Thoughts on Cadaver Organ Donations in India

Organ donation in India is still in its infancy. Everyone from the Union Health Minister Ghulam Nabi Azad to doctors working in both private and public sector hospitals concur on the need for more donations and advocate the creation of Organ Banks, greater public awareness about the noble cause of organ donations as well as on the urgent need of passing laws and developing transparent, hassle-free mechanisms, which allow swift organ retrieval, banking and transplantation.

I believe that the entire Transplant Program suffers from at least three severe malaise. These are lack of governmental regulation, poor infrastructure for quick retrieval and transplantation and total public apathy.

Apparently a comprehensive ’Transplantation of Human Organs Act’ is being considered by the Indian Parliament. The act once cleared by the parliament will hopefully lead to a far better utilization of the donated organs and create a network of Organ Banks, which would be able to freely exchange information about the availability of an organ, its swift retrieval, its likely recipient and the hospital, where the procedure might be done. While one can hardly fault the government on its intent, the execution of the program will determine its success.

The government must establish clear guidelines on brain death, when can organs be harvested, which hospitals (both privately owned as well government hospitals) are notified for organ harvesting as well as transplants, who all can donate an organ and what would be the process for locating the recipient once brain death has been established.

I would recommend that the government should establish an autonomous body, comprising of eminent doctors, organ transplant surgeons, lawyers of repute and other medical professionals who can come together to formulate guidelines on organ donations and transplants, establish mechanisms for quick retrieval and harvesting of organs from a brain dead donor and most importantly locate a recipient awaiting a transplant.

A national registry of all those who are in need of organ transplant should be established forthwith. It should list all individuals who need a transplant and should have their detailed medical records available on the touch of a button. The registry should also list organ banks and the hospitals who have the infrastructure and the capability to carry out transplants. These hospitals must have nodal officers/doctors, who can act quickly once a brain death has been established. These officials should access the medical records of those listed as needing an organ on the national registry, check out if they are suitable candidates for receiving an organ, establish the logistics of getting the organ and the recipient together at a hospital where a transplant can be carried out and than start the process of getting the patient and the organ to the hospital.

While, this may sound simplistic, this would require immense coordination and effort. This calls for a dedicated body, state of the art IT infrastructure, logistical support in safely transporting the organ, getting the recipient to the hospital at a moment’s notice and gearing up the hospital for a fairly complicated surgery at a very short notice. The government must take the lead in setting up this mechanism and ensure that it is fast, efficient and incorruptible. Most importantly the workings of this body, should be completely transparent. I fully understand that often this body will have to take decisions regarding who gets an organ and perhaps a new lease of life and who doesn’t. These will always be hard decisions, involving questions of life and death and must be taken with utmost care, without any prejudice and in a completely transparent manner. Thus, we must have people with a track record of great efficiency and of unimpeachable integrity running this institution.

Last but not the least, it is imperative that the government create awareness about organ donations. Cadaver donations in our country are minuscule. The trauma of the untimely and unexpected death of a loved one itself usually numbs the minds of those, who have take decisions related to donations. To make matters worse, many people still believe in reincarnations and can never imagine donating organs lest it impacts life in the other realm. The government must fight these obstacles resolutely, it should educate people about the benefits of organ donations and maybe reward folks who decide in favour of donations.

Donating organs of a loved one so that people, mostly strangers, get a new life is undoubtedly the most noble of gestures. It requires courage, conviction and immense generosity. The government must ensure that once someone takes a decision like this, the organ reaches the right recipients and many lives are saved. This should happen all the time, seamlessly and without fail.

The Perils of Standardized Health Care

Can healthcare delivery be standardised? This is the question, which has been bothering me this week.

The thought itself was triggered by a report in ‘Mint’ earlier this week titled ‘Government plans common healthcare standards’. (http://www.livemint.com/2010/08/24233218/Govt-plans-common-healthcare-s.html)

While the report portrays the benefits of standardization of care with millions of patients receiving standard care prescribed by the government thus saving them from being shortchanged by unscrupulous doctors and mercenary hospitals, there is also a flip (and a more real) side of the argument that we must understand.

