India's Public Health Care Delivery - Policies for Universal Health Care

This book describes the present awful state of India’s Public Health Care Delivery, its dismal planning and implementation. It argues that it can be remedied comprehensively and effectively, using its ‘own already present’ resources. A radical re-evaluation of some sacrosanct ideas and discarding many of these, especially in Primary Care and its structure is required. It can be done without disadvantage to the last man served. This book starts with the sea change India has undergone and emphasizes new ways of managing health. High quality work force creation and its deployment, an unsolved problem is effectively given a solution. The bulk of the book discusses the entire public health care structure and function and how it can be newly laid out with proper work force allocation, hitherto grossly inadequate, including professionals from other training backgrounds. It is total solution that will help India to achieve the goal of Universal Health Care. Acknowledgements Contents Abbreviations Chapter 1: Introduction Formal Public Health Care Structure and the Pandemic Where Lies the Deficiency? The Health Care Activities of Non-Covid-19 Nature The Inept Handling of Public Health Resources Inept Handling in Maharashtra Health Care Infrastructure at the Periphery and Covid-19 When the Governments Function Well and People Cooperate Inept Handling of Data The Challenge of Urban Prevalence The Illegitimate Scare of Rising Covid-19 Numbers The Good Statistics The Covid-19 and Public Health Measures Migrant Workers as a Health Issue How Serious Was the Spread After Migration? Migrant Labor—Whose Failure Is It? Failure of Employers and House Owners Was It Failure of the Central Government? Engineered Migrations Deaths During Migration Herd Immunity A Good Measure to Meet the High Covid-19 Patient Load Non-Health Care Decisions and Actions The Heroes of the Struggle Down Side of Dealing with Doctors and Paramedics The AYUSH Ministry Contribution References Chapter 2: Philosophical and Social Basis of Reorganization Background Changes over Last 30 Years Health Thinking: 70 Years Sans New Ideas Some Philosophical Considerations: The Hegelian Idea How Humans Deal with Obsolescence in General Limitations within Health Thinking Consequent Failure of Primary Care Need for a Philosophical Basis for Reorganization The Health Theorists and the Indian Scenario Reorganization: What It Does and Does Not Mean? Criteria for the Four Rs Structural Reforms and the Four Rs The Social Basis of the Context of Reorganization The Population Shifts Will Smart City Idea Help? Pervasive, Iniquitous Modern Medicine: Will it Help? Will the Public–Private Partnership (PPP) Help? Dealing with Ancient Systems of Medicine The New Psyche Transactional and Litigious Mindset Why Matters Deteriorate in Public Health Care? Curative or Preventive Medicine? Crowding at the Primary Care Level NGOs and the Health Work The Church Panchayati Raj and the NGOs Matters Relating to the Community Health Workers Predicament of National Programmes Predominance of Non-Communicable Diseases Decline of Voluntary Sector Incompatibility of Government and Private Sector, Including the Voluntary Organizations Unionism, Welfare Model and Its Consequences Quackery, Anti-Science Occultism at the Periphery The Moribund, Incompetent and Unjust Referral System The Hilly, Remote Tribals of the Jungle Exclusion from the Main Tree of Health Care Delivery: A Necessity Mobile Health Services, the Answer Some Crucial Considerations A Brief History of how the Structure and Function of Public Health Care Evolved Evolution of the Primary Health Care Ideas: Community Health Workers Dai or Village Midwife: For Safe Labour and Related Matters Unipurpose and Multipurpose Health Workers Mitanins and ASHAs Supervisory Hierarchy Primary Health Centre and the Lone Medical Officer What Reality Do We Have in Front of Us? Some Ideas to Work with: It Is the Quest for Alternatives References Additional Reading Chapter 3: Shortage of Doctors and Government Medical Colleges Preamble The Colossal Deliberately Misconceived Myth of Doctors’ Shortage Generalization of Ratios and International Bodies One Basic Doctor in a Population Segment Some More Myths of Statistics and Doctor-to-Population Ratios Medical Seats Available as of 2014 to 2015 Continued Myth and the Concern