West Bengal: Health Care & Public Policy

Punyabrata Gun

Bengal is the state where the chief minister herself is the health minister. So one can expect that health care will get proper importance in government policy.

l    In February, 2012 government doctors were ordered to write prescriptions in generic names of medicines. In the first phase generic prescription was introduced in Medical College, RG Kar Medical College and National Medical College.

l    A high-level taskforce was constituted under the leadership of Dr Tridib Bandopadhyay to reduce mortality of neonates and infants.

l    Another high-level taskforce under the chairmanship of Dr Subrata Moitra was constituted, whose task is recommending for improvement of the secondary level hospitals.

l    Before 2011, there were 6 sick neonatal care units (SNCU) in the state. Now the number is 40. The number is likely to be 50 by the end of this year.

l    In addition 127 Sick Neonatal Stabilising Units have been established in different government hospitals. The government plans to set up another 173 SNCUs by the end of this year.

l    From December 11, 2012 till August, 2013 Fair Price Medicine Shops have been established in 35 government hospitals. Patients can buy 142 essential medicines from these shops at 48-67.25% concessional rates. Artificial pace-makers, stents used in angio-plasty, orthopaedic implants are also available in these shops at concessional rates. Government has plans to set up Fair Price Medicine Shops in 86 more hospitals.

l    Fair Price Diagnostic services (patholcgy and radiology) under Private-Public Partnership have been set up in 84 block primary health centers and rural hospitals. Now there are 22 CT Scan centers and 8 MRI scan centers in different hospitals, mostly under PPP.

l    Government is planning to install Digital X-ray, CT scan, MRI scan and Dialysis facilities in some hospitals, where these services are lacking. The health department will pool money from different funds and buy the machines and private entrepreneurs will "Operate & Manage' the services.

l    Now there are 17 medical colleges and 2200 MBBS seats in the state. There is initiative to set up 3 medical colleges under PPP.

l    There are now 7 new health districts-Bishnupur, Jhargram, Nandigram, Diamond Harbor, Asansol, Rampurhat and Basirhat.

l    It has been learnt from Prof Abhirup Sarkar, the chairman of the state finance commission and member of the multidisciplinary group on health, that 13 multispeciality hospitals are being set up in rural areas and they have plans to set up 21 more in future.

l    District hospitals and medical colleges are being enlisted in the Rashtriya Swasthya Bima Yojana (RSBY). Now one can get RSBY facilities from 5 medical colleges, 13 district hospitals and 2 sub-divisional hospitals.

l    In a memorandum released on January 9, 2014, the government has committed to free supply of life-saving and essential medicines to all in government hospital OPDs and free indoor beds. One found 48 life-saving (vital), 67 essential-A, 68 essential-B and 56 essential-C medicines in a govt. list of January 18, 2011.

l    On 3rd March, 2014, the ministry has ordered to supply full courses of medicines to the patients. Earlier, patients used to get merely 3 days' medicines from the OPD pharmacy.

THE REALITY
The majority of the above information is from the ministry of health and family welfare publication 'Health on the March', 2012-13. But what is the reality?

l    There is vast disparity between the urban and the rural areas. Nearly two-third of the population live in the rural areas. In 2012-13, there were 13117 qualified modern medicine practitioners in rural areas and 39349 in urban areas. For practical purpose, the number in village is much less than the figure of 13117, because most of the doctors posted in village health centers or hospitals spend only 2-4 days in villages. The number of hospital beds is 16862 in rural areas and 92,100 (nearly 5.5 times) in urban areas.

l    The health personnel posted in the rural areas are dissociated from the rural life. The government is unable to fill the vacancies in the rural health centers and hospitals. One cannot understand how it will run the multi-speciality hospitals.

l    Generic prescription is definitely a positive step. In fact in 2002, in its Code of Ethics, the Medical Council of India instructed the doctors to use generic names. The Left Front government of West Bengal ordered the government doctors to write generic prescriptions, but in vain. This time the TMC government is maintaining strict vigil on the doctors. But problems remain.

l    Most of the essential medicines are not produced or marketed in generic names. While serving a generic prescription, the shop-keeper chooses the brands, the brands giving him most profit. The people cannot enjoy the benefit of generic prescription unless all the essential medicines are available in generic names. The pharmaceutical industry is not under state govt. control, but the State Drug Control is under the state ministry of health. The state drug control can refuse to give licenses to the brands. Several sick drug companies were undertaken by the state government, it can produce generic medicines in these factories.

