Filed under: Health Care Human Resource Management
The carpenter makes furniture and goldsmith, jewellery, not vice versa. The barber cuts the hair and makes it stylish, not the mason. That is common sense. It involves no rocket science.
But the irony is such conventional wisdom is grossly lacking in the public health structure in most States. Specialists are not available in the so-called “referral hospitals.”
In case of a road accident, the public hire a taxi or an autorickshaw and rush the victims to the nearest taluk or sub-divisional hospital only to realise that there is no surgeon or orthopaedician. The post is vacant for so many years! To their utter disgust, the relatives find that there is in fact an orthopaedician but posted in a Primary Health Centre (PHC) supervising immunisation and family planning programmes as the Medical Officer!
The same is the fate of many pregnant women — especially those with complications — reaching many Community Health Centres (CHCs) identified as the First Referral Units (FRUs) or Comprehensive Emergency Obstetrics and Newborn Centres (CEmONC). They are supposed to be saved by an obstetrician, anaesthetist, and paediatrician team. At times, all of them are absent or only one is present which is not effective. The result is such patients have to be taken to the medical colleges or district headquarters hospitals for any meaningful life-saving intervention and care.
During an official visit to Nizamabad district in Andhra Pradesh in 2006, I found that many identified FRUs did not have the combination of anaesthetist-obstetrician-paediatrician. At the same time, five specialists were wasting their time as MO-PHCs or as in charge of public health programmes. This was immediately brought to the notice of the then Principal Secretary and Commissioner of Health and Family Welfare.
Can’t we relocate the specialists within the district, region or State for better utilisation of their skills?
This proposition is not a theory of probability, but a feasible option demonstrated by Vikas Sheel, Health Secretary, Chhattisgarh. The State has rationalised the deployment of the available specialists with the firm principle that “no specialist doctor will be posted at the PHC level in order to ensure the filling up of all specialists in the district hospitals and community health centre as per norms.” They could identify 26 specialist doctors and nine doctors with short-term skill training in life-saving anaesthesia and emergency obstetric care, who were serving as general duty medical officers in the PHCs. They were compulsorily transferred to the district hospitals or CHCs.
Additionally, when the Public Service Commission was about to complete the selection of doctors for the PHCs, there were 61 doctors with post-graduate qualifications in different specialities. The government took a proactive step of appointing all of them in district hospitals and the CHCs and they were not sent to a PHC which would have been their normal entry point to government service.
Out of the 9,856 doctors appointed till September 2010, under the rejuvenation effort of State health systems in the country by NRHM, 1,572(15.9%) were specialists. It is worthwhile to evaluate whether they are posted in the right places giving the best output?
There are ENT surgeons and radiologists managing malaria and leprosy control programmes in some districts and ophthalmologists are posted as epidemic and diarrhoeal disease control officers. Is it not absurd?
There is a shortage of specialists for many reasons. Agreed. But who asked you to fritter away whatever specialists you have? That is unpardonable. If there is some accountability to the people, you will wisely deploy them. Such a professional challenge will be in the interest and career progression of the specialists too. They will get motivated to serve the public health system longer rather than quitting when and where they pick up a good private practice on the sly.
Otherwise, they lose their skills and society loses them too. During 1997-2001, I came across many paediatricians in Uttar Pradesh, who could not intubate and resuscitate a newborn as they were not using those skills in a PHC or rural setting for many years. At a State-level workshop facilitated by Sight Savers International, it came to light that only 39 out of about 70 ophthalmologists in government service could do cataract surgery. The rest were “non-operating eye specialists” doing administrative jobs and managing the PHCs!
Unfortunately, specialists are not produced as per the country’s needs. They are generated as per the prescribed capacity and norms of training available in medical colleges and speciality training centres. So there are historical production lags vis-a-vis the need for anaesthetists, ophthalmologists, obstetricians, paediatricians and qualified Public Health specialists, for example. At the same time, we find many postgraduates qualified in anatomy, physiology, or forensic medicine earning a living by doing general practice as the posts in teaching institutions for those branches are exhausted. If the available posts in a particular speciality are saturated, why spend public funds in training doctors in such a speciality? Why dangle a deceitful carrot to low-ranked candidates in the postgraduate entrance test? Can’t we have a need-based moratorium on intake in post-graduate medical studies?
