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Is it worthwhile to visit a government hospital at all?

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Public HealthGovernance

When the “who’s who” of the secretariat are preferring quarantine services of private nursing homes and corporate hospitals over government hospitals, it remains a complex question in common people’s mind, whether it is worthwhile to visit a government hospital at all.

On June 19, the 23-year-old son of medical education secretary, V Umesh, landed at the Bangalore International Airport (BIA) from New York. He had developed symptoms of swine flu and was referred to Rajiv Gandhi Insitute of Chest Diseases (RGICD).

There were around 10 vacant beds in the general ward. But in the absence of special wards, the attention of his parents immediately shifted to Lakeside Hospital, Malleswaram. After preliminary screening at RGICD, the patient was immediately shifted to the nursing home.

What could be a better reason for Umesh to shift his son from RGICD to Lakeside Hospital other than complete lack of faith in services in government hospitals?

For the full text of the article that appeared in the New Indian Express, click              here

In fact, will anyone amongst the PRAJA members ever want to avail the services of a government hospital, even for his/ her servants? Certainly not me. The (dis) services provided by the government hospitals are becoming increasingly costly, in terms of negligence, apathy, mamools (no longer small as the term may imply), fresh infections due to unhygienic conditions, and not in the least life itself on account of all of the above and many other factors. It is time the government re-looked at its role. Check-out               this              also.

Muralidhar Rao

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Vasanthkumar Mysoremath's picture

Hundreds of crores for improving temples of ever healthy gods...

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Karnataka boasts of Medical Tourism as one of its most ambitious tourism attractions.  It is catering for the novea rich and local 'haves'.  But 'have nots' and government employees themselves have no faith in their own health care systems that are lacking in money, man power, infrastructure, life saving drugs, corruption, exchange of babies for gains, the list is long.

- What people want is minimum possible health care and emergency services during that 'golden hour' and when the sirens are blaring and rushing madly to save the life of the sole bread earner of a family.  These simple needs of aam aadmi are not available even after he reaches government hospitals.  To carry the sick person inside on a stretcher needs greasing of palms.

-  Administrators wake up and start rubbing their *eyes* for identifying some means to combat an incurable disease only after it has hit the BPL/Slum areas, some dead bodies are lying around etc. 

- Instead of letting the people die unnatural deaths due to medical negligence or lack of infrastructure by the service providers in government maintained hospitals, despite collection of taxes from people, it will be better to close down these 'Narakas', allow private hospitals to treat  people with qualified doctors and para medical staff with a sense of service, regulate fees and operation charges for identified sections of the society, open more and more peripheral/ essential services from government funds like, diagnostic, scanning, x-ray, drug stores at subsidised rates, elders homes, creches, orphanages, etc.

- Prevention is better than cure does not exist in Govt's dictionery.

Medical tourism for ordinary people in Bengaluru/anywhere, is like "ootakke illada uppinakaayi..."

- Anybody listening?

- Vasanthkumar Mysoremath

Rithesh's picture

Could universal health insurance be a possible solution?

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The government instead of investing in healthcare facilties (apart from the absolutely necessary ones like isolation facilities, etc) should concentrate on providing universal health insurance. The investments made into this bleeding organizations could instead be used for paying the health insurance premiums for the needy people. Let the private sector take care of the treatment based on the insurance. And since the insurance companies will be involved, they will ensure that private organizations do not overestimate on the treatment charges. The sucess of "Yeshasvini" scheme introduced by the karnataka govtment is prrof that this concept might work.
asj's picture

Lack of vision, conviction and much more

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There is no simple answer to the title of this thread. Even today, the best of Indian doctors (like our engineers) come from public funded teaching hospitals. If you were knocked unconscious, your best bet of surviving may not be in the adjacent private hospital that refuses to accept unknown patients but the local public hospital that offers emergency services.

Many sectors in India are ailing, some could (as some believe) thrive if they were privatised. Not every sector can or should be privatised, health is one of them. As a doctor, my prime responsibility is to treat the patient as per clinical needs and not based on their ability to pay. Private healthcare thus in itself creates an ethical conflict. Ethics aside, no developed country has a satisfactory private healthcare model - US healthcare is in shambles despite a 15% of GDP worth money spent on health.

I can write reams on NHS and EU models, especailly the purchaser-provider model, but will not do so for want of time. It would be academic anyway, as if our health ministers were keen they would have snapped it up long ago after repeated jaunts to West on study tours.

Rather we can simply focus on how much we spend on health in India. On paper we spend a healthy 6% of our GDP (UK spends about 8). So what is the problem? Less than 1% comes from Govt funds and 5% is out of pocket spot purchase of expensive services provided for a significantly small minority of Indians who work all their lives saving for the bypass surgery (or the like when they hit 60).

The first step if we hope to reform our health and social welfare is to start a mandatory National Health Insurance scheme (no, not private - those interested may study US failings in their own time). Let every one pay 10% of their salary and employer pay 10% in addition in to this fund (over and above usual tax).

When I say the above will actually fetch year on year a large pot of money, the bog standard answer is - but a very small proportion of Indians are earning money enough to hit tax brackets. Well, on average only 30% of EU population pays taxes!!

Last year IR collected Rs 1,47,197 crore in taxes. India's budget for health is Rs. 16,534 crores in 2008-2009 (yes, the states contribute similar such petty amounts). One can imagine that very easily a massive corpus can become available for reforming the ailing health sector through a mandatory national insurance scheme.

Sadly, one needs to only compare these figures with amounts spent on less than 100 million people in 6 metro cities. Compare the above budget with the estimated loss of revenue through tax sops to SEZs (companies that do not need tax sops are milking the system - India needed to get rid of license Raj, investment flows where there is a market, tax sops or not). 

Again, I must end as an insider who informs, privatisation is not the answer - one needs to be a doctor to know how corrupt the private health sector is (it beats public sector hospitals in this regard many times over). As for Medical Council of India, the less said the better.

ASJ 

Rithesh's picture

Doc - thanks for the input

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Thanks Doc for that input, incidentally i saw Micheal Moore's documentary "Sicko" over the weekend and i cant agree with you more. I didnt realize the fact that insurance companies can act in ways as they do in US (well Moore could have over stated the problem, but i am sure he is correct to some extent). Probably a government managed universal health insurance is the way out. Apart from the contributions from individuals and companies, revenues from taxes on cigarettes and liquor (atleast some of it) could be put in this fund.

But the question remains, how can govt hospitals be made more accountable and how can we improve their services. The state govts do spend considerable amount of money on health care and yet it is in such a bad state. It is very saddening to see how poor people are treated in these facilities. Incidents of fake drugs being used and treatments being denied is very common in hospitals here.

asj's picture

Do State Govt's spend enough on health?

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We spend 1% of our GDP on public health. Yesterday it was in news that 50% of us are BPL. WHO norms for health spend in developing world is 3.5% of GDP. Most downtroden economies in developing world do better.

I have no evidence of there being enough money. How does one define enough money in the context of 50 years of under spending (Bhor Committee immediate post independence had recommended close to 9% spend).

In 07, I visited a WHO center of excellence de-addiction ward in Mumbai to lecture. Damp, leaking walls, dim lights, pealing paint, rusted beds........what a way to rehabilitate - it felt as if everything on the ward resembled the country liquor shop.

90 minutes from Mumbai, in Thane tribal areas or western coastal villages - we went there as interns in mid 90's. There was PHC with no furniture. What more when it rained, it was expected that doctors waddle through knee deep sludge, there was no access road. Villagers said, they have no access to anti-snake venom, they put a victim on hand cart, take them to nearest local train station (30 minutes away) and then get the person to a hospital.

In 95/96 I and my colleagues toured a mental hospital, massive site, thousands of petients with severe psychiatric problems. Dress code - cement bags with 3 holes cut open to convert it in to a vest. Nurses said they have so many that no one is aware of patient names, they do a head count each evening. Shock treatment does work, but the method used here was without anesthesia (a la torture), something that happened 70 years ago. We were then taken to backwaters - dirty wards - the most ill patients, lying naked, not a shred of cloth, but that to surrounded in their own urine and stools. Ironically, the patient who is most well in the lot does the cleaning.

I spent 10 years, my mother retired as Prof and Head in a teaching hospital. After 35 years of her service, a graduate from poxy MBA institute earned more than her. A call center class XII student with fluent english got more than a lecturer's pay. This is still true in many states. Every pay commission gave small rises with retrospective dates, we never saw the money for up to 3 years on average.

In Mumbai, I have worked in Dharavi, Cheeta Camp, Shivaji Nagar Camp (transit camps with refugees from B'desh) - we saw patients, we dispensed medicine with our own hand. People were supposed to queue with their own unwashed bottles in which we would pour paracetamol or other medications for their kids. We used to make paper pudi - the kind of stuff that holds channa sold on streets - and dispense tablets in same. We would go house to house to immunise kids and did this standing on swamps and gutters under our feet.

