Some Refl ections

Anand Zachariah

are difficult to sustain in times of economic distress.

In India, the situation is the reverse. Planning has focused on providing primary healthcare, immunisation, maternal and child healthcare and family planning at the expense of hospital-based care. The provision of government-funded, hospital-based care at the taluk, district

Tertiary care plays an important role in determining the structure of the healthcare system and universal access to it. Breaking away from western-oriented tertiary care medical knowledge, a number of issues have to be rethought to define tertiary care in the Indian setting that can be provided by the existing system. Providing tertiary care with district health services will mutually reinforce both and provide healthcare that is affordable and appropriate to local conditions.

I am grateful to R Srivatsan for his comments. The conceptual background on the need for reorientation of tertiary care and medical education originates from Towards a Critical Medical Practice, Reflections on the Dilemmas of Medical Culture, edited by Anand Zachariah, R Srivatsan and Susie Tharu, Orient BlackSwan, 2010. A presentation based on this paper was made at the Medico Friend Circle 39th Annual Meet on “Exploring Roadmap for Health Care for All/Universal Access to Healthcare in India” on 6-8 January 2012 at Wardha.

Anand Zachariah (Zachariah@cmcvellore.ac.in) is professor of medicine at Christian Medical College, Vellore. He was a member of the Planning Commission’s Working Group on Tertiary Care Institutions.

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Tertiary care developed in western healthcare systems after 1940 with large hospitals, technology-oriented investigations and expensive treatment. In the UK, it was the government’s intent to provide universal access to healthcare and the budgetary support for this through the Beveridge plan that made it possible. In western health systems, tertiary care developed for diseases common to those regions, using tests and treatments that were affordable to them. Even so, this has resulted in escalating health expenditures in developed countries, consuming up to 8% to 10% of their health budgets, making it almost unaffordable to many. Recent developments in the UK and the US show that there is a crunch in funding, implying that the mode of provisioning healthcare has r esulted in expenditures that

and medical college levels in the country has developed in a skeletal manner. With the liberalisation of the economy after the 1980s, there has been a proliferation of private tertiary care institutions, first in big cities and then in smaller towns. So private tertiary care has not only developed with the active support of the government (provision of land, tax concessions, and so on) but also because of the lack of government investment in hospital-based care. Private hospitals have transplanted the western mode of tertiary care to India, focusing on diseases, investigations and treatments that enhance profitability. This is one of the reasons for the catastrophic costs and debts that result when patients access hospital-based care in the private sector.

Any move to address the problem of universal access to healthcare has to confront the issue of providing tertiary care to all citizens. Is there another mode of imagining tertiary care for India? How will it pull away from the current system of market-oriented tertiary care? What would be its characteristics? How would it be provisioned within the existing health system? In this article, I attempt to answer the following questions:

Defining Tertiary Care

An important point to understand is that tertiary care medical knowledge undergirds the edifice of the western medical system. Today, all medical knowledge, evidence-based guidelines and primary

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and tertiary care management protocols are based on this format of tertiary care knowledge. This knowledge format has spread to all countries, including India, and examples of this are the scans, testing facilities, angiograms and endoscopies now used. This presents a difficulty for redefi ning tertiary care in the Indian setting.

To define tertiary care in India, we need to define the common public health conditions in the country that require outpatient care and hospital care, including emergency conditions. Emergency conditions (for example, head traumas, strokes, heart attacks, organophosphate poisoning and neonatal emergencies) and chronic conditions (for example, cancer treatment, palliative care and stroke rehabilitation) require provisioning of tertiary care at the district level or within the extent of a district. These services, particularly for emergency conditions, should be available to the public as close to their place of residence as possible.

Therefore, one, the definition of tertiary care should focus on public health conditions requiring this; and, two, on tests and treatments that are cost effective and can be provided to everyone at different levels of the health system (PHCs, CHCs and medical colleges). Such a redefinition requires data on the epidemiological prevalence of different diseases at the community level in different districts, states and regions, and current and future projections. It also needs cost-effectiveness data on different tests, treatments and technology interventions. Such data is not currently available. It is important that the government institute a technical group to define the parameters for tertiary care in India. The example of the National I nstitute for Health and Clinical Excellence (NICE)1 in the UK is one such approach to the problem.

