can also help and guide the unit in theirmore complicated cases and impart deeper knowledge incomplicated cases.

As exphasized earlier they are not designated as teachers,therefore, they cannot set the question papers or becomeexaminers. Beyond demonstrating and imparting their knowledgeand skills to the students who desire to learn from them, theyplay no direct role in the mandatory medical education system.



12Working

Pattern in(Med. College)

Hospital

It is evident from all the discussion so far that to run a goodmedical college, it is absolutely essential to run a good hospital.The administration of the hospital, therefore, assumes greatimportance in determining the standard of education in theinstitution. Unfortunatley the importance of the ‘system’ or‘management’ is not realized even by the very educated class -leave apart the politicians and journalists. Individuals are blamedfor shortfalls, but the system under which individuals are workingis not even remotely discussed. So the blame falls on individualdoctors if the services are poor. Occasionally individuals areglamorized if they perform something exceptional but the systemof working which enabled the individuals to work properly istotally ignored, if indeed it was contributory. It must be realizedthat it is the system of working that promotes good workers ormakes them to leave the institution and it is the system whichgives a wide scope to the inefficient, corrupt persons if it is faulty.Therefore, we have to consider a little in details how the hospitalworks or must work.

Every employee-and medical teachers or doctors are noexception-wishes to minimize his work and find idle space duringhis own working hours; though he wishes to earn the maximum.Minimum work for maximum salary is an accepted principlein the present scenario. The task of the management,therefore, is to work against this tendency and ensure that everyworker gives his optimum, if not the maximum, output of the work

Yet they will contribute a lot to the standard of treatment andeducation in the medical college hospitals. The service willimprove and the education will become more practically oriented.To me this step is as important as 25% paying beds in each unit.I do not expect Indian Medical Council to agree easily to such amodification. Technically and legally I see no reason why theMedical Council should object to the appointment of additionalconsultant doctor in each of the teaching unit. However, if councildoes object I feel it is time that the students, teachers and themanagement stand up and go to the court of law against theIndian Medical Council to support this system.


entrusted to him and to offer him incentives if he gives moreoutput than the average. Let’s look at the working of a clinicalunit. Every unit has only one day in a week for attending the out-patients. Emergency i.e. serious patients coming out-of-turn forurgent treatment to the hospital, are also treated by the same uniton that very day. Thus, resident doctors and junior consultantsremain busy examining large number of patients that come to theoutpatients department, while at the same time they are called toattend to urgent cases admitted directly to the ward (or throughthe critical care units, if such were established in the hospital). Inaddition patients are referred from other branches, for example,the surgeon may be called to see a patient in the medical wardor a female patient in a medical ward may require an opinionfrom a gynecologist. The cross references are plenty everyday.Again the same doctors of the same unit attend to thesereferences of other braches. On the surgical side small urgentoperations like incision of an abcess or reduction of a fracturehave to be performed on the same day in the evening hours.Some patients in the outpatients department may require smallnon-urgent operations and could be sent home without beingadmitted like a biopsy or removal of a cyst and so on. Againthese operations are done on the same O.P.D. day after theO.P.D. hours are closed (the cards are given to the outpatientsgenerally from 8.00 a.m. to 11.00 a.m. and the last patient isseen by about 12.30 p.m. to 1.00 p.m. Thus, the team isengaged with multiple duties on the same day. At the sametime many patients are admitted from O.P.D. and yet some moreserious patients are admitted as emergencies from Casualtydepartment. Therefore, the day becomes too heavy as thepatients are being admitted whole day long till 8.00 a.m. nextday. All these patients as well as emergency cases must beexamined and treated, their histories are to be recorded,investigations are to be done and so on. Therefore, the next daybecomes heavy too. But for the next four days, the juniors andseniors in the non surgical units, have no other specified dutyexcept a round of indoor patients which may last about two tothree hours. So, they are relatively free on all the four remainingdays of the week. In the surgical department there are twooperation days in a week which keep them busy. But again atleast two days remain when the specified duties are very few and

the team has a lot of time to spare. The senior residents and thelecturers are expected to take tutorials for the under graduatestudents and it is strange that they prefer the same emergencyday for taking tutorials as ‘they have to stay the whole day in thepremises in any case.’

Thus, the pattern of working has been made most suitable forthe doctors but not necessarily suitable either for the patients orfor the medical students. Seniors and residents are always busy,everyday, somewhere between 9.00 a.m. and 12.00 noon, whenthey take a round to see and decide the treatment of all indoorpatients. The medical students too are given bedside clinicsduring the same hours right in the wards and as mentionedearlier, this is the main part of the teaching of the medicalstudents. Nine a.m. to twelve noon is the time specificallyreserved for indoor or outdoor patients and for teachingundergraduate students in the hospital. But there are many alliedactivities like clinical meetings, functions like hospital annual day,guest lectures by eminent professionals from other parts of thecountry or from the foreign institutions, or there are meetings ofthe various committees like Drug Committee, purchasecommittee with the Dean. Invariably all these lectures as well asadministrative meetings and hospital functions etc. are all held inthe morning hours somewhere between 10.00 a.m. and 12.00p.m. it is exactly this time which is easily spared for any functionor lecture or meeting etc. Afternoon hours are more or less leftfree, so every one retains these leisure 'working' hours. Whendescribed in details, it looks obvious that the working system isnot proper and needs correction. The various functions need tobe redistributed over the whole week. Yet I am surprised thatenough attention is not given to change the system.

In the modern days the need for hospitals is becoming lessand less and many patients can be treated without beingadmitted. Such procedures are termed as ‘Office Procedure’ or‘Day Care Surgeries’. Therefore, the outpatients departmentneeds to be expanded a great deal. It is no longer just a roomfor consultants. There is a need to have a minor operationtheatre or procedure room and a few beds to keep the patientsfor a few hours right in the OPD. If such a system is to befollowed, it is obvious that the team of doctors attending the OPDcannot have any other duty like attending emergencies. There is

Working Pattern in (Med. College) Hospital


also a need to group the patients and call them at different hoursso that every one gets proper attention. For example, patientsreferred from peripheral hospital or primary health centre,dispensary etc. have to be given a specified time as they arerefered by qualified doctors and from the same governmentadministrative machinery. So it is advisable that patients comingdirectly to the hospital may be attended say from 8.00 a.m. to10.30 a.m. while patients referred from various peripheral centresbe attended from 10.30 a.m.to 1.00 p.m. Non urgent minoroperations need not be rushed through on the same day. Theseminor operations can be conveniently done by appointment, on aday prior to O.P.D./Admission day. The team is relatively freeafter morning rounds in the wards and the patients will be easilyfollowed up next day in the O.P.D.. Urgent minor surgicalprocedures have to be completed in the evening on the O.P.D.day as is the practice today. But this clinical unit which isattending to the outpatients department will not have anyemergency duties nor will it examine any referred cases onthat day. This way the team will also have adequate time toexamine the cases which have been admitted as routineadmissions from the OPD and write their history properly andplan their investigations. Emergencies will be attended andreferred cases will be seen by a unit which has only the routinehospital round duty i.e. by the corresponding unit. For example.If ‘A’ unit has outpatients duty on Monday, ‘D’ unit will be on theemergency duty on Monday Again, ‘D’ unit will have OPD onThursday and ‘A’ unit will attend emergencies. Mondays andThursdays are corresponding days. This way emergencies will belooked after promptly and immediately because the team has noother specified duties. Similarly it must be a strict rule that seniorresidents or lecturers will not have any routine teachingprogramme like tutorials, demonstrations, lectures etc. on theirOPD and emergency days. Tutorials will be taken in theafternoon hours, on any of the non – OPD / non – emergencydays. Secondly it is unclear why the doctors of a unit areavailable to his O.P.D. patients only once a week – that too forjust 2 hours. In private hospitals, consultants are available almostdaily for the patients for their follow up treatment. So it isparadoxical that in the medical college hospital, the patient cansee his own doctor only after one week, as there is only one OPD

day for each unit. This is intolerable. There is a definite need tohave afternoon OPD clinics of about two hours twice a week forthe old patients for their follow-up advice and treatment. This isespecially needed in the medical departments, where they canhave follow-up specialized clinics like ‘diabetes clinic’, ‘cardiacclinic’ and so on, in addition to the general follow–up clinic.

In short, every clinical unit has multiple duties1) OPD duty2) care of indoor patients,3) looking after emergency and referred cases,4) formal teaching duties like tutorials, lectures etc.5) writing histories and keeping proper medical records and6) follow up of old patients. In the surgical departments, the

unit has to perform actual surgeriesa) minor day care emergency operations;b) minor day care routine operations;c) routine major operations on the indoor patients andd) the emergency operations. These duties and operations,

must be conveniently spaced in the whole week so that the teamis answerable to one duty at a time. This also ensures that theteam is busy in its clinical work every day for all the workinghours. As this increases the answerability of the team, clinicalservices are bound to improve a good deal without many modernequipments. Medical education would also improvesimultaneously, if only the system is changed and accountabilityis increased.

If 25% of the beds are reserved for paying class, obviously theseniors in the team will have their paying OPD clinic andoperations in the evening hours, twice or thrice a week. However,they will not have any (private) paying clinic on their emergencyday and only follow-up clinics on their operation days. No newcases on these days. They can see all new cases on any of theother days.

In short, the specific duties of every clinical unit must bespecified. No one can perform two duties at a time. If allottedmultiple duties at the same time the answerability of any worker-not only doctors-is reduced. Hence, the time table should bearranged in such a way that every one is entrusted with only oneof the duties at a time. The brief pattern of duties is shownbelow :-



(If need be, Hon./Part-time Asst. Surgeopn in each sub-unit In OPD-one resident will sit with one consultant in each room.

Working Schedule (Major Departments)

Sub-Unit 1A(Monday OPD)

ProfessorLecturer

Sr. Registrar1st, 2nd, 3rd Year

residents

Unit 1

Sub-Unit 1B(Thursday OPD)Asso. Professor

LecturerSr. Registrar1st, 2nd, 3rd

Yearresidents

2A(Tues-

dayOPD)

Unit 2

2B(FridayOPD)

3A(Wednes-

dayOPD)

Unit 3

3B(Saturday

OPD)

Typical Time Table of a unit (Unit 1A) - Medical

Unit 1A Monday Tuesday Wed. Thursday Friday Saturday Sunday(Day 1) (Day 2) (Day 3) (Day 4) (Day 5) (Day 6)

OPD Day Grand Spel. Emerge Follow Winding ByRound Clinic ncy Day up up Day Rotation

8 am to Gen. & Ward Ward Ward Ward Ward E11 am refered Round Round Round Round Round & M

OPD Clinic E

11am to Direct Palnnig Ward Clinic + all R1pm (Semi-Pay) Ward Clinic & records G

OPD Clinic E1 pm to N

2 pm

2 pm to Minor Minor Special Follow-up Specl. C3.30 pm ProcedureProcedures Clinic I O.P.D. Clinic II Y

(Emergn.) (Planned) +follow-up

4 pm to Ward Day6 pm New Adm.

Investig.

6 pm to Private8 pm OPD

(Consul.)

8 pm to Joint P. G. Programs, Seminars & Discussions etc.10 pm

EMERGENCIES

Routine Clinical work for general patients stops at 3.30 pm4 pm to 10 pm reserved for private patients.4 to 6 pm & 8 to 10 pm - Private OPD for other consultants fromother unitTuesday & Saturday - 5pm to 9pm Operation day for private patients- Unit 1 ASimilar Timetable for all units

Tyfical Time-table of a Unit (Unit 1A) - Surgical

O

P

R

A

T

I

O

N

S

O

P

R

A

T

I

O

N

S

E

M

E

R

G

E

N

C

Y

Unit 1A Monday Tuesday Wed. Thursday Friday Saturday Sunday(Day 1) (Day 2) (Day 3) (Day 4) (Day 5) (Day 6)

OPD Day Grand OP. Day Emerge Post. OP Winding ByRound ncy Day Day up Day Rotation

8 am to Gen. & Ward Ward Ward11 am refered Round Round Round &

OPD % Clinic

1pm E

11 am to Dieect O.T. Clinic minor1 pm (Sem- planning M operation

paying) Ward E in OPDOPD Clinic (Planned)

1pm to R E C E S S2 pm

2 pm to Ward OPD Follow-up Sp. Clini3.30 pm New adm. Sp. OPD follow-up

Investig- procedure Ration

4 pm to Minor Office G Day6 pm Opera. & E

(Emerg) records Ne.g. abscess C

6 pm to Private Y8 pm OPD

(Consul.)

8 pm toJoint P.G. programs, Seminar, Discussion etc.10 pm



13 The Dean

The head of the medical college hospital is Dean. A personwho holds the post of professor is eligible to compete for the postof the Dean after five years of experience. The Dean is anacademic post. He comes from amongst professors who areexpected to be masters in their own subjects. As I had discussedpreviously, these professors ought to be good either in theirprofessional work or teaching or research. It is pertinent to notethat the teaching staff does not have any formal training inadministration. They do not attend any training course-not evena few lectures-to understand administration. The professor whoheads the department i.e. senior most amongst professors ineach department learns some administration out of compulsionbecause he is forced to take part in the administration.

All this clearly proves that the post of Dean is an academicpost and his primary duty is to promote good medical education,research and provide good medical services to the patientsthrough properly supervised system of clinical practice. It issurprising, therefore, that such an academic person is suddenlyforced to spend 90% of his time in purely administrative aspectsof running the hospital. On the other hand, there areadministrative posts in the colleges and hospitals like AssistantMedical Officer (A.M.O) or Assistant Dean. (now a days calledAsstt. Commissioner) who look after all the administrativeaspects. For them the ladder stops at the post of Asstt. Dean.They are not eligible to apply for the post of Dean. Similarly, nowpeople are getting trained and qualified in hospital administrationand/or business administration, and others obtain degrees inI.I.M.s. or do financial management etc. or become masters inadministration. It is a crime to waste medical talent on theadministrative duties which he normally does not understand fullyand to waste the talents of qualified administrators by not

appointing them to do the administration.Even in India, in Triruanantapuram, Kerala e.g. the Dean has

his office in the medical college which is about 2 to 3 Kms. awayfrom the campus of medical college hospital. The hospitalcampus is managed by hospital superintendent. In institutionslike All India Institute of Medical Science (AIIMS) of Delhi orChandigarh, the Dean is an Academic Head and is not burdenedso heavily with the administrative duties. The hospital is lookedafter by another person. It is high time that the hospitalmanagement should be entrusted to the qualified hospitaladministrators; MBAs or even graduates from Institute ofmanagement. The problems and solutions which I am trying toemphasize here will be easily understood by the IIM graduateand they would easily surpass the ideas mentioned herein.

The Deans, apart from the academic activities, should beinvolved in the administration only to the extent of major policydecisions like budgetary provision for each department, purchaseof additional equipments for various departments either tomaintain the present services or for expanding the services. Day-to-day routine administrative problems must be dealt with by theadministrative person appointed for that purpose. He need not bea medical professional.

What is true for the Dean ought to be true for medicalsuperintendents in secondary care hospitals in muncipalities ordistrict hospitals in the state governments. The medicalsuperintendent ought to be concerned with the clinical aspects ofadministration namely, appointment, supervision and maintainingperformance records of all medical and paramedical personnel.He has to plan the schedule of working, emergency duties, etc.of clinical departments, as also the need for more equipments formodernising the medical services. But all the purelyadministrative functions of the hospital like maintainence andrepairs of buildings and equipments, electrical and civil workadministration of the meniral and entire staff, salaries and leavesmust be the function of an administrative officer who may besuitably called hospital superintendent or chief administrator.

