Tertiary Health Care And Manipur

The recent Health Reform by President Obama in the USA, despite doubts and reservations raised by concerned sections of society is unique. The main objectives reportedly are to bring as much of the public as possible under the umbrella cover of the managed care and to bring in the concept of health supermarket (shopping mall), where different health packages affordable to different income groups will be sold, since the failing Medicare and Medical concepts became evident, what with the health sector eating away around 16% of the GDP per annum. In simple terms, the cost of health care in the USA has become exorbitant and unsustainable anymore in the present economic realities so much so that now from 2014 nurses (physician assistants) will be part of the primary care level interface with the health care seekers. The trained nurses at MSc level would have to undergo 1-2 yrs additional training before becoming a physician assistant, thereby filling the gap between the traditional job demarcations of a doctor and a nurse.

Nearer to home, we have Bachelor of Rural Health Care (BRHC) of total 4 years duration including 6 months rotating internship, and even district hospitals would be eligible to run the course and admission would be hopefully district-based. The Government of Assam is already committed to the concept. This concept arguably fulfils Indian Rural Population’s ‘[‘˜Legitimate Expectations’ towards ‘˜Right to Health’ as a part of entitlement to ‘˜dignified and decent life’ under Article 21 of the Constitution of India]’. These developments have occurred in light of the present manpower inadequacy to fulfill the health care needs of the population and the State of Manipur is no exception in this respect. But if one looks from a nationalist perspective towards health care needs of Manipur, the near-total absence of tertiary health care cries out for equal recognition. Rest of my essay will deal mainly with tertiary care issues only, by choice.

India produces more 700 super specialists (DM/MCh/DNB) per annum compared to 15,000 postgraduates (MD/MS/DNB) and 34,000 undergraduates (MBBS) according to Medical Council of India (www.mciindia.org/meetings/EC/2010/ECMN). The State of Manipur till date could produce a little more than a dozen super specialists. One cannot help wondering if lack of incentives played any role in the scarcity apart from lack of self-motivation and competitiveness on the national platform. Whatever is the reason, the super specialists alone cannot man a tertiary health care centre (Superspeciality Hospitals and Teaching College Hospitals). Specialists trained further in other specialties and providing high-risk and advanced services also man such facility.

Why a fully functional Tertiary Care Hospital does not exist in Manipur? The answer is a rather complex one, at best. Firstly the concept of a tertiary health care is valid within the context of the premise that already a well-networked referral system is in place and working. Which is not definitely the case in Manipur, for that matter in most of India where only around 17% of the approximately 5% GDP on health expenditure comes from taxpayers’ money. The rest is from out-of-pocket expenditure and the majority of health buyers in India and Manipur go directly to the doctor of their choice i.e., a primary care level interface. Even in the ‘˜supposedly’ tertiary health care centers, the health care seeker is the arbitrator of the specialty and doctor. The only functional referral system in place is for outside-state medical treatment and reimbursement (‘˜de facto’ tertiary care referral in Manipur).

Another inherent concept relevant in understanding tertiary care delivery is the ‘˜system’. This concept is particularly important if one deals with a ‘˜tertiary care hospital in the making’ from a previous secondary care hospital, and if there is a theoretical danger of upgrading only the manpower and gadgets without upgrading the system simultaneously.

Also a tertiary care centre means ‘˜something’ only when seen through the filter of a state health system infrastructure. Only when there are credible primary and secondary care centers in the State, will a tertiary care centre make any sense. The ultimate health policy of Manipur is driven by the National Health Policy 2002. Under the guidance of the same policy, to fulfill the requirement of evenly spread out tertiary care centers, NEIGRIMS has come up. Therefore none of the Institutes in Manipur figure in the scheme of things for direct central undertaking. Apart from these six AIIMS-like centers of excellence and NEIGRIMS for the North-East, the rest of Tertiary Care Hospitals in India are set up mostly by NRI-sponsored and Multinational Companies and obviously their focus is on Health Tourism, looking at a large profit-margin. If we want tertiary care facility here at Manipur, I am afraid we have to work for it ourselves.

Running a Superspeciality hospital is costly. It has been estimated that annual expenditure for running a single Superspeciality bed is around Rs 0.7 million to more than Rs 3 million in India. A poor and economically backward State like Manipur where the problem of insurgency drives away any potential health care provider MNC, upgrading the existing public infrastructure is the only viable option.

A particularly interesting and frustrating observation is that most of the trained super specialists are not even utilized after their training till the time they start to forget what their hard-earned degree taught them. The reasons need to be explored so that such scarce human resources for tertiary health care are utilized in time and properly and they should be given their proper dues on par with the rest of the country. This should help in encouraging future bright young doctors to opt for a career in Tertiary Health Care.

Part of the blame, I am afraid, must be shared by the unscrupulous public. The very concept of tertiary health care involves high-risk nature of the interventions. In simple terms, occasions would occur when a patient cannot be saved or may be left with some temporary or permanent disability in exchange for the natural outcome if untreated. There is a prevalent reluctance among the medical fraternity especially surgeons against ‘˜high-risk’ interventions. This may have been exacerbated by the frequent singling out of individual doctors instead of finding fault with the system.

Another unique situation of super specialists of Manipur is that they are expected to ‘˜serve’ as a primary care physician. And most of them remain practically ‘˜theoretical-super specialists’, who also act as the ‘˜health tourist guide’ of board-referred Manipuri health care seekers.

These are some of my personal observations. It is high time we stopped looking at central fund-driven programs alone and instead start asking for it also for a real and convinced need which includes a functioning Tertiary Health Care Centre in Manipur and stop draining the economy from unnecessary outside referrals. At least the poor and self-employed people who desperately need tertiary care management, may gain part of their ‘˜right to health’ rather than having an undignified last breath, unknown to the policy-makers of Manipur.

*The article is written by Dr Nongthangkheekpa.

(Courtesy: The Sangai Express)

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