In this article, I attempt to outline the scope of tertiary care in the Indian setting. Tertiary care services that should be provided at the medical college level in a district is given in Appendix I (pp 44-45). This is based on the common diseases that occur in districts and the requirements of tertiary care in them. The difference between these suggestions in the appendix and the current Medical Council of India (MCI) guidelines for medical colleges is that the latter are planned on the basis of educational requirements. The tertiary services shown in Appendix I should be available in medical colleges but are now available only in private hospitals. These services should no longer be available only in specialist centres or superspeciality hospitals, but be acces sible at the point of need in district medical colleges. So it is suggested that medical colleges be located at the district level and they be planned on the basis of the tertiary care requirements of each district.

In defining tertiary care, we need to consider not only prevalence and costeffectiveness, but also appropriateness. Some treatments may be appropriate in a western setting, but may be inappropriate for Indian patients. For example, coronary artery disease, a common public health condition, requires angio plasty, stent placement and coronary artery bypass graft (CABG) surgery according to standard treatment guidelines. However, these interventions may be inappropriate in the Indian setting because of cost and the lack of centres and trained cardiologists and cardiothoracic surgeons to perform these procedures. Since most of these treatments evolved in western settings, the research base to evolve evidence and management guidelines for the Indian setting does not exist. Therefore we need research into the management of conditions common to our setting. We need innovations that address the issues of cost and appropriateness. Examples such as the Jaipur foot, the Aravind eye care system, the Sri Chitra valve, acute respiratory infection (ARI) protocols for children and oral rehydration solutions/salts (ORS) for dehydration are treatments that turn conventional tertiary care wisdom on its head. They provide new management paradigms appropriate for our own setting. To define such a knowledge base, we need to reset research agendas and involve medical colleges, private practitioners and PHC doctors in research in the community. There is the need to reconceptualise “evidence” and “quality” in more real settings, taking into account not only short-term but also long-term effects in various aspects.

However, such a reorientation could face hurdles. For instance, with legislation on blood banks to ensure quality, many of them in rural hospitals have closed down because they cannot meet the standards regarding space or afford air-conditioned rooms and personnel. This has led to a lack of access to blood transfusion in rural areas for lifethreatening conditions. Similarly, standards for ultrasound machines require radiologists to operate them, making it difficult to carry out ultrasound scans in rural areas. The cheap mosquito mesh is a very effective implant material for h ernia repair compared to commercial mesh. But surgical departments in m edical colleges are reluctant to implement such a non-western solution. Redefi nition may also face pressures from professional bodies, regulatory agencies, corporate hospitals and pharmaceutical companies.

Providing Tertiary Care

Ideally, tertiary care should be well integrated within a functioning health system. Most conditions would be taken care of at the primary and secondary levels. Patients would be referred to tertiary care when required and referred back to the primary and secondary levels after completing their tertiary care treatment.

However, in India, tertiary care is not well integrated with the functioning health system. The health system functions up to the district hospital level (PHCs, CHCs, taluk hospitals and district hospitals). Set apart from this chain, medical colleges function as standalone entities under the department of medical education. Public-funded tertiary care varies in availability, depending on whether a medical college exists in a region. While government medical colleges are supposed to provide tertiary care, they may often not have the infrastructure, resources and staff to do so. This means that they effectively function at the secondary level. The following is necessary to ensure that tertiary care can be provided by the existing health system.

• Medical colleges should be responsible for healthcare provisioning in a given

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geographical area (one district or a set of districts), providing tertiary care services in liaison with district health services.

It is suggested that there be one medical college for every district or for every two to four districts, depending on population, geographic area and the existing availability of hospital-based services. The medical college should support s econdary and primary level services through referrals and training. The district health system will, in turn, offer the medical college an opportunity to expand its training base. Undergraduate and postgraduate students could be trained not only in the medical college, but also at the district hospital, taluk hospital and PHC. This arrangement would solve the problem of economic viability of tertiary care at the district town level. Normally the problem of providing such medical care in rural areas is that patient catchment is low. If the district tertiary care centre is also a training establishment, the patient base need not be economically rewarding in itself. This change would require that medical colleges be conceived as part of the referral system of government health services. The functioning of this referral system would require referral guidelines, training, referral linkages, the transfer of patient information and mechanisms for ensuring quality and accountability.

