Ward boys, pharmacists and class 4 employees or sweepers have been caught on camera giving injections, putting stitches, giving medicines to patients in hospitals in Bulandshahr and Ballia in Uttar Pradesh. The doctors have not been present.
The question is whether the government hospitals in Uttar Pradesh need shock treatment. CNN-IBN Deputy Editor Sagarika Ghose took up the big question with a distinguished panel on her show Face the Nation.
Following is the transcript of the discussion on Face the Nation:
Sagarika Ghose: Hi there good evening. Where are India's missing doctors? Ward boys, pharmacists and class 4 employees or sweepers have been caught on camera giving injections, putting in stitches, giving medicines to patients in hospitals in Bulandshahr and Ballia in Uttar Pradesh. Doctors have not been present. Is this a case of the terrible state of government hospitals across India or are these barefoot doctors in fact essential in providing primary health care in small towns? Let's get an update first before we get into the discussion.
First in a Bulandshahr hospital, then in a Ballia hospital, a class 4 employee, a sweeper caught on camera- attending to patients in the emergency ward of a government hospital in Balia. A similar case was reported from Bulandshahr on Tuesday where technician and a ward boy administered injections and stitched up patients in the emergency ward. The Chief Medicinal Superintendent in Ballia has cited a shortage of doctors in govt hospitals. Meanwhile the Director General of Family Welfare is now in Bulandshahr to carry out an investigation.
The appalling conditions in government hospitals do government hospitals need shock treatment? What is the nature of the problem? What is the scale of the problem? What can we do to improve the government hospitals? Joining us tonight, Doctor Rajib Dasgupta, professor, Centre of Social Medicine and Community Health at JNU and a Health activist. Doctor Sanjeev Bagai, CEO and Dean, Director, Radiant Life Care. Doctor DR Rai, Secretary General of the Indian Medical Association.
And we will also get you the views of Doctor Devi Prasad Shetty, acclaimed cardiologist and chairman of the Narayana Hrudayalaya in Bangalore to whom I spoke earlier. I started by asking Dr Devi Shetty, what he thought of this situation where ward boys and sweepers and not doctors are giving treatment to patients in emergency?
Dr Devi Shetty: This is the reflection of acute shortage of manpower in healthcare. First of all we are short of at least one million doctors and at least one and a half, two million nurses and may be more technicians. And the biggest problem is most of the medical colleges, nurse colleges are southern state affair. Northern and Eastern India has less than 40 per cent of the medical colleges. So unless something drastic is done, especially in small districts of northern and eastern Indian region to build medical colleges, nursing colleges, you will keep on having this kind of incidences very often. Unless you address the problem of manpower this problem will keep happening.
Sagarika Ghose: But many say that these are the barefoot doctors, in the emergency when there is no doctor what is wrong of a technician provides stitches or if a sweeper comes in and gives injections? Many say that this is a kind of measure you need in an emergency.
Dr Devi Shetty: See when I was a medical student in a government medical college in Mangalore, we had a group of people called dressers, wound dressers. And these people could do wound dressing much better than doctors. They are specifically trained to do the job.
They are not the one who would do the dressing and then go back clean the toilets. It's a different category of people all together. But over a period of time things have changed. I admit that in an emergency situation as a life saving situation, the non doctors can perform this procedure. But the way it was projected, I don't want to give my opinion because I don't know the whole story that it may not be the case. I wish it was an emergency situation to save life of a patient when the doctor is not available.
Sagarika Ghose: Why are things so bad in government hospitals. Is it because good doctors, qualified doctors don't want to go there? They either do private practice or they go overseas.
Dr Devi Shetty: Situation in the government hospital will get worse. What you are seeing is nothing. Unless we do something dramatic the government hospital will have much worse problem then what they are having. One of the solution what everyone comes up with is government is not paying salary that is the reason why people go to private hospitals. If government hospitals increases the salary straightaway the private hospital will increase it more, so in the process healthcare will become unaffordable. The biggest problem is that we have to accept that there is a shortage and also this shortage is regional. A doctor from south India wouldn't like to work in UP district hospital. Let's face it, how many south doctors are working in UP healthcare. Similarly UP doctors do not want to come to north Karnataka and practice. Healthcare is a regional affair, if you want doctors to work in UP district medical hospital, start colleges in UP districts. We are short of 500 new medical colleges. We have close to 250 medical colleges. That is not sufficient.