When someone got admitted to public hospital, and we never said no to anyone, if need be, people were given floor beds on wards where every health norm was broken due to the demand (there is meant to be 10 feet between patients). Every patient who seemed to have some money, we asked them to buy syringes, needles, gloves.........in excess of what they would need..........why............because the really poor who had not a dime in their pocket, we used the extra stuff for them.

A relative last year with cancer, needs chemotherapy cycles, repeated visits to Tata Memorial - India's leading public sector cancer Institute, no private sector can match it but for shear workload these people deall with. I know this from personal experience of a close relative, people - well cancer patients and 1 relative, they queue up at the door of the ward, when doors open all hell breaks out, its like catching a Mumbai Local train, cancer patients have to run to get to a bed, those that do, get treatment first, others wait for round 2. Cancer patients playing musical chairs!! Some care we provide.

 

I can go one for ever with such examples. Where is the money?

Now lets come to accountability. This is a matter of ensuring structures of accountability exsist, it has nothing to do with money. Where is the evidence that private hospitals are any more accountable.

A bypass operation is done, a relative in Jaslok Hospital was given breakfast with a bread's face covered with butter!!

I have seen everything - from sham appendix removals, sham shock treatments, sham abortions, heaps of CT and MRI scans for no rhyme or reason...........what accountability is there is private sector?

An inner ear surgery goes wrong, patient is left with life long side effect - what are the chances of staff coming clean on whether they botched it or not?

It is not ethical to practice other that what one is trained in. Every private hospital - where do the ward doctors come from - they are not allopaths - they are people doing Ayurveda, Homeopathy, Unanni........cheap labour

Every posh private hospital is managed on paper by Trust.......why.......tax sops...........these paper charities charge lakhs of $$...........where is the price control, where is the quality control?

Mumbai Corporation last year spent less money on health than Worli-Bandra Sea link which is to be inaugurated today. 1.5K crores in service of 75k cars per day (Mumbai has 1 million vehicles). But less than 1k crore last year was meant to serve population of 10 million or more (note, I have treated patients from Nepal to Sri Lanka in Mumbai Corporation hospitals meant to be run on corporations tax collections) - 50% of Mumbai lives in its slums - work out the per capita spent.

MCI - the only job done is recognising and de-recognising private medical colleges.......its a scam....it was in news not too long ago........I once taught in a private medical college, there were students, but not a single patient.............what kind of doctors are coming out of these Institutes (only a small handful of private medical colleges have actually done justice).

The logic is that we need sea link to drive economy. Don't we need a healthy population to drive an economy? Better education is directly associated with better health - look at the uselss education budget, it dwarfs in comparison to what is planned to be spent on metro rail projects in 6 cities with population of less than 100 million.

Lets get real - do visit a public hospital or better still a primary health centre in a village.

ASJ

Mani1972's picture

A small step towards the solution

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Feel like standing and applauding ASJ. Well said Sir.

Since last two years, I have involved myself in issues of health care, thanks to my senior and mentor, Nilay Mitash, who was heading the National Rural Health Mission (NRHM).

I agree with whatever ASJ says. Privatisation is not the answer to the problem. I also realise that there may not be a readymade solution to this complex problem. But, i know one right step. That is managing the government hospitals through management experts and not just by doctors, unless they are formally trained or exceptional personalities.

With due regards to the doctors, they are very poor administrators/managers. There are of course, exceptions, like Dr. Vikram or Dr. Reddy. But, majority of the doctors, at least majority of them who are in the government are extremely bad managers, though they are excellent doctors.

Why? Because, they are never trained on managerial issues. Their knowledge about management and administration is almost zero. (Two of my brothers are doctors and I have worked with so many government doctors so closely) You may say that management is just commonsense. Yes, it is, but when you come to government, you need more than commonsense. You need to know basics of political science, public administration and sociology. Else you can’t manage a government hospital.

A public hospital is more than a health centre. The dynamics involved in its proper administartion go beyond the realm of medicine. Proper induction training will bring in sea change. Or maybe the government can go for training separate Hospital Managers. This small step is bound to make a drastic change the government hospitals function, more so in the background of the huge investment that is likely to come in the coming years under NRHM.

 

Manivannan, P

96633.69333

Manivannan

Manivannan

Rithesh's picture

This is depressing

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ASJ - you post is damn depressing. I have been to govt hospitals in Bangalore and the plight of the under priviliged people is as bad as else where and sometimes even worse.

Doctors salary or infact the salary of all govt servants is a major issue. It is ridiculous to expect them not to make money (aka bribes) when their compensations are so low - and as long as we dont solve this problem - corruption will never end. 

And yes then there is always this problem of morals - we are such a screwed up country that we are more bothered about how people dress and are least bothered about our unethical practices.

MCI - they have made this noble profession into one money making business. What else can we expect from doctors who have paid multi millions as donations and bribes to get seats - dont they have to recover their investments.

Rhetoric apart - whats the solution? To a great extend we know whats the problems are. Manivannan sir points the lack of management skills and may be NRHM will address it to some extent. But what about accountability?

We all understand civic issues and hence we constantly query the govt for updates and classifications (atleast thats what a few of us have been trying to do). Can we do the same thing with the hospitals - obviously not many of us understand how govt hospitals work. But i am sure there will be doctors who are more ethical than the rest of the lot - can these people act as independent auditors of govt hospitals - the RTIs is always there to help them?

Ravi_D's picture

Some personal views...

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My family has experienced both good and bad of this health debacle in Bangalore.

In a couple of cases, private hospitals really messed things up - my father in law breathed his last in one of them. While on other occassions, care was excellent. But there was no accountability whatsoever - and ofcourse, if you couldn't afford, forget it.

Public institutes such as Jayadeva did commendably well on some occassions. But again, I have seen complete neglect at KIMS.

While the type of enterprise (public, private or charity) has its influence, I think the first topic of discussion has to be accountability. Not the kind of senseless law suits persued in the US for example (contributing its share to the rise in cost of healthcare), but the kind that respects one and all.

Another important issue we ought to tackle right away relates to the recently in vougue assured-benefit insurance schemes. We have this great habbit of blindly following the west, and especially good at imitating the bad. The type of schemes doing the rounds in India will ultimately drive the cost of healthcare thru' the roof, and no one (haves and the have-nots) will be able to afford it. I can see us running that sprint quicker than you imagine. Two decades from now, we will all be making a beeline infront of Saibaba clinics just to register for a subsidized angioplast.

But, as usual, the question remains - who bells the cat? Somehow in our culture (myself included), we seem too keen to discuss the world, but not get anywhere in the end.

Ravi

srkulhalli's picture

Focus on prevention, some other ideas

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ASJ has written from personal experience and it shows. I have a problem with the approach of western medicine today (thankfully things are changing).  They are more post problem approach and the whole damn thing is so commercialised. What I mean is they are so focussed on the latest and greatest drugs, thats what brings money. There is comparatively insignifcant research on root causing and prevention through non drug based treatments (and they can work)

Good hygiene, healthy lifestyes, simple cures for common ailments will prevent a lot of the hostpital visists to start with. Part of the budget should be focussed on prevention and education as well. The ideal scenario is where we have all the best of facilities but dont need to really use them.

On the management side, really really true. Does not apply to doctors only - applies across the country, whether it is our administrators, politicains, BMTC, and even our METRO gets delayed for poor management. Its not rocket science and the basic concepts should be part of our school/college education. (I am not talking big theories, just simple things like planning, ablitliy to see big picture, structuring the tasks involved, taking care of all details etc).

If apathy and neglect are issues with govt. hospitals, excessive energy and focus are problems in (some)private hospitals. The excess energy and focus is only on one thing, how to extract the maximum off the patient. At least in the private space, we should not wait for the govt. to do but start with some form of consumer redressal/feedback . Like a website where there patients can put in their feedback, put in stats on hospitals (like success rate etc). That will bring in some kind of pressure on them to improve, they know they are being watched.

 

 

Suhas

poowonder's picture

Accountability addressed in NRHM

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NRHM addresses the issue of accountability too. One of the core strategies of the NRHM is to empower local governments to manage, control and be accountable for public health services at various levels.Upgradation of (Community Health Centres) CHCs to Indian Public Health Standards (IPHS) is a major strategic intervention under the National Rural Health Mission (NRHM). The purpose is to provide sustainable quality care with ACCOUNTABILITY and people’s participation alongwith total transparency.

 

Rogi Kalyan Samithi was a successful initiative by  Government of MP,  a  management structure to ensure a degree of permanency and sustainability which also is called (Patient Welfare Committee) / Hospital Management Society (HMS).