When medical colleges are responsible for a functioning health system, the priorities for medical education will need to change. Specialists now dominate the MCI board and postgraduate boards, which means there is undue e mphasis on specialist courses. Integration of medical colleges with the health s ystem will require a reorientation of medical training. It will have to change from a medical education system based on western requirements to one that will meet the human resource requirements of the health system. This may require an expansion of paramedical training (village health nurses, nurse practitioners, physician assistants, paramedics,

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and so on) and the setting up of family medicine departments in every medical college to train multi-competent general practitioners (GPs).

District Hospitals for Secondary Care

If good tertiary care is to be provided at the district level, district hospitals have to be strengthened to provide high-end secondary care while they are seamlessly linked to the medical college in the area. Many specialist conditions can be effectively managed at the district level, r educing the need for referrals. This r equires a good referral linkage with the medical college, which can support the district hospital in a referral continuum. Medical colleges could support districtlevel care through telephones and telemedicine, consultant visits and specialist clinics. They could also be involved in training district hospital staff in specialist care. Ambulance services and electronic transfer of patient information can bolster the referral linkage.

Tamil Nadu’s health system project has shown that obstetrics and neonatal care can be upgraded through a health systems approach, with improvements in infrastructure, staffing, training, guidelines and health system management. In many parts of the country, maternal and neonatal services have improved through similar approaches. With similar attention, improvements could occur in medical, surgical and emergency care, chronic disease care, cancer detection and prevention, rehabilitation, mental healthcare and palliative care. Appendix II (p 45) has details on how the secondary level at the district level can be strengthened in specifi c areas.

What are the difficulties of doing this in district hospitals? To begin with, it is difficult to get doctors to stay in the districts. Medical students usually come from cities and more elite backgrounds. There is a social expectation that a medical graduate will specialise, go abroad for further studies and do well fi nancially. Working in districts does not fulfi l these expectations. Doctors working in districts find it difficult to look after the schooling needs of their children and feel socially and academically isolated.

Therefore, strengthening the district health system also requires selecting students from the local area, orienting training to the needs of the district, supporting doctors working in the area on a long-term basis and providing them with suitable incentives.

Medical Colleges for Tertiary Care

In planning and regulatory terms, medical colleges are defi ned as educational institutions, not as service institutions. Hence the standards that defi ne them and their planning requirements are based on the needs of education (infrastructure, staffing and patient care f acilities). If medical colleges are to provide tertiary care services for a district, it is necessary to define their standards of care and services based on the requirements of each district.

There are several specialist services that medical colleges at the district level will have to provide but they may not be required for undergraduate medical education. For example, general medicine services should be upgraded in the areas of cardiology (echocardiogram, cardiac catheterisation and pacing), nephrology (haemodialysis and peritoneal dialysis), gastroenterology (upper and lower gastrointestinal endoscopy) and critical care (ventilators and monitoring equipment). General surgery services should be upgraded in urology, neurosurgery and oncological surgery. This may require specific skills training for general specialty faculty (endoscopy or echocardiography) and the employment of s uperspecialists in specific areas (for example, neurosurgery, cardiology or urology). Radiotherapy, palliative care and rehabilitation departments should be e stablished in each medical college. In some cases, a specialist service (for example, cardiology, neurosurgery or urology) could provide for the needs of two or three districts. Infrastructure development and technology upgradation for the provision of tertiary care services in each medical college is necessary to facilitate the development of specialist services. Appendix I provides details of the nature and requirements of such services in a medical college.

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In each of these areas, the medical college would provide tertiary care services for the district. The medical college would also support the services at the district and sub-district levels through telephone and telemedicine consultation and training for district-level staff, thereby strengthening the referral linkage. Hence the planning requirements of the medical college should keep in mind the health service requirements of the district. For providing universal access to healthcare, the government may have to contract such services from private sector hospitals if there is no medical college or if the medical college does not have the facilities to provide the services.

How would these services be different from tertiary care services that are currently provided in private hospitals? The structure of many of these services in private hospitals today is driven by the profit motive, which results in high costs. However, many of these services – for example, echocardiogram, dialysis or endoscopy – are today no longer so esoteric as to be not found in apex referral centres. Work in the non-governmental sector shows that when a suffi cient number of these services are effi ciently provided, economies of scale reduce cost. These examples show that it is p ossible to provide tertiary care in a cost e ffective and accessible manner. We hold that it is possible to reinvent tertiary care so that it can be provided in district medical colleges, using resources judiciously and effi ciently.