While the government pushes through the Healthcare Standardization agenda, one wonders how can the delivery of healthcare be standardized across all medical facilities in the country? Every individual is different, reacts differently to treatments, the doctors are required to take decisions based on their experience and training and not on the basis of a set of guidelines decided upon by the government. If I was to fall sick, I would want my doctor to treat me based on his knowledge and experience and do what he feels is the best for me rather than stick to a standard set of guidelines mandated by the government. All doctors and medical establishment should have one guiding principle – the interest of the patient must be supreme and if there is a situation of uncertainty, I would want my doctor/hospital to always err on the side of caution.

Also, the healthcare delivery model in the country is hugely diversified. In its current form with poor regulation and monitoring it just does not lend itself to any standardization of care.The government-run tertiary care hospitals in large cities are filthy and over-crowded with patients and over-worked and under-paid doctors. The government run district hospitals as well as Primary Health Centres are even worse off with out dated equipment, poorly trained doctors, who often do not even show up for work. The private healthcare is dominated by secondary care establishments (usually called nursing homes), which have 10-50 beds and are usually owned by a doctor or a group of doctors. These are mostly mom and pop establishments, where owner doctors reign supreme and are answerable to none. Quality of care in these establishment is of dubious standard and these are neither properly regulated nor monitored vis-a-vis outcomes or treatment protocols. Christian missionaries and other charitable institution also run a large number of hospitals and now we have a nascent category of corporate style hospitals coming up in large cities offering cutting edge care. My point-all these hospitals are differently equipped, have differing goals (for profit, non-profit, govt. owned etc.), have vastly different resources at their disposal, have different cultures and widely varying medical expertise available to each of them. How on earth can they all provide standardised, similar quality care to their patients?

Last December my father underwent a prostate surgery in a hospital in Delhi. Elderly men usually require this surgery at some point in time in their lives. Now, while I researched the treatment options for him and took surgeon’s opinions I discovered that we had several options. Our surgeon felt that the best and the safest alternative for him would be a laser surgery involving a cutting edge holmium laser. Now, this option is not available at most of the hospitals even in a city like Delhi, thus it can safely be ruled out from the ‘standardised treatment guidelines’ that are being framed by the government. In a situation like this, will it mean that patients like my father will be denied this option and he will have to endure the conventional surgery with its attendant risks of infection, excessive bleeding and a much longer hospital stay?

Let us now also look at the genesis of all this.

The health insurance companies (mostly state-owned) want treatment protocols for some common diseases to be standardised so that they can fix a rate for these procedures, irrespective of the hospital and the doctor one chooses to go to. For the insurance companies this will lead to a state of nirvana, as they would be required to pay a fixed lump sum to the hospitals irrespective of the bill a patient runs up. They can then squeeze the hospitals further and make greater profits. Now, I am not against profits, however the problems that I see in this arrangement is that the patient will suffer, the quality of care will go down as hospitals will try to manage the delivery of care with in the financial limits set by the insurance companies (after-all they also need to be profitable). This is clearly hazardous.

One buys a health insurance cover to ensure that in the time of need, financial constraints do not come in the way of accessing the optimum quality healthcare. The operative words here are ‘optimum quality’ and not ‘standard quality’ as mandated by the government. To equate these two will be a great folly. If the insurance companies believe certain hospitals are taking advantage of the situation by excessive billing (which I submit happens), they must put in place strict monitoring mechanisms including peer group reviews of treatment provided by the hospital. A healthcare regulator needs to be set up by the government to arbitrate between insurance companies and the hospitals. The regulator can possibly frame broad treatment guidelines, which can serve as references in case a dispute arises between a patient, the hospital and the insurer.

Standardizing treatment protocols in a healthcare environment as complicated and as unregulated as ours is a dangerous and mostly an impractical idea. We need to first standardize our healthcare delivery systems before even thinking about standardizing treatment protocols. Paying hospitals based on these standardized treatment protocols because it makes health insurance companies profitable is inviting hospitals to cut corners. Once this happens, it will lead to serious erosion in the quality of care and even more importantly a big trust deficit between patients and hospitals will emerge.