of Shortages at High Levels Population Size, Level, Needs and Shortages: A Statistical/Theoretical Argument Administrative Block and CHC, the Best Levels Best Levels for Specialty Professionals Levels Irrelevant for Calculation of Shortages Worthless Alternate Ideas for Making Up the Shortage of Doctors in the Periphery Public Health Care Structure in India Government Medical Colleges: The Key Factor Govt Medical Colleges and the Infrastructure Work Culture Sloth, Dirt and Corruption in Medical Colleges A Laudable Improvement Initiative The Selection Process of Medical Admissions The Examination System for Admission Aptitude Tests before Admitting a Student: The World View The Bond System The Externalities Needed for a Good Education Process The Administrative Failure Student Teacher Relationships Today Medical College Teachers Improving Teaching in Medical Colleges The Results of Medical Education Today References Chapter 4: Medical Education Preamble The Steadily Worsening Situation of Teaching in Medical Colleges The Original Aim of Medical Education and What Happened to It Rote Learning: Is It the Only Way to Learn? The Traditional Individual Subject Approach: The Preclinical Years Learning Pharmacology, Pathology and Preventive and Social Medicine Pharmacology Pathology Preventive and Social Medicine Virtual Techniques in Procedural/Surgical Learning The New Decisions of the MCI about the Preclinical Subjects ‘New Skills’ Added to the Medical Curriculum: Communication and Vernacular Skills Medicine, Surgery and Gynaecology The British Didactic Model Lecture-Based Education: A Few Words The Clinic-Based Approach, Grand Rounds and the Post-Mortem Rooms The Real Hands-on Learning A Word about the Postgraduate Education and Degree Indian Text Books for Indian Medical Education The Examination System: On Evaluation of the Students The State of Education of Established Practitioners, the Teaching Methods, Related Ideas and the Continuing Medical Education Examining the CME Content and Methodology NRHM and the Continuing Medical Education The New Thinking about the Foundations of What to Teach Ideas of Education: New and the Old Thinking National Education Policy 2020, Ministry of Human Resource Development, Government of India Preamble One Major Shift in the Thinking On the Major Problems Plaguing the Higher Education System in India Other Structural Measures, Ideas, Obstacles and Corrections University-Affiliated Colleges, Its Nexus, Future and the Restructuring The National Medical Commission Model Discarded My General Observations on the Policy Issue of Deemed Universities, Individual Colleges as Deemed Universities Higher Education Teachers and the National Policy for Education Curricular Content and the National Education Policy Curricular Content Professional Education Health Care Education Online Distant Education Structural Reforms Within the Higher Education Policies Identifying the Ills of Regulatory System of Higher Education Aptitude and Attitude Testing Experience of Aptitude/Attitude Testing World Over Process of Medical Admissions in India New Considerations about What Should the Medical Education Do Problem-based learning, or the (PBL) PBL Is Not a Part of Existing System Innate Qualities of PBL The Columbian Experiment in PBL The Japanese Evaluation of PBL Experience of Charité University in Berlin, Germany A Pilot Study Underway in Charité University The Australian Experience of PBL About the PBL Sessions, the Main Stay of PBL in General Relevance of Other Educational Methods The Indian Experience with PBL The Initial Shocks in Indian PBL Experiment Important Achievements of PBL in India Verification of the Measures of Success of the Indian PBL Courses Why Did PBL Succeed in India? Development of the PBL Course for India Net Social Change from the Indian PBL References Chapter 5: The De Novo Manpower Deployment Processes Manpower Deployment: The Greatest Government Failure Key Questions About the Deployment Failure at PHC and CHC Why the PHCs Do Not Deliver? Is CHC the Best Level of Deployment? Possibilities of Many Failures and Occasional Successes in CHC Preparing the Manpower Purposefully Public Health Care: Manpower Structure Procuring Manpower to Correct Shortage: The Barriers Additional Factors in Creating Dysfunctional Units Crowded Hierarchy of Similar Units: PHCs, CHCs, SDH and DH Five Undelivered Health Care Vectors