 

Objectives of RKS involves but not limited to the following -

  • Ensure accountability of the public health providers to the community;
  • Introduce transparency with regard to management of funds;
  • Display a Citizens’ Charter in the Health facility and ensure its compliance

through operationalisation of a Grievance Redressal Mechanism;

  • Improve participation of the Society in the running of the hospital;

 

RKS  is a registered society at district level acts as a group of trustees for the hospitals to manage the affairs of the hospital. It consists of members from local Panchayati Raj Institutions (PRIs), NGOs, local elected representatives and officials from Government sector who are responsible for proper functioning and management of the hospital / Community Health Centre / FRUs. RKS / HMS is free to prescribe, generate and use the funds with it as per its best judgement for smooth functioning and maintaining the quality of services.  http://www.health.mp.gov.in/rogi.HTM

 

RKS was a successful venture in MP and NRHM had proposed to replicate in other states too. In Karnataka these committees are called Arogya Raksha Samithis, (ARS)23 functional.

 

For List of ARS in Karnataka click here

http://www.mohfw.nic.in/NRHM/Documents/List_RKS_Karnataka.pdf

 

NRHM framework for implementation has within it ample provisions for community participation and ownership where concerns could be raised and accountability sought. Seems there are systems in place but we the prajas need to be aware of them and be proactive in utilising them to the maximum possible extent.

asj's picture

Belling the cat

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Quick reflection on some issues that have come up. Yes, the cat needs to be belled, but this cat is running amok, first it needs to be bolted. A better anology is that of a wild horse with no reins that needs to be tamed.

I will start with accountability - even a cobbler has to be held accountable - this is more to do with principles of governance. The corporate world uses the jargon of corporate governance. In health sector, the phrase is tweaked and called clinical governance. I have spent dozen years in this profession in India before getting to UK, not once was this phrase ever heard or mentioned. One can imagine thus that actually there is no structure, no policy in place on such matters - its no different from our road traffic which is informed by a rudimentry Motor Vehicles Act rather than something as substantial as the UK Highway code. But again, lack of clinical governance is just as if not more applicable to private healthcare in India - who governs an indpendent GP or surgeon, who inspects their practice - no one (MCI does not even make us pay an annual membership, they do not know if a doctor is dead or alive or has changed residence).

Managers - are welcome, but we will get better results by skilling up doctors with the acumen for such matters rather than having independent managers who do not understand medicine (I say this because poor decisions are made by best of managers if they have no clue of what medicine is about - 50 years ago, one economist studied British rails and found out massive number of lines made no profit - all these lines were stopped - today, 50 years on, we know it was  a stupid, costly mistake as cars are not the answer - a purist view of an economist failed UK rail network). Like clinical governance - not a single doctor in India gets even an hour of management training. Having spent almost a decade in UK, I can state that my clinical skills learnt in public teaching hospital in Mumbai are at par with best of trainings worldwide - but I learnt Management only after getting to UK - and there are enough like me, some even more experienced, who will love to contribute to reforming India's health care provided we knew we had a say in these matters.

As for whether there is a sloution - one needs to go back to 1948 and study the politics and history of how the NHS Act was passed - pre 48, UK healthcare was no different from what we have in India today - so there is hope - we only need look around for answers. Interestingly, 90% doctors in UK opposed the bill, by the time of it being passed, 90% had registered as NHS doctors on the simple fundamental basis of being assured an industry standard salary - ask a local GP if he/she will like to induldge in cut practice for making a living or get a lakh rupees a month as ssalary for working honestly - its not hard to guess as we all want to sleep well with a clear conscience.

Medicine is costly - its evolved a lot - as we live longer, the agenda of prevention which is our sole focus can't remain the sole focus. This is why there is an urgent need for reforms.

I won't come back to this again, but those keen on having further disussions on writing a paper which can be sumbitted to local governments, please write a private message.

ASJ

idontspam's picture

Selective private participation

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what accountability is there is private sector?

Who is enforcing accountability? What is the enforcers failure? How are they being taken to task?

Also why cant we have private hospital maintenance but public caregivers? This way the care can be social but the quality of hospital can be improved in PPP model. Privatization does not mean laissez faire.

Private hospitals play an important part in unburdening the govt hospitals by providing a choice for people who can afford, but it need not be construed as being the only one or the one that need not exist.

Vasanthkumar Mysoremath's picture

Majority private hospitals are swindlers- Dikhaawaa

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Marble flooring, bar-like environs, gleaming brass staircases, air conditioned, page3 nurses in starched uniforms out of 10 stuttering around, hardly 3/4 are actually trained nurses - doctors - mostly just MBBS medicos wanting to gain experience and certificate for paltry sums like Rs.1500 to Rs.2000 for almost 6/8 hours duty (MY DOCTOR SON AND DOCTOR DAUGHTER IN LAW ARE LIVING EXAMPLES) - just out of Medical Colleges - Even a coolie in a Railway Station/clerk in a govt office earns more.  

In case of emergencies, the sleeping doctors should not be disturbed by these half baked nurses, specialists will flutter and come only when they are free or when it is too late.  These nurses try their whatever best, finally when somebody croaks, put them on artificial respiration, make the relatives of patients believe that their patient is serious without allowing them near the 'body' and shift the body into the operation theatre, get some so called specialist run in and after some time just to come out and announce that the body is dead.  (This is a true incident).

And diagnostic centers are profit making centers - for the doctors who make the patients believe that without such diagnostic results, they cannot and should not diagonise a patient's illness and prescribe a number of tests/scanning etc., for making their own life that much easier.  These centers are milking the gullible patients because doctors have a cut in each and every test that is prescribed by them and conducted by private centers.

How much do you think a blood sugar test costs?  My son who is a diabetologist shocked me when I asked him to be truthful to his father as to how much it costs for this fasting blood sugar etc.?  He could not escape.

Including everything that goes into conducting a test like antegens, chemicals, testing apparatus, building, nurses, technician fees, profit etc., etc.,  it should not cost more than Rs.20 per test.

- Avoid illness - Touch wood - adopt prevention is better than cure method. If there are adgoolajjiees, ask them - they may suggest Tulasi leaves for cure of simple cold, or arishinada pudi for caugh and throat problem, or karpoora with coconut oil for curing chest infection.

- Health care system in India is not worth talking about. Government hospitals are hell holes - by mistake I had become unconscious while working in the office and had been admitted to an emergency ward in a government hospital.  When I gained consciousness and came to know from my peon who was kind enough to stay back with me at that late hour, I was about to go into coma and just managed to help myself, remove all the trappings that had been put on me, managed to put on my pant and hoodwinked the staff, managed to get out and ran for my life.  Real life experience. I can go on but..

- Saaka innoo Beka? 

- Vasanth Mysoremath 

asj's picture

Sample a few more opinions

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http://www.gopetition.com...

and

http://www.gopetition.com...

----------------

I can imagine place for private players, but not as the only players as is the case today.

In EU, this is how it works - if a Govt run hospital can't provide the given care, the patient is sent to a private hospital but the Govt pays the private hospital. Payment is based on fixed tariffs and often contracts are drawn up on a principle called - payment by results.

Will private players in India agree to price caps?

Look at our land use policies - South Mumbai has dozen or more posh hospitals, many more smaller private hospitals and nursing homes - why this concentration of a provisions in one pocket? In contrast, whole of Middlesex county has 3 hospitals of DGH level.

Planning permissions are given right left and centre to private players - are these players ready to go to remote India?

One small pocket of Mumbai may have 100 CT and MRI machines working sub-optimally - This is a complex math. If there was one player who was private and unregulated, monopoly will allow charging sky high prices. Now we have 100 unregulated providers, there is competition, prices are hence 1200 for a CT (for e.g) - but there is a limit to how low the can go as these machines have been bought at high prices and loans need returning. Instead, in reality, the same work can be done optimally by 10 machines run by a public run facility for throw away rates (explains why a test for diabetes costs much more than what it should).

How do doctors survive? Try google the phrase 'cut practice' and see how many results come up? Here is how it works, the secret of success is not skill of a doctor, its whether one plays the secretive game of cuts or not (public are not aware, its hardle mentioned on google) - patient goes to GP for headache, GP says see neurologist, he refers to Dr X, Dr X may see patient M for 5 times, charge 500 each time........at end of month GP gets  a packet from Dr X with 40% of 2500 - poor Dr X, such a big expert, 12 years of training, his survival depends on local GP nexus.........he makes up for the cuts.........he says get 10 blood tests done, then a MRI................MRI center sends 40% to Dr X...........and so on

Get the picture...........private sector playing its role for reducing burden of society (or perhaps of our pockets that get empty).

There is a reason why so many like me run away from the system.

ASJ

 

idontspam's picture

Environment and recovery

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 Marble flooring, bar-like environs, gleaming brass staircases, air conditioned, page3 nurses in starched uniforms out of 10 stuttering around.

Why do we assume rickety buses and spit stained walls are appropriate to dole out to the downtrodden? Regardless of your hyperbole a decent clean environment with hygenic attenders will speed up the time to recovery.

idontspam's picture

Wearing a patients hat

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I can imagine place for private players, but not as the only players as is the case today

India has both pvt. and govt. hospitals. So which country are we talking about here?

 private sector playing its role for reducing burden of society (or perhaps of our pockets that get empty).

