Original Article written and edited by Dr. Anoop Prathapan and published online on 8/1/2023
The Healthcare Sector in Kerala is considered one of the best in the world. We have some of the best doctors on the planet who have been in continuous demand across the globe, irrespective of the nationality, caste or creed of the patient demanding them. This author has had the opportunity to experience the UAE and the UK Healthcare systems, which despite being technologically advanced than in our State, is accessible to a very limited number of people with the ease with which it is accessible in the State of Kerala.
A job in the State Health Services is a lucrative one with decent pay and a post-retirement pension. Even after the employee breathes last, a part of the pension is disbursed to the spouse as a family pension. Such aspects make this one of the most secure jobs on the planet, from where throwing you out is almost next to impossible unless you commit a grave mistake. Being in such a stronger and secure position than 95% of the other residents of the state, why have more government doctors committed suicide over the last few years? It is plainly because of the issues that they face in the Department - there are several - but this essay will discuss just one - correcting which the facade of the State Health Services might look totally different - and that is the issue of the unmanageable crowd of patients who come to waste those resources that are provided by the State for free and who dissuade genuine patient care.
Most of the establishments under the Health Services always complain of being understaffed. That might look true at the outset, but I look at it from a different angle The only reason why a workplace becomes understaffed is when there are less number of staff to cater to the number of clients that turn up. There are two parameters here that could be adjusted to solve the issue - either the staff numbers should increase (as is always demanded) OR client numbers should be markedly reduced. Always the melodrama is with increasing the staff. But, to improve the quality of health services, it is the number of unnecessary, unsolicited client/patient visits that should be reduced.
Some people turn up to the Government Hospital for absolutely no reason because it is free. Let us take the case of the accident and emergency (emergency room) of any hospital under the State Health Services where, in my opinion, the maximum misuse happens. An emergency room in my understanding is for treating emergency patients who have had an unexpected medical situation all of a sudden, like chest pain, shortness of breath, a road accident or an accident at home, an assault on oneself leading to injuries, etc. But what comes to the Government Hospital emergency room more, are those patients who have a cough, cold and fever, who could easily wait until the next morning with home remedies and present themselves to the General OP. It is for those patients that a General OP functions from 8 am to 7 pm, Monday to Saturday in almost all bigger establishments that treat all general illnesses that do not require specialist attention. Those cases are so trivial that they are not even worth presenting before a physician in the Medicine OP for it is a simple waste of their time when they could see more complicated cases demanding their skills and expertise. Paracetamol/Mefanamic Acid, Cetrizine, Cough Syrup and B-complex tablets would be the medicines that any doctor in primary care prescribes the most. Such patients flood the emergency room at all times of the day and even at midnight. They are almost always so impatient that they can’t wait, that they argue with the doctor, shout at the doctor and on a couple of occasions have thrown crimpled and torn OP tickets on the doctor to mark their protests, JUST for being asked to wait. Such an aspersion has happened the past week (and on a couple of occasions before) in the hospital where I work. Such acts should be treated as nothing but indignation to the noble profession. These people are primarily not supposed to utilise emergency medical services because whatever illness they claim to have is not an emergency at that moment and maybe not even the next day. Still, why do such people have to come to the emergency room and that too at odd hours? On Sunday afternoon when there is no General OP, the crowd in the emergency room increases manifold.
Even when token equipment was installed in such hospitals and made use of, people barged in when there were no new tokens called for more than an hour due to doctors having to attend major emergencies. So implementing a token system, in my opinion, will only help in parts, but such a system is inevitable.
People who wait for long, even for hours together, do not leave, because I have noticed that this hospital visit is basically an outing for them after work, with family, stating trivial complaints that could be well managed at home (with an OTC medication, and/or with a cup of steaming hot coffee and/or with tepid sponging and/or with steam inhalation) as they have no other better place where people can socialize with minimal expenses.