Sagarika Ghose: If you have to give suggestion how do you think government hospitals can be improved.
Dr Devi Shetty: First look at the district headquarters hospital. Start a medical college attached to every district hospital in north and eastern India. Because once you start a college, quality of healthcare in that hospital will improve significantly. Then you should have all other paramedical services like nursing education, paramedical education. Offer a health insurance like we have done in Karnataka with Yashaswini to all the residence of the district. So that when they come to hospital, they don't come with empty hand. There health care is paid by the insurance scheme then the entire quality of healthcare will change. There is no bandage for the solution, there is no quick fix. We have to address this problem because healthcare is one industry which is totally dependent on manpower. It is not mainly dependent on the availability of medicine or on equipments. You need to have skilled manpower, you address it first then everything else will become a minor detail.
Sagarika Ghose: Address the question of manpower Dr Devi Shetty giving us his views on the problems and solutions of Indian government hospitals and healthcare. I'm going to turn the discussion to our eminent panel doctors who are here with me in the studio. I'm going to put it to Dr Sanjeev Bagai to give me your analyses of the problem of the government hospitals and what is your understanding why these problems arise. But as we do that, I'm also going to ask you to react to this quote by Abhay Vaidya who has written in Firstpost, “Real story of Ballia and Bulandshahr is not that a ward boy and sweeper administered injections to patients but whether they did it flawlessly. If the ward boy followed the procedures correctly and helped save the lives of accident victims, then he and his seniors deserve to be felicitated and not punished." So first respond to that and then give me your broad overview of the government hospitals.
Dr Sanjeev Bagai: Interesting quote, I think what we have been seeing on the screen on various channels and in your channel, I don't think it gives mandate to sweepers and ward boys to come in like John Rambo and start dressing and stitching wounds without gloves or other person coming like John Wain and despairing like (*) into the sunset. I don't think that is right at all.
Sagarika Ghose: You don't agree with this prescription at all?
Dr Sanjeev Bagai: I completely disagree with it. Having said that the larger problem is of manpower. But before coming to manpower and focusing on this story as a completion. We have a 170 bedded hospital and we just have 23 medical professionals. Why is there just one person on call at that given point of time? So therefore the medical administration needs to be taken to task. They need to be made accountable; they need to asked why is there just one doctor out of 23 available at that time. So the medical administration needs to answer that question. Coming to the larger question as to shortage of manpower. I completely agree with Dr Devi Shetty and I voice this at various forums. We need a lot of doctors, we need a lot of nurses and we need lot of hospitals. It is very much tilted south centric as far as the regional education is concerned. Healthcare now is very closely liked to healthcare and education. Unless and until we do not provide medical colleges, we can't produce doctors. Doctors take six year plus three years to become a postgraduate. Now if you are going to produce doctors in the numbers we need then we need more hospitals. The government should help us by easing the norms to open teaching hospitals.
Sagarika Ghose: Many more medical colleges. Many more teaching hospitals. What about the doctor, is it because good doctor or a qualified doctor as health activist asking you because… is it because the good doctors like Sanjeev Bagai all going to private hospitals, are all going to overseas. Is it because good doctors are not going to government hospitals. Are doctors being more idealistic, are doctors thinking more of their own career? Is that the kind of concerns that bothers you?
Rajib Dasgupta: Well there is largely a moral burden on doctors. Where this moral burden is not applicable to other professions. And that is something which is intrinsic to the nature of the science that we learn and medicine. Nevertheless there are issue that the health service needs to address and that is what largely was being spoken about.
Sagarika Ghose: So you don't blame doctors for going to private practice and going overseas. You don't think that we should unnecessarily beat-up on doctors.
Rajib Dasgupta: In an open market this is inevitable of sought.
Sagarika Ghose: Right but you were saying that the problem of the healthcare system.
Rajib Dasgupta: The problem is of healthcare system. The fact is we have huge shortages, these shots come from UP where the shortages are far above the nation average. Be it the population covered by an individual doctor or be it health centers without adequate infrastructure, say electricity or running water. The levels in UP are fairly high above the national averages by the government's own data.