Similarly, the financial management of the hospital must beentirely relegated to the Chief Accountant or Financial Manager.The entire staff at the registration, billing and medicine supplycounters must work under the chief accountant, In the

The Dean


14 MedicalCurriculum

I would not go too much into the details about the curriculumfor the undergraduates. Basically a student used to spend 1 1\2year to learn normal structure and function of the body i.e. thestudies of anatomy, physiology and biochemistry during theperiod of first MBBS. Another 11/2 year in second MBBS wasdevoted to the study of diseases of the body and drugs andmedicines to be used for the patients – pathology andpharmacology. He also studied medico legal aspects in thesubject of forensic medicine. The students are posted in thehospital in the morning hours from 9.00 am to 12.00 noon afterthe completion of the first M.B.B.S. for a continuous period of 3years. They attend various departments as per the schedulerecommended by the Indian Medical Council. It is here that theyget maximum practical experience by observing patients beingtreated both in the ward as well as in the out patients department,through bedside clinics by the senior teachers. The knowledge ofpreventive medicine, ENT (Ear, Nose and Throat) andoptholmology (eye disease) are studied in the 3rd MBBS duringthe fourth year while in the final examination 41/2 years later, thestudent appears for Medicine, Surgery, Obstetric & Gynaecologyand Paediatrics. If the student passes the examination, he isexcepted to work as an internee for a period of one year, workingin the department of medicine, surgery, obstetrics andgynaecology and preventive medicine wherein he works at urbanand rural health centres. Thus, it is long course of 51/2 years.There is a craze amongst experts of several new branches in themedical field to insist on including their portion in the curriculumof the M.B.B.S. course. Yet, despite criticism and shortfalls, andinsistence of new branches to add to the course, I personally feelthat the medical course as implemented for the last 50 to 60years or more is quite adequate. Unfortunately the Medical

government and muncipal set-up. The accontant in notanswerable to the Dean and has almost the same independantpowers as the judiciary has, in respect to the collector of thedistrict. At present, this semi-independant authority of theaccountant is playing more obstructive role than constructive rolein the hospital management. They are not responsible for anyshort-falls in the services. Yet they have the full authority to raiseaudit objections for purchases - for that matter - for anyexpenditure proposed by the superintendats. I have alreadysuggested, in an another chapter, that the registration and billingdepartment should work under the accountant, so that thedepartment will be responsible to show adequate collection of thecharge from the patients. If the Dean or the superintendent is notanswerable for the collection of the fees for medical services orthe charges of investigations or medicines supplied, they will alsobe freed from the pressures from politicians and relatives toreduce the charge. And the chief accountant will becomeanswerable to show adequate collection of charge on the onehand, and purchase of essential intems for clinical services onthe other. The obstructionist will now become practical andconstructive. Their answerability towards proper functioning ofthe hospital will increase. A major problem of successfullyrunning medical services will be solved.


Council has decided, of late, to reduce the first M.B.B.S. courseto just one year. One year is too short a period to learn thenormal structure and function of the body. The period getsshorter due to the fact that admission process gets prolongedevery year and the students get admitted to the college as lateas in September instead of in June. Thus, the period for theactual study of anatomy and physiology turns out to be hardly 7to 8 months. Unless the basic knowledge of normal is sound, theabnormal cannot be grasped. It is the opinion of almost allteachers that shortening the course to one year for first M.B.B.S.is not adequate. It should be reverted back to 11/2 year at least.Secondly, the habit of condoning the shortfall in the period ofeducation must be strictly prohibited. If the students get admittedin the month of September they cannot appear for theexamination in the month of April of the next year and will haveto appear at the next term namely October (or November). It istrue that admissions are delayed for no fault of the students butthe fact remains that the period of training was not completed.The same thing is true when the absence is condoned for finalM.B.B.S. examination for reasons such as illness, strike and suchother circumstances. It is unpardonable. Period of training asscheduled is the most minimum that is required to train him tobecome a good matured doctor. Hence prolonged absence dueto any reason, however genuine, is not pardonable. The ill effectsof partial training are finally suffered by the population at large.As regards the curriculum of the other branches of medicalfaculties-Ayurvedic, Homeopathic, Unani etc.. It is an establishedfact that most of them do practise allopathy to a very large extent.To some extent this has helped the community because 80% ofthe general practitioners now belong to these other faculties ofthe medicine. Therefore, it is imperative that their curriculum isadjusted to include atleast two years of allopathic medicineduring their course. The exposure to the allopathic system forthese students at present is too inadequate. Exposure toallopathy for two years would be akin to creation of a ‘basic’doctor with the training which is much below the standard ofM.B.B.S.; however, adequate for basic needs of the large poorpopulation.

The Indian Medical Council is strongly opposed to the idea oftraining an ‘inferior’ type of doctor and has thwarted the efforts of

the politicians to create three years, four years programme atvarious times. However, the same council stands helpless whenthe graduates of the other faculties practice allopathy freely asmentioned earlier. Therefore, I feel that increasing their exposureto the allopathy for a period of at least two years is a goodcompromise-solution to the present problem of shortage ofgeneral practitioners for the community especially in rural andsemi-urban areas.

After completion of internship, the M.B.B.S. graduates are nowcompelled to appear for a common competitive test if they desireto enter into postgraduation studies and become specialists invarious branches. Nearly 80% of the students desire to do post-graduation. Earlier there was no such competitive (C.E.T.) testand the students were selected as postgraduate students invarious branches as per the marks obtained by them at M.B.B.S.examination. The competitive test has now added a new burdenon the students during the period of internship. Actually thisperiod of internship was the best time in the life of a medicalprofessional; some ‘donkey’ work but almost no responsibilityand no examination to face! It would have been the best time,when they could have been made to develope a deep interest insocial and administrative aspects of clinical practice, so that theywould be better prepared to face the competition in actual life andgive proper service to the community when they are thrown intothe field of medical practice as full-fledged responsible doctors.Men, money and material are the three ‘M’s, every body has tolearn to manage to become a professional. A glimpse of trainingof financial and personnel administration and administration ofmedical store could have been usefully included during thisperiod of internship, through lectures, seminars, visits to thesedepartments and discussion with the officers in the variousdepartments of the hospital – if only they did not have the burdenof competitive tests. A good perspective about socio-economicconditions and the psychology of the people in rural and urbanareas and of the poor and lower middle class would also help tomake these doctors more sympathetic to the needs of thecommon man, through lectures by competent social workers andteachers in social studies. As I mentioned earlier, majority ofstudents are now from the upper strata of the society and havevery little idea of how 60-70% of the population manage to live.

Medical Curriculum


Therefore, I suggest that the competitive test (C.E.T.) should betaken immediately after M.B.B.S. – say within 3 months after theM.B.B.S. examination. The portion for the competitive test is notdifferent from the portion for the M.B.B.S. test. The student hasto choose the subject in which he wants to specialize. Therefore,for this test examination, three months period after the finalM.B.B.S. examination is quite adequate. It would be an idealtiming when the graduate is quite fresh with his M.B.B.Sknowledge and can take another examination easily in his stride.The management course and socio-economic awareness coursecan now be conducted in the remaing 9 months. Even thestudents are aware of the importance of the subjects I mentionedabove, namely financial and personnel administration and socioeconomic aspects of society and most of them are very keen toundergo this training.

There is no need to have any examination. If one is taken, itwould be optional – for an individual to know the proficiency hehas reached. Lack of knowledge of the socio–economicproblems of the poor society is one of the root–causes of thealienation of the doctors from the masses; greed for money beingthe next important cause.

However, there is an absolute and urgent need to introduce apost–graduate course in General Practice. Like the other P. G.courses, this course will also be for the duration of three years.Today, there is no special training for a general practitioner. Notonly that, it is a gragedy of sorts, that those students who areunable to secure a post graduate seat in any speciality, finallydecide to go in for general practice without any special training.No wonder, the most important primary health care remains themost neglected aspect of health care system. with more andmore emphasis on 'super speciality modern medicine.' Ifspecialization was provided for 'General Practice' - M. D. (G. P.)it is quite likely that good students with good marks would opt forgeneral practice.

Like all other P. G. students, these students also will have athree year residency program. In the morning hours, from 8 amto 1 pm they will be posted, by rotation, in various departments,like Medicine, Surgery, Ob & Gyn.

Paediatrics Orthopaedic in one unit or the other, for a periodof 4 months each and will have an option of choosing any three

minor specialities for a period of 3 months each, like E. N. T.,ophtolmolgy, dermatology, psychiatry, preventive medicine, etc..Last 6 months, they will return back to general medicine. Whileattending these specialities, they will learn more about when toadimt and what is to be done after discharge as much as whatis being actually done for the patients in the wards. Naturally O.P. D. and follow-up clinics are mandatory. And in the evening,they will attend attached dispensaries, from 4 to 9 or do aNight duty in the dispensory.

Even ofter passing the M. D. examination and starting generalpractice, they could continue to work for a further period of 3years in any non-teaching secondary care hospital. The societywill gain a lot, if such matured doctors enter general practice afterdue formal training.

Finally, I firmly believe that super speciality departmentsshould have no place in the medical college premises. Theyhamper the flow of patients in general specialities. Also thegeneral specialists develope a tendency to refer and push, eventhe cases that they could have handled easily. This tendencywould no doubt, be curled to some extent, by evolving thecharges for consultants, as mentioned elsewhere. It would bewiser to establish super speciality centres, close to but not withinthe medical college and hospital premises.

Medical Curriculum


15Referal System

& ChargingPattern

Another important feature of the hospital system which isneglected totally is the way patients approach any hospital anytime. There is no step-wise ladder, hierarchy while approachinghigher medical centres as per the seriousness of the illness.Often the patients attend directly the medical college hospital ormajor tertiary hospital, but as many as 50% of these patientscould have been treated more conveniently at secondary centresor even primary centres like dispensary or primary health centre.Ideally the medical college hospital or any tertiary hospital shouldget only referred cases from the vast network of primary andsecondary centres established by government or private sector.I presume, it is so in developed countries. Thereby, the numberof patients to be seen at the hospital is limited and adequateattention can be given to each patient. At present, not only thereis an immense overcrowding, but there is no sense of guiltamong the attending doctors. The residents, full time doctors andthe public administration proudly mention that they treat 100 to200 patients or even more per day in their outpatientsdepartment. None realizes that it is not a matter of pride but is amatter of shame that such a large number is compelled to attendthe outpatients department during that short period of 3 to 4hours just once a week. Neither the care can be good nor canrecords be properly maintained. The medical college hospitalwhich cannot maintain proper records cannot be called as acentre of education at all. Therefore, there should be a system ofreferral for the patients to attend such hospitals. For example, inthe city of Mumbai, there are number of municipal dispensaries.Many of them have very poor attendance. Then there are

upgraded municipal centres and there are secondary carehospitals spread throughout the city. But not even 10% of thepatients are referred from these secondary care hospitals ordispensaries nor is it obligatory that the patients must be seenonly if referred by general pactitioners or peripheral centres inpublic sector or from private sector nursing homes. It is high timethat such a system is established. It could be fully justifiable totreat a patient with nominal charges (or even free of charge) if hehas been referred through the proper channel to the secondaryor tertiary hospital. If any patients is not relieved within a fewdays in any acute condition or within two to three weeks in anychronic condition, the doctor at the primary centre must refer thepatient to a consultant at the secondary centre or if the patient isconsidered serious enough directly to the tertiary centre i.e.medical college hospital or district level hospital. Similarlypatients not getting relief at the secondary centre within astipulated time or patient needing highly specialized, major caremust be referred to the tertiary centre by the consultants of thesecondary centre. Under the present circumstances, even thepatient may be allowed the right to present himself to such ahigher centre, if he is not satisfied with the treatment in thestipulated period. It could be further stipulated that patientssuffering from specified diseases like cancer, symptomatic heartdisease, burns beyond 25% or major accident cases with multipleinjuries or internal injuries must necessarily be referred to thetertiary centre, after getting urgent life-saving treatment atwhichever hospital he was seen first. Parameters for referral fromone centre to the other can be stipulated as best as one can andthey will get revised as years pass by, through review of data andexperience. Such patients who come through the proper channelmust be justifiably treated with nominal charges, as mentionedearlier (or even free, for the time being). However, many patientsmay not be willing to get treated at the lower centres and,therefore, would insist on coming to the secondary or teritiaryhospitals directly. Such patients, even if they attend generalOPD, must be charged about 50% of the charges as defined forthe paying patients. Also if the patients are referred from theprivate sector, they can also be charged upto 50% like thepatients coming directly. However, care must be taken that nopatient should suffer delayed treatment in this system. Some

Referal System & Charging Pattern


administrative steps would be needed to fine-tune the system butsuffice it to say that the system can be tuned to give adequaterelief to the maximum number of people, with a periodical reviewto improve the system. year by year. Secondly from each clinicalunit especially of the major branches like medicine, surgery,gynaecology, paediatrics, orthopaedic and ophthalmalogy,seniors could attend one such secondary centre once a weekand a consultant from secondary centre could visit a singleprimary centre so that the primary centre is ----- attached to thatsecondary centre, so-to-say. Lectures from medical collegehospitals could similarly attend up-graded primary centres once aweek. If this is done, after major part of the treatment at theteritiary centre is over, many of the patients from that particularsecondary centre could be referred back and then be followed upat that secondary centre without the need to come to the tertiaryhospital. Such a pyramidal system will improve the medicalservices for the general public, as also will pave way to disbursethe crowd of a tertiary centre to various smaller centres.Necessary clinical records at the medical college hospital cannow be maintained more easily and, therefore, clinical reseachwill also get boosted. Everybody gains and nobody loses.

So far, all attempt to charge the affording patients in publichospitals have failed basically because the charging pattern wasbased on the income slab and it was impossible to determine theexact income slab of the patient at the window of registration. Italso increased the work of the clerks, whose salaries andpromotions were unaffected, whether they collected the chargesor allowed the patient free treatment. Therefore, even when apatient declared his income above the stipulated limit, it was thevery office clerk who dissuaded him and advised him to declarehis income in the range of free treatment. The situation wouldchange in the new pattern as suggested above.(a)the charging pattern has been developed as per the patient’s

behaviour and his desire to get treatment out of turn.(b)There is a direct incentive for the senior consultants/medical

teachers, if they refuse to treat affording patients in thegeneral OPD and insist on their coming to the paying clinicand

(c)The burden of collecting adequate income for the hospital canbe put on the Accounts Section, by some steps. Basically, the

main step would be that the staff working at the RegistrationSection, responsible for ensuring proper collection of chargeswill work directly under the Chief Accountant and the ChiefAccountant will have a certain budgetary responsibility toensure that a fixed percentage of the total budget of thehospital is collected directly from the patients who receivetreatment there. This aspect need a more detailed discussionbut it is a complicated lesson in management and hence, I amavoiding the detailed discussion on it.

Referal System & Charging Pattern


16Service

Charges forPatients

When we think of the charges in hospitals for medicalservices, we must emphatically realize that there are two clear-cut separate components in them. One is hospital expensesdetermining the hospital charges and the second is the chargesof the medical expert / professional / specialist, the professionalcharges. Strangely the aspect of professional charges of thedoctors is ignored not only by government institution but almostequally by charitable hospitals and private hospitals who givefixed salary to their specialist doctors. Actually, it amounts to theMarxian thesis of buying the labour (of the doctor) and taking thefull returns of the product by the owner-the capitalist. Thescheme does not work in this situation. Besides it iscondemnable as far as any professional, be he a lawyer, C.A. orthe like. Hence a look at the pattern of payment to the specialistdoctors / medical teachers becomes imperative.

First the principle must be accepted that there cannot be ‘free’service from a professional. (Herein, we will restrict to theconsultants / specialists / medical teachers).

It is generally said that 80% of the doctors treat 20% of theaffording, affluent population while the remaining 20% of thedoctors are burdened with the responsibility to treat theremaining 80% of the non–affording population. What does itmean? Presuming that there are 100 doctors and 2000 patients.Eighty of these doctors are treating 400 people; the ratio ofdoctor : patient is 1:5 The remaining 20 doctors are treating 1600people. The ratio of doctor : patient is 1:80 That means he treats16 times more potients than the former. Presuming that theformer charge Rs. 100/- per patient (These figures are forshowing the proportion, not actual), for the latter, only Rs. 6 have

to be charged per patient, as he is seeing nearly 16 times thenumber of patients compared to his counter–part treating therich. In short, whatever be the average fees charged by thedoctors of the affluent class, a mere 6% of that amount will givethe doctor of the poor, an almost equal monthly income.Presuming that a little lesser income will do, it is difficult to digestthat a patient cannot pay rs. 5/- in small towns, where middleclass pays Rs. 100/- and Rs. 10/- in cities where the averageprivate charges are Rs. 200/- per visit. Even if it is presumed thatthe ratio has changed, and it is now 70% doctors for 30% affluentclass and 30% for 70% of the poor, the ratio rises to 15% of thecharges by the former class, or a little less - Rs. 10 in small townsand Rs. 20 in cities. As mentioned and as will be discussedfurther in detail, there will be a good number remaining who mustbe treated free of charge, but in the case of these, some one elsewill have to pay the professional fees. Either the government orthe many aid groups, trusts or N.G.O. s (including foreign NGOs.)or the students in the medical college must accept the burden ofpaying the professional fees. But in my opinion, professionalservices should never be free. They will be quite affordable toevery one under the system, I am advocating.

It is high time, medical and consultant associations condmn allso called ‘free medical camps’. They are farcical and no onegains, everybody loses.