I am sure nowhere else on this planet would people treat a hospital as a post-work-hangout. But it happens here in this literate heaven called Kerala, as they have reasons to - where else in the year 2024 anywhere on this planet can they consult a doctor for a fee of just INR 5 (USD 0.06), get all associated parenteral medications or IV fluids for free, and when they leave, get all take-home medicines for free? Why wouldn’t anyone treat such a place as a hangout? The State Government established such a penny-less system many years ago to not let even one truly deserving person die of not getting proper treatment because he can’t afford it. But over the years, the administrative higher-ups failed to realise that their noble intention was being misutilised and misappropriated only because the terms and conditions of the provisions were not upgraded in tune with the changing socio-economic scenario.
People who collect the free medicines do not use it properly - more than 60% of them carelessly misplace it and come shamelessly the next day to get the same medicines - because it is free of cost. When doctors question them - they get framed for treatment denial. On Sunday afternoons the emergency room is flooded more by people who are on their way back home after a wedding or a family outing, all in party wear, socialising with everyone around, picking up an OP ticket for just the paltry 5 rupees they need to shell out, and waiting for hours at length, just to get a tablet of paracetamol or cetirizine written for the most trivial complaint you can ever think of. When such people demand immediate attention and make a fuss about it, the patient with the real emergency suffers. With the rise in living standards in Kerala, and since banks started offering vehicle loans to all ragtag and bobtails, not considering the carbon footprint or road safety parameters, almost all households in Kerala have access to one or the other kind of motor vehicle which empowers them to rehearse their imprudence at the Government Hospital 24/7.
The Solutions
The inflow of such patients should stop or at least reduce significantly for the better functioning and utilisation of the existing resources. For that, the most prescribed OTC medications should reach the patients without having to meet the doctor. The patients should be educated with learning cards on the dosages of these medicines that are prescribed the most and should be encouraged to get them straight from the pharmacy without meeting the doctor. There should be drug vending machines installed in every hospital where people can come, swipe their digital e-Health card and get the OTC drugs which they require. The machine could be programmed to not disburse the same medication for a second time within a week if the allowed maximum pharmacological numbers are disbursed already. Antibiotics or other complicated drugs could be excluded from such disbursal as they could be associated with side effects. I believe 75% of common ailments do not need antibiotics to treat. So in a way, this system curtails antibiotic misuse as well.
While it is technically true that any drug, be it even OTC medications, could be associated with side effects, and so should ideally only be prescribed by the doctor, there are innumerable patients in this 100% literate state who go to the pharmacy across the street and take the advice of the pharmacist on what medicine to take for their illnesses. The pharmacist, with his limited knowledge, acts the expert and issues all sorts of medicines including antibiotics and eventually the patients come to the doctor with worsened symptoms. This happens regularly, every single day, without fail. In such an environment, isn’t it better that we publicise the correct doses ourselves so that the patients, at least the sensible ones would stop going to the pharmacist for advice and would stop coming to the emergency room at night for a high-grade fever or a common cold or loose stools? These scenarios apply to the various OPs as well. I am sure 60% of the cases that appear before a physician in the Medicine OP are cases that do not require the expertise of a physician. When a genuine patient with an illness that needs to be examined and treated by the physician presents before him, he is masked by the colds, coughs and fevers that cram the OP.
There should be a list of medicines, equipment and other medical accessories that the Department of Health should publicise that every household should mandatorily keep at home in case of an emergency and also the scientific ways to use them. A comprehensive list of such essential supplies is beyond the scope of this essay. Educating people to be self-sufficient is the only means to restrict a huge population of 3.5 crores from unnecessarily utilising and wasting the free services the government provides for a totally different reason altogether. I am sure not even 50% of the crowd who misutilise the government services might follow these recommendations if we were to ever publicize them. But even if 25% does, and comes less to the Government Hospital, it is tantamount to more doctors and staff serving the more genuine patients who have illnesses that cannot be managed at home.