That would really be the ultimate irony, for if a patient does not trust his doctor or hospital, he really would have nowhere to go.

The Apathy of Delhi Hospitals Towards the Poor

The Delhi High Court has been after private hospitals in Delhi to honour their commitments regarding the treatment of the poor, but sadly to no avail. The hospitals are just not willing to treat poor for free, a condition that they agreed to while accepting land from the government at hugely subsidised rates. In-spite of the Delhi high court directing the hospitals time and again to fill up the beds for the poor, the hospitals are dragging their feet by hiding behind every legal loophole that they can find.

For the uninitiated here is the story. As many as 38 private hospitals in the city managed to get land at subsidised rates from the government under the condition that they will treat certain number of poor patients free of cost. The list of these hospitals today read the whose who of the hospitals in the city. However, once these hospitals commenced operations, they never honoured their part of the bargain. Thus the poor continue to be unwelcome in these hospitals, while beds reserved for them either remain empty or are filled up with full paying patients. This needless to say is criminal.

The reasons for this, however are not too difficult to fathom. The business of healthcare is a capital intensive business and the cost of real estate in Delhi is a prohibitively high expense. Thus, getting land from the government at very cheap rates against a commitment of treating the poor once the hospital starts, seems to be a good way of grabbing land. I seriously doubt that any of these private hospitals had any intention of treating the poor to begin with. This was just a ploy to grab land to build the hospital.

Now with the hospital up and running they had to find excuses to wriggle out of the commitment made. Here is a sample of what the hospitals have been saying. A large 600 bed hospital sitting on prime land in south Delhi and part of the largest hospital chain in the country claims that they are unable to treat the poor because they can not find them! As per them the government needs to refer poor patients to the hospital, and since there has hardly been any government referrals, they can not fill up the beds reserved for the poor. They further claim that ‘free’ to them means a free bed and the patient has to pay for all other expenses, thus making the hospital out of reach of the poor. (Mercifully, this claim has now been thrown out of the window by the high court). Other hospitals too advance similar claims. Strangely many do not offer any reason for not filling up these beds.

A recent report in The Times of India indicates that 16 of these 38 hospitals have not even bothered to submit details of the status of their free beds to the government. Hospitals like Dharmshila Cancer Hospital and the Jaipur Golden Hospital have submitted that all their free beds are empty. The Times of India report also alludes to a nexus between the health officials of the government and these hospitals. The health officials refer their kith and kin or their political masters to these hospitals and they are treated free against the beds meant for the poor.

While all this has been going on for many years, some public spirited Non Governmental Organisations have moved the courts. The high court has made all the right noises but justice is yet to be done. While the cases against these hospitals meander in our courts, the poor, as always continue to suffer silently.

Pic courtesy http://www.flickr.com/photos/9019392@N08/552358084/

National Emergency Services-The Need of the Hour

The other day I was at the Delhi airport early in the morning waiting for the security check to get over, when I realised there was some commotion ahead in the queue. As I moved on, I saw a man flat on his back, and a lady, apparently an air hostess trying to revive him by administering the CPR. There were a bunch of people including some security men looking on. The lady was doing her best, but it was quite apparent that she would not succeed. She appeared to be going through the motions rather than making a desperate attempt to save a life.There was no one else to help her, while many watched idly. I did not see any medical personnel or the emergency medical paraphernalia, that one would expect on such an occasion. The man had been without a pulse for almost 20 minutes, before CPR had commenced.

How can a busy airport (brand new to boot) be without adequate medical emergency back-up? Almost a year ago when I was working for Artemis, we had proposed to the authorities to allow us to set up an emergency service at the airport. Artemis is reasonably close to the airport, has an Advanced Cardiac Life Support (ACLS) equipped ambulance service and the hospital is fully geared to manage medical emergencies round the clock. Nothing came of our proposal and the last we heard was that Indraprastha Apollo Hospitals has been awarded the contract to manage the medical room at the airport. Apollo Hospital is all of 40 kms or more from the airport and with the traffic that one usually encounters on the way, there is no way that an ambulance can reach the hospital in less than an hour. That fateful day, there was no one for at least 30 minutes from Apollo or anywhere else, to help the unfortunate man.

