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| What Needs to Change? | | Healthcare Delivery in J&K: Challenges & Opportunities | | Dr. Syed Amin Tabish | 12/26/2010 11:18:36 PM |
| Medicine is constantly changing - today’s answers become tomorrow’s questions. All knowledge which you seek for working in the service of humanity and for the uplifting of the world brings you a step forward. Little information when shared can go a long way. The most valuable lesson that knowledge can teach us is that its creation depends upon a continuous line of human relationships and traditions that go far back into the past. The continuity is an unbroken thread. It links cultures and peoples; it brings tolerance and understanding; it delivers hope and compassion. Fundamental changes must occur in health care systems to make them more equitable, cost-effective and relevant to people’s needs. All people and communities should receive essential public health and personal care services known to improve health status.
According to the 2001 census the size of Jammu and Kashmir’s population is 10,069,917 i.e., 0.98 per cent of the all India figure of 1,027,015,247. Its geographical area is 222,236 sq. km. and accounts for 6.76 per cent of the country’s size. Only 54.46 per cent of the population is literate. The national literacy rate for the same period is 65.38 per cent. Jammu district tops with 71.95 per cent literacy followed by Kathua with 62.64 per cent. Surprisingly, Srinagar district falls at the bottom. Jammu and Kashmir is one of those states in the country where both the demographic situation and level of socio-economic development remains far from satisfactory. It is important to note that both social and economic development and demographic situation are actually multi-dimensional processes and each dimension of development as well as demographic change has its own specific determinants.
The population growth rate in the state has been consistently high. The population is expected to grow to 12031825 in 2015 and to 13809601 in 2025. An increasing population in the face of already scarce resources and land can only result in diminishing returns in the absence of increase in other factors such as capital, better-trained labour and technological innovation. Higher level of the necessary investment is essential to achieve a given average output. More capital will be required to support, even at the subsistence level, an increased number of mouths to feed. A rising population decreases the ability of the state to save, as the dependency ratio is high. The rate of growth of the population has important implications for the health services. Increased number of hospital beds will be needed to maintain the same bed/1000 population ratio. A similar problem is faced in respect of doctors, nurses and pharmacists. The cost of such an expansion therefore is naturally very high. Moreover, the demand for medical services depends on the age composition as well as the size of the population. In the state, more than 5 per cent of the population is above the age group of 60 years. Therefore, in order to ensure that the standard of health remains good, an investment in preventive and related social services including housing and education will be essential.
The social infrastructure falls behind most of the developed states in India. The social indicators here are literacy rate, infant mortality rate, death rate, birth rate, status of children and women and level of poverty and rural development. In terms of literacy, J&K ranks third from bottom at 54.46 per cent. The Total Fertility Rate is 2.3, the Infant Mortality Rate is 51 [All India 55], Crude Birth Rate is 19.0 [All India average: 23.1]; Crude Death Rate: 5.8 [All India: 7.4]; and the Sex Ratio is 892 (All India:933). Estimated Death Rate 5.8 ((All India: 7.4), and Life expectancy at birth 65 (All India: 65.8). [SRS 2008]
Health Infrastructure
In J&K, Government institutions are overloaded: 91% in-patients load is on the Public sector against 41.7 % at national level. State needs 1666 Sub centres (1907 in position), 271 PHCs (375 in position), 67 CHCs (85 in position), 238 Allopathic Dispensaries, 2282 Multipurpose Workers (existing 1794), 1907 Male Health Workers at Sub centres, 375 Female Health Assistants (in position 27), 375 Male Health Assistants (in position 89), 85 Gynaecologists (28 in position), 85 Physician Specialists (44 in position), 65 Pediatricians (17 in position), 340 total specialists (135 in position), 85 Radiographers (59 in position), 460 Lab Technicians (396 in position) and 970 Nurses (403 in position). (Source: RHS Bulletin, March 2008, Ministry of Health, GOI). Moreover adequate number of Anaesthesiologists has to be posted at District and Sub-District Hospitals. Blood Banks have to be made fully functional and responsive to the needs of population. Appropriate Laboratory facility including trained manpower is a necessity.
At present the state has 3400 health institutions, over 5800 doctors, 12855 hospital beds in the government institutions and private aided institutions, including 4 Medical Colleges, 22 District Hospitals, 2 Ayurvedic hospitals, 273 Ayurvedic dispensaries, 2 Unani hospitals, 235 Unani dispensaries.. On an average one medical institution has to serve 3127 persons. 111 hospital beds and 48 number of doctors/vaids/hakims put together are available per lakh population. Community Health Centre (CHC) is a 30 bedded hospital/Referral Unit of 4 PHCs with specialised services. Primary Health Centre (PHC): A referral unit for 6 sub-centres, 4-6 bedded manned with a Medical Officer in-charge and 14 subordinate paramedical, Sub Centre: Most peripheral contact point between Primary Health Care System and community manned with one MPW(F)/ANM and one PMW (M)/or Pharmacist.
