Dr Sanjay Kumar Bhasin
World over healthcare delivery system is divided into Primary, Secondary & Tertiary level care to ally health related human sufferings. As such healthcare system has two components: treatment of the patients and medical education to the students. The healthcare is extended to the ailing population through Sub-centre, Primary Health Centre, Sub-District Hospital, District Hospitals. Part of Secondary healthcare and all of tertiary healthcare and Medical Education/ training (MBBS, MD/ MS, DM/MCh) is provided at Medical Colleges, PGI’s and AIIMS, treatment part being secondary to teaching part. Unfortunately for a welfare country like India having majority population belonging to low socio-economic strata, there is fast emergence of Corporate Health Sector and simultaneously last one decade has seen fast deterioration in health sector as well as medical education. In order to strengthen both these Government run welfare sectors, the previous UPA Government with Ghulam Nabi Azad as Health & Family Welfare Minister sanctioned 58 Rural Medical Colleges, being from J&K he sanctioned 05 Medical Colleges for the state. The intent was to give boost to rural health services and to produce doctors suitable for providing services in rural India. With the final consent of GOI to Medical College at Rajouri, Anantnag & Baramulla, the process set in motion by Ghulam Nabi Azad seems to be assuming practical shape with inauguration stone put by Union Health Minister and the Chief Minister of J&K on Sunday last. It reminds me of the inauguration stone put in place by the then Union Health Minister in 2004 with a hype of GMC, Jammu being upgraded to the level of AIIMS. The columnist put forth his apprehensions by way of an article, “GMC to AIIMS-Is It Possible”. The apprehension turned out to be a reality, when a so called AIIMS turned out to be mere up gradation of few sub specialties. The hospital came to be erected in Reshamghar locality with 06 sub-specialties (Cardiology, CTVS, Urology, Nephrology, Neurology & Neurosurgery) shifted to the building after prolonged hic coughs, with quite a large number of staff from GMC but without proper medical equipment. All these specialties are having inadequate number of trained doctors especially at senior positions, paramedics and proper gadgets. If there is all politics in the announcement & inauguration of these medical institutions, then the motto of this article ends, but if really there is a politico-bureaucratic Will, certain inputs can definitely help in proper planning and operationalisation of these institutions that can take care of health & medical education in rural settings. It has been seen that so many medical colleges as well as few AIIMS erected in different states of the country are not running the way they should run. So let us discuss some vital areas to be considered in policy formulations to run these institutions smoothly for overall benefit of patients and medical education.
1. Medical Education Vis a Vis Health Care: The primary goal of all medical colleges is to impart highest quality of education to undergraduate & postgraduate medical students viz MBBS, MD/MS, MCh/DM etc. The process involves extensive research and practical training. The patients in these institutes are needed for tertiary care and for research purposes. Over a period of time, all state as well as Central Government has not realized it in a proper way and teaching medical institutions are flooded with patients for even primary & basic secondary level of health care that can easily be provided in a good Sub-district & District hospital. Both politicians and Bureaucrats try to thrust treatment part on the hospital administration and the teaching faculty. This has led to compromise with the research & teaching activities. There is no second thought that medical education in India is on downhill course. Sooner the policy makers realize and decide that research and teaching should be the focus in medical institutions and not primarily the patient care better it is for all. Added to it is the fact that Government must focus on strengthening sub-district & district hospitals. Referral to medical colleges for minor & moderate ailments needs to be stopped.
2. Qualified Faculty & Emoluments: Engagement of best teaching faculty for medical colleges and even AIIMS/PGIMER has become a great challenge especially after the boon in Corporate Health sector in India. The situation of faculty in 06 already sanctioned and operational AIIMS like institutions at Patna, Bhopal, Raipur, Bubneshwar and others is not good. In Raipur only 64 faculty members are working against sanctioned strength of 305, similarly against 1800 nurses required to run the institution, only 200 are working. In Bubneshwar only 68 faculty is there and super specialty facilities are all together lacking there. In spite of the fact that pay/perks are being offered to the medical/paramedical manpower on the pattern of AIIMS/Delhi, still the situation there is grim. Similar is the situation in both government & private medical colleges across the country. At contemporary posts there is huge gape of pay/perks between corporate hospitals and government run institutions. Buildings alone and good equipments cannot make an institute. Every time a medical college or AIIMS like Institution is build, the thrust of policy makers is on erecting buildings and purchasing equipments. Due to this wrong policy these medical institutions have not yet been operationalised in a desired manner. So the basic problem of highly qualified Human resources especially teaching faculty & paramedics need to be sorted out even before making buildings and purchasing equipments.
3. Input-Output Balances/ Employment generation: In J&K, every year 500 MBBS graduates come out from medical colleges, SKIMS & colleges from outside the state. Similarly 250 or so MD/MS/Diploma holders come out of these institutions. In last few years, in view of no defined policy of their getting adequate employments in the state, they either prefer corporate sector outside the state with lucrative pay/perks or leave the country. On starting of 05 more medical colleges, 500 more MBBS graduates shall be available to the state. There was a mandatory provision of getting an affidavit from the students of MBBS/MD/MS to serve in far flung areas for few years after completion of their degrees on government expenses. In view of lack of politico-bureaucratic Will, that policy still needs to see light of the day. Employment policy for this increased strength of graduate & postgraduate doctors with proper pay/perk needs to be redefined well in advance to fulfill the essence of building these medical institutions.
4. Medical Equipments: purchase of new and good quality medical equipment to cope up with the growing trends in medical science has always remained a great problem for already established GMC’s. Even repair of the equipments needing very small amounts is a great problem in government run institutions. This not only hampers patient care but also a big block in research and academic activities. Long and tedious purchase processes needs to be simplified and given in the honest hands to tackle this very important aspect of healthcare delivery system. This ordinarily shall not happen during establishment of new medical colleges as thrust of the policy makers always remains in erecting buildings and purchasing equipments/machineries even much before start of specialties. In the even these costly equipments/machines gather dust/rust. By the time they are put in use new variants reaches market & corporate hospitals. Hence the purchase of machinery & equipments should be in the last leg of establishment of these GMC’s.
5. Autonomy to the Medical Institutions: For smooth running of medical institutions, they should be given greater autonomy in the sense that there should not be unnecessary Political & Bureaucratic interference and influences. A high powered College council or Institution council needs to be established with medical persons of highest integrity and qualities as members of the council including Dean/Principals of all medical institutions and all HOD’s. The annual budgets should be kept at the disposal of the council with a well placed accounts and planning department whose head should preferably be an HOD of major specialty. Head of medical institution should preferably be from major specialties and the process of selection should be streamlined and unbiased.
In nutshell, although the decision to establish 05 medical colleges & 02 AIIMS in J&K is a well come step, yet highest level of political will to establish them as institutions of repute and giving greater autonomy to them is a big question of debate. A medical university, qualified & dedicated manpower, quality equipment, accountability & answerability to the patient & the system, best academic feast and very good pay/perk and no private practice shall be the hall mark of these institutions. If Government wants to make proper policy and operationalisation of these institutions at the earliest, a high power committee of experts need to be made and a time bound task should be handed over to them with a pre-condition that derelictions from the real issues can even punish those who are entrusted with the responsibility of establishing these institutions. This can definitely produce good results in producing quality doctors and imparting secondary and tertiary level care to the ailing population of the state. In the way we may save this noble profession from further deteriorations.
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