That the health services in JK state are in far from desirable state is known to all and sundry. It is not that no attention has been paid to it; in fact much has been done to improve health services for over six decades. In addition to building health care institutions right up from rural health dispensaries to tertiary care centers, due attention has been paid to develop human resources to man these health services. Human resources development was initiated in 1959 with the opening of Government Medical College Srinagar (GMC) in Srinagar at the site of present Lad Ded hospital for women, which is now an associated hospital of GMC. Subsequently GMC Jammu was commissioned and later Sher Kashmir Institute of Medical Sciences (SKIMS) was developed as a public/private joint enterprise with a governing body. Jhelum Valley College (JVC) in Srinagar started as a private initiative, subsequently it got linked to SKIMS for training Medical graduates, while as SKIMS became a Post graduate institute.
The core activity for developing human resources kept pace with the times, however the effort to retain the products of these institutions in the state was lacking. While as he urban centers of the state, Srinagar and Jammu mainly had a surfeit of doctors, the same is not true of rural areas. Majority of doctors avoid rural postings due to poor facilities. All efforts to appeal to their moral sense, compulsory service initiatives have been tried without producing the desired results. This has resulted in uneven utilization of available human resources, due to variety of reasons, all of which may not be ascribed as failure of official initiative, though the government needs to do more than it has done so far to improve living conditions for doctors, including suitable residential premesis.
The latest news reports on the state of health of our health institutions make a dismal reading. There is only one doctor for at least 2142 patients and a single bed to accommodate more than 1063 patients. Here again the infrastructure requirements in the state health department have not been able to keep pace with the population growth, which denotes failure of planning. The demographic data forms an essential element of planning any sector of economy, more so the core sectors of health and education, which affect all & sundry. As per the statistics of the health department, the average population covered per health institution (including both private and government) across the state is 3678, while bed strength per lakh population was calculated at 94. Similarly, population per doctor has been worked out at 2141 persons. As per the economic survey by the Directorate of Economics and Statistic, the number of doctors in 1950-51 was 184, which increased up to 2129 in 1980-81 and 5847 in 2008-09. While in 1980-81, around 37 doctors were available per lakh population, in 2008-09 the number reached to 47 medicos per lakh population. Though the figures quoted are a year or two old, not much has changed. This clearly indicates that all parameters required for meaningful planning have not been taken into consideration, mainly the demographic factor. Brain drain could be constituted as a cause, but it does not provide a total perspective of the problem. 47 medicos per lakh population in 2008-09 compared to 37 doctors were available per lakh population in 1980-81 makes a poor reading.
A study of health card of state hospitals makes a very poor reading, especially of hospitals associated with Government Medical College (GMC) Srinagar and Jammu. These associated hospitals play a pivotal role in the health related activity of the state. It has often been seen that cases, which pose problems of diagnosis and are liable to develop complications get referred to these hospitals, even though it is often possible to provide care in district or even sub-district hospitals, for variety of reasons. The doctors in district centers do not want to take the flak, in case complications develop, although their line of treatment might be the same as in associated hospitals. The doctors might not be liable to blame wholly, as generally the people because of poor education in health related matters do not accept the complications associated with health care. In case these complications do develop, the first question that gets asked is ‘why was the patient not referred’? It has been seen that in the ensuing argument, the doctors get physically assaulted, before better senses prevail. Contrary to the routine here, in advanced states, the aggrieved party tends to seek legal remedy. The case gets referred to the medical board, which fixes the blame, in case medical negligence is proved or as happens in most of the cases, no basis is found for the complaint. This is a civilized way of treating matters, rather than the stormy encounters with those, who provide health care.
The stress that associated hospital and apical care centers, called the tertiary care centers like SKIMS are subjected to is hardly appreciated and no visible effort is made to meet health objectives, at various levels of care. The health planners have set parameters for ‘Primary Health centers’ [PHC] ‘Districts & Sub-district centers’ and then higher and tertiary care centers, though there may be no strict compartmentalization of cases or which case should get treated where. However, PHC’s and ‘Districts & Sub-district centers’ taking the desired work load, without seeking the easier option of referring cases at random, needs to be ensured. Many cases report to higher centers of health care, without a referral and there is no mechanism to stop the inflow of such cases. The mechanism of ensuring the stoppage of such an inflow and also restriction of needless referrals could be worked out in seminars, by engaging the best minds in the field of medicine, persons who have wealth of experience of health care in J&K state in the state and the health planners. The society at large needs to be involved, the civil society grouping, in order to educate the population groups on different levels of treatment. Information can disseminated by establish health channels in on DD hook-ups. In England, where ‘National Health Scheme’ is in operation, it is impossible to seek specialist care in sate sector, without a referral from the ‘General Practitioner’ [GP] though a person may chose the option of private health care, which is highly expensive. The option is limited to families that fall in the higher income groups.
Having taken stock of the stresses that associated hospitals are subjected to, it is indeed a matter of regret that over a long period of time associated hospitals attached to GMC Srinagar had teachers of GMC take-up the task of administering these hospitals. GMC is already short of teachers and subjecting the teachers to additional strains is hardly a sane option. Besides GMC teachers have hardly ever administered hospitals, hence they lack experience. Their experience is subject specific, concerns the subjects, they teach. To say that administrators are not available would be denying a fact. There is a whole lot of senior doctors waiting for promotion, however the exercise needs input from higher echelons of health services and might involve a joint exercise of ‘Ministry of Medical Education’ and ‘Ministry of Health’. That exercise unfortunately is not being undertaken, leading to difficulties in ensuring proper administration of the associated hospital and also to spare the medical academicians for the activity, they are supposed to indulge in! That is to provide our future doctors with the best of the training; they may be capable of providing! With their teachers having the additional job of administering hospitals, it may not be possible to spare time and effort to train students.
Lack of proper attention to private sector growth can be gauged from the fact that 91% of state’s population compared to 47% at national level depends on public sector health care, which makes a strong case for private sector encouragement in the health sector, on the same level as witnessed in the educational sector. And this needs to be taken as a priority. There are several reasons why private sector growth is lacking. There are severe restrictions placed on constructing hospitals in residential areas. However, while the master plan implies that private hospitals may not come in residential areas, it allows polyclinics, and even health care centers that do not treat cases with in factious diseases. Hence contradictions abound. There is no meaningful effort to re-visit the master plan and get over these contradictions. It is precisely in residential areas that health care facilities are needed. Of course ailments like tuberculosis, leprosy need isolated centers. It is indeed a mockery that while scores of public health care facilities are located in thickly populated areas, private sector is denied access. SMHS in Srinagar, SMGS in Jammu, and SKIMS in Srinagar are located in thickly populated areas. Even Chest diseases hospital treating cases of tuberculosis is located in a thickly populated area in Srinagar. This makes master plan restriction, an argument unsustainable.
The government harps day in and day out on the need to develop private health care centers. There is no lack of investors. Expatriates…NRI’s have come with money and viable projects, only to find that there are no takers. The government needs to take a hard look at the problems involved, the contradictions in master plan and provide room for those willing to invest. Only harping endlessly that state needs private investment in health sector is not enough, without clearing roadblocks in private health sector growth.
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