I believe as patients and recievers of health care we need to audit and control the quality of care being provided and meddle less with the economy of the providers. An injustice inside the provider system will need to be sorted out by the providers themselves or will request intervention of a regulator if required.

Now we have 100 unregulated providers, there is competition, prices are hence 1200 for a CT (for e.g) 

The price is low and this is good. Why do we want govt to get into price fixing? 

asj's picture

Too many arm chair experts

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Its a free country, a free forum and like 90k spectators who think they know better than Tendulkar we have commentators who have little if any clue. Ctrl+C and then make a statement but nothing else.

Is it not obvious we are talking about India? Do the examples above seem to have come from a EU country?

Have you counted number of Govt hospital beds and private beds in Bangalore? Those who care to will realise in no time that almost of all Indian healthcare provision is private.

One needs to understand the bigger picture, 100 CT scanners doing the work of 10.....it actually means we have as a country ended up investing in 90 scanners for no good reason...they would serve us better if there was one in each village.

I keep promising my self not to bother trying to convince the category of - don't know, but don't know that they don't know (and hence think they know every thing and sit taking pot shots).

Study the situation, leave the arm chair, then we may get somewhere.

ASJ

idontspam's picture

Potshots? Who?

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 Have you counted number of Govt hospital beds and private beds in Bangalore?

A skewed balance does not justify the comment "but not as the only players as is the case today". Misinterpretation and hyperbole can pass, but reasonable armchair questions cannot?

 100 CT scanners doing the work of 10... they would serve us better if there was one in each village

Having 100 private scanners bringing down the cost of scan in a city does not mean the govt does not have to provide scanners in the govt hospital in the village.

ike 90k spectators who think they know better than Tendulkar we have commentators who have little if any clue

If that is not a potshot, what is?

s_yajaman's picture

A bit unfair to IDS

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Dr.ASJ,

With due respect to you (and I have a great deal of it) the "arm chair" comment was harsh on IDS.   Understandably this issue is very close to your heart and you have an advantage over most of us here.  But that should not stop a lively debate. 

We are all pretty much arm chair commentators here.  The purpose of this forum is to get people interested in civil issues.  Not everyone has the same grasp of grassroot problems.  some of us tend to see privatization with very rosy eyed glasses, some of us with skepticism and even suspicion.  I think we cover a fair bit of the political spectrum on this forum.

IDS and I pretty much disagree on all economic issues (he being a right winger and I am on the centre left).  But that is the beauty of this forum - that we can disagree and debate without coming to fisticuffs.  

Thanks,

Srivathsa

Drive safe.  It is not just the car maker which can recall its product.

psaram42's picture

Armchair Experts

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 Ctrl+C and make a statement. Better still Ctrl+C and don’t make a statement. That is democracy. But at the end of all expert comments though from arm chairs, there should be some deliverables. Let us have some dispassionate conclusions with some “consensus”. Consider the situation a generation before. Heart ailment had no treatment of the kind what we have now, in the country. BTW Heart ailment is a rich man’s disease.

asj's picture

Do I respond to sarcasm - is that unfair?

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SY,

Allow me to reiprocate that the feeling for respect between us is mutual.

But there is a limit to all talk and no play. I have finished my quota of patience for sarcasm such as 'So which country are we talking about here?' - Is it not blatantly obvious which country I was referring to.

Neither do I have time for repeated cut n paste approach where a line is taken out of context, petty time spent on semantics and some comments made without slightest of backing with either data or experience.

Rude I may have been, but unfair, I do not think so.

To be honest, I very much anticipated this, I made a reference to this and it was never hard to second guess who it may be. Its rather amazing that people have told me off in language that can be interpreted as 'personal attack' on other threads for harping on certain models be it London or Mumbai, yet the very same people seem to not bat a eyelid when talking / displaying pictures from Singapore to LA.

To be fair to this forum, this is a serious forum not Tweetor nor Facebook. I expect more, if I am wrong in expecting better quality debate, then so and I will make sure not to return.

ASJ

asj's picture

Prevention V cure

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Back to the thread.

This vital issue has be highlighted in many posts above. Let's dig a bit deeper. The main reason for life spans to increase over last 80 years is - our ability to deal with infections.

Immunisation is preventative when vaccines are available. The side effect of increasing life span is increase in rate of non-communicable diseases - diabetes, stroke, hypertension, cardiac problems, cancer and so on. These conditions will afflict all, rich and poor, urban and rural, its a matter of time as the main risk factor is increasing age.

Where does hard core medicine fit in this? Largely its immunisation, which actually is cheap and should be available to all.

But does a person with BCG vaccine not get TB? They can, many do - immunity is a function of social circumstances more than medical - those who do not get a square meal to eat, live in slums, have no sanitation facilities with sewage flowing at door step, no clean drinking water..............and hardly any education - the last factor plays a big role in lifestyle choices - worldwide poor people eat more junk food, lack of education affects the level of care people take with whether they will use mosquito nets or not, level of education of drivers determines our rate of accidents, deaths and hence burden on healthcare.

WHO had a target for all developing Nations, Health for All by 2000. We made a joke out of it. We set our goal to the minimum, like literacy - where someone who can just about read and write is literate (and we then look up meaningless stats on this as in real life this level of education offers no protection to anyone who has it) - we set about creating Primary Health Centers in village after village - never mind that there were no medicines to dispense or no doctors and other staff. Like Pune bus transport which has a bus stop within 5 minutes of where everyone lives, but no bus for an hour on average.

Thus, beyond immunisation, doctors (and immunisation is best carried out by nurses) have actually no role to play in prevention. Its more to do with social care provision - this takes us back to comparing per capita spent on 700+ million rural India for mid-day meal programmes, schooling and our lofty budgets in Urban India.

Every successful western democracy has strong socialist agenda. We blame Nehru for his brand of socialism.......my contention is we never really got to implementing quality social care models (where some schemes got implemented they were mere lip service provisions)......what we have implemented over years can be described as only 'corruption'.

Like PSA, I like action over words (and I have done a lot of that with regards transportation). I would love to write a white paper on this (with a few others who are involved in this area), but will bother with it only if Health Ministry is involved in taking the initiative - otherwise it a waste of time.

ASJ

 

idontspam's picture

Quality of debate is in your hands

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I expect more, if I am wrong in expecting better quality debate

As a practitioner you have the upper hand, so the quality of the debate is in your hands. I have asked a cumulative of  9 questions (with question marks) in all my comments and a few other opinions which can be answered dispassionately if there is an intention of sharing knowledge with non practitioners. 

Funnily enough it is not a debate if everybody agrees with you. 

s_yajaman's picture

We make the debate quality here

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Dr. ASJ,

Such is the written word - the lack of non-verbal cues can cause misunderstanding.  (Not sure why I am trying to play peacemaker, but it is a bit painful to see such discussions on this forum)

If your statement had read "There is a space for private players but not for only private players as is the case being made out today", (if indeed that was what you meant) then there might have been less confusion.  I doubt if IDS was being sarcastic when he asked that question.  (Sarcasm is not encouraged here.)

(IDS - MRI and CT machine centres are not like movie theatres where more competition leading to lower prices is better.  At best a bad movie theatre will leave you with a headache.  A CT scan centre with poorly maintained equipment and badly trained staff is another proposition altogether.  Proliferation of these means less control on standards.)

What action can ordinary people take on these matters to bring about institutional change?  One thought is RTI. 

I personally hope you will stay on and enrich the forum - but that is your decision.  I have had my share of heated arguments here and elsewhere and found them most futile. 

Surprising that the Canadian model has not featured here.  Having lived in Singapore and seen a couple of govt. hospitals, I can safely say that with the right accountability they can be as good as any.  (Singaporeans though complain about them).

Srivathsa

 

 

 

Drive safe.  It is not just the car maker which can recall its product.

asj's picture

Answers

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what accountability is there is private sector?

What in my posts does not answer this question? The answer is 'NONE'.

Who is enforcing accountability? What is the enforcers failure? How are they being taken to task?

Have I not covered this? No structures exsist to manage this, its obvious from what I describe above. Is it not obvious from the day light quackery on our streets, do I need to even qualify this any further?  

Also why cant we have private hospital maintenance but public caregivers?

Again, reading the entire post helps. A fundamental conflict is introduced when a doctor patient relationship is influenced by $$$ - and yet, I said, I can come up with a model where there is room for private players. For goodness sake, even you cars insurance has fixed pricing tags on it......will you get in to a rickshaw with no meter......why not just leave the price of a rickshaw ride to market force, and that of food.....

So which country are we talking about here?

Its obvious, is it not, do I have to reply to this question? I would expect people on this forum to find some answers to their questions - you have google at your finger tips, my reply to you was to go find the differential between private beds and public beds, then you would have an answer to your question.

