Helicopter Dropping of 50 Free Allopathic Medicines; Prescribed by Homoeopathic Doctors at Ground: Sorry this is not Universal Health Coverage

Abstract

The provision of Universal Health Coverage (UHC) is being discussed in India. Crippled by the charges of corruption and unethical practice by media and public at large, medical professionals are largely unaware, disinterested, isolated and edged out from this debate. The traditional general practitioner is a dying breed and deficiency of doctors willing to work in community settings is rampant. Is UHC model proposed in present form good for an ordinary Indian citizen? This editorial looks into the underlying politics of health care in India in the past and how this ongoing debate could impact the future of primary care and health care of people in India.

Universal Health Coverage — The background

After the second world war, rapid economic development and growth in social index among several of the European countries led to a wonderful achievement — universal health coverage (UHC). The National Health Service (NHS) in the United Kingdom is one example. Heath was therefore recognized as one of the fundamental rights of the citizen. Though good health care has never been a priority political demand by the citizen in the Indian democratic system; a discussion about UHC has begun due to push from the international agencies such as the World Health Organization (WHO). There is also some interest from the academicians and civil society. As the discussion and debate are progressing, several contradictory arguments are emerging.[1]

Universal Health Coverage — International Developments and Indian Perspective

Among the hallmarks of UHC in the developed countries are quality, standards, clinical gate keeping, referral system, sound financial backing, defined population, and outcome audits. These concepts are missing within the discussion taking place in India. With a significant volume of resources and funds at stake, it is doubtful whether the UHC framework being proposed in India is positioned to uplift the health status of the people or whether it is just a realignment of the processes aimed to maintain status quo. Is it simply about funds being spent or is it objective and outcome — based, bringing bringing benefit to the population?

Corruption and unethical practices by medical professionals are under the scrutiny by the media and common people alike. However, corruption has not only inflected the practice of medicine but it also has a systemic origin and dimensions. MCI places ethical and compulsory restrictions on doctors, there appear to be no similar restrictions on the pharmaceutical industry on their ability to bribe. Interestingly, the pharmaceutical industry comes under the Ministry of Chemicals and Fertilizers and not under Ministry of Health and Family Welfare. Corruption is also rampant in the public health delivery system; scams emerging in few of the states under the National Rural Health Mission scheme are classic example. Individual primary care providers — general practitioners (GPs), medical officers, family doctors or primary care providers, who also form the majority of medical doctors in India, are just pawns. They should rather be considered victims of the existing designs in our society.[2,3]

Systemic Restriction on Development of Good Primary Health Care System

Various factors have prevented or delayed standardization of practice of medicine in primary care and community setting; leading to noncoverage of outpatient consultations under all insurance schemes — public or private. Various forces such as the pharmaceutical industry, tertiary health care industry, specialist doctors, hospital owners, the private medical education industry have partnered to prevent good primary health care system for Indian population. The insurance schemes provided for the poor are being bled to perform hysterectomies on young women or hailed to be able to cover heart surgeries on children. The whole idea is to develop and maintain a system where people are forced to visit hospitals by creating and maintaining a high level of morbidity in the community with no respite available. The premise seems to be that whether rich or poor, for any small or trivial problem,people should visit a tertiary care centre or hospital.

The Traditional General Practitioner or Family Doctor is a Dying Breed

The old tradition of GP and family doctor has been given a slow poison to die its own death. Senior GPs; retiring in their 60s, 70s and 80s, from cities such as Mumbai, Pune, Surat, Delhi, Kolkata, Chennai, report that not a single young doctor has started GP practice in their locality during last 20 years. This is not a default situation, this appears to be by design, whereby GPs seem unable to survive! There is a gradual decline in the respect and trust towards medical practitioners - which is of course an objective of the power players. As an outcome, for ordinary physicians, the position and power to negotiate on the behalf of patients or populations has significantly decreased.

During previous two decades, several vague ideas and concepts have been fed into the mind of a common man. The mainstream media has published tall claims of rising India with reports on medical tourism, telemedicine, high end technology, robotic surgery; sophistic surgeries, angioplasty or joint replacement in a 100-year-old man; this is frequently public relations exercise of tertiary care business. When did you last read in a newspaper about work of a good family doctor? When did you last see news report on an honest medical officer doing his or her job a deep rural pocket of India.

