Debate Room: Does Kashmir’s healthcare needs a prescription for change?

Kashmir’s medical fraternity is filled with doctors and paramedics who stood with the people at the time of crises. Be it during the turbulent ‘90s, or amidst public uprisings of 2008, 2010, and 2016, when bullets and pellets were copiously used against a defiant population, the medicos showed great spine and character in trying conditions.  It’s also a fact, however, that a good number of doctors here are operating like ‘baniyas.’ Fleecing gullible and distressed patients, for them, is part of the profession. Probity is the last thing on their minds.

The government, for its part, will be happy to see the blame game going back-and-forth between the media and doctors as long as it is not held responsible for the prevailing mess in the healthcare sector. In 2009, for example, a local magazine, Conveyor, reported how a number of quacks, including a so-called skin specialist, were doing their dirty work right under the nose of authorities. Eight years, and two Chief Ministers later, the quackery not only continues, it’s thriving. [The ‘skin specialist’ who started with a small clinic has, meanwhile, graduated to a mega clinic in front of a government hospital here — a classic example of Kashmiri proverb ‘daidi tal charas.’] Can someone inform a particular TV channel?

The recent uproar on the private practice of three top doctors from SKIMS Srinagar, and their consequent suspension, was bizarre. First, it is an open secret that many SKIMS doctors practise in their private dens. Second, the suspension came in the wake of a rabble-rouser Indian TV channel’s so-called exposé, without verifying the facts. Is everything said on that anti-Kashmir channel the Gospel Truth for the Mehbooba Mufti government? Indeed, it appears that the government is worried only about its image in Delhi, belying a colonial mindset.

The government, as an expert participating in this debate argues, must not interfere with the private lives of doctors as long as they do their public service diligently. It’s also argued that the authorities need to revisit the ban on private practice of senior doctors. It’s, indeed, beyond the capacity of any law-enforcing agency to stop doctors from private practice. Suppose a senior doctor from SKIMS offers free medical check-up to patients at his residence. Does anyone have the right to stop him or her from that? Who will check whether the doctor is sincere in the “free check-up” claim? How can one stop a patient from giving the same doctor a gift if he’s cured at his hands? It is not a question of law. It’s a question of ethics, and ethics are abstract with no binding nature.

Therefore, the prescription for change, experts say, is simple: the government needs to allow doctors to function without persistent interference. The doctors, for their part, need to improve their approach towards the patients — in terms of time spent with them, explanation of treatment options, and a holistic approach to healthcare, which includes prevention, early detection of diseases and comprehensive care. Let’s read the complete ‘prescription’ of the experts:

Prof Syed Ashiq Hussain Naqshbandi

Ex-Principal, GMC Srinagar

The biggest problem with Kashmir’s healthcare is non-availability of workforce. Talk about any department, there is shortage of doctors and paramedics. The first prescription for change is to ensure adequate staff in every hospital, be it in the centre or in the periphery.

Another problem that is eating up our healthcare is the brain-drain of our young talent. When they see no future and no appreciation for their talent here, they move out. This will hurt us badly in the long run.

Coming to the recent furore over the private practice, I believe that the government cannot and should not pry into private lives of doctors as long as they are doing their public service diligently. Why should government stop doctors from private practice? There was a time when Dr Muhammad Sultan Khuroo used to hold his private clinic at the SKIMS itself as was allowed by the government then. It was a very good step taken, well appreciated, and well received by the public.

We’ve to understand that Kashmir is a restive place. Hence, healthcare will naturally be the first casualty here. But the medical fraternity must take upon itself to ensure that even in absence of a proper system, justice is done to the profession they have opted for. The doctors must realise their duties and perform in the best way possible. I remember when I was the principal of GMC, I used to make a surprise inspection of LD hospital, SMHS hospital and other associated hospitals in the night. This must continue.

Prof Shad Salim Akhtar

Consultant Oncologist, Srinagar

Healthcare scenario in Kashmir cannot be judged in isolation. Like most of the developing nations, population characteristics and lifestyle have changed in Kashmir, too. New risk factors have become major players in causation of diseases. It will be naïve to say that healthcare system in Kashmir has completely failed. We see its success in treating victims of atrocious onslaught on Kashmiris on daily basis.

Vanishing of small pox scars from the face of our society and absence of polio-stricken children in paediatric hospitals may not touch a cord with our younger generation. But those of us who have seen it know what a great respite it is. The proportion of elderly people in our mosques today is probably the highest in our history. The healthcare system prevents death and disability in young age and helps us to live longer than we would before. It’s a success indeed. This in turn has increased burden of non-communicable diseases for which the system is poorly prepared and that is where we see deficiencies.

