A vision for the public health sector in Uttarakhand

A vision for the public health sector in Uttarakhand
Rajive K. Dikshit, MD, FCCM, MPH

PUBLIC HEALTH is one of the most important areas of human development and sadly one of the most neglected in modern India. Even in Uttarakhand, with its unique distinction of achievements in the health sector, there are huge shortcomings. One of the most important pillars of the system, that is the general health service, is now in a state of flux and disrepair. In the face of challenges mounted on the curative side by well-equipped private institutions and on the preventive side by uncontrolled epidemics, the system is reeling and its record is abysmal. I have based my observations depending on scenario in one State, Uttarakhand, but it is no different when it comes to other States; it is actually worse.
Most of our district and taluk hospitals are motley collections of century old structures and more modern blocks added with no overall plan. None of these buildings are properly planned to house a health care institution. Health Personnel are mostly experienced and well trained but lack motivation and incentive. Their deployment is unscientific and done in knee jerk fashion. Corruption is endemic.
Primary health care continues to focus on family planning and immunization and other urgent issues like epidemic control and non-communicable diseases receive little attention except when there is an emergency.
I would now outline briefly what I believe should be the ultimate aim or Vision 2020, as the cliché puts it.
Taluk or sub-divisional hospitals should be provided with all basic specialties. This would entail a modern operation theatre; post surgical ICU, medical ICU and a full fledged anesthesia wing. "Latest" equipment such as endoscope, arthroscopy, etc., should be available. Laboratory services to perform all but rare tests should be there round the clock. Existing structures should be abandoned to construct a single spacious block which will house all specialties and will have airy comfortable waiting areas and consultation rooms, computerized OPD registration, polite staff to guide patients to various services, and sufficient greenery inside and outside to promote holistic healing. In addition to these, district hospitals should provide sub-specialty services including neurology, cardiology, and gastroenterology, etc., apart from separate ICUs for cardiac cases. Waste disposal should follow established guidelines. Material management and medical records should be computerized.
Control of the hospitals should be ceded to hospital management committees set up with representatives from local governments, doctors, and NGOs. Private practice should be banned after providing 50 per cent of total emoluments as non-practicing allowance. Vigilance cells should be set up to investigate allegations of corruption within 48 hours. Doctors should be given 5-year terms to ensure continuity of care and reduce corruption in transfers.
Minimum acceptable standards at primary, secondary and tertiary levels should be codified and a Health Regulatory Authority set up. This body should be entrusted with regulatory and recommendatory powers in the sector including private sector.
In the primary health care sector, while continuing to provide demand based services in the Immunization and Family Welfare sector, field staff should be retrained in trauma care, accident prevention, and supported with sufficient infrastructure for accident transport and trauma care. They should also be trained to provide information on non-communicable diseases like diabetes. Epidemic reporting and control should be reorganized by computerizing all field offices like sub centers and primary health centers and ensuring paperless and rapid reporting.
Resource generation
I shall briefly outline a few non-conventional but practical proposals for resource generation:
Reasonable user fees should be charged after a political consensus on the issue. This should be tied to concrete plans to improve the system.
Real estate rendered surplus after scientific redesigning of hospitals should be commercially used. Funds accrued should be ploughed into a separate fund managed by the hospital management committee. A trust can be formed to reinvest part of this money in government securities. Part should be directly invested in the hospital.
Pay clinics providing sub-specialty services and other high end services should attract richer clientele who can cross-subsidies poor patients.
Ancillary laboratory services can also operate commercially, to outside patients.
Governments can float Health Development Finance Corporations to collect deposits and provide loans to private health sector. The profits should be ploughed back into a dedicated fund to improve health systems.
The health insurance scheme already announced should be effectively implemented.
A health cess should be imposed on  liquor  & Tobacco Product sold, the proceeds of which should again be ploughed into the dedicated health fund.