The best the Government could do from their end to cut down on unnecessary hospital visits is to retain the current tariff of charges to only the BPL category and to make the rest pay a nominal amount for consultation, and each other service they avail, including medications. The cost could be less than what a private hospital charges, but there should necessarily be a few extra quids charged, only to act as a deterrent to cut down on unnecessary hospital visits. Such money collected could be utilized by the State for the overall development of Health Services and for the payment of salaries to contract staff or for the purchase of medicines/equipment as required. With the overall improvement in purchasing capacity, a few extra bucks for treatment would be fine with 90% of Keralites. ECG and Blood tests which were once free are now charged, and nobody takes an ECG less because they need to pay INR 60/- for it. There is a man in Neyyattinkara, Thiruvananthapuram who comes to the General Hospital to get an ECG done almost daily because he “feels” he has chest pain - when actually the ECG is invariably normal every single day. This scenario is an exemplification of two facts - one of the overt misutilisation of Government resources and two - of the fact that people will pay Rs. 60/- daily if they genuinely feel like it. This also means, once implemented, people will pay for OP tickets and medicines as well, at least those in the APL category - but surely unnecessary utilisation would come down. However, it is a political decision that needs to be taken.
Implementation of a proper triage and token system is another means by which the crowd could be restricted, for administrators who think strictly within the box. Placement of proper signboards letting the people know that an emergency room is ONLY for emergencies could enlighten some, but not all. Nevertheless, that needs to mandatorily be done for those minority of sensible souls to read and act accordingly. The availability of security personnel 24/7 in the emergency room and the OPs is another means by which doctors could save their vocal cords from overuse and themselves from attempted assaults. It is an imperative requirement in any major hospital from Taluk upwards, as they can assist in crowd management in the prevalent messy environment. These are conventional thought processes which the authorities who propogandise these, should realise that the public, over so many years, has learnt how to make holes into.
Educating patients to manage primary ailments by themselves,
Educating patients to keep listed medical equipment at home for self-monitoring and
Significant increase of hospital tariff for APL category
are the ONLY genuine methods by which fewer people could be attracted to the Government Hospital. The authorities like DMOs or the DHS should utilise their powers to the fullest to implement these across the State and should depend less on people less qualified for advice. The Government hospital should be made less favourable a place to hang out with family and should be treated as a medical assistance centre where people should only come when they have illnesses they cannot manage themselves at home. Implementing a triage system or enabling a token system will only help to a certain extent in the current socio-political scenario where the scornful people who just cannot wait, call the elected representatives to complain that they are not being given quick treatment. It is only common sense to understand that the elected representatives would try only to enforce their hegemony on officials to secure their votes. This again leads to the doctors, and other government servants being treated even more ruthlessly by the general public.
Therefore, more than desperately trying to increase staff strength, more focus should be on limiting patient visits and making the hospital a less attractive place to unnecessarily visit with family just because it is free. “Contain the spillage and, Save the resources” should be our motto. Unless the wastage is controlled, appointing all registered medical doctors and nurses in Kerala to the State Health Services will not suffice. The more the crowd is contained and the more the general public learns to manage common ailments by themselves, the requirements for new doctors will come down drastically over the years. Subsequently, the unnecessary appointments of new doctors by the DHS could best be avoided and more genuine patients could be served with better precision by a limited number of specialists and general practitioners.
Conclusion
There might be plenty of other issues in health services like the issues with decentralisation, improper utilisation of e-Health facilities, and improper modus operandi deployed in the transfer of doctors leading to certain doctors celebrating 25 years in one hospital when some others are ruthlessly transferred to locations not of their choice, or there might be many others issues that I do know even know. But I find this one that we discussed, the most significant that needs to be corrected before anything else. Procuring equipment and medicines or adding human resources are all a waste if the added resources are wasted like trash. Therefore, the primary focus should be securing the bottoms and hampering wastage rather than pouring more and more to the inside from the top. Once that is done, Kerala State Health Services has the potential to be the best in the world in the future and shall provide quality services to deserving people at minimal cost.
Dr. Anoop Prathapan
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