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India – A healthcare system in the emergency

Puducherry is a popular medical hub for patients in Tamil Nadu and elsewhere in the south, but a problem-ridden system appears to be tottering under pressure

The patient was dead. Govind (name changed), the doctor in charge, had been monitoring the patient for hours and was weary. He had prescribed a paracetamol injection and an antihistamine — both common drugs — hours ago. Neither was available at the hospital pharmacy. The patient soon developed dengue shock and died. Before he knew it, Govind was surrounded by around 20 women who spat on his face. “What kind of doctor are you?,” they asked.

Soon after the attack, Govind was suspended from the Indira Gandhi Government Medical College and Research Institute (IGMC&RI) in Puducherry. Scarred by the incident, he decided to take a break from practice. His wedding was called off and he even contemplated suicide. “The whole episode was preventable,” says a colleague. If the hospital had stocked simple drugs such as paracetamol, and had provided the doctor protection from angry relatives, none of this would have happened, he explains.

Assaults on doctors, and poor infrastructure in hospitals have become serious concerns in a Union Territory (UT) with nine medical colleges and around 150 clinical establishments. The sheer number of hospitals has prompted patients from other States to come to the UT for treatment. Almost half the patients seeking medical care at Puducherry are from other States — mostly Tamil Nadu. In 2015-16, 12,32,307 patients (around 48 per cent of the total patients) who received in-patient treatment, were from outside the UT. However, incidents, such as the death of three patients on the dialysis machine after a power outage at the IGMC&RI earlier this year, have raised questions on the quality of medical care on offer. While the deaths created a furore in the national media, local politicians and activists largely remained quiet. The only protests were by the All India NR Congress (AINRC). “We were not sure how the three people died, so we stopped the protests within an hour,” says AINRC chief N Rangasamy. In the meanwhile, the government appointed a team led by Srijith Parameswaran, nephrologist at the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), to submit a report on the incident. V Govindaraj, medical superintendent at IGMC&RI, says dialysis at the hospital has been stopped until further instructions from the government.

While authorities insist dialysis machines have adequate power backup, and can operate without electricity for at least 20 minutes with backup generators programmed to restore supply in under a minute, sources in the hospital refute these claims. In 2015, sources say, the hospital staff had written to the health department requesting a generator and power backup for the hospital, and so far nothing has been done to install proper backup. Also, there is no full-time nephrologist at the medical college since the department is shared with the main hospital. “Nurses are deputed to manage the machines, because of shortage of technicians. These nurses are not trained to handle emergencies,” alleges a source.

Inadequate manpower and infrastructure are an issue across public sector hospitals in the UT. There are three main hospitals in Puducherry: Indira Gandhi Government General Hospital and PG Centre (IGGGH); Rajiv Gandhi Women and Child Hospital (RGWCH); and IGMC&RI. The government hospital is the oldest among the three and is housed in a century-old building in the heart of the town. The fairly-new RGWCH, is well-equipped, but understaffed, and is located around two km from IGGGH; and so is the medical college.

The three hospitals face different kinds of problems. While IGGGH is housed in an old building and has old equipment, it has trained technicians. IGMC&RI, on the other hand, has the latest equipment but lacks qualified technicians and staff.

The medical college has had troubles since its inception in 2010. The Medical Council of India (MCI) has repeatedly pointed out its infrastructural limitations and poor staff strength. In 2014, the MCI refused the college permission to admit final-year students, pointing out its 36 per cent shortage in faculty strength and 65 per cent shortage of residents. The college has since received approval, but the staff and patients alike point to other problems. “For almost a month, I have gone every day to get a CT scan, and I am always told that the machine is not working,” alleges Sundaravel, a patient. Govindaraj, however, says the machines are brand new, but need routine maintenance.

On the other hand, at the government hospital, most machines run overtime. Technicians are forced to carry out minor repairs periodically to ensure the equipment do not break down, because the maintenance contracts are behind on payments, explains a CT scan technician.

According to V Perumal of the CPI(M), the IGGGH faces a serious shortage of beds. “Patients in the wards are forced to share beds or even lie on the ground because many of the beds have been shifted to IGMC&RI. There was a point where the IGGGH did not even have an operational ventilator, because of poor maintenance,” he says. There is no monitoring mechanism for healthcare in the UT, he adds. “Healthcare is ignored in the budget. In the previous budget, there was no allotment for infrastructure or any kind of development in healthcare. The only allocation was from the chief minister’s fund to help continue the existing schemes,” he says.