It is very important to give particular attention to the incomeearned by the doctor in public sector and maintain it at acomparable level, if not the same level, compared to the earningsof his conter-part in private sector. There is an immense jobsatisfaction for a consenscious doctor while working for the realneedy ill patients. Besides these is a greater security and manylong term benefits in paid jobs and hence, he will easily acceptsome difference in his monthly income. But if the difference is toomuch, they are bound to leave the public sector or the medicalcolleges and crowd the private sector. That is what is happeningat present. Overcrowding of doctors in private sectorautomatically leads to unindicated investigations and operations,costly medicines given to the patients for favouring companies(for a price, of course), and all sorts of mal–practices seenrampantly to-day. It is not presumed that all these mal-practiceswould be totally corrected. They will be minimised to a significant

Service Charges for Patients


extent, as the public sector grows healthily on the soundprinciples of management. The healthy growth of public sectorwill create a healthy competition between the private and publicsector. Also, the contribution of the poor patients for their ownhealth-care, in the form of professional fees of the consultant, willhelp to retain many eapable consultants in the public sector field.

As far as the hospital charges are concerned, the poor strata,and the low income strata which largely seek medical servicescertainly need a lot of subsidy. Yet I maintain that the ser-vicesshould not be free, except for those below the poverty line, (aftersome sort of scrutiny and written exemption from an authorizedperson in the hospital). Nor should it be arbitrary, the so called‘token’ charges, for they have no correlation to the actualexpenses. If the ‘Gold-Card’ or ‘Smart – Card’ is issued to everycitizen of the country, (a scheme which Mr. Nilekani (of Infosysfame) has been given charge of,) it will become very easy todecide how much subsidy who deserves. But there are two waysavailable even at present. Costing is not difficult. At least a crudecosting exercise could be easily done for each of the services –O.P.D. visits, admission to wards, cost of X-rays and an averagecost of standard routine investigations, and for operation andprocedures. The new modern investigations like Endoscopies,C.T. Scan, I.C.U management will have to be individuallyvaluated. The costs involve(a) cost of original set up including construction cost and

purchase of equipments etc. for the first time(b) Annual costs including maintenance, repairs, and various

taxes to government, electricity, water bill etc.(c) The expenses on general staff from sweeper, wardboy to

nurses, technician and administrative staff;(d) specialized technical staff or specialized nurses in the case

of all special modern equipments;(e) consumables, depreciation etc. and(f) the junior doctors (excluding the consultant / medical

teachers, whose charges have already been dealt with)Of these (a) and (b) must be borne by the government. On

the other hand maximum effort must be made to collect thecharges of consumables and standard depreciation of theequipments. (e) This is the most minimum recovery of the totalhospital expenses incurred, which must be recovered. Then

depending on the socio economic status, the charges of (c) couldbe recovered i.e. costs of general staff and technical specialiststaff, as also (d) as will be applicable to sophisticated equipmentsand procedures, in modern high-tech equipments and must berecovered. As regards (f) junior doctors, it will be consideredlater. In general, till this exercise is completed, at least 10% to15% of the expenses in each section of services must becharged to every patient. The rest of the expenses be subsidizedby the government.

This is as regards taluka and district level hospital, theequivalents in mumbai and other large municipalities beingmunicipal hospitals. In the case of medical college hospitals too,free treatment in the general ward must be abolished and thepatients in the general ward must be made to pay proportionatecharges. As stipulated earlier, the medical college hospitalsshould get as much subsidy as the patients in district hospitals.But in addition, the students pay about 30 % of the expensesincurred on them. For reasons to be discussed, the studentsshould be paying, as much for their paying class patients (i.e.same as what they subsidise the general ward, in absolutefigures). The charges for general ward patients then would bequite manageable. For those who can not afford there are manydonor trusts, NGOs and religious bodies who are too willing tohelp patients in medical college hospitals or district levelhospitals. As far as paying patients in medical college hospitalsare concerned, it is accepted that the charges here cannot beand should not be equal to the charges in private sector. I havestated earlier that the patient who comes to the medical collegehospital is particularly at a premium because of the presence ofthe medical students and the necessities of teaching andresearch. Also marketing in the public sector is very poor andhence they will not be able to compete with hospitals in privatesector. They are expected to serve a relatively middle economicclass, not elites or higher middle class. Therefore, these payingpatients, too, deserve partial subsidy. Therefore, in addition tothe partial payment by the medical students, subsidy equivalentto a) & b) should be equally justified. Besides, both general andpaying class patients can get their investigations and therapyexempted (paid by the research company) if they agree to offerthemselves for the research projects.

Service Charges for Patients


17 Supply ofMedicines

In the private sector, nothing in free and the patient has tobuy his medicines. Food and Drugs Administration keeps acontrol on prices and quality of the drugs and within its limitedman-power and authority. it is doing a commendable job. I donot propose to discuss this aspect, as it covers a wide field ofpharmacentical industry and the drug control by F. D. A.(Medicines includes orals and injectables or skin-application,dressings etc.)

But in order to control wild prescription of costly drugs-often quite unnecessorily - I suggest that the "basic doctors, i.e. general practitioners should be prohibited from prescribinghigh-cost high-tech investigations, as well as high costmedicines and modern medicines introduced in the last 2years. F. D. A. could be pursuaded to force the companies tomark these medicines as "To be prescribed by consultantsonly." The medical council and luckily the pharmaceuticalcompanies are seriously considering a total ban on gifts,presents, conferences or foriegn tours, offered by companiesto doctors as in inducement to prescribe such high costmedicines. It is a welcome step. Earlier it is implemented, thebetter. These two measures would hopefully reduce theunnecessary expenditure on drugs and medicines by thecommon man.

In the public sector, the state govt. and the muncipalcorporation buy medicines, through a process of tenders. Atender committee goes through the tenders and accepts thelowest compatible tender, for each particular medicine. As aprofessor of surgery and later as a Deam, I was a member ofthe tender committee of Mumbai. Muncipal Corporation and, Ifeel, the system of selection of drugs was fool-proof. Therehas never been a complaint about faulty supply of medicines,

In addition the doctors professional fees could also be kept atabout 75% of the average fees in the private sector. Thus, therewill be a fair reduction in the cost of health–care for these middleclass paying patients and that will hopefully balance the grudgeand handicaps of medical students examining them and arelatively longer stay in the hospital. Overall, the paying patientwill pay about 40% less in hospital bill and also 25% less inprofessional fees.

In short1) free treatment should be abolished or at least minimized in

medical college hospital as well as in all public hospitals :2) all patients must pay some proportion of medical expenses,

general ward patients must bear at least 10% of theexpenses if not more. Such charge should not be mentionedas ‘nominal charge’ but should be strictly proportional to thefull-fledged charge, as a fixed percentage. The public shouldbe reminded that 90% expenses are subsidized and that thesubsidy will be progressively removed as the economiccondition of the population improves.

3) The investment required for the further expansion of themedical facilities to improve the services must necessarily beborne by the government or the Institution running themedical college.In summary the present pattern of administration of the public

hospital and the administration of the medical college isextremely irrational. The system gives unwarranted concessionor subsidy to those who do not need it and leaves a wide scopefor corruption. The fees of the medical students should be basedon sound financial principles and the charges of the health careprovided in the hospital must also be recovered appropriatelyfrom each of the beneficiaries namely the patients, medicalstudents and the industries and the government. Poor people willbenefit more than at present and education will also improveimmensely. The subsidy will be given exactly to those who needit and in exact proportion they deserve. ‘From each according tohis ability and to each according to his needs’ is the first principleof socialistic society. The hospital will become viable, thecompetence of medical staff would improve and the society willreap long term benefits for the next 2 generations.


injectables in the B. M. C. in the last several decades. Despitecriticisms, I am inclined to believe that the process is quitegood in the government too. But the compulsion to buy onlythe lowest quotation, leaves all the doctors in the state with achoice of a single brand of any particular drug. It is advisibleto accept upto 3 or 4 different brands, or all those brandswhich are close competetors in price and leave the option tovarious health centres to opt for any one of them as per theirchoice. The state will have a very marginal higher expenditurebut the doctors will have some freedom to choose the brandthey prefer. It will also reduce the chances of the item,becoming not available due to short supply due to anyextraneous causes in the approved company like strike,disputes, mismanagement etc. There will be adequatealternatives available. However, the main difficulty in thesupply, apart from lack of budget, is a highly centralisedsystem of the state government. It causes long scrutinies andthus long delays in supplies reaching peripheral hospitals andprimary health centres. Once the tenders are approved, thepurchase procedure should be decentralised and the districts.if not the talukas–should be authorised to puchase anddisburse the drugs wihtin the limits of their budget. Thehospital should have the freedom to choose the particularbrand from among the approved brands. This way thecomplaints would be reduced to a minimum.

One great advantage of tender purchase by the state is anextremely low price that companies quote for such bulkpurchases. Compared to their market price, medicines andinjections are quoted, at least 30 - 40 % lower-sometimeseven at half the cost - than the market price.

Hence, the patients in the public sector will still benifit a lot,even if they have to buy these medicines at the publichospital. As stated earlier, the government or the municipalcorporation gets these medicines at about 70% of the retailprice-or even lower. Hence, selling at 'cost-price' still means30% reduction in cost for the patient. I have aheady groupedthe patients in 3 groups.

i) These who attend primary health-centres or publicdispensaries and are refered to secondary or tertiary hospitals.They have come through proper channels, and therefore are

entitled to highly subsidised charges. A fixed charge of Rs. 2per one day's medicines in villages and Rs. 5/- in towns andsecondary hospitals would be chargeable to them. It could he'free' for all those below poverty line.

ii) Those who attend public hospitals directly or those whoare refered from the private sector will pay the 'cost-price'actually incurred by the government or municipality companiescan be asked to mark 'govt. price', along with M.R.P. on allsupplies to the state.

iii) Private paying class patients will have to pay the marketprice–M.R.P.. They can be given even 10% concession overthe M.R.P., as an incentive to attend public hospitals.

I have also emphasized that the whole section of medicalsupplies should be under the chief accountant. Thus the chiefaccountant will be answerable to balance the purchase andsale of drugs. If some patients below the povety line aretotally exempted and others subsidised as mentioned, theaccountant will be able to claim this subsidised amount fromthe government on paper, so that he can balance theexpenditure with income. This will greatly reduce chances ofpilferage and thefts.

The doctors must be prohibited from prescribing drugs notquoted in the tenders. If required the superintendant is alwaysauthorised to make special purchase within some financiallimits.

Thus the supply of medicines will be more assured thanbefore. Pilferage, thefts and unnecessory costly prescriptionswill be prevented to a large extent and a part of the expenseon drugs will also be recovered from those who can afford tothe extend they can afford.

In Summerya) High cost medicines and modern medicines introduced

during the previous two years should be prescribed byconsultants only. Basic doctors should be prohibited fromprescribing these drugs in public sector.

b) Tender committee should approve 3, 4 or more brands,which are reasonably close to the lowest quoted brand. It willensure supply.

c) Hospitals should be free to purchase any of theapproved brand wihtin its budgetary limits.

Supply of Medicines


18Adequate

Emopumentsfor MedicalPersonnel

The problem of inadequate salary for the medicalprofessionals is discussed several times but inadequatelyattended to. The salary structure of any professional must beconsidered in the light of what another person in another fieldwith equal merits is likely to get. This is termed as horizontalparity. In short, the salary should be some what similar to whathis counter part with equal merit in the field of computer, I.T.,engineering is likely to get. In the case of doctors as well as thelegal professionals, this rule does not seem to be followed. Theresult is obvious. Doctors with good merits or skill avoid joiningthe medical service especially in the government. If at all theyjoin, they aspire to gain additional income through clandestinepractice of one sort or the other.

This is not desirable, and everybody knows this. Thegovernment knows about these methods of clandestine practicebut is unable to take strict and adequate action (a) because of itsown laxity and (b) because it will be left with shortage of doctorsif action is taken against them. Adequate salary and perquisiteswill not prevent all clandestine practice but will certainly minimizeit. It will also enable the authorities to implement rules moreeffectively because there will be sufficient number of applicantswaiting to take up the job, if a vacancy occurs. Doctors whochoose to do postgraduation and therefore join major hospitalsas resident doctors are paid even much lower salary, as ‘they arelearning’. They are considered as 'students' and, therefore, they

d) The process of purchasing should be decentralised tothe district level–if possible even to the taluka level.

e) Medicines should not be 'free' except for those belowpoverty line and a fixed charge of Rs. 2/- for village and Rs.5/-for town-dwellers should be charged to all at primary centresand also in hospitals when they are refered properly fromprimary to secondary to tertiary health care centres.

f) In hospitals, the patients attending 'out of turn' or referedfrom private sector should pay 50% of the the 'cost price',which the govt. / corp. has paid. Paying class should pay themarket price. but can get 10% discount.

g) The whole 'Suuply of Medicine' section should workunder the chief accountant, so that the expenditure and thesale income is properly tallied. This will help to preventpilferage and thefts.


get ‘stipend’ not salary. The government makes anotherspaceous argument that it is spending so much money for theireducation. Both the arguments are very fallacious. A doctor whopasses his M.B.B.S. examination and opens a dispensary rightacross the hospital and starts treating the patients without anysupervision and guidance can collect far more in terms of feesfrom his patients, whereas the doctor who treats relatively moremajor illness in the medical college hospital and that too undersupervision and guidance of senior consultant and therefore islikely to make less mistakes than his counterpart across theroad, is considered a student. At best he is an apprentice. Hespends his full hours of service in the hospital and that too for thekind of illness which is as grave as or graver than in generalpractice. Therefore, there is no justification to pay him salary farless than the doctor in regular service. Another dangerousargument is made and accepted by almost all without hesitationis that when he finishes his course and leaves the medicalinstitution, ‘he is going to mint money’ – a most dangerousargument. The logic of this argument is, in fact, an open invitationfor the doctors to exploit the patients as much as they like, afterthey become specialists. This argument should be thrashed evenbefore it is uttered. Therefore, it would be in the interest of thesociety, if the resident doctors and the doctors in the publicservice are paid adequately and the residnts are paid, if notequally, nearly comparable to the salaries of other doctors inservice. Another factor to be considered is the amount of moneyspent for the education. If it is presumed that medical studentspends Rs. 15 lakhs for his entire course of education and if thatis considered as loan, the E.M.I. (Equal Monthly Instalment) onRs. 15 lacs even at a soft loan interest of 6 to 8 per cent wouldbe not less than Rs.1000/- per lac (i.e. Rs.15,000/- E.M.I.). If thefees are lowered, and he completes the education with Rs.8 to10 lacs, the E.M.I. would become 10 thousand and if hiseducation was subsidized as suggested earlier because of hiseconomic condition, his repayment would be equivalent to thisE.M.I. Therefore, they must be compensated, to an equivalentextent, while considering their salaries. One would realize thatthe salary given to M.B.B.S. doctors and the residents as well asjunior specialists are too low.

I easily accepted the fact that the government cannot pay

such high salary say Rs.35,000/- to 40,000/- to M.B.B.S. doctorsand Rs.50,000/- and above for a junior specialist. But as I haveemphasized again and again in my previous pages, the paucityof the funds with the government is due to their insistence ongiving the so called 'free' treatment to every one. Thegovernment may give all other facilities free if it can afford but atleast the fees for the doctors for their specialized services mustbe recovered and that should form part of the income the doctorcould earn. In fact, repeated salary revisions (without adequategovernance) have never helped. I have found again and againthat services did not improve a bit, when fixed salaries wereraised even to double or triple the original figure. In fact, if thesalaries are raised beyond a reasonable limit, the professionalsseem to slacken and become even more inefficient. Theproportion of improvement in the quality and quantity of serviceto the salary paid is parabolic. When salary is low, servicesimprove with better salary structure. But after the optimum isreached, the services decline when the pay is increased. It is,therefore, very essential that the professionals are given part oftheir income as fixed salary while the rest he will have to earn forhimself, through properly devised incentives. The earnings of thedoctor improve automatically, if and when he gives the betterservice.

The doctors in public service (M.B.B.S.) level, should get, atthe present level of prices and living index, at least 20 thousandper month to spend. Therefore adding the E.M.I. of Rs.10,000/-for the first 10 years the salary cannot be less than Rs.30,000/-p.m. The E.M.I. can be deducted proportionately from those whogot subsidy or loan during their education for the first 10 years.As mentioned again and again the professional charges shouldnot be free. A private practitioner charges about Rs.20/- in smalltowns, going upto Rs.50/- in bigger towns/cities (Mumbai is anexception where charges are even higher-) Hence, every patientcould be charged Rs.2/- for first visit and for follow-up every weakin all primary centres, dispensaries etc. as professional chargeswhile the rate may be increased to Rs 5/- in bigger places. Inhospitals, the same amount on an average could be added inhospital charges and it will contribute towards the junior doctorssalary.