Health Institutions Average Rural Area (sq.Km) covered by a Health Intuitions Average Radial Distance ( Kms) covered by a Health Institutions
J&K All India J&K All India
Sub Centre 117.21 21.47 6.111 2.61
Primary Health Centre 591.67 139.40 13.72 6.66
Community Health Centre 2766.07 770.90 29.67 15.66
Average Rural Area & Average Radial Distance Covered By Primary Health Institutions.
Impediments to Growth: Low density population, difficult terrain (problem of accessibility), poor road connectivity, limited presence of private sector/NGOs and private sector largely owned/operated by in-service doctors.
The slow growth of the state can be attributed to various factors. The civil unrest in Kashmir during the past two decades has been a major factor. Low productivity in agriculture and allied sectors has impeded employment and income generation. Poor industrial infrastructure along with the poor investment climate has left the industrial sector in its infant stage. There has not been a suitable strategy for the potential sectors to achieve higher economic growth. Lack of sound fiscal management has also been responsible for the poor economic growth of the state.
The health status of the people has not been able to keep pace with the national level of achievements. In order to improve health conditions and promote women and child development, a concerted effort should be made in the fields of water supply, unemployment, health, education and health care delivery system.
There is an urgent need to provide safe drinking water to the people with regular water surveillance and water purification on cost effective methods. Informal health education on sanitation, hygiene, etc., needs to be imparted at family level. Information can also be disseminated through mass media by showing plays on negative aspects of bad sanitation, etc.
Challenges and opportunities
As a state with unique features and a strategic location, the speedy development needs an integrated approach. Sound policy and good governance can lead the state to a faster development path. District and Sub-district hospitals must be strengthened. The infrastructure of the hospitals: buildings, space, technology, latest biomedical equipment (like CT scan machines, ultrasound machines, X-ray equipment, Autoanalysers, etc) has to be upgraded. The problem of shortage of manpower should be addressed. A scientific human resource development program must be a top priority. Qualification and experience need due consideration while recruiting technicians, nurses and other staff. Patients should be looked after by appropriately qualified nurses and paramedics and not by unskilled persons. Facilities need to be provided to the district and Sub-District hospitals so that they remain functional 24x7. Emergency Medical Services are essential part of healthcare delivery. Functional Emergency Department (Casualty wards) should be set up at all the district hospitals. There is a need to streamline the functioning of the Out Patient Department’s. Residential facilities to doctors should be provided at the district hospitals so that they remain available 24x7. The bed strength of the District hospitals has to be increased. Mental Health has been neglected for far too long. It needs our urgent attention. Birthing Centres at strategic locations must be provided to take care of mother and child.
Doctors working in far flung areas should be given incentives like rural service allowances. Government must invest reasonably in imparting hands-on training to doctors and paramedics by arranging regular aggressive Continuous Medical Education Programmes both at district and state levels which will help them to enhance their knowledge and skills. Competencies of Health Professionals have to be continuously enhanced. Only proficient staff can provide quality care. Special attention must be given to the training of doctors and nurses in Critical care including Trauma management. All training programs (Symposia, Conferences, Workshops, Seminars) must fetch Credit Points to those who attend it. Earning of credit points should be made essential for professional growth of doctors.
District Hospitals should be made a hub of health care activities and designated as teaching centres for doctors and nurses so far Internship and Residency programmes are concerned. These hospitals should be managed by professionally qualified Hospital Administrators. Quacks that are playing havoc with the lives of poor and vulnerable populations must be brought to book. Drugs should be dispensed by the chemists against a proper prescription by a qualified doctor. Deviations by the chemists need to be dealt under rules.
Our view of health is changing to encompass a social as well as a medical model. The social model includes changes that can be made in society and in the lifestyles of individuals to make the population healthier. Illness is beginning to be defined from the point of view of the individual’s functioning within society in addition to monitoring biological or physiological signs. In other words, good health is determined not simply by access to medical care, but by a range of factors, some of which are closely related to the quality of the physical environment.
In tandem with these changing perceptions of health and well-being, the provision of modern healthcare is undergoing a fundamental change as a result of more integrated strategic planning on the part of healthcare providers and professionals.
This is affecting the type of services offered, how care is provided and the settings in which it takes place. Whilst predicting future trends comes with great uncertainties, particularly in relation to technological advances, it is likely that the pace of change will be faster than before.
A proper Referral System must be in place to treat the Right patient at the Right Place at the Right Time. The system needs regular monitoring by higher authorities. Referring institutions/doctors must be made accountable for it and performance determined with proper feedback from referral centres to the referring doctors (two-way). Arrangements can be made to make CHCs functional round-the-clock and PHCs can work in two shifts.
Quality Assurance must be at the heart of all health facilities. Mechanisms have to be in place to measure the outcome of interventions in accordance with principles of Evidence Based Medicine. Clinical Audit is a necessity for improvising patient care.
A robust Health Information System including Electronic Medical Records is an inescapable necessity for planning, policy making and continuity of care. Networking of healthcare facilities by combining all the three levels of care through Telemedicine is required.