And there was this whole business of private sector taking on the burdon of public sector....does my narration of cut practice, which afflicts 90% of the doctors not explain how they create a burdon on common man......I have to charge you 500 to make sure I keep a decent amount with me as 40% per charge per appointment is a handout.........if this did not exsist, would healthcare not be cheaper?

Can't find any more questions worthy of my time.

ASJ

idontspam's picture

Complete lack of faith in services in government hospitals?

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  A CT scan centre with poorly maintained equipment and badly trained staff is another proposition altogether.  Proliferation of these means less control on standard

Absolutely and this is where the govt needs to put in all their effort audit and monitor standards. Is todays BBMP health inspector equipped or knowledgable enough to audit these and other violations without corruption and compromise? Or would you rather the health inspector start his own CT scanning center? What garuntee that it will run with good quality? This was my first comment if you notice. Have we recognized the inefficiencies in the basic functions of govt as a regulator? We are asking govt to pump in more money but without making sure they are accountable to the quality of output. Isnt this what we have been fighting in Praja. The returns on tax money pumped in?

Private participation in public life with strong regulation makes for a dynamic and economically strong society. Healthcare as a whole may have a socialist agenda but does not mean they cant take private help. Give me one good reason why the hospitals cannot be maintained by private parties to stringent SLA's while the care is taken care of by the govt. This was my question in the other comment.

The title of this post is the original question asked. 

idontspam's picture

This is better

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 Also why cant we have private hospital maintenance but public caregivers?

Again, reading the entire post helps. A fundamental conflict is introduced when a doctor patient relationship is influenced by $$$

I was talking about facility maintenance not doctor patient relationship. 

and yet, I said, I can come up with a model where there is room for private players

This is encouraging.  I would like to hear more of this. What areas can private people participate to make health care better for the public? How will the govt play a role in regulation of quality of health care?

Help me understand this so we know socialism does not mean trashing private participation in public life.

asj's picture

And I have already replied

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My reply was a simple one liner - I see a role for private players - but not the way it is today, even the failing healthcare provision in US has 6-7% of GDP as public spend, another 6-7 comes from private insurance schemes and out of pocket expenses..yet they are in trouble.............in India, 90% of health provision is private............its all unregulated and its a model which fails to ensure provision for all...........profits rarely are put back in to the system. 

You want one good reason for why PPP is not a solution - from where do people get their faith in private - from todays banking sector worldwide, car makers, builders.....every road in Bangalore is built by a private contractor, is it not...........what is the end result, what quality do we get? Will private players leave Mumbai and Bangalore and go build hospitals in Durg and Billai - where individual doctors are now taking loans up to 1 crore to build their own hospital facilities...leaving them with having to find a way to pay of the debt.....a sure method to make way for corruption.  

Yet, when core principles of governance are put in place, IIT, IIM, majority medical teaching hospitals, ISRO, BARC, ............a whole lot run well. There is ample evidence of public sector doing well. Would you rather study in IIT or one of the many useless engineering colleges in Bangalore?

We need structures of clinical governance, we need money to back it up...........is the Govt ready to find 5-6% of its GDP worth money year on year for healthcare........in 10 years we will see a massive difference. Is the Govt ready to implement mandatory insurance schemes? Is the Govt serious about this or just hell bent on selling of public hospitals...a common emerging theme across the country.......despite lack of an ounce of regulation and control.

And I have not even scratched the surface of the Pharmaceutical industry and its corrupt nonsense - and guess what, they are all private. They are just as responsible for running dirty scams.

ASJ

 

 

 

s_yajaman's picture

Is this what it boils down to...

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a. Need for a broad consensus that the government should have its hands only where absolutely needed - BPL.  Private players will not go where this is no profit - e.g. rural health care. education for poor people, etc.   Or if they are forced to go can tend to give bare minimum.   The question to be asked is - Can the government make a difference or will it offer parity services ?  If the former, then they stay, if the latter they exit (case in point - Air India)

b. Need for it to develop its regulatory framework for each public service.  Who, how, how much, etc.  How will it be measured?  Who is accountable?  What are the rewards and punishments? Without this we are setting ourselves up for disaster.  

c. How do we bell the elephant in the room - Corruption?  We have reached a point where pretty much everything is for sale.  What is the guarantee that numbers won't be fudged, dirt swept under the carpet.  Yes it happens today, but profit is a huge motive to do more of it.

Srivathsa

Drive safe.  It is not just the car maker which can recall its product.

Ravi_D's picture

So what are we suggesting here?

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Passionate debate is good sometimes - can churn out things we wouldn't see otherwise. But in this case, it is hard to think of a way forward.... What is our next step you think?

Since our Doc mentioned White Paper - How about collectively working on a white paper project here on Praja to point out the pros and cons of potential options?

Ravi

asj's picture

Hence we need a bill / Act on Universal Health care

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There is a need for a bill / Act to be passed in the parlament. As I hinted, UK is where it is today because of NHS act, a bill passed in 1948.

There is plenty of know how, doctors in EU, US, down under from Indian orgin with experience and knowledge (of having worked in different systems, many like me have also had intimate knowledge of working in Indian Public sector, the private practice in india and then leaving because the grass seems greener on other side of the pond) to help write such a bill (and we would love to help).....................but is there a will?

The sole reason why IT professionals of today unlike those of 70s who were part of brain drain return to India is because they can make a decent living here - anyone who want to revive this profession and bring back some of its honour has to find a way of ensuring that doctors are paid decent salaries (private teaching hospitals pay same salaries as Govt teaching hospitals despite lakhs of rupees in donations).

As a medic, I know how it feels to have disparity. When I was a registrar in Mumbai, in 3 years I managed to earn and save some 60K - this was 4 times less than doctor of same experience in Delhi? Its demoralising that a cardiac surgeon earns tens of lakhs per day (not even UK docs ear that in a month) when an equally important skin specialist, GP, a psychiatrist, a pathologist are offered petty salaries in these private hospitals.

I attended a conference in 07, it was in the 7* hotel at Powai. I could make out which doctor was doing well at his business (that is what we should call it) and who was not. Those who gave cuts, had eneough patients, wrote lot of prescriptions........they were escorted in air-conditioned cars by pharmaceuticals, they had rooms booked in same hotel or other 5* hotles.............the honest colleague almost certainly had to find his way to the conference in BEST, train or rickshaw. Half of my colleagues every year make round trips to EU and abroad...all courtesy Pharma..........other half can't dream of finding money to attend such conferences from their pockets simply because they somehow do not generate enough business................can we stoop any lower?

ASJ

s_yajaman's picture

Middle class participation is critical

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Dr.ASJ,

Silkboard made an interesting observation.  He said that most discussions among the middle and upper classes in Bangalore happens around traffic (not water, not schools, not healthcare).  He said that that traffic is one of the few problems that the middle class cannot buy its way out of and hence all the noise about it.

Our govt. hospitals and schools are in the current sorry state because the people who can shake up those systems, viz. the middle class, have opted out of them.   Our class differences start right from childhood as children from different economic classes rarely mix.     A few exceptions might send their children to govt schools out of strong personal conviction, but personal virtues cannot be the basis of public policy. 

Srivathsa

 

Drive safe.  It is not just the car maker which can recall its product.

idontspam's picture

Example of benefits

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 The sole reason why IT professionals of today unlike those of 70s who were part of brain drain return to India is because they can make a decent living here

It is important to analyse what role this industry has played, physically and psychologically, in the prosperity and growth of India. Also important to understand what role (if any) the government have played in wage control or creation of opportunities for people returning back. Hope we pass on the lessons good and bad to other industries and get them to shine similarly. We should look at this maybe in another thread or blog.

asj's picture

True

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Ironically, it was our middle class educated leaders who got us our freedom.

We could go back to the thread from TS on living in enclaves, not leaving our comfort zones. Middle class India has no time for society and quality of life as we have no social care or universal healthcare. Each of us has to work till we retire to ensure we have saved enough for the odd foreign tour + by pass treatment. There is no time for reforms, there is no time to think about our problems.

In contrast, a small country like UK manages significant number of patents every year. The innovator can sit down and focus on his research........he/she knows the system will take care.....everyone gets a state pension even if they have not worked, jobless get support, everyone knows the same ambulance that may pick up a celeb after dialing 999 will come to their door step with qualified paramedics in a state of the art ambulance in 10 minutes. Sense of security allows for people to play with adventure (read as being industrious).

UK managed a significantly high number of glod medals at olympics.........why........majority were related to water sports............every school kid gets (and 90% go to state schools) mandatory swimming lessons each week as part of curriculum. In contrast the nearest pool in Mumbai where I lived required membership which costed couple of lakhs 30 years ago!!

Mumbai population has grown from 2-3 million to 17 million, yet, only one major teaching hospital came up, the one in Thane, its named after late R Gandhi - so one can guess how late in the day this investment happened. Common Wealth Games Budget of 2K crore is more than that of Mumbai Corporation's health budget (which serves 8-10 million people).