l    The SNCU can be a good weapon in reducing neonatal and infant mortality. But in reality, they are under-staffed. One example : in an old medical college SNCU, there were nearly 70 babies, 2 doctors at a time for them. There were 3 nurses each in morning and day shifts and 2 nurses in the night shift. 90% of the time for the nurses go to feeding the babies, they cannot even keep watch on the warmers (to keep the babies warm). Sometimes the warmers shut down causing cold-injury, sometimes excessive heat causes blisters. In some SNCUs, proper room and/or equipments are missing.

l    The Fair Price Medicine Shops and the Fair Price Diagnostics are PPPs- private entrepreneurs make profit using public infrastructure, sometimes even fund (as in the cases of ensuing Digital X-ray, CT scan, MRI scan and Dialysis facilities).

l    There are some positive impacts of the Fair Price Medicine Shops. Bengal Chemists & Druggists' Association has been compelled to sell medicines at concessional rates. In Fair Price Medicine Shops, the cardiac stents and pacemakers are cheaper by rupees twenty thousand each. Now the dishonest doctors can get less cut-money. But the number of available essential medicines is not 142. It is 133, 9 are repeated twice. Different strengths and forms of the same medicine are enumerated in the list as different medicines. There are 90 useful medicines in the list. Among the 90, 68 are in the 2011 National List of Essential Drugs (having 348 drugs). The concession offered at different Fair Price Medicine Shops varies from 48% to 67.25%.

l    Among the 17 medical colleges, 3 are private. One has to spend rupees forty thousand and five hundred for the four and half years' MBBS course in a government medical college. The same course in a private medical college costs nearly rupees five lacs for a joint entrance examination qualified, rupees twenty-two lacs for local college admission test qualified, fifty-five lacs for one getting admission in NRI quota. The three proposed medical colleges in Kuchbihar, Dhubulia and Bhangor will be PPPs. The private entrepreneurs will make profit and will supply doctors for the corporate hospitals.

l    The government has increased MBBS seats in many medical colleges. But the number of teachers, hostel, lecture theaters remain the same.

l    The medical curriculum remains unchanged. The health problems of the marginalized people get scanty importance in it. In 2012, in West Bengal 23035 suffered from snake-bite, of whom 328 died. But medical graduates are not taught how to administer anti-snake venom. They cannot diagnose or treat occupational diseases. Surprisingly, the medical graduates are not skilled enough to treat diarrhea and cough & cold, though they know a lot about the rare diseases.

l    On RSBY—this scheme was introduced on April 1, 2008 for the population below poverty level. But many BPL and/or poor families are yet to get RSBY cards. Renewal of the card is free. But in some places, card-holders are being charged. RSBY has opened up flood-gate of corruption in the enlisted private hospitals and nursing homes. Patients having RSBY cards are being admitted even when the conditions do not merit hospital stay. Patients undergoing procedures under definite packages are being forced to spend out of pocket on one pretext or the other. Patient undergoes small procedure, record shows larger procedure to enable the hospital to gobble up extra money. BPL women in a certain district undergo hysterectomy for trivial gynaecological conditions as hysierectomy fetches good money to the hospital.... In enlisted government hospitals, patients having RSBY cards need permission from the hospital superintendent. There are touts who get your applications signed and charge money for their service.

l    The January 9 memorandum on supply of free essential medicines and the March 3 order on supply of full course of medicines have not yet reached the government—say some doctors from Nadia and South 24 Parganas.

l    In the January 9 memorandum the health department claimed that it had Standard Treatment Guidelines (STG) for primary, secondary and tertiary levels. But one finds STG only for the primary level, that also prepared during last government's regime. This STG is not widely publicized among the government doctors.

IN CONCLUSION
The problems of health care are deep-rooted. The reforms by the TMC government are only bringing cosmetic changes. The necessity is of a system of Universal Health Coverage, where the state will bear the responsibility of health care of all its citizens. The High Level Expert Group on Universal Health Coverage (constituted by the Planning Commission in 2010 under the chairmanship of Dr Srinath Reddy) advocated for such a system.

Let us dream of a system, where all the doctors are state employees, one can avail free consultation at pre-determined points, one is treated according to Standard Treatment Guidelines, one gets free diagnostic tests, free medicines, free specialist referral, free hospitalization... The state bears the costs from the money collected from direct taxes.

It is not a Utopia, it is possible. Nearly half of the countries of the world, some socialists, some capitalists, some developing countries like India, have Universal Healthcare. One should demand for Nationalization of the healthcare services.

Frontier
Vol. 47, No.11-14, Sep 21 - Oct 18 2014