with Such Health Structure Dismantle Superfluity, Restructure Continued Learning of the Medical Graduates Learning in Internship in Medical College Learning in Internship in the Three/Six Months in the Rural Areas The System Proposed for Interns in CHCs Posting in CHC and Issues of Postgraduate Qualification for Interns Objections to These Suggestions Objections by the Interns/Doctors Themselves The Internship Format: Should It Be Preserved or Changed? MBBS as Under Trainee After Internship In Case of No Postgraduate Registration Postgraduate Consultants/Specialists in CHCs Maturation of a Specialist Degree Holder in a Consultant Specialists in CHCs Inter-CHC Movement and the Superspeciality Training Full-Time Culture in CHCs Surrender or Indifference to Public Good More About the CHC Scenario and the Manpower Solutions Defence of Obsolescence National Rural Health Mission, NRHM, and Indian Public Health Standards, IPHS: New Thinking About the PHC and CHC Bane of Continuation of Erstwhile PHCs Under NRHM/IPHS Much Greater Need for GDMOs Compelling Factors to Shift the PHC Officers to CHC The First Proper Place for the AYUSH Graduates The Bedrock for Success of This Model: Teaching The Shortcoming: Time with Patients Prevailing Mode of Work Rift Between the Specialists and the Residents Training Without Strain and Its Benefits Making CHC a Vibrant Place to Work in The State of Teaching and Learning Thinking of the Entire New Generation of Doctors What the Facilitators/Consultants/Teachers Do and Think When and How Do the Medicos Earn? The Anticipated Cycle: From the Entry to Exit References Chapter 6: Primary Care, Government Planning and National Rural Health Mission Preamble Statistics and Functional Issues of Indian Public Health Care The Sub-Centres: The Existing Structure The Sub-Centres: Manpower and Distances Sub-Centres: Multipurpose Health Worker (Male) Measures Suggested by the Government of India Financial Maintenance of the Sub-Centres Work–Time Ratio and the Multiplicity of Community Health Workers Community Health Workers and Primary Care A Profile of How the Work Gets Done in the Sub-Centre Area Reporting of the Work Done Adverse Factors Affecting the Ground Work Too Many Unproductive Supervisory Levels Higher Levels of Redundant Supervision Discrepant Views: On Ground and at the Top The Work Profiles at the Sub-Centre Level: Too Many Questions Need to Be Asked The Long Arm of the State The Random, Inequitable Remuneration System for CHWs Causes of Discrepancy ASHA and the NRHM Imaginative, Ingenious or Faulty Conceptualization? NRHM: Referral and Escort Services for RCH by ASHA NRHM: ASHA to Look After the Construction of the Household Toilets NRHM: Other Health Care Delivery Programmes to Be Looked After by ASHA More on Financial Arrangements for Sub Centers Under NRHM NRHM and Its Thinking About ANMs Issues in Recruiting ANMs NRHM, ANMs and the Nurse Practitioner: A Colossal Misconception NRHM: Effective Integration of Various Agencies NRHM: Developing Capacities for Preventive Health Care NRHM: Reduction in Consumption of Tobacco and Alcohol NRHM and the Panchayati Raj Institutions in Health at Sub Centers Panchayati Raj: An Evaluation NRHM and Its Ideas of Infrastructure NRHM and the New Thinking on Sub-Centre Restructuring Alternate Mechanisms of Doing Field Jobs Suggestions for Efficiency Improvement of the CHWs Future of CHWs: The Career Path New Roles for the Supervisory Cadre, Now Defunct References Chapter 7: Structure and Function I: The Primary Health Centres Preamble History of the Primary Health Care Ideas in India Bhore Committee and Primary Health Care: Less Known Facts Assessment of Bhore Recommendations Difficulties in Implementation of Bhore Committee The Paradoxical Activist View about Bhore Recommendations Evolution of Primary Health Care Primary Health Care Structure and the Activists Primary Health Centres: Thin and Ineffectively Spread Government Conception of Referral System State-Level Health Structure PHCs Under the States Functional Profile of PHCs and the Planning The Design, Manpower and Infrastructure of Curative Structures at Periphery Segregating Curative and Preventive Health Work Current Government Thinking About PHC The New IPHS and General Impression Post IPHS Manpower Shortage Still the Biggest Issue The Pathetic Story of Referral against Upgradation The Supply Chain Management Corruption in