We seem to think we can outsource our problem - Bisleri to take care of lack of water supply, inverters for lack of electricity, poxy third rate private engineering and medical colleges run by politicians because the Govt can't find the money, the middle class can't stand the queue to buy a train ticket....so we got touts and now agents......might as well sell the country.

PSA said it - think of next generations - middle class may go richer, the rich may get richer....trust me, our great grand kids may get lynched, mugged, looted if the poor have no choice but to steal.........we will end up with a mutiny, a civil war....and more.

ASJ

 

 

Vasanthkumar Mysoremath's picture

Dr.ASJ is right-mutiny,civil war,maoism,naxalism,pwg,AIDS Nagar

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The Stigma of HIV/AIDS/cancer and other incurable diseases will be forcing setting up of AIDS NAGARS in all urban aglomerations.

I foresee that by 2020 many nations, particularly under developed and over developed countries will have separate AIDS NAGARS due to absence of proper health care / awareness programes.

Havn't Prajas had enough of high level interaction and many lightning flashes straight from the Stallion's mouth - Dr.ASJ?

Isn't it time to cull out plausible variables and deliverables for presenting it to Government so that the Budget may consider favorably the health sector and see that the poorest of the poor who are more prone to simple ailments that turn out to be deadly can be nipped in the bud?

We cannot expect government to deliver a good health care system because they always look at any project aimed at people with MISTRUST and there is a conspicuous absence of transparency in executing anything and they have their own doubts about their credibility.

Time to either deliver or raise hands and surrender to privatisation which cannot be the anathema. 

- Vasanth Mysoremath

 

psaram42's picture

It is a question of affordability

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 IMHO

 The answer to Murali’s question:- “is it worthwhile to visit a government hospital at all” is:-

 It depends.

 It is worth while for people who cannot afford the high cost at private hospitals to go to Government hospitals. There was a time when the accommodation problem at Bangalore was so acute, that the rich guys stayed at Manipal hospital special wards. It was cheaper than staying at star hotels perhaps. When the economy was booming the stars were also in resonance. Now I see lot of “to let” boards in my locality.

 Medical care and expertise is not an issue any more. As ASJ says life expectancy has increased in our country to equal that in advanced nations. In fact we in Bangalore are offering medical care to foreigners at competitive rates.

 I am covered by CGHS (Central Government Health Scheme). I go to Jayadeva ( a Government) hospital (which is also air conditioned) to get prescription. The medicine cost per month is around Rs 1000/- I get it free at my CGHS hospital. I see lot of ordinary poor / middle class including me using the Jayadeva facility.

 Greed, Inefficiency and mediocrity is a human trait. It is not all pervasive. Nor it is limited to government hospitals by default.

 There is a difference between Jayadeva a cardiology hospital to let us say Bowring Hospital a non specialty hospital. (Heart disease is a rich mans disease)

 

asj's picture

No time for circular arguments

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I think Praja has enough information to act on, leave aside a healthy debate. That I speak so openly of my profession should have sufficed. I can envisage different models, but this is not the place to spend time writing about them.

Most private doctors one may consult are products of public teaching hospitals. I have spent enough time in public teaching hospitals of Mumbai and barring a handful of experiences, I would say given the limited financial resources, these hospitals and their staff do a phenomenal job (go on a visit for 10 days to make full sense of it all). These hospitals have not failed because of lack of expertise, they have failed because of lack of money.

Even if (its a big if) private players are thought to have role and offer treatment for poor for which the government pays fixed contracted prices - where is the money going to come from? That is the moot question.

This takes me back to the very first step I suggested - we need mandatory national insurance to create a corpus - this is not about 100 million people who can buy their way out, it is about a population of over a billion.

I have no time for circular arguments, Praja can contact me if they manage to take an expedition to state health sec / minister and they show interest in considering the first step suggested above.........everything else rests on this promise of starting a mandatory insurance scheme.

ASJ

silkboard's picture

action depends on numbers

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Any action on ground requires numbers.

To get numbers (as in people), you have to attract them via more content and 'education'. To draw healthcare sector enthusiasts to the site, you have to first have quality talk and debates to attract more of them.

Or, you need more threads like these to make existing readers and members 'convert' their interest from common place subject like transport, to more impact-ful subjects like healthcare (Srivathsa already shared my take on why most of us bother only about traffic here).

That is exactly why our philosophy is to not belittle talk - talk is a must, you can't just expect people to get together and start on something. And when you talk, you would need to be patient, sometimes like a teacher, sometimes like a good friend.

Keep talking sense, and goods will result, either directly (as in you would see people announcing and journaling their action on Praja), or indirectly (things happening as a result of thoughts seeded from here).

So anyway, the point is - believe in 'indirect influence'. Positve thoughts and energy will find meaningful outlets. Let lack of 'direct' and visible action not annoy you, unless you are expecting a handful of people to do the running around for rest. I certainly dont like that old fashioned model of on-ground action.

E.R. Ramachandran's picture

Better management, administration is the answer

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Thanks Dr. ASJ for your insightful comments.

I have visited some Primary Health centres around Delhi and what did they keep in their small refrigerators ? Shoes. Yes shoes! Since  there was no power almost whole day, the fridge practically had no use for them. This seems to be the general pattern in rural hospitals.

Private hospitals is another story. Apart from fleecing patients with a battery of unwanted tests, most of them do not even dispose off  deadly medical wastes properly beacuse there are no stringent measures to tackle those who break rules.

I feel  in Public Government hospitals there are very good committed doctors and support staff. What  they need is  some good administration to show that the system works. We must support, nurture and improve govt. hospitals with better  infrastructure. finance and management. These are OUR hospitals. We can't throw them away, because they are sick! All the more reason to take care of its health.  They will surely deliver.

ERR

abidpqa's picture

Government has all the rights to invest in healthcare

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When should the government leave the healthcare? It may be done when the private sector does a better job than the goverment. It is not the case now, so the goverment need not leave the healthcare sector. I encourage the government to invest more in healthcare. Even if the private says the government is not efficient, it does not have any data to support it most of the time.

The government does not care about healthcare. That is why both public and private health care is not up to the mark.

There should be reform in regulation. The selfregulation of healthcare by the doctors in India is a failure. There should be role for nondoctor members in the regulation of healthcare. The patient is also a stakeholder in the healthcare.

Private sector hospitals are not run by doctors, so there will be ethical conflicts. So doctor's associations should formulate ethical guidelines when working in those conditions. If we go to MCI website there is no mention about any ethical guidelines.I did not see anything in the IMA site too.

The charges in the government hospital is less which is enough reason for thegovement to continue investment. Again, there should be a regulator regulating the prices charged by the private sector. We have regulatore for telecom, insurance, stockmarket, etc. why it is not applicable to healthcare? The charges private sector will not come down with efficiency. I am not sure of the reason; atleast it has not come down ever. Even if there is insurance the healthcare providers cannot be allowed to charge anything they want. Because the insurance will be unaffordable

Medical education is another problem area. The funny argument they say is that parents of meritorius students are rich. They do not find anything wrong when a nonmeritorius studet is able to "buy" education when his/er parents are rich.

idontspam's picture

Control and Private participation

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When should the government leave the healthcare?

It should not. Even a hardend rightwinger will agree healthcare, defense and core strategic sectors cannot privatize completely. But identification of opportunities even in these core sectors where non-govt parties can bring in expertise to make things better is very important to any system. 

Here is a simple private partnership agenda I suggest for Health care.

1. Draw up the facilities that any hospital needs and define mandatory service level of these facilities in terms of infrastructure(equipment etc), availability, cleanliness and hygene

2. Put a tender and have the private sector construct and lease it to you while they own the service levels. 

Let me know why this cannot be done.

We have regulatore for telecom, insurance, stockmarket, etc. why it is not applicable to healthcare? 

I whole heartedly agree with the regulation part. Every sector needs a regulator. Price fixing is not acceptable while band limits can be set. For example there is a circuit breaker in the stock exchange, while it is not price fixing it ensures there is sufficient control.

murali772's picture

I have my answer

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My original question was 'will any PRAJA member want to visit a government hospital?' From the responses, I have been reading, it is obvious that not one would want to go anywhere near any of them - not even Doc ASJ, were he not a doctor himself. The question arises then as to where will one go, if one has to.

As far as Bangalore is concerned, there are a number of private hospitals where you can be assured of reasonably good quality service, and at what can be considered as fair charges - Manipal, Narayana Hrudayalaya, St Martha's, St John's, St Philomena's, Chinmaya Mission, to name a few. It is not as if there are no complaints whatsoever against any of these - check         here          But, the difference is in the numbers. Whereas in the case of the government hospitals, it's plain and open racketeering, in these private institutions, there are perhaps the odd cases of negligence, and even of malpractices, like in any other industry or profession. On account of that, can one make sweeping statements like there's no accountability whatsoever at all?  