Sagarika Ghose: Right and I think that is a very interesting point coming out from what Dr Devi Shetty and what Dr Sanjeev Bagai ahs said that north India is particularly bad, south India is doing much better. Let me put to you the state of shortages. India is short of six lakh doctors, short of 10 lakh nurses, short of two lakh dental surgeons. Indian doctors form five per cent of the medical workforce in developed countries. Almost 60,000 Indian physicians are working in countries like the US, UK, Canada and Australia. Indian doctors seem to be giving up on Indian. Can we blame the doctors for that?
Dr DR Rai: I think we should discuss why doctors are going out of India. If they are finding better positions there that is why they are going. But as far as you have told me something about the manpower and north Indian, south Indian comparison, I would say it is faulty policies of the government. Why they have concentrated by giving permission to medical colleges to be open up only in the south? It is with the government only; it has given permission to nine medical colleges in Pondicherry and nine colleges in whole of Bihar. In UP only 10 or 11 medical colleges are there and in Pondicherry there are nine colleges.
Sagarika Ghose: But what could have determined that decision.
Dr DR Rai: Government will have to answer that. Government can say well gentlemen if you want to open the medical college why you don't what to go to the remote area. Just go and open medical colleges there. The corporate sector is coming in this area, I think; government should say ok open a corporate hospital in the city but have smaller hospitals in the rural areas. And corporate is coming in a very big way. And Indian is now a days recognised as a medical tourism hub. I think our doctors are excellent at power. The only fault is of the bad policies of the government. Even the government is not recruiting doctors regularly, they are just blaming doctors are not there. I can give you just an example in Bihar seven years back 1540 doctors had joined on a contractual bases and after those doctors have joined, the parameters of healthcare has gone very high. The records are with me and I can give you the records and recently the Bihar government has advertised to raise new jobs for doctors. And now they are just asking you first appear for the examination they come for the viva. I ask only one thing once these doctors are working on contractual bases they have improved the parameters of health also why you are not recognising them? Do you think in today's scenario doctors should be employed on contractual bases? And there are states where Rs 14, 000 is given to the doctor.
Sagarika Ghose: Right, so the government is simply not respecting the doctor. Not realising that the doctor want to perhaps work in India but is simply not encouraged to do so. Let me come to you, Dr Devi Shetty talked about having insurance. He has started that Yashaswini scheme, in fact a very path breaking scheme where you only pay Rs 10 and you get medical insurance, therefore when you go a hospital you are not a beggar, wanting free treatment. Is that the answer because if you want to provide complete free treatment then there is no incentive for that hospital to be a going concern, as they say? You can't have it absolutely free, you must have medical insurance because that is what can have quality government hospitals.
Dr Sanjeev Bagai: That is very true, less then two per cent of the Indian population, pan India, has medical insurance. It is a little bit more in major metros but pan India is two per cent. There has to be a contribution from a common person, however, the small contribution many be on a monthly bases and annual bases. And the way forwards is let the patient contribute little bit on monthly bases, less than his telephone bill, for his annual insurance and the government funds the rest. But the larger questions are there are restrictions put on medical teaching institutions. The size of land, the availability of land, difficulty in getting in funds… and I think of the government helps the private players which is 75 per cent contributory towards the overall national healthcare scheme. I think the way forward will be to open more medical colleges.
Sagarika Ghose: Just increase capacity. But someone like you, you know, who has opened a hospital in Delhi, why don't you open a hospital in Ballia or Bulandshahr?
Dr Sanjeev Bagai: I think if we have land which is given at concessional rates, if we are given infrastructure in tier 2, tier 3 in cities definitely yes.
Sagarika Ghose: You would be incentivised. Its worth you while to go to these rural areas. Do you think government is abdicating its responsibility; too many private players are coming in the big cities, therefore the rural areas are being leftout?
Rajib Dasgupta: Which is true on the one hand, on the other side the private side is also fragmented, heterogeneous and that is playing out, there is a lot of talk about insurance. The government has recently launched Rashtriya Suraksha Bima Yojana, which is meant for BPL population. Our own work just to clarify, I'm not an activist but an academic, our own work in several of these states actually show that the nature of fragmentation with in the private sector is or could be inimical to insurance playing out a fairly positive role. So let's not lump all the private sector together. It is a wide spectrum of things.
Sagarika Ghose: So it is not as if there is a huge difference in the kind of players in the private sector.
Rajib Dasgupta: Insurance also works well on certain assumptions which are often not there on the ground.
