THE COST OF RECONSTRUCTING HEALTH-CARE PYRAMID IN INDIA – CAN YOU SACRIFICE HALF CUP TEA PER WEEK?!

This is a thought provoking article. So, I am starting with few pre-requisites:

• If you are busy and cannot complete reading this in one shot, please don’t start!
• These suggestions on modus operandi are just a beginning. As many ideas as possible need to be added to make it is a collective venture.
• Criticisms of every type are welcome. But, when you have any objection to any point, please suggest a remedial measure to improvise or to overcome the fault. Don’t just pelt a stone and be happy about participation!
• This discussion should shape into a tag and should propagate till it reaches a logical conclusion. The longer it is in air, better the chances of reaching helping ears. So, please keep commenting!

With the premise, let me start. This piece is a sort of continuation to my earlier article – Resurrection of MBBS and Family medicine: Can it check quackery in India? (Link: http://www.docplexus.in/questions/97117a2c-8318-4d81-8dde-65c0ce12ec95/resurrection-of-mbbs-and-family-medicine-can-it-check-quackery-in-india)

Few basic statistics as per PWC data on Indian Health-Care (year 2012) to begin with:

• 1.3 beds per 1000 population with 70% from private hospitals: about 7 lakh beds in private hospitals in India.
• About 10.5 lakh practicing Doctors of Modern Medicine registered in India with medical council. Please don’t use the term “Allopathy”; it is not same as what we practice. We are trained in “Modern Medicine” which is NOT Allopathy!

Indian Health-Care pyramid is skewed! I don’t see any need to elaborate on this. The bottom of this pyramid is infested with quacks – anyone untrained in medical care or trained in a different form of medicine but practicing Modern Medicine

If we want to reconstruct Health-Care pyramid in its proper perspective, these quacks should be replaced by qualified doctors. Anyone getting trained in their respective variant of medicine, be it AYUSH or Modern Medicine should practice in their own field. Unfortunately, neither the legal system nor the government feels the need for this!

In such a situation, we have the onus of restructuring the pyramid on our own without support from government. It is possible only through involvement of more and more MBBS doctors at the base of pyramid. The question is: HOW?

The chief reason for MBBS graduates not pursuing practice are:

• Lack of confidence: the training imparted in medical colleges during MBBS is no way helpful to establish clinic practice at present! One can count multiple reasons for it, but the end result is same. Barring few brave ones, most of the MBBS pass-outs are not confident of succeeding in clinic practice.
• Social Constraints: In the bargain of elevating the status of a specialist, we have deliberately denigrated MBBS as “just MBBS”. It is extremely myopic of such people. There was no need to kick down our own brethren to establish superiority of “specialization”. But unfortunately, it is built that way. Slowly, “just MBBS” has become a social taboo. This needs atonement!
• Finance: With lack of confidence and social taboo, there comes another devil to face- MONEY! Middle class students are drained out with fees and additional expenses by the time they finish MBBS. In an age when their BE/BTech peers are earning in six-digits, these bright brains are morally depressed for asking their parents for daily needs. It is humiliation of highest order. There is no way they would dare taking another loan for starting a clinic, success of which is uncertain.
• Lack of professional support: “Just MBBS” gets hit by even specialists! Caustic criticisms, unsavory remarks, hateful tone of speech are all very common. But, not many would try to help them imparting with what is needed for MBBS practitioners.

The list may go endless. Somewhere, we need a beginning to stop these. Here are some of suggestions: Please add to them.

First and foremost is finance. Don’t even think of help from government. They detest educated people and tax-paying population! Whatever is needed should be practical and should be on our own.

The proposals would be simple:

• Each private hospital should contribute at least Rs.1000/- (one thousand) per bed to a corpus. With 7 lakh beds, it should be 70 crore rupees.
• Each specialist professional body (like API, IAP, FOGSI, SSI, CSI etc) should contribute a minimum of Rs.500/- per member towards this corpus. This would amount to another 25 crores. Each non-specialist professional body run by MBBS doctors (Family Physicians Forum) can also contribute to this corpus.
• Each doctor of Modern Medicine should contribute Rs10/- per week (cost of half tea!) towards this corpus. With 10 lakh such practitioners it would be additional 50 crores per year.
• If this continues for a period of just 3 years, a cumulative corpus of 400 to 500 crore rupees can be generated.
• We should identify 4 or 5 reputed banks of national spread. IMA or any important medical body can moderate this. The entire amount would be under their custody with supervision from apex professional body.
• Each MBBS student should be encouraged to become a student member of IMA for an extremely nominal amount. When they finish MBBS, all such members should be entitled to avail loans of about 5 lakhs per doctor at extremely low interest (under 5% per annum) from these banks for starting clinic. EMI repayment should start from one/two years after the date of disbursement.  The rules of disbursement and loan recovery will be with banks, supervised by IMA. Also, IMA should act as guarantee for all such doctors.
• By 3 years, this will be self-sustained system. IMA can receive 1% interest per annum from banks for administrative purposes and for executing the process.
• This arrangement would encourage many MBBS doctors to dwell into practice. They should strongly feel that specialization is not essential or mandatory for being a good doctor and for serving the society! With time, the pyramid gets better and better!
• The entire handling of money would be done by banks in a professional way. No professional body would be directly involved. Detailed rules can be formed using the legal committee of IMA with banks to ensure simple yet thoughtful rules. Banks have to be accountable for IMA and other professional bodies. A committee of eminent doctors can be formed for this purpose to work on honorary basis. Since the reputation of banks is at stake with doctors, they will not dare foul play!

1. Each professional body should contribute to welfare of these MBBS doctors. There is no fear of losing practice. The referrals would be so good that each specialist or subspecialist would end up seeing more meaningful patients. Thus, individual consultation can go up with more attention given to each patient.
2. How can they contribute? Each specialist professional body should have online support forum in their website. Algorithms should be created for specific symptoms or problems with clear indication of how to manage and when to refer. These should be available in simple print versions also. Specific upgradations should be done to these algorithms as and when guidelines change. In addition, each specialist professional body should conduct specific CMEs meant for MBBS practitioners on periodic places at various places using locally available specialists. This would bring up tremendous rapport amongst them.
3. IMA should encourage student membership for all MBBS students right from 2^nd year. Monthly talks on practical aspects of clinic practice including legal hurdles, tips for good practice, medical ethics, government norms and everything a practitioner needs should be elaborated in these lectures with active participation from students.
4. Mentorship programme should be started by IMA. In this, any doctor willing to mentor one MBBS student should be enrolled into a database. Students should be offered an opportunity to stay with the said practitioner for a period of 6 months during practice hours to learn the nuances of practice, body-language, communication skills, art of practice and anything that helps practice on long run.
5. Active legal and indemnity insurance support should be provided by IMA to all MBBS practitioners at a very nominal cost. This works out due to good volumes.

This is an incomplete list. Huge modifications are possible. The biggest advantages of these steps are: government not involved at any point; no involvement of MCI is sought; no demand for change in curriculum- these are anyway not possible to achieve by mortal humans like us! These suggestions appear do-able!

Of course, this involves active participation of IMA as liaison office to collaborate and facilitate the overall process. This is the only hitch because we have never seen IMA standing firmly for the cause of doctors! However, some income generation and power bestowed upon should encourage IMA to be more proactive. There is always a choice of parallel body with time!

This lengthy piece of write up is meant for strong criticism and suggestions. Please remember: don’t criticize without suggestions on overcoming your criticism!

We need to change; we need a start! Let us begin somewhere. Let this beginning happen at DocPlexus forum!