As mentioned, the resident doctors should also get an amount

Adequate Emopuments for Medical Personnel


19 Nursing Homes

What is true of primary health care is almost equally true ofsecondary health care system. The glamour of complexknowledge and high technology of tertiary care system, coupledwith aggressive marketing by the companies manufacturingthese costly equipments, have easily diverted the attention of thesocialites, the politicians and even the general educatedpopulation from the need to stabilise and improve secondaryhealth care system. The very high cost of installing these hightech super speciality departments diverts the meagre fundsavailable and thus creates shortage of fund for the much neededsecondary health care. As mentioned earlier, in public sector,taluka and district hospitals in the state government andperipheral hospitals in muncipal corporations provide thesecondary health care, while private nursing homes and mediumhospitals and charitable medium hospitals help the affordingclass in the private sector. Nursing Homes cater to more than60% of these paying class of patients.

Individual consultants opened their small nursing homes totreat their own patients who needed indoor treatment and/oroperation. They provided a minimum of 4 - 5 beds to a maximumof around 30 beds. The facility is created by buying one or twoflats in residential buildings. So far, the doctors have proved to bepoor management experts. The owner consultant has to dependon other consultants to see that his beds are occupied. Generallyat least 60% occupancy is considered essential for a nursinghome to run profitably. This dependence on other consultants,who had no monetary stakes in the hospital, increased theirgreed and ambition and made the owner agree to whatever theydo and whatever personal charges they asked for, thusincreasing the costs for the patients while lowering the quality ofmanagement. The family physicians started demanding a a

sufficiently close to their amount. I felt that the salary of 75% ofthat of service doctors would be justifiable, to be increased to80% and 85% in the second and third year of their post graduatecourse. If they continue in service, these years should beconsidered for terminal benefits like gratuity, pension etc. Thebenefits of continuation of service should be granted to theresident doctors too.

It must be borne in the mind that the government spendshardly 1.1% of G.D.P. on health while even small countries likeMalasia seem to be spending 7 to 8% The suggested betterpayment to the doctors would not raise this percentage beyond2 to 2.5% I expect. But that will give far better results than buyingcostly equipments at various hospitals, only to lie idle within ayear or two due to bad management and inefficient doctors.


percentage of the fees charged by the consultants or by thehospital. Naturally, this tendency is seen far more in metropolitancities but has spread even to the small towns. But, even worse,these nursing homes are having a huge standing expense andgross under utilisation of the manpower and equipments. In theO.P.D. whether there is one consultation room or four rooms, aservent, a nurse and a receptionist has to be appointed. Theoperation theatre, could be utilised for hardly 2 - 3 hours, insteadof its capability of 12 hours in two shifts. Even if the ward isempty, the number of resident doctors, nurses and menial staffcan not be reduced. Thus, the owner consultant is forced tocompromise quality in lieu of quantity. Untrained nurses,incompetant semi-qualified resident doctors, cheap equipments-be it suction machine, E. C. G. machine or X-ray or sonographymachine are the order of the day in many nursing homes.Government is making rules and regulation which the nursinghomes are unable to follow and the various inspectors aremaking hay while the sun shines. The whole burden of thismismanagement and bribes falls on the patients who are, thus,paying exorbitant charges for a poor quality of treatment.

The remedy is quite simple and very effective; if only 8, 10 ormore consultants were to join together and create their facilities,the problems could be solved both for the owner as well as thepatients. O. P. D. consulting rooms, investigative facilities,operation theatre(s) and intensive care unit can be established asa common property the expenses being shared equally by all.Naturally, the profit/earning will also be shared equally by all. Allthe space, equipments and manpower would now be fully utilisedby their own patients. Hence they need not compromise on thequality of manpower or equipments which they can easily affordnow. There is no dependence on 'other' consultants any more.Even the general productioners will be more sub-dued, aspatients would always prefer a well equipped hospital withadequate facilities and trained staff, irrespective of what their G.P. s advise. The ward and the beds could be independent orshared as per what the owners prefer. Together they could buy4 to 5 or more storied, one wing of a building, with a separatepassage, stair-case and even a parking space for themeselves,as decreed by supreme court recently. Instead of begging forattachment in some major charitable or private institution, they

would have created their own secondary care hospital, wherethey have a role in management too. The patients will get notonly better quality of treatment but it will be cheeper too.Everyone gains and nobody is a loser.

Why is it no happening?First is a techincal / legal sgag, at least in Mumbai. The

municipal corporation allows the change of use, for nursinghomes only on the ground and first floor but not above that level.It may not be difficult to convince the authorities, to allow a wholewing upto 6 th floor to be converted into a mini hospital, providedthat their is not a single residential flat in that section. Thischange of rule is absolutely essential.

But the consultants are reluctant because,a) Natural inertia–people like to think and act as per existing

tradition and are most reluctant to any new line of thinking. Infact, inertia is defined as 'a body remains static. unless forced todo otherwise', and 'force' is definied as the energy. 'that makesthe body move.'

b) Consultant doctors are high intellectuals and are highlysceptical and suspicious of each other. They can not cometogether easily. There are a few sporadic cases in Pune,Bangaluru etc. where doctors have successfully combined toestablish their own hospital but they are exceptionally few only toprove the law.

Hence, they will have to be forced. Financial contraints andeven increasing obligations of new regulation are making someof them to think. Stringent application of rules and insistantexpectations of people for good standard of treatment would goa long way to make the doctors act faster. Mandatory display ofhospital charges and a system of accreditation (topics which arediscussed later) will surely force the doctors to abandon theirpresent single owned nursing homes, in favour of joint venture ofestablishing a proper hospital. Suffice it to say here thatSTABILISING AND IMPROVING the secondary and primaryHealth Care System is the need of the hour not theglamorous high tech tertairy Health care 90% of the people donot need tertiay care.

Nursing Homes


20 HealthInsurance

It is true that the cost of health care is rising year by year andit is difficult for the common man to meet the expenses; if everhe suffers from any major disease requiring admission and/oroperation. It may be difficult even to the upper middle class tosuddenly take out Rs.1,00,000/- to Rs.2,00,000/- or sometimeseven more when illness strikes. One possible remedy is to thinkof it and provide for it. Health Insurance – popularly called as‘Medi claim’ is the right step to provide for the expenses of thehealth care under the Health Insurance Scheme. A person paysa fixed amount per annum for himself and for his family whichensures the payment of total expenses of say rupees one lakh torupees five lakhs as per the insurance premium he has paid. Notevery one needs hospitalization. If one out of 200 people is likelyto fall ill and if the expense for his treatment is Rs. 1,00,000 (Onelakh), but everyone pays a premium to share the risk, then thepremium for each of these 200 people will be Rs. Five hundredonly 1,00,000 ÷ 200 = 500. This is a simplified explanation ofhow the rate of the premium is calculated. Nevertheless, it provesthat the premium to be paid is far less than the actual bill. Onpaper this appears to be a complete solution for the financialdifficulty of the common man about paying the hospital bill. Butin practice it is not so. The Health Insurance Scheme, aspracticed, suffers from many lacunae. Most important lacuna isthat the health insurance policy excludes many diseases with alist of 13 types of diseases like birth-defect, pregnancy and mostimportant pre-existent diseases under the terms of medi-claimpolicy. The insurance companies stretch to a limit this lastexclusion namely ‘pre-existing disease’. For example, if a patienthas blood pressure and after some years he suffers a heartattack, the insurance company is likely to deny the benefits of thepolicy by claiming that the heart attack was due to high blood

pressure which was a pre-existing disease. Luckily recently thecourts have come down heavily on such over-stretchedinterpretation of the rule of “pre existent disease”. So nowadaysmajor diseases that could arise from the pre existent diabetes,hyper tension etc. are not excluded as pre-existent diseases, ifthe major illness occurs after 2 years. It is a welcome step. Thereare companies which allow treatment even for the pre-existentdiseases, after certain stipulated period, say 1 year after the preexistent disease was detected but the premium is raised stiffhigh.

But the most important defect in the present system of healthinsurance is laxity of the patient himself. He feels secured that heis covered for a big amount of the bill, say rupees five lakhs. Theimmediate tendency of the hospital and the consultant is to raisetheir charges by making them double or even more than what theuninsured patient pays; even though most institutions and mostconsultants will deny this. Even the companies seem to presumethat the bills are inflated and, therefore, almost all the healthinsurance companies object to the anticipated bill and try toreduce it as much as possible. This, in turn, makes the hospitalissue an inflated anticipated bill and the vicious cycle continues.The patient himself remains unbothered initially as he feels thathe is covered by insurance and does not object to the inflated bill.But he forgets that in case of second illness he may not be leftwith any balance amount to pay for the second bill and that hisnext premium is likely to rise. But more importantly, as the patientis insured, the consultant and the hospital tend to investigate thepatient more extensively and prescribe costly drugs even if it wasnot so imperative. The patient is, in fact, happy because hethinks that he is getting a better check up through manyinvestigations done on him. This is the most important reasonwhy the expenses of treatment become high under the HealthInsurance Scheme. Very soon, over investigations andprescription of ‘latest’ costly drugs/procedures becomes a habitfor the consultants and the hospital is only too pleased with thistrend. In order to prevent the practice of inflating the bill or toprevent the shock of unexpected high bill for the patient whetherhe is insured or not, the Medical Council of India had issued anorder that charges like bed charges, operation theatre charge,fees of the doctor, surgery charges, investigation charges should

Health Insurance


all be displayed in all hospitals. Medical fraternity stronglyobjected to it and ridiculed this directive which, according tothem, was comparing medical practice with a grocery shop. TheMedical Council and the government are not insistant anymore.But to me it appears, that this was an extremely important stepto curb the practice of raising opportunistic bills either becausethe patients are not so knowledgeable or because his expensesare reimbursed under company rules or health insurance. Itshould be noted that the Medical Council did not specify anypattern of charges. Therefore, while one consultant chargedRs.200/- for consultation, another was free to charge Rs.500/- ifhe so decided. Insistence was on declaring whatever are thecharges, so that the patient is forewarned about likely expenses.There was no plausible reason to object to the displaying ofcharges and in my opinion the government needs to implementthis directive very strictly

As explained earlier, the tendency to over investigate or over-treat will not be resisted by the patient, even if the charges aredisplayed. Not only the patient does not object but he issomewhat happy that he is getting very ‘thoroughly’ investigatedand is being treated with costlier (meaning best of the) drugs aslong as the bill does not exceed the amount for which he isinsured. Ideally it is necessary that the patient should criticallyevaluate both the needs of the investigation and the treatment asalso compare the cost incurred, with costs in other hospitals.

This is impossible under the present system. However, thepatient will critically evaluate the need for the variousinvestigations and the need for costly drugs, at least to someextent, if he has to pay some part of the bill. The best insurancepolicy, therefore in my opinion, would be the one which will coverupto 80% of the bill and the patient will have to pay 20% of thebill from his own pocket. Coupled with the insistence that allcharges must be displayed in the hospital, this step of making thepatient pay directly, from his own pocket, atleast 20% of the totalbill will help in curbing the tendency mentioned above. That inturn will also help to reduce unnecessary investigations in otherpatients to some extent. Health care will become a little cheaperthan at present or the annual insurance premium will come down.

Health Insurance for the poor and ElderlyWorst effected are the elderly and the poor. The health

insurance does not help all the people. Health Insurancecompanies refuse to insure any person above the age of 50years/ 55 years at the most. The health insurance is not availableto any elderly person above age of 55 years unless he has beeninsured for his health from the earlier age of his life. One lessonto learn is to insure one's health almost on the day one startsearning. The insurance premium at that time is pretty low andworth paying even if one is sure that he will not need anyhospitalization. Similarly the poor are greatly handicapped. Eventhough schemes are announced for the poor wherein the poorpeople can pay about Rs.300/- per year or Rs.25/- p.m. to getcovered for the expenses upto Rs.50,000/- these schemes arenot put into practice by the companies. (such an insurance policywas announced during Mr.Vajpayee’s regime), In fact, a circularwas issued to the Insurance agents not to accept any policy forless than one lakh rupees even while the circular mentionedabove was announcing the scheme for the poor. So, even if thepoor man wishes to insure for his health it is impossible for himto do so. Only those who can pay a premium of more thanRs.2000/- and going up to Rs.8000/- to Rs.10,000/- for gettinginsurance cover of one lakh, can take advantage of healthinsurance scheme. For 60% of the population in our country theHealth Insurance Scheme is not available at all. This needs to becorrected.

Though I have repeatedly suggested the measures to bringthe expenses of health care down, I must say that making thehealth care cheaper is not going to be a very easy task.Measures I have suggested might help only partly to bring theexpenses within the reach of common man. It is therefore,imperative that the government itself works out a scheme akin tothe health insurance, collects relevant health cess from everyone above poverty line, as also from elders above 60 years ofage and arranges to pay for all these people through its ownhealth care scheme. Families below the povery line will have tobe registered separately and given insurence cover. Asemphasized again and again, free treatment is not a solution butpayment done through health care scheme would be a muchbetter way of ensuring health care to the needy. The service-charges suggested earlier will have to be paid to the hospital byeach patient but now these will be made through government

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insurance scheme, if not from private companies.Consumer Protection Act v/s Cost Reduction

However this also would become difficult if the health carecontinues to remain as costly as it is today and further efforts arenecessary to see that the cost should be reduced. I believe thatthere are enough number of doctors in the society who have asense of social responsibility and good conscience and all thesedoctors would be eager to see that the cost of health care isreduced. They would be willing to avoid unnecessaryinvestigations-especially the costly ones and try simplermedicines and/or perform operations without using the high-techequipment, so that the cost of treatment can be reducedsubstantially. As mentioned in the chapter of medical curriculum,if social awareness is created amongst students during theirinternship programme and throughout their post-graduatestudies, the number of such doctors would definitely increase –provided that doctors', own emoluments are not reduceddrastically in the name of economy. One cannot get a goodprofessional for low cost but a good professional can definitelyreduce many other costs because of his deeper knowledge of thesubject and sympathy for the patients.

But the greatest impediment to all such doctors in theirattempt to reduce the health–care cost is the ConsumerProtection Act made applicable to the medical profession.However genuine the efforts of the doctors, avoiding moderninvestigations or avoiding costlier drugs or high tech equipmentscan definitely result in a failure in a few cases. In many of thesecases, where treatment fails, the failure may not be attributableto the avoidance of these costlier methods. It may be purelyincidental and stastically the results of such conscientiousdoctors may even be better than the results of those doctors whofreely use high tech investigations, high tech operative equipmentand costliest of the drugs. For example, while I was In-charge ofTrauma ward as professor of surgery, I treated several cases ofhead injuries without the use of any high tech equipments. Imerely used some logically simple methods of treatment ofunconscious patients. My results compared well. In fact, theywere a little better than the results in the world literature for thesame severity of the head injury. C.T.Scan of the brain wasavoided in more than 50% of the cases. Yet C.T.Scan not done

on any of the patients would now be considered as a seriouslapse in the management in a case of head injury. Actually,C.T.Scan is merely an investigation and the transport for C.T.Scan itself can cause dangerous complications but in the eyes ofthe people and even judiciary, it has become part of thetreatment because of the powerful marketing of high technologyand the views of elite experts. Therefore, not doing a C.T. Scanfor the case of head injury could become a sufficient proof ofnegligence. Even today C.T. Scans in cases of head injury areavoidable in more than 50% of the cases of head injury but whowill dare to refuse to do the C.T. Scan test, only to be held up fornegligence in the consumers court under the consumerprotection Act ? The consumer protection act was enacted toprotect the consumer’s right of compensation if the promisedqualities were not provided in actual use after he purchased anyuseful article for a price. Deficiency in service was compensatedunder the consumers protection Act. Unfortunately the treatmentgiven by the doctors to the patients was also considered “service”and the patients became entitled to sue the doctors for thedeficiency in service and claim compensation. Doctors startedinsuring against the medical negligence claims. These insurancepolicies are called ‘Professional Indemnity Insurance’. Eventhough such a policy does relieve the doctor from the burden ofpaying the compensation, it does not relieve him of the severestress in his day-to–day clinical practice as also from possibledisreputation he gains in the society, as and when suchcomplaints of negligence are publicized in the press. Thus,doctors go into a defensive shell by advising more investigations,calling more specialists or super specialists, giving more drugs orcostlier drugs or using high tech equipments which are presumedto be safer than the old styled equipments and procedures.Everything adds to the cost of health care. There is a furtheraddition of the premium of professional Indemnity Insurance tobe recovered from the very same patients. In U.S.A. I met a teamof 3 orthopaedic surgeons, who together paid a professionalindemnity of 2,50,000 dollars per year i.e. 80,000 dollars perhead merely to protect themselves and that was more than 20years back. Naturally the consulting and operation charges gotrevised upwards proportionately for the patients who weretreated by the team. The ill effects of such heavy health–care

Health Insurance


costs have now become evident in U.S.A and most low incomepopulation is virtually denied any heath care service there. Infact, president Barack Obama has won his election with one ofhis main promises that he will give affordable health care to thecommon man. Yet we are going in the same direction. Theapplication of consumer protection act to medical practice hasbecome counter productive. A team of workers in social sciencesstudied health–care in U.P. and Bihar and found that 40% ofthose who were admitted to major hospitals for major illness wentbelow the proverty line, at the end of hospitalization. Luckily theSupreme Court in a very recent judgement has come downheavily on the complaints of negliegence against the doctors anddeclared that…. “Doctors will not be able to treat patients freelyand conscentiously, if they are burdened with such litigations.Doctors cannot assure that patient will be cured and adverseoutcome or error in the judgement, cannot be considered asnegligence.” At the same time it must be considered that somepatients have genuine reasons to complain. They areinadequately attended and inadequately treated but suchnegligence can more easily be defined. Not attending the patientwhen the patient was serious and/or when juniors in the hospitalhad reported that the patient is serious, or not taking simpliest ofthe precautions or using entirely wrong method of treatment areall obvious causes of negligence and the patient has a right tocomplain and seek justice. This is criminal negligence and thepatient can sue the doctor under criminal law, since a long time.