Improving health outcomes
One of the main challenges for the future is for care to be planned strategically across the whole system, and in far closer integration with other services. Other challenges to which this new strategic delivery of services has to rise in order to improve health outcomes include societal influences upon health, the expectations of patients, and the changing expectations of health professionals.
Social changes
Social changes affect both how health services are beginning to be delivered — that is, more strategically and collaboratively — and perceptions about health and staying healthy. They include: Greater understanding of health impacts (address negative impacts from environmental factors such as food of low nutritional value, poor air quality and lack of opportunity for exercise), Changing nature of disease (the effects of unhealthy eating and lack of exercise place a growing burden on health, as do smoking and drug abuse, which are often the results of socio-economic inequalities and poor lifestyle choices. Preventative approaches to these factors need not be limited to publicity campaigns; modifying and improving the quality of our surroundings can encourage and enable healthier behaviours), Profound demographic change (older people now make up the fast-growing group in population. longer survival rates come with a higher likelihood of co-morbidities, coupled with the hazards of frailty. These will need to be met with forward-looking designs that identify and mitigate health risks. On a general level, however, the advantages associated with more inclusive and accessible environments can be life-enhancing for all), Patient expectations and cultural change (as the consumer- and user-focused culture gathers strength, patients will be making demands on the quality, context and accessibility both of services and of the environmental components that
encourage good health (as awareness is raised about personal responsibility for health, many patients now expect to receive more personalised care, tailored treatment and to play a greater role in taking decisions about their care, with increased access to information through the internet, people expect reliable, evidence-based information about their health and their treatment, new techniques for healthcare provision will be developed to exploit communications technologies - this will require changes in both professional training and in places where healthcare is accessed, and Rising standards of environments for care
Patients are looking for greater privacy and dignity, such as single bedrooms, welcoming ambience with ease of access, controllable lighting and temperature, reduced noise and views onto attractive external spaces: more hospitality services, such as cafés and shops, and accommodation for relatives and visitors, are also expected. Healthcare buildings have to be designed in response to such demands.
Staff expectations
The impact of service standards rests to a great extent on how staff work and how they are facilitated in what they do. A changing workplace: Healthcare professionals expect the organisations they work for to provide high-quality care. They want healthy and efficient workplaces that enhance the well-being of patients as well as themselves, allowing convenient and rapid access to medical expertise. Innovation in delivery: While acute hospitals offer increasingly sophisticated and effective treatments, there is also a policy drive to shift less demanding care closer to the home, and to integrate it with other community services. Improving staff recruitment, retention and effectiveness: the impact of workplace design is significant enough to affect productivity, attachment to the workplace and levels of staff retention. Research into the therapeutic effect of environments shows how their design can affect health outcomes for patients and improve the performance of staff. A series of investigations into the impact of factors integral to the design and planning of a hospital — and these principles apply in their own way to primary care buildings.
Views visible from a hospital bed can have an effect on the already vulnerable state of a patient’s health. Notable evidence of negative effects of windowless healthcare environments on outcomes has emerged from studies of critical-care patients. Studies have linked the absence of windows in critical or intensive care with high rates of anxiety, depression, and delirium relative to rates for similar units with windows. High noise levels have been found to increase perceived stress levels in staff, and bring about anxiety and sleeplessness in patients. By using the planned environment to help nurture a healthier population, we can reduce the burden on the healthcare service. But, in order to achieve this, there are fundamental issues to address in how we plan, procure and approach the narrowing of health inequalities. Future health explains how good design makes healthy places. It brings together sustainable, health-promoting design with the latest thinking about individual health and well-being.
Health Insurance
The United Kingdom offers a model of a system that is primarily centrally-funded by general revenues, provision of care was an integral part of the functions of the government in the health sector. Canada has a framework similar to the United Kingdom in terms of financing, but differs in the way fees for health care are set and the choices that consumers are able to exercise among providers. It offers interesting insights into ways to contain health care costs without sacrificing patient satisfaction. Netherlands, Israel and Germany offer examples of health care systems that are built around compulsory wage-linked contributions into a fund (or funds) to be used for purchasing health care, or more precisely, purchasing health care insurance from competing insurers. These compulsory wage-linked contributions and the idea of an “insurance fund” have much in common with the Employees’ State Insurance Scheme (ESIS) that currently operates in India. Singapore offers an example of how an “individually” oriented system that seeks to address the need for universal access, a high degree of choice with regard to providers, and a desire for cost containment might turn out. The central element of the Singapore model is an individual medical savings account to which working individuals contribute, and can be used to pay for their own inpatient care and expensive outpatient services. The Singapore model, with its compulsory medical savings accounts, is relevant for India primarily because it is a relatively unique idea, seems to support the objectives of equity and quality of care and indeed Singapore is known to attract patients from abroad to its facilities.
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Professor Syed Amin Tabish (FRCP, FACP, FAMS, FRCPE, MD (AIIMS) is the HoD Hospital Administration, Medical Superintendent and Chairman, Accident & Emergency Department at Sher-i-Kashmir Institute of Medical Sciences, Srinagar)
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