Help small hospitals with policies that work for them

Vijay Anand Ismavel

IN India as a whole, investment in healthcare is minuscule compared to elsewhere in the world. A few states such as Tamil Nadu and Kerala have invested well in healthcare and are reaping the benefits. For poorer parts of the country to catch up, they need funding. They also need policy makers to frame rules and regulations that realistically address the challenging conditions in small hospitals at remote locations where these facilities are all that people have by way of access to healthcare.

 

Speed up insurance payments to small hospitals, they need the money

The government health insurance programme, Ayushman Bharat, under which the Pradhan Mantri Jan Arogya Yojana (PMJAY) falls, helps poor people receive cashless funding for their healthcare expenditure. Many not-for-profit hospitals are registered under PMJAY and offer services to poor patients. But these hospitals face prolonged delays in receiving payment for services rendered which severely affects their cash flow situation.

The PMJAY programme should be strengthened with larger fund allotments and payment for services should be immediate. This will help prevent patients who are unable to use the services of ‘for-profit’ private healthcare or government providers from falling through service gaps.

 

Blood banks and ultrasonography at remote locations will help save lives

Critical services such as access to safe blood and ultrasonography are restricted by Indian law. The present blood-banking law requires a hospital to employ a full-time pathologist or a doctor with one year of service in a blood bank. Most remote location hospitals are unable to meet this requirement. The cornerstone of the blood-banking law is the safe cross-matching and screening of donated blood. This is a simple process within the capability of trained laboratory technicians. If the government allows well-trained technicians (overseen by a medical officer) to be sufficient for the processes followed in blood banks, it will be much easier to start blood banks in remote parts of the country.

Another area where current Indian law is unduly restrictive is the requirement for a radiologist or doctor with one year of experience in ultrasound to order or operate an ultrasound machine. This is part of the Prenatal Diagnostic Tests (PNDT) Act which addresses the problem of foetal sex determination leading to female foeticide and skewed sex ratios. Ultrasonography and echocardiography have evolved all over the world to become high-quality point-of-care diagnostics which greatly aid in clinical examination by imaging. However, the decision to declare foetal sex is not related to the qualification of the sonologist but is a moral decision anyone could make. The requirement to have a predefined qualified doctor to perform ultrasonography (or even order a machine) greatly affects access to this lifesaving technology, especially in remote and rural parts of the country.

 

Give incentives for setting up hospitals  in poorer states and backward areas

The government already has numerous ways to identify geographical locations with the greatest needs: these include the “Empowered Action Group” states, the aspirational districts and the Multidimensional Poverty Index. Unfortunately, healthcare investment — funding, facilities and manpower — continues to be focused on the richer, urban areas.

To counter this, the government could consider major incentives to set up and run healthcare facilities in the neediest areas. This could include funding and relaxation or exemption of criteria to register the facilities. In addition, meeting predefined targets should allow greater incentives to be given to these entities.

Hospitals in locations where government services are poor could be allowed to recruit doctors fulfilling their government service obligations and this service could be treated as equivalent to working in a government institution.

 

Develop protocols that work in resource-poor settings

Gold standard protocols are set in fully developed countries. But they are unrealistic in poorer parts of the world where resources are constrained. Medical colleges should teach students guidelines for the management of disease and allow them to develop their own protocols according to the needs of the situation where they work. Bad practices, such as the indiscriminate use of steroids or antibiotics, should be strongly discouraged.

 

Rein in quacks, but you don’t need super specialists for everything

India has a large, unregulated healthcare sector — where untrained quacks as well as those not trained to do so, prescribe and dispense allopathic medication. This leads to iatrogenic disease, drug resistance and inappropriate treatment.

At the other end, fully trained MBBS doctors or even consultants are not allowed to perform simple procedures like basic obstetrics or surgery. This trend towards super-specialist services makes access to healthcare more difficult and expensive, especially for India’s poor.

There should be national guidelines on the management of specific diseases. Trained people such as nurse practitioners could be allowed to prescribe / dispense or perform procedures such as basic anaesthesia. 

 

Dr Vijay Anand Ismavel ran the Makunda Hospital for 30 years. He is currently at the Christian Medical College in Vellore.