However, if he decides to avoid costlier methods ofmanagement, the doctor must explain to the patient the reasonswhy he thinks them avoidable and record the same in the casenotes. Therefore, he should be fully protected, if he reasonablyproves that the patient was explained the pros and cons.Secondly the doctor must be fully protected if he keeps adequaterecord and proves that under the course of management headopts, his results for similar disease with similar severity arecomparable statically with the results of the other specialists, orresults in the literature. In short, statistical proof of the success-rate by his method of management should protect him fullyagainst any complaint of negligence. As yet there is no evidencethat courts have accepted such statistical proof, nor has any oneoffered such a defence in any case within my knowledge. But this

idea needs to be propagated and adopted. The conscentiousprofessional doctors will thus be encouraged to try cheapermethods of treatment and bring down the cost of heath care.Alternatively it would be much better if the law was madeapplicable optionally i.e. the patient may be allowed to opt outvoluntarily from the application of the consumer protection actand promise the doctor that he will not enter into any litigationover the decision and methodology adopted by the doctor in thetreatment of the patient. He will still be entitled to complainagainst gross negligence as mentioned earlier. Such voluntaryrejection of the consumer protection act by the patient will go along way in freeing the doctor of the hidden fear of litigation bythe patient which in turn will help in reducing the cost to aremarkable extent. It must be realized that most doctors areequally or even more worried about failure of their treatment orof any complications. There is no need to add panic to histension. Personally I am convinced that, in most illnesses, thepatient can be treated with nearly ½ the cost (or may be evenless) without materially affecting the result. Most of the time,there is sufficient time to switch over to the modern methods, inthe few cases where this simplier line of treatment fails; so thatnot much harm is done even if the first line of approach fails. Attimes unexpected complications do develop without anybody’sfault and the patient dies or becomes handicapped or hisexpenses mount sky-high. Immediately the blame-game startsbut leads to nowhere. The out-burst of the relatives isunderstandable, as apart from a huge financial loss, they suffera big emotional shock, especially if the patient was an earningmember in the family. Dr. R.D.Lele had suggested that in suchcases instead of litigation, there should be “a no-fault-compensation” that may be paid to the family through certainfunds created by the hospital or government. These incidents areindeed very rare. Therefore, if only 5% excess bill was collectedfrom each patient and all that money was deposited for this ‘no-fault compensation’ scheme, the families who unexpectedly facesuch disaster would atleast be financially compensated. I thinkthe scheme of this sort is worth being considered seriously.

In short, Consumer Protection Act has become a greatestobstacle in reducing the cost of health care. The fear of litigationhas compelled the medical professionals to go for more

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investigation, more reference and costlier methods ofmanagements, than what he would have done normally. If thisobstable was removed, atleast socially conscentious doctorswould try to avoid unnecessary expenses and give affordabletreatment to the common man.

At the same time sufficient protection can be given to thepatients (a) for unexpected adverse result and (b) against grossnegligence by unscrupulous or incompetent doctors. The risk ofpatients falling in the hand of incompetent doctors can be furtherreduced by some more administrative methods such as...

(1) defining role of various ‘grades’ of doctors like generalpractitioners, specialists and super specialists

(2) accreditation of the medical centres i.e. dispensary,diagnostic center nursing home and hospital etc.

Research on Cast Effective Clinical PracticeMedical science is progressing very fast. Now, there is no part

of the body which can not be mapped and/or seen. C.T. scan andM.R.I. can show the structure of only organ and any distortioustherein. Endorcofric instruments can visualise not only the gastro-intestinal and genito-uninary tracts but can now enter blood-vessels and perform carrective procedures. Knowledge of stem-cells is helping to create healthy tissues to replace diseasedones. Minutest quantities of enzymes and other bio-chemicalingredients of the body can he detected to diaguose variousdiseases, like Dancers of their very onset, and Lazers andrediation can destroy the unwanted cells. High-grade technologyis enabling handicapped persons to move their antificial limbs oreven their own paralysed lumbs. Babies can be formed in thelaboratory and transported across the world to the placed insome-body's womb. The news-papers and television media arewidely showing these miracles of modern science, all over theworld and thus are creating a fond hope in every mind that their'incurable' disease may be cured now. What is forgother is thatall these modern inventions cast lakhs or even millions of rupees,to treat a single patient. But the 'Market of these high-technologies is very aggressive. The specialist doctors, and theupcoming generation is too enamoured by these inventious andeven the political leaders are led to believe that the society willbenefit by adopting all these new technologies. 'We will fuid themoney' 'money is no problem' are common pronouncements

heard from them, when the purchase of these 'State-of-art'technologies is being discussed.

But money is short. The state spends only 1.1% of the G.D.P. ofhealth-even if it is prosurmed to be spending 5% as was reportedrecently, the amount will fall dismally short to cater to the primaryand secondary health-care needs of the average citizens. Yethigh-tech-equipments are purchased both in public sector andprivate sector. The aggressive marketing of these, and the generalattraction of the average health-conscious population results inmassive usage of these equipments, with heavy expenditure forthe patients, but not necessarily with better results. Most oftenthere is a grass abuse and the ultimate results are same or evenworse than before. The patient may or may not have benefited butthe family was definitely ruined. This grass abuse of modernequipments and modern drugs ought to be embed.

But it is not going to be easy. It is a fight against the stream.There is an lugent need to initiate research as to when andwhere the use of these 'modernities' is not at all indicated, whenand where the picture is hazy and its use is, at best, doubtfullybeneficial and, therefore, the limited field when and where themodernities are definitely useful. The research of this kind willestablish the 'Limitations' or 'uselessness' in the use of everymodern investigative and treatment modality, especially whenthey are very costly. The research will thus offer completeprotection to those specialists who limit these uses, and savecosts to the patients a type of protection that will stand, in thecount of law, of complaint of deficiency in service was lodged. Ihave prefered to call this 'Research for Cast-effective ClinicalPractice.' To site an example, repeated C.T. scans in a case ofhead-injury is quite unnecessary. In fact, if a patient rapidlyimproves in his level of uneousciousness or if he was notunconscious at all, C.T. scan may be hardly needed. The patient,however, needs close clinical observation. Similarly, there areenough case-records in the world literature, to prove that someof the cheaper combinations of chemo-therapentic drugs are aseffective as the newer costlier drugs. In every clinical field,cheaper alternatives are often available but convencing data hasto be re-established by proper research methods to convence thepractising doctors to boldly go against the stream and adopt thecheaper modalities of treatment.

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21 Accreditation

First let us look at the system of accreditation of the medicalservice centers. Today any doctor can admit and treat or performany kind of operation in any nursing home or hospital without anyregulations about the needed facilities. Some doctors performprocedures even in their own dispensaries. There are no ruleslaid down in this respect. Many patients have suffered seriousconsequences due to the inadequate facilities compared to theseverity of the procedure. Sometimes there do occur suddendeaths but very often the patients develope grave complicationsin these inadequate nursing homes and they are then hurriedlytransferred to some higher center for further management. It ispossible that a lot of damage has already been done before thepatient reaches the better center. The results are disastrous orthe expenses unbearable. This definitely amounts to negligencebut it is difficult to prove negligence as no rules are laid down andmost consultants and hospitals would plead that the case wasnot, in fact, so difficult; it was manageable in their hospital eventhough facilities were a ‘little’ inadequate, and the complicationwas unexpected.

In order to prevent such incidents, a system of a accreditationhas been established in developed countries. Accreditationmeans that each dispensary, diagnostic center, nursing home orhospital is graded depending on various factors like spaceavailable per patient, investigative facilities, emergency facilitiesincluding Intensive care unit (ICU), the caliber and proportion ofnursing staff, technical staff, menial workers compared to thetotal number of beds, the qualification of all the staff including thespecialists and so on. It is like designating hotels as 3 star hotel,5star hotel etc. Unless specific facilities are available, the hotelcannot be designated as 5 star hotel. Similarly unless full facilitiesand fully qualified staff in adequate proportion and fully qualified

Who will fund such research activities?Obviously, the 'market' would be least interested in promoting

such a self-destructive activity. The 'Elite' consultants and super-specialists are most likely to denounce such research, as 'playingwith the lives of the poor people'. The central government hasestablished Indian Council of Medical Research' I.C.M.R. topromote research but the chunk is taken away for research on'modernities' or for 'fundamental research.' Thus, only the Stategovernment with a political will or a socially conscious large trustcan initiate such a research activity. It is time that the stategovernment should provide a large fund under state council ofMedical Research and promote such an activity. A Journal ofcost-effective clinical practice will be a natural out-come and willpropagate ideas to effectively control the costs of medicaltreatment for the poor. Publications in this journal will comparethe results of different protocols of treatment includinginvestigations, in the same disease with similar sevenrity, withcomparision of the costs incurred. It will help practsingconsultants to choose cheaper methods of treatment–at least fortheir non-affording patients.

Similarly, costs can be reduced by better administration, andfuller utilisation of the facilities provided in the hospital. Thisaspect is allowed to elsewhere again. Publications aboutsuccesses in reducing costs by management techniques will alsohelp the un-initiated hospital managers to try the 'new'management methods. The maximum retail price (M.R.P.) of thesame drug manufactured by different companies varies as muchas 3 times or even more. This discrepancy has been reported inthe media–but very rerely. The Journal of cost-effective clinicalpractice can keep on high-lighting these discripancies–and eventhe response of the coampanies. That will create a healthydelete.

All these methods of cost-reduction-without materiallyaffecting the final results-can be initiated and widely published–only if a -cost-conscious' state governments allots a substantialfund, under the state council of Medical Research and pays thechief research officer adequately. I hope it will be done soon.


consultants are available for the patients that hospital cannot betermed as 5 star hospital. Officially there is no such designationas 5 star hospital but general public itself uses this nomenclaturefor many of the top class hospitals in the city. Under the systemof accreditation, they may be termed as ‘A’ grade hospitals orsome such term. It is not necessary that every health careservice center be ‘A’ grade only. Under accreditation there will beofficial designation of the grade of each hospital or nursing homeor a diagnostic centre or even a dispensary. The idea ofaccrediting the health care institutions has been mooted severaltimes in the last 20 years but it has not been effectivelyimplemented. One reason of course, is the total apathy of thegovernment which is extremely reluctant to increase its ownworkload and apathy of the general public who do not realize theimportance of accreditation for their own health. On the otherhand, the health care professional as well as the managers ofheath care centers are also scared of the accreditation system,though this fear is not openly expressed. One fear amongst thehealth care providers is that after accreditation system isintroduced, those with lesser facilities might be derecognized orbanned and thus they will be thrown out of the profession. Thisfear is totally unfounded. The aim of accreditation is not toderecognize any institution but to grade it so that people at largewould clearly know about the adequacy or the inadequacy of thefacilities in the hospital or nursing home where they seek medicalassistance. Of course, not all the consultants and medicalcenters have this fear. In fact, most of them will be very happynot to accept any risk, even when the patients in blind faith try tocompel the consultants to treat them at their own centre–despiteinadequate facilities. Today such conscentious doctors are putunder great pressure by some patients, who want to get treatedthere either because of faith or because these centers offer lowcost treatment. But the very same patients turn around to abusethe doctors and the hospital for the inadequacy of the hospitaland sue them for medical negligence under the consumerprotection act, if the result is not satisfactory. So for most of theseconscientious doctors accreditation would be a boon as they willbe able to refuse such high risk cases or take consent of thepatient and relatives in writing that they are willing to take theirtreatment here despite knowing the inadequacies of the center.

Thus, only a few of the unscrupulous consultants or hospitalswould be unable to continue their unscrupulous practices. Thehidden fear in the minds of institutions or consultants in thesemedical centers which do not have full facilities is that they will nolonger be able to treat all the major or serious cases as they aredoing at present. There will be a natural restriction on theiraccepting each and every case that comes to their centers. Theydo not appreciare transperancy due to their greed. Thus gradingof all the medical centers would be beneficial to the doctors, tothe health-care centres and will also benefit the public at large.They would now know where they are going and the relativelimitations at that centre and will, therefore, be able to chooseright type of hospital for themselves. Similarly very small centerslike dispensary, OPD polyclinics and diagnostic centers will nowbe compelled to keep certain minimum facilities like oxygen andemergency kits ready at their centers for the unexpectedcomplications that can arise during the management of thesimplest of the diseases. They will have to keep adequateparamedical staff also as per the standard prescribed. Therefore,all in all, the chance of negligence will be greatly minimizedif each and every center is graded and it is made compulsorythat hospital or medical center must display their gradeprominently at their centre.

Define the role of each category of doctorsThe role of different doctors is also not properly defined. As

mentioned earlier there are non-allopathic doctors as also someold-styled diploma holders (RMPs) who practice allopathy. Theirexposure to allopathic training is poor. Therefore, I comparedthem to the bare foot doctors in China. I am sure this comparisonwill not be liked by all the non-allopathic faculties but the factremains that they are not adequately trained compared to theirMBBS counter parts who can be called as ‘basic’ doctors, fit tobe family physicians or general practitioners or assistants inhospitals under different consultants. Then there are specialistsand super specialists. In addition there are some paramedicalprofessionals who are now–a–days claiming to be doctors andare in fact officially allowed to treat patients in their ownspeciality. There are physio therapists, dietitians, clinicalpsychologists and so on who can independently practice in theirown special field.

Accreditation


The role of each of them is not well defined and it is extremelycommon to see each of them intruding into the sphere of theothers. Several non–allopathic as well as MBBS doctors ask forinvestigations like C.T. Scan, M.R.I., Angiography and multitudeof costly specialized blood tests as they proudly equatethemselves with higher categories in knowledge and‘experience’. They are also seen prescribing the costliest of thedrugs or the latest of the drugs with total impunity. Their onlytraining in the use of the new drugs is the talk of the medicalrepresentative of the company which markets these drugs. Allthis needs to be curbed and the role of each strata of health-careprofessionals must be properly defined. I realize that there willhave to be a grey zone and that gray zone may be fairly widewhere junior consultants will be competing with the professionalsin the next upper strata. But at least beyond this grey zone, therole of every strata will be more clearly defined. Thus, if it ispresumed that non–allopathic doctors are needed to cater to thepoorer section of the society, then their practice should be limitedonly to the villages and semi-urban areas and in slums in urbanareas if they were to practice allopathy. Of course, they are freeto practice in their own speciality i.e. Ayurvedic, Homeopathicand Unani, anywhere as they are fully qualified in their ownbranch. Similarly it should be imperative that they must refer thecase to higher centre if the patient is not relieved within twoweeks. Similarly the M.B.B.S. basic doctors should be allowed topractice anywhere as family physician or as Assistant to any ofthe consultants in nursing homes or hospitals or in their privateclinics. But here again they should be allowed to order onlysimple investigation and prescribe only established drugs.General practioners (allopathic or others) should be strictlyprohibited from ordering high tech investigation and prescribingtreatment with costlier drugs or drugs which have come intoexistence only in the last one or two years. If, in their opinion,such investigation or treatment is needed, they must refer thecase to the consultant or to a hospital and take their opinion. Itis only the consultant or the hospital which should be allowed toprescribe these higher investigation or costlier lines of treatment.The consultant was not basically supposed to treat any patientdirectly nor was he supposed to continue treating the patient forthe entire period of the patient’s illness. Therefore, it should be

ethical that the consultants should see only the patients who arereferred to them by the basic doctors or, at best, could see thosepatients who have initially taken treatment with basic doctor andare not satisfied with the treatment given. Seeing those recordsshould be mandatory. Seeing any patient directly without thepatient being first seen by a G.P. should be considered unethical.Similarly, once he has investigated the case and advised thetreatment or performed an operation, he ought to refer the caseback to the family physician for continuing the treatment on theline of advice that he has given and call him for follow-up aftercertain period of treatment is over. It is absolutely necessary thatthe consultant and the general practitioner remain in touch witheach other throughout the process of the treatment. The role ofsuper specialist and the specialist is not yet properly defined,wherein the former seems to be competing with the specialistand both the specialist as well as super specialist seem to treatthe same type of patient. There has to be some distinction andthe super specialist must leave simple cases for treatment by thespecialist and accept only the patients who require high techmanagement or more intense management. But in practice, thisappears difficult to implement. The overlap appears inevitable, atleast at present.