Sagarika Ghose: It has worked very well in Karnataka but it doesn't mean it will work in UP and Bihar. Let me come to you Rai should these ward boys or sweepers or class 4 employees, should they be trained. Because sometimes if the doctor is not there in an emergency situation why should they not jump in and provide that primary care. Should they be trained?
Dr DR Rai: I think if we talk logically once we are having shortage of manpower and district and big hospitals which ever paramedical staff we are employing there, if you give first aid training to them, they will be asset at the time of disaster. You know this Bulandshahr episode is a disaster. And disaster never sees the community, which is coming and which is going they want immediate and quick help. But we are not saying that sweeper should be allowed to do stitching, no.
Sagarika Ghose: But paramedical staff all ward boys should be given (training) because in this situation of lack of manpower what needs to be done. Because if a child comes in… what happened in this hospital was that a child came in with an accident there was no doctor, so the sweeper plunged in, the ward boy plunged in and they took care of him, he survived. So in that sense what they did was not wrong.
Dr Sanjeev Bagai: I still disagree. If the medical superintendent is there as we see and he has said he is supervising the ward boy or sweeper to be doing.
Sagarika Ghose: Because they can't make a diagnoses.
Dr Sanjeev Bagai: There is no hygiene. You have dirty scissors there, no sterile drip, I'm sorry, this is completely wrong.
Sagarika Ghose: We can't romanticise that fact that they jumped in to the rescue.
Dr Sanjeev Bagai: Healthcare is not playing to the galleries. It is extremely serious. Either you do it seriously or you don't o it at all.
Sagarika Ghose: Right. I have just got a message from someone who is saying, “Let's not romanticise the role of the ward boy. Would Manmohan Singh or Sonia Gandhi ever be stitched by a ward boy? If it is not acceptable to them why is it acceptable to the poor people?
Now you already spoke about the solution of more medical colleges, more hospitals but I would like you to speak more detailed about how to solve this problem.
Dr Sanjeev Bagai: Just as an over view, as a macro helicopter almost 75 to 80 per cent of healthcare in India is private driven. Irrespective whether it is private or government, the land which is required to create teaching institution is 10 acres in metros, that should be eased. We don't get 10 acres of pockets of land even in two divided areas. We can have a fantastic institutions in four or five acres. So the land size is one criteria.
Sagarika Ghose: So the government has to decrease the land size that it hgas allotted to hospitals.
Dr Sanjeev Bagai: Most of the time you would now see henceforth medical professionals who have a passion for practising medicine trying to create medical institutions. Now even business houses or medical professionals have to approach 15 or 20 government agencies for approvals.
Sagarika Ghose: We need single window.
Dr Sanjeev Bagai: Pre-commissioning and post-commissioning. My own suggestion with all humbleness is that government in every area, every zone should have one single window system in which you produce all your papers and all the approvals are given from one single window, rather than going to 15 different agencies and taking a year just to get the approvals. Point number three is we should focus on healthcare as a priority give subsidies, give taxes as a much less percentage and allow import of the latest medical technologies. That is the only we are going to create medical institutions which are sustainable in long term. And one last point, I think, it is important that if we wish to cover the gap of deficiency of manpower and human intellect, it is going to take six years of MMBS and three years of your basic post graduation MD or MS that means 10 years. But let us not be deter by the 10-year gap. Let us start walking the path now because every step for us is going to make us move towards our final aim. It's a marathon but let us run the first lap now.
Sagarika Ghose: We have to start now. Because if we don't begin now we will never be able to make it. Very quickly. Dr Rai you want to add up to these suggestions.
Dr DR Rai: You know the biggest problem is coming over the expenses government is doing on the health sector. On 1.2 of our GDP is spend on our healthcare and every time we from the Indian Medical Association have requested the government until unless you are not going to increase the health budget.
Sagarika Ghose: Increases the health budget that is a very good suggestion coming from Dr Rai. Stop increasing the defence budget all the time. Very quickly Dr Rajib Dasgupta
Rajib Dasgupta: Few quick points from the ground. One some basic health workers that we invest in there are states that have good experience with that. And last as far as rural health services are concern, give power to the local self governments that is the panchayats to monitor them and that is also working well in some states.
Sagarika Ghose: Panchayats should monitor local hospitals
Dr DR Rai: I think government should now concentrate more on primary health care centers. You know, until and unless our primitive and basic services are given to the villages.