Alluring jobs in super-speciality centres in the country as well as abroad make the newly qualified doctor specialists close their eyes to the acute shortage of their breed in the public health system of their State. The numbers available are small and precious.
It is all the more reason for searching for them individually rather than through a bureaucratic procedure — notification for an interview with deadlines, catering for their personal choices of posting like place and time and special needs like joint postings for husband and wife and opportunity for teaming up with compatible friends of different specialities in one location, etc.
It is high time the Secretaries and the Directors of Health Services got their act together like high level human resource managers approach good colleges for campus placement in a competitive manner.
By Dr. K. R Antony
(The author is a former Health & Nutrition Specialist for UNICEF and former Director, State Health Resource Centre, Chhattisgarh (email: firstname.lastname@example.org)
This article was published in The Hindu on October 9 and can be accessed here
Filed under: Health Care Human Resource Management, Health Research, Healthcare General
Contributed By Karuna Dayal
India, which holds the dubious distinction of the highest death rate for children under five and the highest maternal deaths in the world, also has a shortfall of 2.6 million health workers, a report said on Tuesday.
The report by Save the Children India said that at 900,000 a year, India has the largest number of newborn deaths and is among five countries that account for more than half of the world’s 3.3 million newborn deaths. The others are Nigeria, Pakistan, China and the Democratic Republic of the Congo.
A majority of these deaths, as well as the maternal and child deaths, are preventable, and occur in just seven states—Bihar, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh andUttarakhand—which are also the states with the fewest healthcare workers, the report said.
“We know that the presence of a health worker could mean the difference between life and death for a mother and her newborn child,” Save the Children chief executive Thomas Chandy said in statement. “This massive shortfall of 2.6 million health workers means that we really need to step up efforts not just to address this gap, but to strengthen the existing healthcare system.”
Only 29% of posts for doctors at primary health centres are filled across the nation, the report said, citing 2009 official data.
The release of the non-governmental organization’s report coincides with the United Nations (UN) General Assembly meeting in New York, and an international publicity event held by UN secretary general Ban Ki-moon in New York on Tuesday to highlight the progress of Every Woman, Every Child, a global programme aimed at saving the lives of 16 million women and addressing major health challenges faced by women and children globally.
Rajiv Tandon, a senior adviser for health and nutrition for Save the Children India, who is attending the general assembly as part of an lobbying effort to increase India’s spending on health, said the country appears to be falling behind in this regard.
“The global gap figure that is being talked about is 3.5 million health workers. But this figure is only for the 49 least developed countries, which does not include India, and India has an additional gap of 2.6 million,” he said. “Twenty-seven million children are born every year in India, of which 900,000 die within the first months, and about 60,000 mothers during their delivery.”
“We are eagerly awaiting the outcome of the India summit tomorrow (Wednesday) to see what commitments the government of India is going to make,” he said over the telephone. “Based on the needs, we hope it will be substantial.”
Malia Politzer, email@example.com
Filed under: Health Care Human Resource Management, Healthcare General
What is depersonalisation?
According to the Chamber’s Dictionary, depersonalization is : to make impersonal or dehumanize and Thesaurus refers to the term as, make impersonal or present as an object.
Considering the wide scope of the term’s meaning, I will take the liberty to discuss depersonalization in two dimensions (although they are interlinked, and so they are discussed in continuum):
- Depersonalisation of doctor-patient relationship (based on I-You: the dialogue principle by the philosopher Martin Buber)
- Depersonalisation as a result of excessive use of technology (in specific the communication technology)
Let us start to build the discussion by focusing first on the doctor – patient relationship.
Why discuss depersonalisation?
In his book “Ich und du”, Martin Buber established a thought of interconnectedness of human beings. Building on this thought, one wouldn’t have the difficulty to understand the importance of communication and interconnectedness that is shared between a Doctor and his/her patient, who is sick. What can be clearly seen in the modern health systems is the traversing away from I-You relationship to I-it, as the patient is seen as an object. The following paragraph is fuelled by an idea, that the doctor and his/her staff forms the most essential and basic unit of health care and health care system.