Implications of Universal Access for Medical Education

The concept of universal access to healthcare has many implications for medical education. It primarily raises the issue of the social accountability of medical education. If healthcare is a social good that should be provided to every citizen and medical colleges are involved in the task of making sure that this happens, questions need to be asked about the social accountability of medical education. How can medical colleges incorporate the principle of social accountability to ensure that universal a ccess to healthcare takes place?

(a) Each medical college should be responsible for the healthcare of a district or a set of districts and have formal linkages to the district hospital, taluk hospitals or community hospitals to support clinical service and training.

On the surface, these recommendations read very much like the Bhore Committee report and for that very reason seem utopian. However, unlike the Bhore report, the proposals here are about upgrading and reorienting what already exists. What would be the problems in trying to implement these administrative proposals?

There are many practical diffi culties. The government administration consists of a state health service (in charge of district hospitals, CHCs and taluk hospitals), the department of medical education (in charge of medical colleges) and the department of public health (in charge of PHCs), each with its own c entralised administration. The proposals envisage better linkages between these different departments, but bureaucratic difficulties between departments may make them difficult to implement.

The imperatives and diffi culties at each level are different. The focus of medical colleges is not on improving health services in the district but on training medical students and taking care of the patients who come to them. Government medical colleges are overloaded and underprovided (lack of equipment, drugs, staff and teachers) and hence work under trying conditions. State governments are unwilling to invest in the infrastructure required for good medical colleges. So medical colleges would hardly be keen to take on the responsibility of improving health services in the districts. Teachers are transferred from one college to another and often posted in departments different from

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their original specialty. Specialists are posted in towns where they cannot practise their specialty. Professors in state medical colleges are underpaid in comparison to the central University Grants Commission (UGC) pay scales. Therefore medical college teachers are for the most part interested in facilitating their private practice. Patients are often taken care of by postgraduates and medical offi cers and the commitment to good patient care is variable.

District hospitals and CHCs are even weaker in infrastructure, staffi ng and supplies. The issue of private practice applies to these levels as well. So even if we were to establish medical colleges in every district, would health services improve? District hospitals are now being converted into medical colleges, depriving districts of functioning district hospitals, which are often moved to more remote areas. Teachers commute from big cities every day to mark their attendance in rural medical colleges. Would private hospitals be keen to provide tertiary care services to people from the districts? They would be interested in doing this if they can earn profits rather than because they want to improve healthcare, as has happened with the Aarogyasri scheme. As the examples of Andhra Pradesh (Aarogyasri), Tamil Nadu (Kalaignar scheme) or Gujarat (Chiranjeevi scheme) have shown, public-private partnerships improve access to private services, but without necessarily strengthening public health services.

Planning Processes

There are several limitations in the planning process and its ability to tackle actual issues on the ground. These include the following:

Delink between Planning and Implementation: The Planning Commission makes plans and advises the government on allocation of funds to ensure implementation. However, the Planning Commission has no control over the implementation of different schemes. For example, the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) was started in 2006 to address imbalances in the availability of tertiary care. Under this

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scheme, funds were allotted to set up six institutions on the model of the All-India Institute of Medical Sciences (AIIMS). However, at the end of the Eleventh Five-Year Plan (2007-2012), all these institutions are yet to be functional, chiefl y because of delays in implementation. The evaluation of implementation is in terms of budgets spent and output (for example, x number of medical colleges upgraded). But there is little data on the outcomes in relation to quality of services or quality of medical education in these institutions.

Centre vs State: Medical colleges and the health infrastructure in districts are under the state government. Therefore improvements in infrastructure, staffi ng and linkages can only be brought about by the state government. The central government can allocate funds to the state governments to upgrade services, staffi ng and infrastructure but it has no control over implementation or the quality of services and medical education provided in state medical colleges.

Accountability: There are different levels of lack of accountability in the planning process. First, planning groups may have experts, but end users are not r epresented in them. Second, public a ccountability does not enter the process in which the Planning Commission makes plans and the government implements these plans. How does the public give its views on a new AIIMS, a new medical college or a new district hospital? What would be the processes to ensure accountability to the local people?