Rich can afford to be treated in hospitals, all urban-based, that are envy of many five star hotels. No one is working to facilitate provision of rural-based quality healthcare, accessible to poor in private sector. Public healthcare sector is essentially meant to serve the poor who take it as a give away from the rulers.

It is said that “services for poor are poor.” How true. Lack of funds, equipment, consumables, and properly trained medical personnel are major impediments. Absence of evidence-based protocols for management of illnesses, lack of accountability and continuing professional development results in poor quality of healthcare. Misuse of free or subsidised facilities by the masses tells upon the provision of services.

Due to a lack of integration of primary, secondary and tertiary healthcare, there is no sleek referral system. Inappropriate deployment of qualified personnel, where available, expecting medical personnel trained in different techniques of medical care to provide care of entirely different kind dents the system further. Poor regulatory system at the level of drug manufacturing, transport and supply contribute further to this mess. We all have to work together to improve it.

Prof Sanaullah Kuchay

HoD, Radiation Oncology, SMHS hospital

Kashmir’s healthcare definitely needs a prescription for change. The biggest problem we face in our healthcare is manpower shortage. Let me give you an example. In 2005-06, when we started Oncology department in the SMHS hospital, we failed to find a single Radiation Safety Officer (RSO). The Atomic Energy Regulatory Board (AERB) of India would not allow us to run the department without an RSO. After a hectic search, all I could do was to recruit a retired SKIMS officer for the job. When this is the condition at the centre, can we envisage it at the periphery? It is impossible to start a cancer centre at district levels.

As far as the private practice is concerned, I must say it is a boon for the patients. Even a casual visitor to the GMC associated hospitals will admit the heavy rush of patients there. So, if a doctor after finishing his/her work at the hospital is seeing patients at the private clinic, what is wrong with that? Even logic demands private practice. What should a patient do if he or she cannot make it to the doctor due to the long queue of patients? They have no choice but to visit the private clinic of a doctor. And why should not he go to our recognised doctors rather than quacks with dubious degrees? Morals also demand it. I am seeing patients for the past 30 years. How can I deny a patient entry to my home if he wants me to see him? My ethics say that I must keep my door open to my patients all the time.

Coming to SKIMS, the story is a bit different. We have reduced it to a general hospital when it was supposed to be a research centre. My suggestion would be to use the SKIMS Medical College at Bemina as a screening place where the doctors will sift the patients and will divert the patient traffic to different hospitals.

Prof M. Maqbool Lone

HoD Radiation Oncology, SKIMS

The Valley’s healthcare definitely needs a prescription for change. But if we compare our state’s healthcare with other states, we have comparatively better facilities here. There are certain areas, though, which are a source of concern for the medical fraternity. We have doctors posted at every place in the Valley. But there is little or no mechanism to check whether he/she is stationed there or not. There has to be proper mechanism to check that. Let the doctors and paramedics be accountable.

Another concern is that the district and sub-district level hospitals lack specialists. What the government should do is to create posts in such hospitals so that a patient at the periphery can be managed there. I cannot say that the government is lacking the will, but the need is to expedite the healthcare reforms for the greater good of the population.

Then there is the problem of lack of machinery in various hospitals. All the diagnostic tools need to be present at district level hospitals so that the patients need not to travel long distances for simple diagnosis.

When it comes to the most important and immediate reform in our healthcare system, it is proper communication between various levels of our system. Let me cite an example. Sixty per cent people who attend SKIMS cardiology OPD have no cardiac problems. This is a glaring example that there is miscommunication between the primary, secondary, district and tertiary level healthcare systems. At SKIMS, a specialist will examine even a patient with a plain headache. Why waste their time when such patients can be managed at dispensaries?

Dr Farhat Jabeen

Consultant Gynaecologist, LD Hospital, Srinagar

I would like to list the following changes in Valley’s healthcare:

To map our population and assess actual human resource requirements at all levels from medical professionals to a Class IV, and to generate that human resource.

To enhance and upgrade the skills of the human resource already available.

To develop an experimental and dedicated core group of health professionals for framing a health care policy.

To keep this core group totally apolitical and free of red tape.

To develop the already existing infrastructure. And make it need based. An example of breakdown is provision of equipment at primary level without the manpower to operate it.

To develop district level healthcare system with all the state-of-art facilities where more than 95 per cent of healthcare needs should be addressed. This will decongest the tertiary care system and these institutions can work for the purpose they are meant for — teaching, research and high-end patient care.

Continuous monitoring and gap assessment by technical core group.