If the role of each of the strata of health care professionals isdefined to some extent, the chance of unnecessary investigation,costly drugs and incompetent treatment will be reduced to a largeextent. Accreditation along with the definition of role of thedoctors together would improve the health care management tosuch a degree that complaints of medical negligence will becomenear zero and may be the consumer protection act may becomeredundant.

Strict implementationRules are made irrespective of whether they can be properly

implemented or not and all aberrations and all excuses for notproperly following rules are accepted with ease. If rules cannotbe implemented, we have a tendency in India to overlookirregrlarities and ‘adjust’ so that there is least headache to theadministration. This is the biggest bane of the country. Thus,making rules and regulations is a meaningless farce. In thehealth-care sector, this is seen very conspicuously. The Health-care system is divided into health-care provided by government/

Accreditation


municipality or by health-care system created by private sector.Large corporate bodies also create their own health-care systemfor their own employees or for general public. For example,railway employees are catered to by railway hospitals. Tata steeland Reliance have their own hospitals. In most of these hospitalsfull time paid doctors are appointed in all the branches ofmedicine. The general rule is that employed doctors areprohibited from entering into private practice. SimilarlyEmployees State Insurance Corporation (ESIS) appointeddoctors to treat the labour (this fact has been referred to earlier).These doctors were paid per family that registered under themfor medical service, but the payment turned out to be veryinsufficient and the system failed. But no steps were taken toimprove the pattern of payment to these doctors. Instead ruleswere allowed to be violated. Another section of full time paiddoctors and consultants is medical teachers employed in medicalcolleges. The task was considered important enough so thatthese consultants were also prohibited from entering into privatepractice. However, most of the full time paid doctors are highlydissatisfied with the salary and perquisites given to them. Thoughoften this dissatisfaction is justifiable, there are equal number ofoccasions where this dissatisfaction is totally unjustifiable.Normally it should have been the duty of the administrator tostraighten out the problems and evolve pattern of payment andrules compatible with the expected services from their employeddoctors. This rarely happens – mostly because employed doctorsform such a small uninfluential group that both politicians andadministrators in industuries can easily afford to ignore them andtheir grievances. Also because the administrators are equallyapathetic towards their primary duty to cater to the health careneeds of their employees or of the people at large. Strangely thisis equally true of all the corporate bodies. Multi-nationals or bigcorporate houses are happy to allocate sufficient funds to satisfytheir employees but are not at all particular to see that the moneyis well spent and that their employees get medical service worththe amount paid for it. The employees are also happy as long astheir medical bills – true or false – are reimbursed and, therefore,often indulge in procuring inflated bills from their doctors andshare the booty with them. The management knows about it butprefers to ignore it. This is one of the reasons for ample

corruption among professionals in these hospitals. But thebigger disadvantage of the apathy of the administration isthat most of these employed doctors indulge in privatepractice. Some of them do justice to their duties and also doprivate practice but there are more number of doctors who ignoretheir primary duty in favour of private practice. For them the fixedpay is merely a ‘stand by’ or ‘a support’ while they earn their mainincome from private practice. Public sector administration andeven the corporate administration to some extent are mostreluctant to increase their headache by properly implementingthe health-care system. They are not bothered if the doctorsindulge in private practice and earn their additional incomebecause this stops them from complaining about inadequatesalary. That reduces their own headache of administration. Thus,almost everyone tries to enter the field of private practice,irrespective of the compartments in which they work, becausethere is 'money in private practice’. Indirectly private practice isconsidered synonymous with the right of the doctors to exploitthe patients. This increases the competition in the field of privatepractice and leads to gross malpractices. This, in turn, brings theprivate practice into great disrepute.

Actually the division of labour is quite clear. It is reported thatabout 25% to 27% of the population is covered for their healthneeds under the organized health care services provided by thegovernment, railways or by private companies and corporates.The doctors who are employed in these hospitals, therefore,must be strictly prohibited from entering into private practice. Asmentioned again and again earlier, incentive practice for theaffording class of patients in their same section can be allowedto all these doctors, so that they will earn their additional incomein the same institution if they prove to be more meritorious. Thesame thing should be true of the medical teachers in all medicalcolleges and of the doctors employed by government at thedistrict hospitals or primary health care centers. They cannothave the cake and eat it to. There are obvious advantages in thefull time service. The hours of service are fixed, long termbenefits amount to nearly 30% to 40% of their salary and theyhave facilities of leave, traveling allowance, provident fund andpensions after retirement etc. If these full time doctors are forcedto have a choice and are thus strictly prohibited from entering into

Accreditation


There are some other aspects of health-care system whichremain uncovered, the main being the need and inadequacy ofparamedical services, transport of serious patients andambulance services and disaster managemet or critical caremanagement in the peripheral parts (not cities, where it is over-emphasized as usual) The need for nurses is supposed to bedouble that of doctors, presently they are less than half the totalnumber of doctors – the deficit is 4 times the actual need. Physio-therapiests are clustered in big cities, technicians are scanty, butstrangely the need is only half-felt because the ‘basic’ doctorsmanage to do half of these jobs, while some other functions canbe conveniently neglected. It is a pity to see doctors doingclerical or semi clerical, purely administrative work orparamedical work – Not so much a problem of dignity but ofwasteful expenditure of creating a doctor at a formidable cost andgiving him a job which could easily be done by people who arebeing trained at a much lesser cost.

Sometimes, I feel that we have too many ambulances butindiscipline and total apathy to coordinate gives us a paradoxicalpicture of inordinate delay in getting an ambulance while plentyof them are parked idly, all over the city. We lack administrationand management.

I have decided to refrain from entering into these aspects ingreater detail because 1) I myself have very scanty data andexperience in this field and 2) because what I have written so farappears to be too complex and ‘head-breaking’ if I may coin sucha word. Will this one Man Committee report – self appointed –work? Will it serve any purpose ? I do not know. If it falls in thehands of high level medical administrators, or bodies or personsin high places in any social field, who are concerned about ourhealth-care system, it would atleast ferment discussion, and

22 Miscellaneous

private practice, the number of doctors in the private practice willbe reduced. That in itself will help in reducing the malpractices inprivate practice to some extent. There is a second populationgroup comprising the poorest section of the society of nearly 40%of the total population who are helpless. They are incapable ofgetting medical assistance with their own income and, therefore,are totally dependent on the government, municipalities, zilhaparishads and the state and central governments who have setup large infrastructure starting from dispensary, primary healthcenters, upgraded dispensaries, taluka level hospitals to districthospitals to highly specialized medical college hospitals or otherspecialized hospitals. Ideally twenty five per cent to thirty per centof the medical personnel ought to be absorbed in this section.But at present only a small percentage of doctors are working inthis public sector serving poor people. Their apathy and the laxityof the government machinery makes it easy for these doctors tobreak the rules and enter into private practice. As mentionedearlier these doctors could be paid adequately but theirperformance must be assessed by the charges collected or thenumber of patients treated, so that sincere doctors will be betterrewarded than their colleague counter parts by early promotion.This was discussed in more details earlier. But under nocircumstances should they be allowed to enter into privatepractice. That leaves only a small section of about 25% peoplewho are not covered by either their own organization or bygovernment machinery but could afford to spend for their health.A certain percentage of patients from organized sector and fromthe poor section who are dissatisfied with the services offered tothem in their respective hospitals would prefer to take treatmentin this private sector. The total number may, therefore, go to 35%to 40% of the population. With the controls mentioned earliernamely accreditation of the hospitals, specific duties for eachstrata of the medical personnels, display of charges assuggested by Indian Medical Council and the over-all control ofthe Health Council, the private sector also would become moredisciplined. The charges would be more regulated andmalpractices would be minimized.


23BILL FOR THE PATIENT IN

MEDICAL COLLEGE HOSPITAL

For TeachingEconomics of Healing

Medicine is an art based on a scientific footing. This basisis mainly the chemical and physical processes involved in thephysiopathology of the body. The materialistic and westerninfluenced attitudes plus the advances in modern technology,have made a medical teacher and a student feel that theseare the only important sciences to be taught and learnt tobecome a successful doctor. He is thus being taught more andmore details of the physico-chemical processes, or what maybe termed as ‘organic’ changes, more and more of the detailedinvestigative approaches involving the great technologicaladvances and is taught to plan his treatment on the ‘SoundBasis’ of these scientific facts. In terms of the best results, Ihave myself no doubt that some of these, if not all, have vitallycontributed to the quality of medical treatment. And yet, this isthe most important reason, in my opinion, for the educationbecoming unoriented to the practical needs of the medicalgraduates in our country.

For medicine, in its fuller concept, is an art based on theabove-mentioned scientific footing. In actual practice, manyother factors come into play in determining the care of thepatient–the social factor, psychological factors, environmentalfactors, the religious biases, etc. But the most important andvital barrier to the effective practice of the knowledge learnt inthe present way is the knowledge of Economics of Healing. Inpractice what to do and what should be ignored, whichinvestigations are necessary and which can be avoided, andwith what material difference, which equipments to buy andwhich would become burdensome, the choice between the

something would come out of it. Otherwise, it will achieve onlyone thing – satisfaction for myself that I have expressed myviews. I wish best luck to myself.

I have added two of my earlier articles. The first one, writtennearly 35 years ago, advocated a bill to be given to every patientin teaching hospitals - even if he does not pay a paise. The ideawas to create "cost canciousness" among students and teachers,which may lead to a concept of "Cost Effective Health CareManagement".

The second article is a word of caution to the poor and middleclass patients. It explains why high tech modern hospitalsbecome ivory towers and how the management therein wouldinvariably become too expensive and often impersonal. It isadvisible to go to middle ranged hospitals for simple or moderateillnesses and reserve these hospitals, only for serious orpreviously untreatable diseases.

I hope, readers will benifit by absorbing these thoughts.


best drug and the cheap drug, everything is determined by thesocio-economic factors rather than anything else. But thegraduate full of knowledge of physico-chemical processes oftenlacks the knowledge of the economic influences on the medicalpractice and fails to satisfy his patients and thus gets rapidlyfrustrated. He tends to blame the masses for their ignorance,being little aware of his own ignorance. What he has not learntin the college covers much wider field than what he has.

The present set up of full-time ‘non-practising’ teachers andfree treatment to all patients in the teaching hospitals makesthis deficiency in teaching even more glaring. The entire costof hospital, equipment and the treatment is borne by thegovernment or some autonomous bodies, while neither theteacher, the student nor the patient becomes aware of theactual costs incurred in the whole process. This results ingrowing dissatisfaction among all with everincreasing demandsfor equipments and facilities, which more often than not,contribute so little to the qualitative or quantitative improvementin the results. In short, neither the teacher, nor the taught andleast of all the patient, ever even think about the cost involvedin the so called modern methods and the relative benefit derivedout of this added expenditure. In actual practice as soon asthe medical graduate goes out of the college, he is confronted,at every minute, with the cost involved and its relative orcomparative benefit to his patient. This makes him unable totake decisions, especially the ‘cheaper decisions’.

Ultimately, some may learn, by themselves, the relativeeconomic and medical values, but many swing to the oppositeside and think that science taught in the medical college ismeant to be forgotten and everything in practice is Art. Thisway the word Art becomes synonymous with pure commerciali-sation, cheating and fraud. Some of the graduates who aretoo good in their science and fail to learn the real art bythemselves i.e. the moulding of medical practice to thesesocio-economic factors, return back to the full time job and, inturn, not only continue to teach the pure science but fullyridicule any practical dilutions in practice.

Thus, the whole cycle of wrong emphasis leads to wrongchoice of teachers, further emphasis on modernity and thesociety pays more and more, to receive less and less benefit

in the poorer countries. The doctors trained by our collegebecome progressively ineffective in treating our people,because the local people cannot afford such treatment.Strangely, the richer countries, already advanced, in suchtechnologies and the relatively affluent people there can affordthem. This mutual satisfaction between those masses and ourdoctors seems to be one of the most important factors, why‘scientific doctors’ are draining to the west. Are we not trainingthem for their needs, and not ours?

Secondly, the present pattern of ‘modern or technological’approach is leading to ‘Office-type Doctors’ with a progressivedeterioration of clinical judgement, which is being substitutedby investigative procedures. I emphasize that investigativeapproach is used to substitute and not to aid clinical judgement.Again the result being same quality to the patient at a highercost and the cause being non-economy-oriented medicaleducation. My personal experience, after having worked innewer and smaller colleges and slowly shifting to the city ofMumbai, shows me clearly that by conscious efforts, clinicaljudgements can be improved and managements economisedto half or even one-fourth.

The present mode of selection of senior teachers by thePublic Service Commissions again shows the same lack ofimportance to ‘clinicians’ as teachers, and indifference tomedical economics. Research and publications are themainstay, but there is not a single ‘column or a confidentialreference regarding the candidate’s ability to treat and teach.Result - unnecessary and elaborate modern investigations onthe poor, advanced cases, long hospital stays, often at thecost of essential early treatment all for the sake of researchand publications - for the sake of promotions - expensive non-productive medicale education.

Clinicians who could teach, what I am advocating, areavailable in plenty, but they seek direct rewards in practiceand would not turn to full-time teaching jobs, which becomeunrewarding both monetarily as well as job satisfaction-wise,as such a person is usually condemned as a ‘non-scientificteacher’ a dilutor, non-research-minded, non-progressive etc.And yet, some objective method ought to be found to find out,retain, encourage and promote such ‘clinical’ teachers, who

For Teaching Economics of Healing


treat well and yet economically. Such teachers automaticallywill teach students the art of clinical judgement. Today, thereseems to be no way, for the Deans, Administrators, or ServiceCommissions to sort out such types of teachers. Can we finda way out?

The answer is not simple but a simple beginning can bemade in this direction, which can expand later to cover theproblems that I have posed. And the simplest way to startwould be ‘to bill the patient’. Every patient, who is admittedto a medical college hospital, should receive a bill ofexpenses, at the time of discharge, irrespective of whetherhe pays it or not. This bill must be given to him by the residentdoctor, so that all concerned would have seen it. The conceptof the bill for the present is for medical education and hencethe charges evolved can be only crudely accurate and neednot be commercially accurate. They will give a comparativepicture of the money spent over each patient over each disease,and would help to statistically evolve the comparative benefitderived to the patients or the masses through additionalexpenses for modernities. For a 600 bedded hospital with15,000 admissions a year, this involves, making about 50 billsa day and the total extra establishment would not be much.

Such a scheme will automatically make all money-conscious.The impact of additional space, personnel or equipment willbe immediately reflected in the bill and the teacher and thetaught would necessarily ponder over it–whether this wasessential or not. Some may now substitute clinical judgementsto investigations bringing the costs down. It would now bepossible to sort out a better clinician as one who gives betterresults with lesser costs, and attempts could be made to retainand promote him or encourage him by offering largerresponsibilities and/or monetary incentives. It would benecessary for making the scheme more educative, to arrangeregular forums for discussions, seminars, monthly meetings,etc. where clinical results would be evaluated with the bills ofexpenditure.

Cost effective managementThe positive concept of health is essentially due to the

economic influences in the modern society. The need to keepproductive, moneyearning population not only not-ill but fit, fit

for skills and possibly fitter than before, through the medicalprogress is a pure product of understanding of economicinfluences in modern society. Unfortunately, it is becomingnecessary in our country to teach the medical profession,especially in medical colleges to distinguish between essentialtreatments and treatment for positive concept of health. For itwill be correct and scientifically appropriate to charge fully forthe latter and increase the direct income to the medicalcolleges, independent of the state or public money. Suchaccrual of direct wealth could make for a self-expanding medicaleducation system and only such self-expanding medicaleducation system and only such self-expanding colleges arelikely to retain permanently their utilitarian character. Againthe beginning is in introduction of medical economics and thefirst step is billing the patient and critical evaluation in periodicaldiscussions, seminars, etc.

The answer is not that simple of course and involves manymore basic changes in the system. While a lot of discussioncentres round the content of medical education, extremely littletime is spent over the need to select proper teachers, and stillless to medical and hospital organisation in the utilitarian way.It is easily forgotten that the student learns from what he seesand not what he hears. Today, he is learning to do less andargue more (discuss is the euphemistic word), because that iswhat some of the teachers do. He cannot decide, withoutmultitudes of reports, because that is what he sees. He failsas a house-surgeon, to talk and explain to his patients aboutthe nature of illness and details of treatment and show sinceresympathies, but merely replaces them by ‘efficient Organicand technological’ approach, because that is what he sees inthe hospital.