Depersonalisation: more harm than good:
In a study of burnout (syndrome of depersonalization, emotional exhaustion, and a sense of low personal accomplishment that leads to decreased effectiveness at work), it emerged that burnout was common amongst the resident physicians and was associated with self-reported suboptimal patient care practices . To be underlined here is the delivery of suboptimal services to the patients, which in turn can prove to be a huge blow to the effectiveness and responsiveness of any health care system. This and many such studies effectively reveal the suffering of doctors who have been idealised for ages, probably forgetting that a doctor is a human being as well.
Where does this all come from? Although there is no single answer to this, but I would like to draw attention to neo-liberalism, simply because we all are so closely associated with it.
Neo-liberalism in health care:
The very term ‘patient’ has undergone a significant change, and in the neo-liberal world patient came to be called as client, consumer or even customer, which highlights the business proposition or intention of health care. We need to demarcate one underlying fact that a health care system is not saddled by business principles.
The collapse of the Pennsylvania’s Allegheny Health system serves as the most appropriate example to explain what application of market and business principle can do, to an essentially human driven health system.
To cut the long story short, depersonalisation is the suffering of both the patient and the doctor (as noted in the earlier paragraphs), which cumulates to the suffering of the health system.
Let us turn our pages back into the past and see what WHO had to say about the health care systems.
Health system and the World Health Report 2000 (depersonalisation and responsiveness)
The World Health Report 2000 enshrines dignity and responsiveness of the health care system in its fundamentals. Despite of the fact that dignity has been recognized by the international law, patients are belittled to mere objects, which challenges the principle of responsiveness of health system, as well as their right to dignity and respect. Dignity as a part of communication within the health system, if not addressed also affects the accessibility of health care. Depersonalisation can not only hamper doctor-patient relationship but can also upset the dynamics of human relationships within and outside the health care system.
Let me pull some inputs from the movie Sicko. The movie is a parody of the American health system through a story of an American rescuer of the 9/11 attacks. She suffered from respiratory difficulties as an outcome of the rescue and relief work. The unresponsiveness of the profit driven health care system, particularly the insurance companies added to her grievance. She finally got to a hospital in Havana, Cuba and was spellbound by not only the low cost care but also by the assurance and personal touch that she received. This raises the question; do we want a techno savvy depersonalised healthcare system or the one that has a more humane face?
Changing patientele – the other side of the coin:
Clientele for many other industries (say for example manufacturing industries) is very different from the patients or people that healthcare systems deal with. The discussion that “healthcare” is a market failure is not new, but in this discussion of depersonalisation, the most important factor to be focused upon is – the difference in the knowledge levels of the provider and the patient. Since clientele is more to do with business, I use the word patientele in order to clearly demarcate healthcare from business. However, more recently health care is not as passive as it used to be and patients increasingly want to be a part of the decisions that are made for their health.
The expounding knowledge of health and disease further adds to the complexity of healthcare delivery, coupled with an increasing burden of disease and ageing populations that adds to the pressure on the healthcare system and the staff within it.
In the given scenario, technology is seen as the answer to this mounting pressure. The new age health informatics is possibly the way around, not to forget tools like e-medicine and tele-medicine. Certainly, if used effectively; technology has a role to play in enhancing the efficiency of health care system.
Understanding the patientele view and attitudes towards technology and the role it plays in depersonalisation is another area that needs to be explored. In a research conducted in Virginia exploring the attitudes of the patients to the use of tablet PC in the exam room demonstrated that, most of the patients had perceived the use of tablet PC positively. However, I would implore that we understand, that such research results cannot be applied to every context of health system, and much needs to be done by the health system of each country to understand its own patientele.
Technology in every stage of health care:
Most of the ancient systems of medicine; diagnosis and treatment had personal attention and human touch; in fact touch therapies were also practiced. Today’s modern healthcare system has technology in every step, from diagnostics to treatment and even after-care. Arguably technology is making the healthcare system increasingly depersonalised and mechanising the doctor-patient relationship, and has far reaching effects on the healthcare costs.