All against Vocational Training and Academic Discipline of Primary Care Physicians

Practice guidelines, training, education, research, clinical gate keeping, clinical audit, enhancement of skill levels, and referral systems are among the essential components of any good community based health care system. These entities are also identified with vocational training and academic discipline of the multi-skilled competent primary care physicians — internationally known as family medicine. Ever wondered why there is so much resistance against family medicine — the vocational training and academic discipline for multi-skilled primary care physicians? Why it took so long for family medicine to appear on the national scene or perhaps why you still don't hear much about family medicine. In spite of being a recognized discipline and recommended by the existing national health policy and several other policy documents of the government of India, MCI never put it to practice. The reason is obvious. Since family medicine is not only training or qualification it is also a system of health care delivery which potentially threatens the existing business model of unregulated unrestricted profit-making health care industry.

50,000 Medical Graduates Per Year and Counting: Do They Have a Role in Universal Health Coverage?

India produces close to 50,000 medical graduates per year, but the majority of them are rendered dysfunctional by the system through a noxious design and not allowed to get actively engaged with the health care delivery system. The large majority should be working in communities. Most of them are available as cheap labor for hospital support work. The employment terms and conditions as well as compensation packages offered by public health agencies only reinforces the fact that there is no real intent to engage medical doctors into public health delivery system. Ironically, we keep discussing the shortage of doctors!

Regulatory Restriction for Young Physicians towards Opting Primary Care Vocation

The MCI has been deliberately not allowing and facilitating community-based residency programs in family medicine. It is possible to create 10,000 post graduate training positions every year in family medicine in India without any additional investment of resources. This could be a key strategy for bringing health workforce to community and rural settings thereby improving the health of marginalized and socially disadvantaged individuals. But MCI has legally not allowed community based professionals to become faculty. Community based health facilities (district hospitals, community health center, primary health centre) have been rendered unfit to be designated as training locations through MCI regulations. Large number of post graduate positions is against the interest of private medical education industry. Unfortunately, all these gimmicks are being promoted in the name of maintaining high standards. The MCI thrives on a theory of deficiency and maintains a control system through monopolistic and inhibitory regulations. We talk about compulsory rural posting for young doctors. But that is just a political discussion in order to keep showing young doctors or doctors in general in bad light -- such as doctors being unwilling to serve in rural areas -- in order to push for other agendas. So there is talk about developing legal framework to allow “homeopathic physicians” to prescribe “allopathic medicine.” Inclusion of “allopathic medicine” in the prescription list of “ayurvedic physicians” is, a political masterstroke as it is looked at as a way to popularize AYURVEDA — the traditional Indian system of medicine. All positions do look interconnected.[4]

All Partners

Public health masters and planners are no better. It seems that the wonderful opportunity to provide high quality UHC to all Indians will be missed or remain a mirage. We do have the resources and capacity to achieve a lot in our system of healthcare. But in all likelihood Indian UHC will include helicopter dropping of fifty essential allopathic medicines free of cost and to be prescribed by homeopathic doctors on ground, due to non-availability of allopathic doctors in India. Ironically, we are producing 50,000 doctors each year and still counting[5,6]. Indian Medical Association (IMA) should have shown the way out and given an equitable, effective, and quality solution to the country. Unfortunately, IMA has become a crumbling ruins of the dreams of Dr. BC Roy and has only contributed towards the existing crisis of not only the medical profession but also the society at large. Most medical professionals are suffering and Medical students are no different in their plight. Apparent and visible leaders of our profession have failed to lead us. At most they are the representatives of the industry or the specialists' associations.

An Appeal to Medical Professionals: Support a High Quality High Standard Universal Health Coverage

As professionals, we all know what is wrong. We, the medical practitioners have been declared corrupt by media and society. We are being condemned for the sin which we may not have committed; and also not ready to commit yet. It is up to us whether we want to accept this blame and live with the stigma or, are we going to do something about it? Let us join hands together to bring a change in our systems - the medical education system and the health care delivery system. Let us not work for ourselves but work for the people of India. Let us make health system better for our people, our communities our country to which each of us belongs to. Let's become a voice of the disenfranchised ordinary people who have unfortunately not learnt to have a political demand for good health as their fundamental right. Let's come out of our shell and be an advocate and champion for a healthy nation. As true professionals, we must stand up to our call. UHC is the opportunity to hit hard! Take your chance! A good UHC system will change India; change the lives of our future generations.