Focus on AIIMS-like Institutes: Central planning has little control over state healthcare institutions. Therefore the focus of central planning is on centrallyfunded institutions, or AIIMS-like institutions. The premise is that the presence of AIIMS-like institutions will improve the availability of tertiary care services in disadvantaged regions where they are located. Questions that are not answered include the following. What exactly is the role of AIIMS-like institutions? How will they improve healthcare provision in a region? How will their

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3 Respiratory Medicine

Every district medical college should have f acilities for pulmonary function tests and bronchoscopy.

4 Neurosurgery

Every district medical college should have facilities to manage head injury with trained neurosurgeon who can drain subdural haematoma with burr hole, perform shunt surgery for hydrocephalus and basic neurosurgical work.

for the whole country though the requirements of each state are different.

Conclusions

It has been argued in this paper that the problem with providing tertiary care is a systemic one related to the western-oriented structure of medical knowledge, the market-driven mode of private tertiary care that has evolved in India and the lack of development of public curative services. Despite the structural nature of the problem, it is possible to reenvisage and redistribute it so that small but concerted changes will result in improvements in healthcare provision.

Our suggestion is that we redefi ne what tertiary care is in relation to c ommon diseases and identify the costeffective and feasible treatments that can be provided to all citizens of the country. In other words, work out what an appropriate tertiary care strategy for India would be. The problem of cost does not necessarily have to do with the actual cost of technology or a drug but with the market cost that yields maximum profit. We argue that it is possible to provide tertiary care at an affordable cost, working with economies of scale and a common sense approach to treatments that can effectively be provided across the health system.

We suggest that tertiary care be provided in a non-market mode through medical colleges servicing a district population and supporting a district health system. Today, the district hospital is the apex referral hospital in the health system and medical colleges are primarily engaged in training, in isolation from the health system. Upgrading district

1 The National Institute for Health and Clinical Excellence (NICE) was set up in 1999 to reduce variation in the availability and quality of National Health Service (NHS) treatments and care. Its guidelines help resolve uncertainty about which medicines, treatments, procedures and devices represent the best quality care and which offer the best value for money in the NHS. Every NICE guideline and quality standard has been developed by an independent committee of experts, including clinicians, patients, carers and health economists.

Appendix I District Medical College – Development and Requirements for Speciality Care

The requirements for speciality care in a district medical college are based on an understanding of services that are needed to take care of a majority of tertiary care problems in a district. These are services that should be provided most physicians would agree, to all patients with a particular disease. These are different from the MCI guidelines for medical colleges, which are based on the requirements of undergraduate and postgraduate training. In this case, the suggested planning requirements of a medical college are based on the health services to be provided in a geographical area. Many of the suggested services (for example, cardiac care, dialysis facilities, neurosurgery, PMR and neonatal intensive care units (ICUs) may not be available in specialist centres in the government health system but are commonly available in private hospitals in small towns and cities. It is suggested that district medical colleges develop the capability to provide many of the much-needed specialist services that are currently provided by private hospitals.

1 Cardiology

Every district medical college should have facilities for treadmill test and echocardiology. It should be able to manage patients with myocardial infarction and other cardiac emergencies. It should have a cardiologist or an MD physician with training in cardiology. One medical college for every few districts should have f acilities for interventional procedures (such as stent placement and balloon valvotomy) and thoracic surgery with a trained cardiologist and thoracic surgeon.

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5 Urology

Every few districts should have a urologist who can perform surgery cystoscopic and open surgery for stone removal, transurethral resection of the prostate (TURP) and other basic urological procedures.

6 Radiotherapy

For every few districts, one medical college should have facilities for linear accelerator/ Cobalt unit for head and neck, breast and cervical cancers with MD in radiotherapy, surgeons who can perform cancer surgery, radiation physicists and nurse educators.

7 Palliative Care

Each district medical college should have doctors, social workers, nurses and auxiliary nurse midwives with experience in palliative care who can administer morphine. Each medical college should have stock of oral morphine.

8 Physical Medicine and Rehabilitation

Each district medical college should have an MD in physical medicine and rehabilitation with physiotherapist, occupational therapist, speech therapist and social workers who are equipped to manage spinal cord and head injury, strokes and other locomotor disorders.

9 Critical Care or ICU

Each district medical college should have a wellequipped ICU with a trained MD physician or anaesthetist with infusion pumps, ventilators, invasive monitoring and ICU technicians/respiratory therapists.

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