Another aspect that threatens well-being is that of self-medication. The ready availability of information, over-the-counter drugs and their indiscriminate use, diagnostic tests and the rising costs of consultation is an impediment to quality and effectiveness of healthcare system. A Wall Street Journal article expressed the fear of degrading doctor-patient relationship, decline in liability due to technology and violation of law.
Even the concept of Primary Health Care that had been seen as an answer to the undermined health care systems, suffered a setback. Let’s see how?..
Increasing investment in technology and the decline of Primary Health Care:
Primary health care by definition includes community participation. Unless a healthcare system and its components are sensitive enough, primary health care cannot achieve, what it had set out to achieve. Despite the Alma Ata declaration and its concept of community health workers (CHW), this revolutionary concept suffered a setback due to excessive investment and focus on technology. The revitalisation of the concept of primary health care and increasing evidence on social determinants of health; calls for more human connectedness.
At one end technology is seen as an instrument for depersonalisation, but nonetheless used in the right direction technology is a medium to reach people in the most remote location. The WHO report 2008 recognises the fact that technology is one way to maximise the return of the health care system.
Having seen dimensions of health care discussed in this essay, we cannot stick to one solution; because there are no magic bullets.
Summarising the dimensions:
On one hand the health care systems across the globe are overburdened and there is a severe lack resources, which in turn cause a pressure on its human resources leads to depersonalisation, thereby affecting the responsiveness, accessibility and effectiveness of the system. On the other hand where technology could have found some relief, it became invasive; and lead to the blurring of Primary Health Care.
Firstly it is important that we understand health care disjoint from business principle, essentially because ‘Health’ is a fundamental human right.
The mounting pressure on the human resources within the system needs to be released, through various interventions, and not by adding more number of people to the system; but by using the existing human resource judiciously and in a managed way. Merely adding employees will add to the costs and further thinning of the available finances.
The working environment should be supportive, innovative ways like ergonomics can prove to be effective tools to help build such environments.
The training of the medical and the paramedical personnel should entrench the wider perspective of social determinants of health. Essentially, medical training cannot just remain technical, but should have a more human face, and that the doctors are not treating just the disease but are treating a human being.
Communication technology is a huge resource, which can be utilised to reach out to inaccessible areas and to a larger number of people and serve to enhance the efficacy of the communication. However, technology is not the answer to all questions; rather it should be used to support the health care system. Judicious use of technology and cutting unnecessary costs on its use is an urgent need. We need to think before we invest.
The Primary Health Care is a concept that will significantly increase the human connectedness and community participation. Surely it is an answer to the increasing depersonalisation of the health system and reduce its burden. While people respond to their needs, health care system can then became an adjunct for meeting their health needs.
As we talk about concepts like Global Village and greater human interactions, we cannot keep the issue of depersonalisation unaddressed within our own health care systems. While the health care systems takes care of its people, so should it meet the needs of its human resource, for which there is no single answer, and that every action we take should be carefully constructed around the values of the society that the health care system serves and belongs to.
- Chamber’s Dictionary
- The Depersonalisation of Health Care. Joseph J. Zealberg. M.D. Psychiatric Services, March 1999, Vol. 5. Number. 3.
- Burnout and Self Reported Patient Care in an Internal Medicine Residency Program. Tait D. Shanafelt, MD; Katharine A. Bradley, MD, MPH; Joyce E. Wipf, MD; and Anthony L. Back, MD. Annals of Internal Medicine. March 2002. Vol.136. No. 5.
- The Art of Medicine. Suffering of Physicians. The Lancet, October 2009. Vol. 374.
- Supporting Communication in Health Care; International Journal of Medical Informatics, Editorial by P.J. Toussaint, E. Coira.
- Patient Attitudes towards Physician use of Tablet Computers in the Exam Room. Scott, M. Strayer, MD, MPH; Matthew W. Semler, MD, Marit L. Kington, MS, Kawai O. Tanabe, MPH. Family Medicine. October 2010, Vol. 42. No. 9.
- World Health Report 2000. Health Systems. Improving Performance.
- World Health Report 2008. Primary Health Care. Now more than ever.
- Wall Street Journal.