Further, in the case of government hospitals, there's rarely a day when one newspaper or the other does not carry a story on some sordid goings on - check            here          So, generalisation can be said to be fairly valid here.

Also, whereas the private hospitals generally bother to respond when issues come up, nothing can ever bother the government hospital administration or their political masters, unless something of calamitous proportions develops.   

Now, when VKM states that a blood sugar test should cost only Rs 20/-, he is accounting for only the direct material costs. What about the indirect costs involved in running a hospital in a city? And, it doesn't come cheap! Also, for paying it all, whereas in a private hospital the chances of your recovering are fairly high, in the case of a government hospital, the chances are very high that you'll eventually land up paying much higher on account of negligence, apathy, mamools (no longer small as the term may imply), fresh infections due to unhygienic conditions, if not with life itself on account of all of the above and many other factors.

Quite like IDS has stated, heathcare is one sector where government presence is very much needed. But, perhaps what it needs to do is to run a few model hospitals, may be on the lines of AIIMS (with good budgetary support - there was in fact some talk in the recent past of bringing all of Vani Vilas, Victoria, and Bowring hospitals under the Bangalore Medical College, and running them all on the lines of AIIMS - wonder what happened to that talk!), and leave the rest to the private sector, after putting together a proper regulatory mechanism or ombudsman in place. If the regulator/ ombudsman takes up each of the cases on the 'mouthshut' site, the hospitals will have little option other than to respond constructively, and qualitative changes should result in no time at all.
 

Muralidhar Rao
asj's picture

I wish it was as straight forward

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I have answered your question. My father in law had his angioplasty at Sion Hospital in Mumbai. If you or someone drops unconscious on the road with no other relative, trust me, chances of surviving will be higher if you are taken to a public hospital. I remember a man brought in unconscious, we did the ususal set tests, had a diagnosis, gave him 50 cc of magic (i will not say what it was) and he rose up with his alcoholic smell to fling abuse at all saying 'how dare, he, the son of xyz be taken to a Municipal hospital.........and walked out...................he did that only because we kept him alive

Secondly, its obvious that private healthcare is corrupt. Kidney scams from Bangalore itself are well known world over, they were connected to private setups.

I have worked in public hospitals, I have done private practice and I can vouch for the fact that many doctors provide the care to the best of their abilities in limited resources. The examples I narrate above highlight something - public hospitals are deprived settings, deprived of much needed money, they are not deprived of doctors with high standrads, and many who left for private practice would remain with these Institutes if better pay was offered. On the other hand, massive scams await to be unearthed in private settings.

Its should shock people that when a private consultant asks Rs 500/- as fees, actually this is so only because of the epidemic of cut practice in vouge, and it all happens only in private set-up (the question of cuts does not arise in a public health setting).

A handful of good private hospitals does not negate the fact that majority of private healthcare in India is involved in corrupt practice, nor does it suggest that public hospitals are bad simply because the building is crumbling. The real reason why people from lower-middle class and above won't go to public hospital is not because care is missing, its because you and me can't stand the fact that these overworked hospitals are frequencted by the BPL families from across the state in huge numbers and it just so happens that we are lucky to have few pennies to avert standing in long queues, crowded wards with dirty linen or toilets where tiles have not been changed for 20 years. Its the very same reason some give for not using the red / black board bus, its the same reasons that stop us from sending our middle class kids to a Municipal school................these school are deprived and most certainly not as corrupt as private schools............they do not have good teachers because the salaries are pathetic..............the buildings are crumbling not because someone siphoned away the money....the money was never there in adequate amounts.

I am not suggesting for one minute here that there is no corruption in public hospitals, its there even in well developed countries like UK.............but I can tell you that in a public hospital majority of staff are people who are honest and hardworking.

This post may be about Bangalore, a city, 7 million people aspiring to make the most for having been born with a golden spoon..................my vision is not restricted to 6 Metro cities of India, it applies to urban poor and more so the 850 million languishing out there in remote India - its a myth that heart disease is a rich mans disease....porr people suffer from exactly the same illnesses.........who is to provide them with the bypass or an angioplasty? Or do they not deserve to live longer?  

ASJ

Vasanthkumar Mysoremath's picture

Murali Sir-misquoting my post?

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Murali Sir u say - /Now, when VKM states that a blood sugar test should cost only Rs 20/-, he is accounting for only the direct material costs. What about the indirect costs involved in running a hospital in a city?/

Read my earlier post - I say - /Including everything that goes into conducting a test like antegens, chemicals, testing apparatus, building, nurses, technician fees, profit etc., etc.,  it should not cost more than Rs.20 per test./

Dr.ASJ is right in saying -

/Its should shock people that when a private consultant asks Rs 500/- as fees, actually this is so only because of the epidemic of cut practice in vouge, and it all happens only in private set-up (the question of cuts does not arise in a public health setting)/.

(The above applies mutatis mutandis to diagnostic procedures also)

- Vasanthkumar Mysoremath

 

 

murali772's picture

Socialism is indeed the ideal

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If government could indeed do some semblence of justice to any of the things it undertakes - from running hospitals to providing bus services, water supply, power supply, etc etc - then that would be the perfect thing to happen. Yes, Socialism is indeed the ideal. But, unfortunately, it never seems to work, barring the few rare exceptions. So, we will have to look for the next best solution, which is a lot easier to be worked, if facilitated and regulated properly. That's what the effort is all about.   

 

Muralidhar Rao
idontspam's picture

Private aspatre

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So the first principle is having a deep conviction that you have to bring world-class (quality) at affordable prices to the poorest people in the world so that you get for the first time, the ability to provide world-class (healthcare). I think that’s the motivating principle. The second thing I think is the willingness to implement entirely different work processes. For example, somebody reading the echocardiogram (in Narayana Hrudyalaya) is someone who has just done high-school graduation or who has done just the first year of college.

The walmart model for healthcare

asj's picture

Corruption V Socialist models

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Majority of the developed world countries have a model which is socialist in idealogy, the proof that it works is very much out there. The proof that skewed private healthcare is not healthy is also very much out there, the most glaring example is India.

In India we have implemented only corruption, we never really did justice to term socialism, to say that something failed when it never was...........that is a wrongful conclusion. And yet, we have living examples of many public sector provisions being the very best.............as I asked - if your son/daughter was getting admission to IIT or KEM Hospital in Mumbai as well as private colleges - where will you send them?

Our helth spend ensures we are in bottom 20% of countries on this planet in terms of per capita expenditure.

There are various reasons why BMTC, BBMC, PMC and the like can be deemed useless, corruption is not the only reason. Incompetent people are placed with responsibility of running our Institutions in general - why may be this case? Other than failed implementation of positive discrimination (something I support but not in the manner it is now), it is largely poor salaries. How many IITians would have stayed back if they were offered the right salaries in Govt sector? Many doctors like me would love to serve in public hospitals, but it won't happen if a value of 25K a month is placed on someone who has been around 20 years in this profession. Many like me detest the unregulated largely corrupt private healthcare, very few doctors do not dream of leaving for greener pastures. Only few years ago, the cream of Indian psychiatry, almost all from places like NIMHANS (a 100 or more), many with 20 years of service and working at level of Profs left for UK (irnoically Indian Govt gave full support to UK Govt in this fellowship scheme offering salaries between 90K to 120K (Sterling).

ASJ

 

 

abidpqa's picture

Every posh private hospital

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Every posh private hospital is managed on paper by Trust.......why.......tax sops...........these paper charities charge lakhs of $$...........
 

This should never be allowed. The running of hospitals by trusts is not Capitalism. There should be strict distinction between for-profit, non-profit, and not-for-profit institutions. If they are champions of capitalism then they should run as profit making companies.
 

Running of healthcare that is hospitals in UK and US is based more on socialist models than capitalist.

As far as Bangalore is concerned, there are a number of private hospitals where you can be assured of reasonably good quality service, and at what can be considered as fair charges -

I do not see them as fair charges. Are they fair to everyone in the society?

idontspam's picture

Proof is in the eating of the pudding

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 Majority of the developed world countries have a model which is socialist in idealogy

This is misrepresentation to suit an ideology you are promiting. Want proof? See below a map of all countries who declared themselves to be socialist states, under any definition, at some point in their history. You will notice socialist countries represent some of the poorest and underdeveloped nations of the world where freedom of choice takes a back seat and corruption rules the roost. There is nothing more to say, the proof is in the pudding. 

SOcialist countries

Many like me detest the unregulated largely corrupt private healthcare

I tend to agree that we should get to a regulated private healthcare system which can complement an effecient and regulated public healthcare system. 

asj's picture

Twist as you may

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Load of cobblers is all I can say. Fact is none of the other successful countries claim to be capitalists per se. Like India, they are free democracies, but with a very strong social agenda that not even blind could miss. That is the only reason why you do not see slums and rough sleepers in thousands on their streets. That is the only reason why, the poor still manage to get a decent education.