Since healthcare is expensive, we need to spend more on preventive and promotive health at primary and secondary levels.

We need to develop a healthcare insurance so that no one is deprived of quality healthcare.

Last, but not the least, coordinated and comprehensive lineage between primary, secondary and tertiary healthcare services would be a dream come true associated with a back referral.

Dr Farooq Kaloo

Ex-Director, Animal Husbandry Kashmir

Even as healthcare system in the state has horizontally expanded over the years, little has been done to improve the doctor-patient ratio of 1:16000 plus. The state has failed to have a health policy that could help the burgeoning population to deal with new and emerging diseases. And not much has been done in studying the disease profile of different sets of populations/communities even as we have four medical colleges and a deemed medical university. Perhaps that is the reason why we are without a health policy.

The overall health awareness in almost all sections of the population is very poor. People are seen popping up drugs like proton pump inhibitors used to fight stomach acidity and ulcers without feeling need to go to a doctor. This kind of self-medication has been responsible for the ever-increasing incidence of chronic kidney disease, mental health problems including depressive disorder, and cardiac and neurological issues. On the other hand, the state lacks haemodialysis centres that could help poor kidney failure patients to have dialysis at affordable costs. Given the ever-increasing incidence of CKD, we need to have dialysis centres in all the districts.

The state lacks assisted reproductive technologies centre that could help the 15 per cent population of issueless couples to help them overcome reproductive health issues.Even though we have an independent bone and joint surgery hospital that takes care of trauma cases, there is no well-developed rehab centre in the public sector. The Shafqat Rehab Centre established by an NGO, Voluntary Medicare Society, has its own set of problems of maintaining the services because of financial constraints. Regardless of its better performance in the rehabilitation of spinal injury cases, the centre has no support from the department of Social Welfare which could support it to pay retainership to experts in rehabilitation medicine.

The healthcare facilities in districts for pregnant mothers are grossly inadequate, leading to huge patient rush at the existing facilities. Our patients with respiratory issues continue to be catered from ill-equipped chest diseases hospital existing at a highly crowded locality of Srinagar. The state is still to find land for such an important hospital!

Last, but not the least, is that the state needs to stop patient-hunting and exploitation of gullible patients by corporate hospitals from Delhi who indulge in hell lot of malpractices.

 

 

 

 

 

Dr Nissar-ul-Hassan

President, Doctors Association Kashmir

Despite huge infrastructure and workforce, our healthcare is in total disarray, both at primary level and tertiary level. And the worst part of it is that the patient care is the greatest casualty in this melee.

One of the important things that we are missing here is that producing future doctors is not the only responsibility of medical fraternity; producing quality research and calibrating it with local needs is equally important. We are presuming that research done in Europe, America or in other parts of the world will hold good for here also. This is a mere presumption.

It is shocking that people still die of simple infections in our part of the world. The reason is that the healthcare centres are not streamlined. They continue to remain out of sync. With the result, we are burdening the already overburdened tertiary care hospitals.

Part of the problem is that we have concentrated all tertiary care at one place. This has to go. Decentralisation is very important if you want to address this problem. Why to overlook 80 to 90 percent of rural population by concentrating all the tertiary care hospitals at one place? If you work on this, more than 95 per cent of your population will receive medical care at its doorstep.

The other important step we must take is to end the dual practice of doctors. It is beyond the capacity of human beings to work in double shifts. Suppose, a doctor is forced to work for 24 hours at a hospital; you can imagine what havoc he/she can wreak on the patients. Similarly, when a doctor leaves the hospital premises after doing his/her work and heads towards his/her clinic, how can he/she do justice to his/her patients at the clinic?

Another important thing that has to be followed is the carrot and stick policy. We must punish erring doctors for their negligence and reward those who are doing their job diligently.

The recent hue and cry against the attachment of Director SKIMS and three HoDs is uncalled for. As the head of the institution, the SKIMS Director must face action for not checking the illegal practice of his doctors.

Dr Omar Akhtar

Consultant Urologist, Jaslok Hospital, Mumbai

Kashmir’s government doctors and paramedics are among the best — they excel wherever they work.   In government service, they are parked in garages, shown off to the people as beautiful pieces of achievement for the government, and yet unable to provide care up to their potential.

Kashmir’s healthcare system has evolved from the British system, with a healthcare administration set up closely mirroring the administrative setup, and not ground realities or needs. What else can explain the need for shifting a Children’s Hospital from the convenience of being next-door to the Maternity Hospital, to a place next-door to the Army Headquarter in Kashmir? How did that improve access, service delivery or healthcare outcome parameters?