This would be only a beginning to give a social bias andpracticality to our education system. Other aspects like social,religious, psychological, environmental, (rural and urban)factors, also might have to be brought home to the newstudents’ notice. Such an expansion of teaching of Art, willnecessarily restrict the horizons in the knowledge of scienceand modern technology. A hue and cry would develop that ourstudents would be unable to compete with others in the WesternWorld, and would be found to be unfit there. It is for the

For Teaching Economics of Healing


24High-Tech ModernHospitals Are they

really usefull?

At the time of independence, the country had very few medicalcolleges. Over the next 25 years, the number, was steady ataround 105, and they turned out about 10,000 M.B.B.S. doctorsevery year. The main objective then was to provide a ‘basicdoctor’ for the ‘basic’ medical needs of the population. So, mostM.B.B.S. doctors opened their dispensaries and became ‘familyphysician’ advising the patients not only on their medicalproblems but equally often on their social and economicproblems. But, with rapid expansion in medical knowledge, thetendency to specialize in one or the other branch of medicineincreased so much, that nearly 80 to 90% of M.B.B.S. doctorsbecame ‘Specialists’ and their place, as family physician or basicdoctor was mostly taken over by other faculties of indigenousmedicine like Homeopathy, Ayurvedic, and Unani faculties.

But the last 25 years have seen further expansion not only inmedical scientific knowledge but also, to a far more extent, inmedical ‘Technology’. Newer and newer, electronic, ultra – sonic,and magnetic highly computerized equipments came into use inthe medical fields, as modern diagnostic tools or therapeuticequipments, and this has resulted in a distinct change in theattitude and philosophy of modern medical professionals. Theknowledge and especially the skills of the ‘specialists’ provedinadequate to properly utilize these ‘high-tech’ equipments and anew creed of ‘super-specialists’ was born. Cardiologist,nephrologists, Urologist, neo-natologist and what not! Thenumber of the super-specialist branches and the super-specialists is ever increasing, in both medical and surgical fields.

educators here to decide, would it be better for the country orworse? It is for us to decide whether we train our students forforeign fitness or for internal fitness. This is what I call,‘Indianization’ of Medicine.

Another common argument put forth is that these thingsneed not be taught, and students would learn themautomatically, when they go out in society, I have myselfconceded this fact in the case of many. But it is at the expenseof many more years, but more discomforting is the fact that aprogressively larger number of students fail to learn this oraccept and adapt to it without a sense of guilt or shame.Secondly, it is leading to wrong choice of clinical teachers. Letus also remember that commerce, business management,teaching, and politics are also being taught today and withadvantage. Were not the former generations practising themand learning by themselves? Lack of natural inheritance in thenew students in all fields today makes it imperative to includesuch aspects in the formal education.

I urge that these things should not be brushed aside, aspolitics, trade unionisms, or purely non-educative subjects; forthey, more than the paper-definition of the contents ofeducation, will determine the progress of medical education inIndia and its usefulness to the Indians.(The Indian Journal of Medical Education Vol. XIV No. 2)

(July-Dec. 1975)


perspective of the very people whom he decides to serve inpractice. He lacks, the broad vision of the super-specialists ofyester–years, and developes a narrow and rigid attitude in hisprofessional conduct. Barring his own (super) branch, hisknowledge in other branches of medicine is almost as poor asthat of a knowledgeable lay-man. In any case, he definitelyrefuses to accept any responsibility for any clinical problems forthese ‘other’ fields – minor or major. No doubt, those whopractise in small nursing homes and small institutions learn thehard-way through experience and come to terms with reality, butthose who are attached to these High-tech institutions or ‘High –tech’ sections continue to live in their ivory towers. ‘(super)specialist is one who knows more and more about less and less’.But medical practice is not the treatment of one organ. It involvesthe treatment of the entire person, taking into consideration notonly his clinical picture but also his social & economiccircumstances. If an old lady developes an attack of paralysis,she will be treated by a neuro-physician. But what if she had highblood pressure or diabetes. Paralysis often affects, respiratorysystem or kindneys; who will treat these conditions? Who will dothe dressings or operation, if she developes bed-sores due toprolonged stay in bed. Naturally for each of these ailments,separate super – specialists visit the patient separately.Sometimes the instructions are contradictory. Multiple doctors,multiple investigations, multiple medicines, and multipleprocedures; naturally the expenses sky-rocket far beyond thecapacity of the patient and the relatives.

Even otherwise, high-tech treatment has to be costly. All high-tech equipments are very costly ranging from a few lakhs to afew crores of rupees. One can not run such equipments withordinary workers. Appointing skilled & trained technicians is amust. In our country of vast population, trained technicians arereally scarce. Besides, they easily get lucrative jobs abroad aftera few years of experience. Hence, they have to be paid highsalaries, in an effort to retain them. Super specialist doctors,skilled technicians and costly equipments can not be managedexcept by ‘management experts’ who also must be well takencare of. Thus the whole set up is very costly; it can never becheap. Politicians and social elites who continuously appeal fromevery conceivable platform that ‘modern medicine must be made

Naturally, it has resulted in establishment of more and moremodern ‘High-tech super specialist’ hospitals or the generalhospitals have opened new ‘super-specilaist’ sections in theirgeneral set-up. It is a common belief that this modern technologyhas 'revolutionized’ health-care, that it is contributing greatly toraise the average life-span of the population and in generaloffering a much healthier life to the society. How far is it true?The question appears silly on the face of it, but I would ratherdiscuss it.

Specialists (and super-specialists – to a smaller extent) didexist in yester-years, but most of the M.B.B.S. doctors becamegeneral practitioners. Even those who specialized almost alwayshad a few years of experience in general practice either beforeor immediately after obtaining the post-graduate qualifications.Most specialists preferred to combine general practice withspecialist practice at least in the initial phase of their professionalcareer, if they did not have G.P. experience before going forpost-graduation. There were no further degree courses for super-specialization and therefore, after practicing as specialist (say aphysician) for 10 to 15 yrs, if he developed an inclination for aparticular smaller branch, he gradually shifted towards it andbecame a ‘Super – specialist’ (say a cardiologist or neuro-physician) at a mature age of about 40 or above. In general,therefore, these super – specialists had a much wider base ofmedical practice and a much deeper understanding of the socialand economic circumstances of the general public they served.

But the situation has totally changed today. Medical educationand especially the selection pattern for post–graduate courses inso peculiarly distorted that even the M.B.B.S. medical studentrefuses to learn the entire medicine fully before he obtains hisdegree. He plans carefully for his post–graduate ambition fromthe beginning. If he is interested is surgery he would prefer toconcentrate on that subject only and study medicine,ophthalmology, obstetrics etc. only for passing marks.Immediately, a 3 years course for post-graduation and he is aqualified specialist. Even without any experience, immediately hecompetes for ‘super – specialist degree’ and if successful he is‘super – specialist’ 2 years later at a tender age of 27 to 28. Alot of theoretical knowledge but no experience whatsoever inactual practising field and extremely narrow social and economic

High-Tech Modern Hospitals Are they really usefull?


procedures are sometimes far more dangerous than thedisease itself. Multiple super-specialists giving multiple advicesat different times calls for a fine co-ordination among all ofthem, and that is not as easy as one may think. This oftenresults in inordinate delays in instituting definitive treatments.But much worse, is the peculiar hostility the patients suffer inthese ‘ivory tower’ institutions. With less social perspective andmore pride-verging on arrogance – in their knowledge, thespecialists are extremely intolerant to even suggestions forsimpler alternatives, requested by patients and relatives. ‘This ismy advice. Take it or leave it on your own responsibility’ is theirattitude. So discussions are out of question. ‘The ivory-tower’attitude soon percolates to all the staff in the hospital & theyalso become intolerant and arrogant. Soon the ‘Red-tape’ ofpublic institutions tightens its hold even here and the patient orhis relatives can not understand what is happening, why thedelays, why the condition is not improving etc. Tension andpanic, besides the high cost, take the toll of the family membersin terms of their own health.

Yet the glamour persists and the conviction remains that themodern technology is very useful and life saving. So whyshould not the poor people get the same benefits? Thus super-specialty sections are established in all major public institutions.The up-gradation of J.J. hospital or the establishment of RenalTransplant Unit at Aurangabad at the cost of 2 crores,announced by the chief minister are but examples of thisphilosophy.

The government spends only about 2 to 2 1/2 % of its bugetexpenditure on health-less but not more. But, now, a majorshare of this meagre expenditure is getting diverted to ‘modernsuper-specialty' sections. The Bombay Muncipal Corporation, forexample, spends more than 60% of its health budget on thethree medical college hospitals, and even there, more than 50%is spent on super-specialty section. Thus, it is not unusual tofind that in the hospital which takes pride in doing many openheart surgeries, the general patient has to buy gloves andcatgut for his simple operation. Are we justified in diverting themoney meant for common needs of common people to thespecialized needs of a few?

Hygene, Nutrution and good drinking water along with

affordable and should reach the poor masses’ are either foolingthemselves or are hipocrats.

Expense apart, are these facilities not really useful? Havethey not revolutionized medical treatment and made impossibleinto possible? The answer is yes and no. Today manyconditions can be diagnosed at a very early stage which wasnot possible before. Formerly cancer cases were cured onlywhen detected in first stage, today patient even in third andfourth stage sometimes need not lose hope. Age and existenceof major associated illnesses, made it impossible to operate onmany patients, with a curable surgical disease. Today, almostanyone can be operated upon despite any other associateddisease (from infants to 100 year-olds). Very major operationswere needed for kidney stones and pancreatic diseases. Butendoscopic surgery now cures them in less than a week, fitenough to join duties. Ultra-sonography and endoscopy have nodoubt revolutionized management of many diseases. In short,when the disease or the patient was in a more advanced stageof morbidity and occasionally for early cure of unmanageablediseases, super-specialsit treatment and high technology is veryuseful and is inevitable. But its impact on health management ofthe entire general population is very negligible – almost nil –because the total number of such patients really needing suchtreatment is very low in the whole population. Hence thesesuper-specialties, have not contributed to the increased life-span of the population nor have they contributed to reduction inthe incidence, severity or complications of various major killerdiseases. This has been proved statistically not only in ourcountry but even in the developed countries of the world.

On the other hand, barring these few lucky patientsperceptible harm can not be ruled out for many otherunfortunate patients who happen to seek treatment in thesehigh tech sections.

Multiple high–tech investigation show up lots of ‘lesions’which were never seen before. Many of them are aberrations of‘normal’ but are now diagnosed as ‘diseases’. Thus over-treatment is very frequently indulged in, resulting in major high-tech operations, like coronary angioplasty, bypass surgery orlaparoscopic gall bladder surgery. Besides, complicationsarising out of these ‘modern interventional’ investigations or



specialist and the super-specialisties would be involved onlyafter the patient is refered to them by the specialists.

If, however, any patient wishes to have a direct consultationand treatment from super-specialists, he will have to bear allthe charges as in the private sector including the doctor’scharges. This way, maximum benefit will reach the deservingpoor, there will no misuse of the facilities by those who canreally afford and public sector super-specialist doctors wouldalso benefit. The decision to open up health insurance toprivate sector is the most welcome step in this direction

Marathi Article Published in Loksatta 2nd June 1997

preventive and primary health care are really what thecommon man needs. It is proved beyond doubt that theaverage life expectancy and general health of the society, asa whole, is improved by these measures, not only in ourcountry but even in the developed countries. Hence, there is areal need to increase the expenditure on these, at least 5 fold.Diverting the funds, instead, from the present 2.1/2%expenditure is absolutely unjustifiable.

As individuals can expect real life-saving benefits but thesociety, as a whole, does not get any benefits, it is but rightthat these modern facilities become available in private sectorwhere the individuals pay for their services. If they were to goto the general specialists first through their generalpractitioners, to ascertain whether their ailments could betreated in a simpler way and at a lesser cost with the samedegree of success before going to the super-specialists, itwould help them a lot in avoiding the harmful consequencesof ‘modern therapy’ as well as the high costs. It would havealso encouraged a healthy competition between the specialistsand super-specialists with great benefits to the society. But,the recent applicability of consumer protection act to doctorshas greatly hampered this competition. Also, the presentmedical education system which teaches such a lot withalmost no experience is resulting in less and less competentG.P.s and general specialists. The society is paying its pricefor ignoring these vital factors.

It does not mean that there should be no super specialistsections in public hospitals for the poor and middle class. But,certainly, these should not be established or run by divertingthe meagre funds allotted for general health services. Thesesections should be funded entirely through special insuranceschemes, compulsory or optional, meant specifically for superspecialities. Agreed that an individual can not spend a lakh ofrupees for coronary bypass operation or for full cancertreatment. But, presuming that one in a thousand persons willneed such treatment (actually it is much less) the cost perhead would be only Rs. 100/- The centers thus raised arelikely to be few but the returns can be even more cost-effective, if no one was allowed a direct access to them.Everyone should be made to pass through dispensary to



e) There is a need for central (and state) Health Councilwith wide powers and superior to all above bodies.

4. a) Health – care is an Industry, and Industrial principles mustapply here too.

b) Health-care is productive and hence must be paid for.c) There is nothing like ‘Free’ medical service. Somebody

else pays for it.d) Money must come in – in a cognizable way – so that it

can be spent and the correlation should be easy for acommon man to understand.

e) There are too many disadvantages of ‘Free’ treatment– It is the costliest method with poorest returns.Government supported or company supported medicalinsurance could be one of the remedies.

5. The need for a pyramidal structure of Health–caresystem. Primary Care Centres - Secondary CareHospitals - Tertiary Care Hopitals.

6. a) High-tech modern medical service is very costly andcannot ever become cheaper.

b) It does contribute to the health of formerly incurable ordifficult disease but it also increases the cost of health-care unnecessarily for majority of the people.

c) It has contributed very little (or non-at-all) to the overallsurvival of the community.

d) Hence it is almost a crime to spend public money heavilyon this high-tech medical service.

e) However, these services can be available in private sectorfor full costs to be borne by individuals, and in publicsector only after proper reference from the lowest to themedium to the high speciality hospitals.

7. a) Considering the need of doctors in a ratio of 1: 1000 thecountry needs 10 lacs doctors.

b) In cities, specialization has increased, so the ratio couldbecome 1:500.

c) Selection for M.B.B.S. course is not strictly by merit – atleast 49% seats are filled through reservations based oncaste/creed.

d) The minimum qualifying marks were 45% aggregate in12th standard in 1950 when the Republic was founded, itis still 45% - in P.C.B. (not aggregate).

25 In Summary

1. In clinical practice, a doctor should be able to answer the all-purvading 3 questions scientifically.a) what is the diagnosis ?b) what is the management ? andc) what is the prognosis ?The approach to all social problems should preferably be onthe same lines.

2. Health-Care is a complex subject-Though health is as important as food and clothing, healthdemands differ in intensity. They are vital, essential ordesirable while some are luxuries. There are three tiers ofhealth-care services primary, secondary and tertiary. There isa combination of art, science and commerce in varyingproportion in all of these tiers of services.The health-care system in India is very haphazard. There aremany systems of medicine – Allopathy, Homeopathy,Ayurvedic, Unani etc. in active practice simultaneously buttheir respective roles are not defined. In addition there aremany spurious systems which, though not recognized, are stilloffering medical services to the public.

3. A Medical Council is established to control the standard ofeducation and to maintain the standard of behaviour of thedoctors at a high noble level. But...a) There is a Central Medical Council and a State Medical

Council which are independent of each other.b) There are separate councils for different systems of

medicine.c) They have very limited powers and there is no co-

ordination between them.d) They cannot deal with quacks nor with anyone other than

doctors - not even para-medical staff or erring patients.

In Summary


e) Research grants must be created and utilized fully, andthe main research officer be paid.

f) An optimum of 25% of the beds in each unit should be‘paying’ beds. There are several advantageseducationaly, administratively and financially.

g) This is so important that the issue should be bitterlycontested, if M.C.I. opposes it.

h) The medical teachers should be prohibited from doingprivate practice outside the premises, but offeredincentive practice within the premises.

10. a) Thus, the fees to be charged will be minimized.b) Paying patients, research grants and subsidy from

government will substantially reduce the deficit of incomeover expenditure. The salary expense of the practisingteachers will be reduced.

c) So the students will have to bear only the remainingexpenses of the college and hospital.

d) Additional training courses can bring additional income.e) The system of professionals on ‘fixed salary’ cannot

work, unless there is an extremely intelligent and efficientmanagement system with M.I.S., both of which we simplydo not have.