With a lack of funding, government hospitals continue to be poorly staffed. At the RGWCH, two staff nurses take care of three wings (over 500 beds) of the hospital during the day. Even the Neonatal Intensive Care Unit has only one nurse to take care of 10 beds, whereas government norms stipulate one nurse per bed. “The number of beds has increased in the government hospitals over the years, but the number of nurses and technicians has not changed in 13 years,” says CH Balamohan, president, Confederation of Pondicherry State Government Employees Association. The Government of India norms stipulate one nurse for every six patients, and every hospital with over 500 beds should have one chief nurse and one nursing superintendent. Neither the IGGGH nor the RGWCH has these posts, he adds.

Government doctors are known to ask patients to come to their private clinics for better treatment. “Even the director of health and family welfare has his own private practice. This shows how focused they are on treating patients at the government hospital,” alleges Log Iyappan, a human rights activist.

Doctors justify their need for private practice as their salaries often do not even cover basic expenses. “On an average, a doctor with five to 10 years of service makes around ₹40,000 a month, so we are forced to supplement our income,” says a general physician from the health department. An additional stipend from the government has failed to deter the doctors from entering private practice.

This problem extends to private hospitals as well, although they fare marginally better. According to a doctor who works at a private medical college on Cuddalore Road, it is common for hospitals to pay doctors working elsewhere so that they can make up the numbers before an MCI inspection. “Hospitals have approached me to come in for a few days to make up the numbers and offered me up to ₹1 lakh a day for it,” he says.

A few private hospitals are also guilty of flouting norms. “Establishments that have permission only to operate as a diagnostic centre admit patients for treatment. This is especially true of maternity care,” Iyappan says. These lapses have become rarer in recent years thanks to stringent inspections and licensing, counters a senior official from the department of health.

Another growing concern is the assault on medical staff. Unlike Tamil Nadu, where an ordinance protects doctors against attacks, Puducherry has no such law. A nurse at the IGGGH says she has been threatened and even slapped by relatives of patients while on duty. “Nurses, ward attenders, and security staff face threats of violence especially when they are on night duty. Inebriated patients are escorted by equally inebriated friends and relatives, and controlling them is difficult,” says a nurse at the hospital. Despite a police outpost at the IGGGH, and the presence of security personnel, incidents of violence occur almost on a daily basis.

For several years, the medical fraternity has been demanding protective legislation. “Currently, it is very easy for someone to walk in, assault a doctor and walk out. Assault cases are hardly registered. This makes it difficult to practice medicine,” says R Duraisamy, member of the Pondicherry Doctors Association. The association’s Facebook page records numerous instances of violence against doctors and other medical staff. “Unless the Central government introduces an Act, it is difficult for it to be implemented in the UT,” he says.

K Lakshminarayanan, parliamentary secretary to the chief minister, says the present government is seeking powers from the Centre to pass bills without the permission from the home ministry. “Once that happens, we will make sure there is proper legal protection for doctors,” he says.

Waste management and contamination of water sources by medical waste are also serious problems in the UT. Recently the Puducherry Pollution Control Committee (PPCC) issued a warning to IGGGH for releasing untreated sewage into a canal. “This untreated waste contains hospital waste as well as sewage. On an average, IGGGH releases around three lakh litres of untreated sewage waste every day,” says a PPCC official. Several private hospitals have no treatment plant for their sewage, he adds.

Despite the drawbacks, patients continue to flock to Puducherry for treatment, preferring it over other hubs such as Chennai. While many outstation patients choose JIPMER, other hospitals too receive a fair share of patients from outside the UT. “For patients from southern Tamil Nadu, Puducherry is closer than Chennai, and treatment cheaper,” says G Sathyavathy from Villupuram, whose husband is undergoing treatment for chronic kidney disease at a private hospital. According to Govindaraj, patients will continue to prefer government hospitals in Puducherry because they are cheaper than most other hospitals in Tamil Nadu.http://m.thehindubusinessline.com/blink/know/puducherry-a-healthcare-system-in-the-emergency/article9693404.ece

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Comment (1)

  1. K SHESHU BABU

    The health care system in India is pathetic. The incidents in Pondicherry reflect shortage of doctors as well as training facilities to the doctors on patient awareness of health condition

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