Such politically motivated decisions have been the hallmark of healthcare in Kashmir. It has resulted in a tripartite division — into SKIMS, Government Medical College and Associated Hospitals, and the Directorate of Health Services. What this means is that a patient with a headache, will usually show a doctor or paramedic at the local level, then, without a proper referral, at the Medical College level, and then again at SKIMS. Without a proper referral mechanism, there is overcrowding of the out patient departments of the city-based institutions, which results in a fall in quality of care, overburdening of doctors at all levels, and ultimately, a breakdown of the system.

The way-out is to integrate the entire system across the Kashmir Valley. Rather than make two new medical colleges and one AIIMS, it would be fruitful to spend that money on the existing institutions, and strengthen them. We need teaching hospitals in all districts, not medical colleges. It is not MBBS students who provide healthcare, it is the Post Graduates, and junior doctors who do so, primarily, working under Consultants. It is not a new model, almost every medical college has peripheral hospitals under its aegis. What it means is that all doctors working in the healthcare system have the opportunity of becoming a part of the teaching system, and as a result, a great many doctors will be available for work in periphery, since the primary attraction of the medical college, namely working in a teaching institution, will be available at district level.

By expanding the number of hospitals and beds available, the annual intake of MBBS students will also be increased, thus accounting for the extra seats at the new medical colleges. This is a process of consolidation, and it was followed in London, where many colleges combined across the board, to save administrative costs, and increase the number of seats, as also convert many smaller hospitals into teaching hospitals.

A simple change that can accompany this is the reorganisation of the departments. Rather than having hernias, headaches, and flu seen at the SMHS Srinagar, it can be converted into a centre of excellence by only seeing referred cases from the district hospitals. Similarly, SKIMS can be another parallel centre of excellence, with its own referral system.

The healthcare system in Kashmir is ready for change — a change that will give better opportunities for career growth, patient care, and outcomes by a reorganisation of resources. Kashmiri doctors and paramedics are second to none; they only need to be brought out and given the best support.

Dr MuzafarMaqsood Wani

Consultant Nephrologist, SKIMS

There is an old healthcare set up in the Valley, which basically is a good network but is lacking and ailing in many aspects. Many things are responsible for this. For a long time everything in Kashmir gets concentrated to capital Srinagar only, which has changed a bit in recent years. It holds true for healthcare wherein till recent times patients from other districts would come on their own or were referred to Srinagar for all types of illness. This strains and drains the specialty hospitals and results in the services getting badly affected. What we need is specialty, rather super-specialty care at district level, too.

So the mindset of people that Srinagar or Delhi is the ultimate panacea needs to be tackled and they must get satisfied that healthcare at their district is as good as anywhere else (of course with few caveats). 

Also, private players are not venturing much in healthcare. People have built big buildings everywhere in Kashmir but most of these are for non-health related businesses. Like private education is propagated and encouraged by the government, so should the healthcare facilities be. On part of the government, a lack of will, mismanagement of trained manpower, and nepotism is largely responsible for the poor state of healthcare here.

I would suggest following measures for improving the scenario: ensure that specialists, senior residents and medical officers are posted in the rural health centres, along with trained paramedical staff; post specialists in these places so that they set up, train and start various services at these places; rationalise patient appointment system and screening for proper referral; and provide incentives and facilities to the staff as are being provided to police personnel.

Dr Shahid Tak

Consultant Cardiologist, JLNMH Srinagar

In Kashmir, the healthcare system has witnessed both bright and dark aspects of the technological advancement. I think the state is providing more than enough to the society, given its limited resources. Every village has at least a health sub-centre. Every district has a hospital and many more sub-district hospitals. Skilled medical personnel are always present in all sectors of community.

Having said that, every system has a scope for improvement; so has health sector. Kashmir division has an age old three regional parts: Maraz, Yemraz and Kamraz. Three equally equipped tertiary care centres should be present in these three areas. These hospitals should be strictly referral teaching institutes. All district and sub-district hospitals should be equipped to tackle emergencies. Emergency diseases should be enlisted and managed free of cost in all sectors of health, government as well as private. For rest of the diseases, patients should be charged with a cap for maximum charges for both sectors. With increase in population, new hospitals should come up every five years so that quality is maintained. Health policies that come in the form of universal programmes should be individualised to states, regions and divisions.

We do not have a malaria eradication policy in Kashmir yet. Wrong and fruitless policies should be withdrawn. A hospital should devise its own module for improvement. It should not be an instrument for implementing centrally sponsored schemes.

This debate was published in February issue of Kashmir Narrator. For subscribing to our print edition, contact [email protected] for details.

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