11. Choice of medical teachers leaves much to be desired.a) There is a lack of incentive and of job satisfaction for

medical teachers.b) There are three desirable qualities for teachers, Every

teacher must possess at least one, preferably two ofthem in very good measure.i) professional skill; ii) art of teaching and iii) researchattitude and skill.

c) i) incentive practice within the premises will satisfy thefirst type which is 80%.ii) Academic incentives are needed for 2nd and 3rd type,and a good compensation for not going into practice.They deserve non practising allowance, and otherperquisites.iii) Having defined job specifications, accurateperformance records must be maintained, shown tothem, corrected if necessary and then firmly used, forpay-rise, promotion.etc.

e) Full advantage of this was taken and is still being takeneven to day by private colleges and deemed universitiesfor malpractice and corruption.

f) There are multiple C.E.T. for the aspiring students – whichis totally unnecessary and again a source of corruption.

g) Confusion is created by central CET and 15% reservationfor admission on an all India basis.

h) Caste-based reservation should be abolished but region-based or community based colleges with 33% reservationshould be encouraged, to be managed by the region orthe community.

i) Minimum qualifying marks in 12th standardexamination must be raised to 60% of aggregatemarks (not PCB). and/or 75% in P.C.B.

j) Only one C.E.T. at the state level – one central.8. Charging of fees-Fee structure is irrational.

a) Fees in government colleges are too low and in privatecolleges too exorbitant.

b) Wrong students are getting subsidy and poor students aredenied subsidy.

c) The criterion for subsidy should be purely economical andnot merit-based, and subsidy should be available ingradation to students both in government and privatecolleges.

d) The fees in government colleges should be raised to non-subsidy level at par with the private colleges.

e) For others soft loan facility should be made available.f) Students getting subsidy must serve in public sector for

10 years.9. a) The number of patients in private medical college

hospitals is very poor due to various reasons – but thisnumber forms the main source of education for them. It ishere that the student gets 70% of his knowledge.

b) The M.C.I. only cares for the total number of bedsprovided – not the total number of patients on them.

c) Full occupation of beds is equally the need of the peopleto get good doctors.

d) therefore, in the private college hospital, the charges ofpatient–care should be subsidized by the governmentequivalent to the expenses incurred in district hospitals.

In Summary


b) The stipulated period of posting must be strictly followed.No exemptions or concessions should be permitted fordeficiencies on any ground.

c) There should be an exposure to allopathy for at least 2years in the courses of all other systems of medicines.

d) The C.E.T. for post-graduate selection, should be heldwithin 3 months of final M.B.B.S. exam, almost at thebeginning of internship and

e) The interns should get mandatory training inmanagement, social studies, logic, psychology etc.during the remaining 6 to 9 months of internship.

f) There is a specific need to start post graduation ingeneral practice.

15. a) Any patient enters any centre or hospital. There is noreferal system in existance.

b) Medical Collage Hospitals see 50% trash in O.P.D. andthat lowers the quality of treatment.

c) Patients must be seen at primary care centres andrefered as per criteria laid down.

d) Secondary care hospitals will see only patients seenearlier at primary care centre–refered or dissatisfied.They will be entitled to highly subsidised or freetreatment.

e) Patients coming directly to secondary or tertiary carehopitals will have separate O.P.D. timing and will pay50% of charges, as paid by paying patients, even ingeneral O. P. D.

f) Paying patients will have a separate O. P. D. in theevenings. their investigations and operation will alsobe done in the evenings only. They will pay fullhospital charges.

g) Same system of referal must be advocated for privatesector also. Consultants must see cases first seen byGeneral Mactioners refered or dissatisfied.

16. a) Charges to be collected from patients – two components;i) hospital expensesii) professional charges of consultants/doctors.

b) There cannot be ‘free’ service from the consultant.c) As public hospitals see a lot more patients, the

professional fee for consultants works out to be 5% to

iv) The present method of promotion or selection isextremely faulty and leaves wide much to be desired.v) M.P.S.C. is most incompetent and slow and must bereplaced by a better expert commission, specifically forselection of medical personel. The performance recordmust be submitted and used.vi) If the work load is more than can be managed by themandatory number of medical teachers, additional parttime consultants can be appointed from amongst thepractising faculty- the best amongst them should bechosen. They are not medical teachers, but will gainteaching experience over years.

12. The pattern of working of a clinical unit in the medicalcollege – applicable (in principle) to other secondary,tertiary hospitals also.

a) Too many doctors in one unit to manage 32 to 40%patients – 1 professor, 1 Associate Professor, 2 lecturersand at least 6 residents.

b) Only one O.P.D. day in a week for non-admitted patients.c) Multiple duties on the O.P.D. day – O.P.D. patients,

routine admission, emergency admission, emergencymanagement /operations, routine and semi urgent minoroperations on O.P.D. patients, etc. – other days arerelatively free.

d) Extreme mal-distribution of work and total lack ofanswerability.

13. A better system of administration is absolutely essential.a) In India, individuals are easily blamed, the system is

rarely blamed-in fact it is hardly even discussed.b) i) The unit should be divided into 2 sub-units, working

independently.ii) There should be at least 3 O.P.D. for each unit, moreif possible.

c) O.P.D. and emergency duties should be on separatedays and all other duties should be evenly spread overthe week. That will increase answerability. Nine morningto twelve noon to be strictly reserved for patients andunder graduate students.

14. a) Curriculum – 1st M.B.B.S. should be extended back to 1½year (instead of 1).

In Summary


in this period.f) Additional expense will be recovered from patients, if

they are charged Rs.3 to 5, respectively, in villages andtowns, and fixed cost of medicine 2 to 5 = a total of 5 inrural area & 10 in towns.

g) Consultants about Rs.50,000/- (including E.M.I.) ofRs.20,000/- p.m.)

h) The quality of service has parabolic ratio to theremuneration.

i) Govt. can spend at least 4 to 5% of G.D.P. instead of1.1% as at present.

19. Health Insurance Scheme :-a) health care is becoming costly and it will continue to be

costlier.b) Health Insurance scheme is the best available answer

but it is not as simple as it looks.c) There is an exclusion clause, worst among these, is pre–

existent disease.d) The patients become relaxed and allow inflated bills-

companies react.e) Over-investigation and over treatment result in mounting

costs, resulting in mounting annual premium.f) Charges are not displayed, in spite of M.C.I. instructions.

charges must be displayed.g remedy – the patient must bear at least 20% of the cost

and he/she can be insured only for upto 80% of theexpenses, with the usual ceiling.

h) Senior Citizens and the poor are not covered.Companies refuse. Therefore, only the government canand should cover both of these under a special insurancescheme with health-cess for all.

20. a) There are many doctors who would like to treat thepatients in simpler ways with greatly reduced costs.

b) But they are impeded by consumer protection act madeapplicable to doctors.

c) Doctors insure themselves against damages, thatincreases the costs of health-care but relieve the doctor'stension only partially.

d) There are serious disadvantages of this ConsumerProtection Act, for general public.

15% of the charges in private.d) Free Medical camps should not be allowed by medical

associations.e) Even the hospitals charges should not be free nor should

they be ‘nominal’ ‘arbitrary’. They could be subsidizedeven to the extent of 90%, and only 10% could becharged, for poor patients, if they come throughestablished proper channels.

f) Costing and way to decide subsidies can be easilyworked out – a method has been worked out here.

g) Even in the medical colleges, charge must be collected.These patients are already subsidized by students,research and the government to some extent.

17. a) Despite criticisms, tender system for purchase ofmedicines is good.

b) The cost price to government and muncipalities is 2/3 oreven half of what companies sell to others due to bulkorders and competition.

c) But instead of single lowest item, 3, 4 or more comparablebrands should be approved. Hospitals can purchase anybrand, it likes.

d) Purchase system should be decentralised to district level,if not taluka level.

e) Drug should be sold at 10% market price at primaryhealth care and to those properly refered to the highercentres. at cost price to those attending hospitals directlyor after referal from private sector & at 90% market priceto paying patients.

18. a) Salaries (or income) of the doctors should becomparable to his counter parts of equivalent talents inother fields – horizontal parity.

b) It is easy to be strict, if remuneration is adequate.c) The post-graduate students in medical colleges should

receive ‘contract-payment’ proportionate to salary andNot ‘stipend’. They should not be considered ‘students’they are employed workers – on contract/apprentices

d) Public service doctors must also be paid adequately.e) The E.M.I. for study-loan works out to be Rs. 10,000/-

p.m. and that must be added to what they deserve for thefirst 10 years. Subsidized students will re-pay the subsidy

In Summary


21. a) Rules and regulations must be strictly followed andaction taken.

b) Full-time doctors should not be allowed privatepractice except incentive practice within thepremises.

c) Same with medical teachers, as already discussed.d) They should be adequately compensated, but they

cannot have a cake and eat it too.e) This will reduce over-crowding in the field of private

practice and that will help in reducing malpractices, over-treatments etc.

f) Patients, in public health service, must go through theestablished hierarchy to entitle them for (nearly) freetreatment or pay from their own pocket.

e) The patients must have some protection in a differentway, if this act was to be repealed.

f) Criminal negligence was and is always punishable in thecourt of law, but the doctor should not be held guilty foradopting cheaper methods, at low cost, if he hasexplained the patient why and how?

g) or the C.P.A. should be made optional. The patientshould be given a right to opt out of the act and give thedoctor a free hand.

h) Substantial statistital evidence with good records shouldbe acceptable.

i) For unexpected complications and loss of earningmember, there can be a system of some compensation,irrespective of who is at fault.

21. Accreditation :-a) Any doctor can treat or perform any operation anywhere.

There are no rules and regulations, defining the role ofeach category of doctors. This is dangerous.

b) Accreditation of hospitals is one of the answers. Eachhealth-centre, nursing home, hospital should be gradedofficially, as per the equipments, and staff and systems inthat place.

c) The health-care centre can under-take only what it canmanage and send more serious patients to a highergrade centre.

d) Most professionals will be happy and feel secure. Onlyunscrupulous or greedy professionals will be worried.

22. The role of different doctors must also be defined.a) Basic doctors cannot advise high-tech investigation

nor prescribe the costly or latest drugs introduced inthe previous 1-2 years.

b) Non-Allopathic doctors can practice only in rural andsemi rural areas or in slums, if they do allopathy.

c) The specialist should see only cases referred by the‘basic’ doctor or at least treated earlier by him, except inserious cases.

d) The patient should be referred back to the basic doctorfor further treatment.

e) The line between specialist and super specialist must bedrawn, even if vaguely.

In Summary

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MANAGEMENT

OF THE

SICK HEALTH-CARE SYSTEM

(WHAT IS WRONGWHAT CAN BE DONE)

Dr. S. V. Nadkarni, M.S.Formerly,

Professor of Surgery & DeanL.T.M. Medical College & Hospital

Medical DirectorBhatia General Hospital, Jaslok Hospital

Report Prepared between March & August 2009

MANAGEMENT OF THE SICK HEALTH-CARE SYSTEM

DEDICATED TOALL PATIENTS

FOR ALL THEIR PATIENCE.I PRAY

THEY BECOMEKNOWLEDGEABLY

IMPATIENT.

}

Born - Mumbai 3rd May 1932

Education - in Pune - Open merit scholar of Fergusson College,M.B.B.S. & M. S.

Extra curricular - 12 years with a socialist organization

- Kabbadi, Drama - won university and state awards.

Medical teacher - Education, research, organization & administration.

Reader in Surgery - Manipal and Mangalore - Private Trust Institution.5 years (Private Medical College).

Associate Professor - Goa - Central Govt. college6 years (Full Time System)

Professor of Surgery - L.T.M. Medical College, Sion, Mumbai -& 13 yrs Muncipal Medical College

Dean 5 years - 18 year (Partly Honarary & Partly Full Time System)

Medical Director - Bhatia Hospital - Middle Class Trust Hospital 2 years

Jaslok Hospital - Elite 5 Star Trust Hospital 1 yearPikale Nursing Home - Private Nursing Home Owned By Son in Law &

Daughter

Advisor to Govt. of Goa - 2 years - Organized Trauma Care Service in Goa MedicalCollege.

Established Trauma Care Unit at L. T. M. M. C. which is the first of its kind, well -Organised Unit in India in the civilian sector.

Specialised in offering extremely low cost, high quality surgical treatment in apublic hospital.

Thus, wide experience in Private, Central govt. & municipal hospitals and privatehospitals for all strata of society.

Greatly concerned with the appalling deterioration, in the standerd of medicaleducation, public health services as also private,medical services in the country.

Dr. Sadanand Vinayak Nadkarni - M. S. - (Gen Surgery)

PREFACEPREFACEPREFACEPREFACEPREFACE

I have spent nearly 55 years in the clinical field-first 5 years as agraduate M.B.B.S., doing resident posts and later anaesthesia inPune till I passed M.S. in general surgery. For the last 50 years, Iam in the medical field doing varied functions like surgical practice,teaching, research, administration and development ofhospitals.Initially I worked in a private trust medical college;thereby I developed an insight into the pros & cons of a privateteaching institution. later I worked in the central government runmedical college with a 100% faculty of full time consultant teacherswho were not allowed any private practice, while in Mumbai Iworked in the muncipal medical collage which showly transformedfrom Honorary consultant system to the full time consultantteachers who were not allowed to practice outside the premises.However till do day it has remained a mixed system. I headed thecollege and hospital as a Dean and got a wide experience inadministration and development. After retiring from the college, asa medical derector, I managed a middle class charitable trusthospital as well as an elite hospital like Jaslok Hospital and spentthe last 20 years in running a proprietory nursing home owned bymy daughter and son-in-law.

Thus, I had the widest experience ever for any medicalprofessional-cum-administrator, having seen from the poorest tothe richest class of patients and all kinds systems of administrationfrom full time to Honarary to only private practice and intimatelyexperienced the working in muncipal corporation, State andCentral Government. In a way I was fortunate that I was notcontaminated by "Foreign education or experience" but observedtheir working only late in my life. In addition during my cllage days,I had a 12 years’ association with a social organisation, whichbrought me in close contact with the poor to the poorest strata ofsociety and which gave me a lot of training in sociology andpolitics. Though, I never entered political field, this helped me inunderstanding the real problems of the common-man in gettingproper care and in understanding the anamolies in the health caresystem.

To-day, health care is going beyond reach for even the middleclass people and the costs are likely to soar higher & higher. The

glamorous high technology is blinding the people's vision and theever increasing demands for such equipments is only helping tomake the situation worse. It is not realised that what the peopleneed is good primary health care and a reasonably pricedsecondary care. Unfortunately, "Free Treatment" is not onlyconsidered the right of every citizen but has become an acceptedslogan for politicians as well as public health doctors and all thecitizens. They take immense pride in advocating "free treatment",despite the fact that people are spending more & more and gettingworse and worse treatment in these "free hospitals". I also realisedthat the main problem in our system is an extremely faulty medicaleducation and an equally faulty primary health care system. Theseare the root-causes of the chaotic health care system.

Hence it is necessory to give a body blow to the concept of "freetreatment" and earn revenues from every one capable of payingfor medical services, whether in private or public sector. It is alsoessential to radically improve the medical education system. Thesociety benefits or suffers for the next 35-40 years, depending onwhether the doctors brought out are good or bad. It must also berealised that a poor ineffecient public health care system results ina highly exploitative, costly private health care system; it has nofear of any competition from the former. In addition people havewrong concepts about the medical insurance schemes, consumerprotection act and its consequences etc.

All this prompted me to write this book. I have explained wherethings are going wrong and what needs to be done. I would be thehappiest person, if the book leads to a wide discussion on all thepoints I have raised, irrespective of whether my ideas are acceptedor not. I feel convinced that many of them will be accepted, if onlywidely discussed.

– Dr. S. V. Nadkarni

1. Introduction 1

2. The Present Scenario 3

3. Health Care Delivery System 11

4. Health care system is an industry 15

5. The need for qualified Doctors 22

6. Selection pattern for admission to Medical College 24

7. Fee for Medical Education 32

8. Subsidising Private Medical Colleges 37

9. Paying Patients in Med. College Hospitals 41

10. Effective fees for Medical Education 46

11. Selection of Medical Teachers 52

12. Working pattern in (Med. College) Hospital 61

13. The Dean 68

14. Medical Curriculum 71

15. Referal System & Charging Pattern 76

16. Service charges for patients 80

17. Supply of Medicines 85

18. Adequate Emoluments for Medical personnel 89

19. Nursing Homes 93

20. Health Insurance 96

21. Accreditation 107

22. Miscellaneous 115

23. Bill for the patient in Public Hospitals 117For Teaching Economics of Healing

24. High-Tech Modern Hospitals - Are they Really Useful? 123

25. In summary 130

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Healing a sick healthcare system

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