Supply Chain Tender Processing for Supplies in the Government Availability of Drug and Consumables in Public Sector and the Government Regulators Functional Aspects of PHCs Inadequate Coverage Under a PHC Burnout: An Unrecognized Consequence The Manpower in PHC under the IPHS: An Assessment Availability of Beds in PHCs PHC a Referral Unit for Six Sub-Centres The PHC Medical Officer, One and One More as Essential per PHC: Profile Closer Look at the Numbers of the PHC Medical Officers IPHS, NRHM and the Peripheral Units PHC Conversion to CHC Under IPHS The Other Personnel Provided in PHCs Pharmacist: One Post per PHC and Related Issues of Pharmacy IPHS Recommendation: One AYUSH Doctor/AYUSH Pharmacist in Type-B PHC Nurse Midwife (Staff Nurse) Health Workers (Female) ANMs and the PHC Work Health Assistant (Male)/Health Assistant (Female)/Lady Health Visitor Health Educator Laboratory Technician, One Post Driver The Relentless Charade of Curative Care CHC: First Curatively Oriented Unit Principles to Dismantle PHCs Rationally, Relocate Resources to CHC The Budgeted Manpower in PHCs PHCs, Phased Closure: Principles, Processes and Potential Changes New Thinking About the Staff of the PHC Pharmacist, Laboratory and X-Ray Technicians Nurse-Midwife (Staff Nurse), Additional Staff Nurses ANMs, Health Worker Female, the Lady Health Visitor, Health Educator, and the Health Assistants, Male and Female Multiskilled Group D Workers Upper- and Lower-Division Clerks Class IV Workers Health Assistant Cadre Other Gains of Closing PHCs: Improving the Quality of Quacks The PHCs and the Non-State Players Closure of PHCs, Deserting the Poor Concern About National Programmes References Chapter 8: Structure and Function II: The Community Health Centres Two Ways of Restructuring the Community Health Centres Selection of CHCs The Process and Consequences of CHC Build-Up Evolution of CHC Under Government Prehistory of the Community Health Centre, CHC Community Health Centre Staff: Before and After the Revised IPHS 2012 Speciality Services per IPHS Medical Officers Nurse Midwife (Staff Nurses) Paramedical Staff: Pharmacist/Compounder Lab Technician Other Paramedics Administrative Staff Community Health-Related Workers Ward Boys Driver and Other Menial Staff Block Public Health Unit Block Medical Officer/Medical Superintendent, One, under NRHM/IPHS Qualifications Responsibilities Public Health Specialist 1 Qualifications Any One of the Many Public Health Nurses (PHN), One +One Qualifications and Requirements The Health Educator Statistics Physical Infrastructure CHC Post-IPHS Manpower in CHC Post-IPHS Issues Related to Medical Officers About the In-Service Candidates in PHCs About the Fresh MBBS Graduates Logistical Issues of the Training Itself Other Measures to Get Fully Qualified Specialist Services in Rural Areas A Much Simpler Scheme for Training, Admission and Deployment MBBS General Duty Officers: Numbers, Role, Training and Related Aspects Workload, Financial Viability and Non-Availability of Doctors More About Specialized Training of MBBS MBBS Trained in Internal Medicine and Paediatrics The Government Logic and the Ground Realities about Anaesthetists Surgery, Gynaecology Other Worker Categories in CHC Under IPHS NRHM/IPHS: Nurse Midwife (Staff Nurse)—Seven + Three Posts Significant Barriers in Procuring the GNM Nurse for CHC A Way Out for Getting Nurses for CHC Need for a Decentralized System for More Graduate Nurses Pharmacist/Compounder; Laboratory Technician, Radiographer Dresser: One Post: Certified by Either Red Cross Or St John’s Ambulance Service Ward Boys and the Ayahs, the Lady Menial Workers Sweepers Shape of Care in CHCs Complexities of Disease Profile More About the Role of Surgeons in CHCs Powers of the Services in CHCs Causes of Non-Availability of Specialists for CHCs Facilities and Its Absence Bureaucracy and Government Vis-à-Vis Health Care Potential Sources of Specialists Working for CHCs The Remedy Over the Shortage of Specialists in CHC Teaching and Work Profile of Five Specialists More about the Internship in CHC Remuneration for Interns During the CHC Tenure NRHM and CHC, Ideas for Betterment The Law of Care Inverse to Distance HDUs and Critical Care References Chapter 9: Structure and Function III: Expectations and Realization Preamble High-Dependency Units Cost an Immediate Concern Mandatory Infrastructure and Manpower An Existing Paradox