ASJ

idontspam's picture

Poverty and Socialism

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That is the only reason why you do not see slums and rough sleepers in thousands on their streets. 

Capitalism has been dominant in the Western world since the end of feudalism. Capitalism gradually spread throughout Europe, and in the 19th and 20th centuries, it provided the main means of industrialization throughout much of the world. It has been proven at least for the last 100 years that inclusive growth can only come when private enterprises participate in the public space and not otherwise. 

Further reading

kbsyed61's picture

Time for a time out !

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All,

It's time out for a moment. Thanks to all those who enlightened the Praja with such good ideological laced discussions on such an important subject.

Now let us put forward some concrete ideas as the blue print for a sustainable health care infrastructure in India. Let us put forward our ideas that show cases the best practices that could be practiced in India. Socialism, capitalism. The poor souls doesn't care as along as they get some helping hand in need.

Syed

asj's picture

Lost the plot

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The point is that capitalism has had its succes because of free democracy, these countries are democracies first (not capitalists as being tried to make out). Free democracy killed feudalism (not capitalism).

And anyway what is the point, its so out of context. Bottom line is that significant number of capitalists (if that is what you want to call them) countries have huge investment in socialist agenda.

ASJ

idontspam's picture

Fallacious conclusion

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Free democracy killed feudalism (not capitalism).

You cannot conclude with a fallacy.

asj's picture

If you say so

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Now we are ready for a lesson in history.

Carry on - till you feel satisfied.

ASJ

idontspam's picture

Someday, somewhere

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 Now we are ready for a lesson in history.

Sure... but someplace else... not here.

murali772's picture

the IIT reference

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@Doc ASJ

You had brought up the point about the IIT's. The following is an extract from my blog captioned "a dissenting voice" dt 2.03.07, which may be accessed here. There's a lot more there. In this thread, I shall confine it to just this much. May be we can take it forward in a fresh thread.

Now, as reputed as the IIT’s, IIM’s, Central schools, etc have been the numerous Christian Missionary schools and institutions like St John’s Medical College, CMC, Vellore, etc; the Manipal group of institutions; and lately, the NPS, DPS, etc. And, the International Business School, in Hyderabad, promoted by a consortium of business houses, is currently ranked at no 15 in the world, far higher than any of the IIM's.

Muralidhar Rao

 

Muralidhar Rao
Vasanthkumar Mysoremath's picture

Enough of discussions-List 5 important solutions

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We have discussed enough variables; poured out enough scorn; expressed disappointments at the systemic failures in providing basic health care system to the people of India.    

As KBS has rightly pointed out - it is time out

- let us list, Five most important points that can be treated as deliverable solutions from the angle of Prajas for consideration and implementation by the Government of India:

1.   Government should play the role of a facilitator and with PPP,  invest GDP allocated money in upgrading the existing hospitals (real estate value of land held by government hospitals in urban areas is in itself an investment) in a class action mode.

2.   Create a State wise high level Board/committee with Corporate Social Responsibility consisting of eminent medical specialists/hospital management experts/corporate honchos/ non-political Dalit-Minority leaders/NGOs-RWAs for running the hospital with all necessary services for managing deliverable health care to all class of people.

3.   Create sub-committees to oversee different areas of operation - raw material to finished product mode - that will ensure transparency and accountability in finance and costing management, procurements, variables and deliverables for effective running of a corporate entity hospital.

4.   Invest in existing private hospitals with minority share holding pattern so that they can be brought into a broad spectrum of universal governance in order to ensure compatible health care system on the same lines as corporate contrlled hospitals albeit with strngs attached for economy class patients and club class patients. Reservation under economy class will be commensurate with the investment holding pattern and charges should not exceed as fixed by the Board for ensuring universal class health care to all. 

5.   Health Insurance scheme to be extended to all citizens, only if they have voted in the elections may be a better way of ensuring participatory democracy since incentive would be an attractive proposition for all kinds of class actions. 

In addition to the above Government may with the same PPP arrangement, invest in peripheral services pertaining to health care viz., O&M, Research & Analysis, Diagnostic centers, at 10+2 level as job oriented course, create modules for Training course at 10+2 level for Nursing, lab technicians, X-Ray technicians, Physiotherapy, Elders Home Care, rural health care capsule and other para medical staff with a sense of service.

- Prajas may like to carry this forward.  We need solutions.  We need not continue with 'stating the obvious' or finding faults with what has been suggested by some Prajas, anymore.

- Vasanthkumar Mysoremath

abidpqa's picture

The poor souls doesn't care

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The poor souls doesn't care as along as they get some helping hand in need.

People should have more demands and "know, care, participate" rather than stay poor souls.  That is my solution, but I suppose that is not a solution that we can take to anybody. 

vinod_shankar's picture

Need of the hour....

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After reading through  voluminous amount of discussion on healthcare above, althrough i found one common theme 'Need for regulator in the health care sector-both public and private'. Let it be called Indian Health and Hospital regulatory Authority (IHHRA)  Something on lines of say TRAI and IRDA.

I firmly believe a well intended regulator can do wonders to the health care sector.  We should think on  these lines and present a white paper to the government of india.

We should discuss, the objective and functions of such a regulator(IHHRA).   Take a look at the history of TRAI, it has brought down call rates from  Rs.16 /min to almost  40 paise/min in approximately in 15 years.  Increased teledensity form 3-5% in the mid 90's to 39% in the last quarter, reaching almost 450 million people in india.  And also TRAI publishes quality metrics for all operators in India every quarter and it also specifies the metrics acceptable for good quality.  This information is available on the  trai website. 

Some may take exception for comparing  telecom to health care.  But my intention is we can look at similarities and evolve, quality metrics acceptable in terms of infrastructure, hospital charges,amenities etc.  Let us define and make the regulator....

vinod

PS: Let  IHHRA overlook both private and public hospital.  Because in times of desperation and epidemics,emergency needs, the government hospital response is much swifter.

 

 

 

asj's picture

Yet another doctors strike

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http://epaper.timesofindia.com/Repository/ml.asp?Ref=VE9JTS8yMDA5LzA3LzA5I0FyMDAzMDA=&Mode=HTML&Locale=english-skin-custom

Gives salaries and discordance in the same across the country when same amount of work is done, in fact Delhi resident doctors work in shifts of specified periods.

Pay scales are better in States closer to power. Karnataka has amongst the lowest salaries. BTW there is another strike going on in TN currently.

Interestingly, a doctor in training in Delhi gets more than Associate Profs in Mumbai who may have served 10 years or more beyond 9 years of training.

Make no mistake, resident doctors may be deemed as trainees, but they are already MBBS and are the backbone of medical Institutes (in EU this is recognised to a point that the hardworking frontline resident doctor in EU earns salaries close to those earned by their consultants).

ASJ

vinod_shankar's picture

Regulating private healthcare Hospitals in karnataka

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A move in the right direction i guess, it would be good if we could lay hands on the bill and also the rules made to see how effective it will be.  Please find the link to article here

vinod

 

murali772's picture

a fine example, but - -

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Karnataka health minister KR Ramesh Kumar was admitted to the government-run Bowring & Lady Curzon Super Speciality Hospital on Sunday.He is being treated for diarrhoea.

- - - Kumar has been vocal about politicians and government servants setting an example by going to government hospitals which cater to the common man.


For the full text of the report in the ToI, click here.

A fine example set by the health minister, unlike the many others who will never even step into a government hospital leave alone getting admitted into one. Likewise is the case of Sushma Swaraj-ji, who is getting her kidney transplant procedure done at AIIMS, though as a cabinet minister in the central government, she would have been entitled to the best of treatment at the fanciest of hospitals in the world, like quite a few have known to have availed.

But, for all of that, if the government hospitals have to improve their services, I doubt there can be any other option than to go in for PPP arrangements as suggested here, apart from in this blog itself, and here too.

Muralidhar Rao
murali772's picture

a laudable initiative by the government

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A bill is expected to be introduced in the budget session of the Karnataka legislature, likely to be held in the second week of March, to regulate the functioning of private hospitals and improve services in government ones.

On Thursday , the government asked the National Law School to draft the bill based on the recommendations of a 20-member committee headed by retired high court chief justice Vikramajit Sen. This follows widespread complaints that private hospitals have been fleecing patients. The government asked the committee to submit the draft bill within three weeks.


For the full text of the report in the ToI, click here.

That there was something like this in the brew was reported over two years back (check here). Wonder why it took so long to make progress. Well, at least now one hopes it'll see the light of day soon, and hopefully become the model for the rest of the country, and in fact the world, to follow too.

For all of government initiatives of the recent past, this is perhaps the most laudable. As such, it would do well to pass and implement the bill fast, if nothing else but to boost its otherwise sagging image.

Muralidhar Rao

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