in Acute or Critical Care Causes of the Paradox The Costs, Usage and Feasibility of Establishing HDUs Meeting the Capital Costs to Raise HDUs Logistics and Manpower in CHC/HDUs Dynamics of Manpower Reallocation and Development Better Nurse/ANM Development in CHCs Creating Manpower Resources from Within: ANMs ANM Schools Located in CHC: Other Benefits Paramedics Outside CHCs: Facilitating Quality Enhancement Training Ward Boys and Ayahs for Higher Skills in CHCs Quality vs Qualification: An Important Consideration Making Up the Shortcomings of National Skill Development Initiative Prioritization of the CHCs and Their Placements Some Out-of-Box Thinking Positives the CHCs Can Achieve CHCs Beyond the Tehsil Level Monetary and Financial Consideration of the CHC/HDU Saving Money Is Earning Money Saving on Infrastructure Saving on Doctors and Paramedics Phased Closing of the CHCs: Frees Manpower Already Budgeted Optimal Utilization of the Specialist Consultants Thinking at the Level of Five CHCs as a Group Attitudinal Changes Needed Among the Specialists Reducing Professional and Ancillary Workers Within Health Services Consumables and Cost Savings Earning Sources for the CHC User Fees for CHCs Drugs and Its Optimal Management Insurance Schemes as Cost Savers CHC as an Economic Driver The CHCs and the Non-State Players The Sub-District Hospitals The Naïve Planning A Definite Presence of Private Players—A Reason for SDH Closure Human Resources at Sub-Divisional Hospitals References Chapter 10: Structure and Function IV: The Final Picture Preamble The New Additions Planning Deficiencies within the New Additions Making CHOs Available Inadequate Scope for Work of Coordination Difficulties Created in the Management of CHCs Adding More Functions, Services and Workers as Revised Guidelines: NRHM Ideas Medical Rehabilitation Services: National Programme for Health Care of Elderly Oral Health, Dental Care and Dental Health Education Services: One Dental Assistant School Health The Third New Functionary and New Functions as Planned The Fourth New Functionary: Public Health Nurses Advantages of a Community Health Officer at the CHC Geography for Operation for the CHO Functions of the CHO Vis-à-Vis CHWs in CHC Critique of the Issues Related to the National Programmes National Programmes and the Covid 19 Pandemic Challenge About the Existing National Programmes Independent Verticals Did Things Go Wrong with National Programmes? Where and How? Executive Integration of national programmes How Will It Now Change with the New Structure? What Does the New Model Mean? Rectifying the Deficiencies in Executing National Programmes Illustrating Changes in Greater Detail National Tuberculosis Control Programme (NTCP) The First Model and its Shortcomings Detection and Treatment of Tuberculosis: Unusual Issues of Animal TB RNTCP, DOTS and Human Disease in India DOTS: A Bag of Mixed Issues and Disappointments The DOTS in Actuality DOTS, the Programme and Some Difficulties The Biological Issues about Tuberculosis Possible Causes behind the Rise of (MDR) Tuberculosis The Toit Review and Drug Delivery in TB Discrepancies in Treatment Data and Development of Resistance in TB INH or Isoniazid Resistance through Different Inactivation Rates Bedaquilline: The Breakthrough Anti-TB Drug Extra Pulmonary Tuberculosis: An Absent Feature Some Thoughts on Eradication of Tuberculosis by 2025 the Indian Initiative National Blindness Programme Debulking Disease Load in a Community The Idea of a Programme, a Process and a Tradition Mass Campaigns and Gynecological Disorders: A Success Story and a Model Analysis of the Strengths of the Proposed Model of CHC Bed Strength of 50 Not a Top-Heavy Model Superspecialities in CHC Contribution of Superspecialists to CHC Population The Most Valuable Effect of Such a Huge Exercise Blood Storage, Transfusion Facilities and CHC Blood as a Carrier of HIV AIDS, Hepatitis B and C Viruses Sufficiency and Efficiency of Ten CHCs in a District Future of CHC: How Will It Develop Further? Level of Medical Care Quality The District Hospitals References Chapter 11: Health Institutes and Voluntary Health Work The Idea of an Institute Prehistory of Health Institutes Defining an Institute Trusts and Ownerships Characteristics of an Institute Power, People, Expanse and Service Quality in Institutes Money and the Institutes Not Just Financial Honesty The Institutional Culture The Large-Sized Institutes Managing Institutes Well Optimization of Work in Processes High-Cost Gadgetry and the Institutes Institutional Mindset of Specialists Needed Institutes: The Standard Bearer and the Bench Mark Institutional Performance On Government Colleges, DNB Centres and Decline of Teaching Issues with State-Owned Institutes Summery Regarding the Health Institutes Voluntary Agencies and Health Work Perspectives in Health Action by Voluntary Agencies Definition of Voluntarism Characteristics of Voluntary Agencies The Psyche The Primary Health Care Voluntary Agencies Think Tanks of Primary Health Care Limitations of Think Tanks Certain Negative Elements of the Think Tanks Think Tanks of Secondary-Level Health Care Activities in VAs National-Level Voluntary Agencies The Journey of Voluntarism Voluntary Work and Market Economy More Models to do the Work The Christian Voluntary Medical Work Problems of Christian Ideology Skilled Procurement of Government Funding Neglect of Non-Christian Service Organizations Retribution Funders and Primary Care Unholy Nexus Continued Government Neglect and the Voluntary Agencies The Paper VAs Unhealthy Influence in the Voluntary Sector Sociopolitical Voluntarism Left of Centre Organizations Gandhian–Sarvodaya Approach Organizations with Nationalistic Fervour Government and Voluntary Agency Collaboration The Follow-Through Addendum The Issues References Appendix A: Work Profiles of Community Workers and PHC Medical Officer Duties of Medical Officer, Primary Health Centre Job Responsibilities of Medical Officer at the PHC under NRHM and Now under IPHS Curative Work Preventive and Health Promotional Work Duties Common to All the Activities under Package of Services for MCH Universal Immunization Programme (UIP) National Vector-Borne Disease Control Programme (NVBDCP): Treatment and Prevention Malaria Filaria Kala Azar Acute Encephalitis Syndrome (AES)/Japanese Encephalitis (JE) Dengue/Chikungunya Control of Communicable Diseases Leprosy Tuberculosis Sexually Transmitted Diseases (STD) School Health National Programme for Control of Blindness Training: All PHC Staff and ASHAs Administrative Work Other Non-Communicable Diseases: Diagnosis, Prevention, Treatment and Referral Ear, Nose, Throat Disorders Cancer Common Psychiatric Disorders Metabolic Diseases Management of Medical Supplies Appendix B: Controversies Surrounding the AYUSH System of Medicine Ambivalence over the AYUSH Systems and its Doctors Serious Neglect of the Other Systems of Health Care Corrections Undertaken The Anguish of an AYUSH Graduate A Disturbing Exclusion of AYUSH Graduates in Health Care Mainstreaming AYUSH Doctors in Hospitals and Public Health Care The Contentious Bridge Course Many Questions about the Issue Q. Trainability of AYUSH to Acceptable Level of Competence Q. AYUSH Learning Modern Medicine Systems Q. AYUSH Doctor Achieving Same Level of Understanding as an MBBS Q. About the Limitations of AYUSH Doctors as is Believed Controversies and Opposition over AYUSH Status in Modern Health Care System Background Objections Sketch of the Agitation against NMC and its Critique Wrath and Counterarguments of the IMAs: Likely Reasons Behind The Story on the Side of AYUSH IMA must Face the Inevitable Welcoming New Initiatives to Make AYUSH a Better System Improving Quality of AYUSH Colleges Standardizing Ayurvedic Formulations A Step Further in Standard Ayurvedic Drug Manufacturing Major Errors Committed by the Government with Respect to AYUSH Populism against Status of AYUSH as a Science: Undesirable Trends Appendix C: Urban Poor and Health Care Delivery Overview of the Health of the Urban Poor Constituents of Urban Poverty Differences in Urban and Rural Public Health Structure Understanding of National Urban Health Mission of Urban Poor Health Differences between the Urban and the Rural Poor Effective Available Curative Health Services in Urban Areas Limited Contributions Paramedical Personnel can make for Health of Urban Poor Issues of the Most Vulnerable Groups Establishing Connections Necessary for Better Health of Urban Poor Issues of Behaviour among the Urban Poor Curative Services under NUHM National Health Programmes for Urban Poor: Another Disposable Programme Many Matters of Irrelevance in the Urban Health Mission Document More about the NUHM Document Problems of Targeting the Poor on the Basis Of BPL Cards References Index