India attracts scores of patients from across the world, most of them benefit from the world class healthcare services now available in the country yet we do not have an emergency service that can be remotely called world class. This is a serious concern.

The government must take the lead in establishing a centralised medical emergency service through a statutory body, let us say, Medical Emergency Services Authority of India. It can work out the details of how this service will operate, the nodal hospitals, the communication infrastructure and the logistics of transporting patients to these network hospitals. It should set clear guidelines on managing emergencies (who, what, where, how), establish internationally benchmarked service levels and establish a monitoring authority to measure efficiency and service levels

The Medical Emergency Services Authority should be allowed to set up emergency handling outlets in high traffic areas like airports, on national highways and busy malls etc. The Authority would be required to invest in the communications and transport infrastructure including paramedical personnel, while the participating/network hospitals will be responsible for patient's care once the patient reaches the hospital.

While all this and more is possible, the key question is whether we should have private participation in something like this. I believe we should not. This is a service that should be rendered by the government to its citizens in distress. It should be paid for by the taxpayers. The government can charge a small sum from the taxpayers annually to keep the service afloat. The real challenge for the government would be to maintain high standards in the face of crippling bureaucratic controls that underlie all government initiatives. Corruption, sloth and inefficiency so characteristic of all government organisations must not be allowed to eat at the vitals of this service.

Easier said than done. Maybe the government can find another Nandan Nilekani or an E Sridharan and give him a free hand to set this up. I would like to believe if there is a will and a burning desire to accomplish something as important as setting up the National Emergency Services a way can certainly be found. It is afterall the need of the hour.

Pic courtesy www.flickr.com

Compulsory Rural Postings After MBBS

The Hindustan Times reported a few weeks ago that the Union Health Minister Dr. Anbumani Ramdoss has announced that young medical graduates, fresh out of medical schools will now have to mandatorily serve one year in rural and semi-urban centres in India.

Dr. Ramdoss believes that this will help in augmenting healthcare services in these parts of the country. It is well known that in the Indian hinterlands the availabilty of healthcare services is pathetic.  In villages, where more than 66% of India lives, it is rare to find a qualified doctor. In semi-urban centres too modern, good quality and reliable healthcare is largely unavailable.    

The government has set up a network of Primary Healthcare Centres in the rural areas. However, these centres are mostly crumbling buildings with poor or non existant medical infrastructure. The doctors posted in these back of the beyond places are mostly conspicuous by their absence. District Hospitals established in all district head quarters are also in a bad shape. The medical infrastructure is poor, doctors are poorly paid and are mostly buried under an avalanche of patients. 

While good quality healthcare remains out of the reach of most Indians living in rural and semi-urban India, their does seem to be a crying need for qualified doctors. However, I am not sure if a compulsory posting of young doctors is the solution.

The minister must recognise that young doctors passing out of India's medical colleges aspire to a career in medicine, which can afford them a modern and comfortable life. They see their peers passing out of fancy business schools choosing high profile careers in business . A doctor toils much harder-many years at the medical school to earn a grduate degree, followed by a gruelling post graduate course and than the struggle for a job in an intensely competitive medical world. Now to send them for one more year to the inhospitable Primary Healthcare Centres and District Hospitals appear to be cruel.

Moreover, one is not sure how competent fresh medical school graduates are and what quality of care will they be able to deliver in ill equipped and distant rural and semi urban medical centres, where they might have to work unsupervised. While, they may be much better than what we have today (assorted quacks), they will hardly be able to do justice to the demands of their profession.

While the minister might argue that since medical education in India is largely subsidised by the government and therefore it has a right to ask these young graduates to spend one year of their professional life working for the government in far flung inaccessible areas, this would hardly cut any ice. By the same logic shouldn't engineers, business and science graduates passing out of government owned colleges and Universities be also required to serve in remote areas. This can never work.

I do believe that there are no easy answers here. It will take many years for good quality healthcare services to 'trickle down' to these remote rural areas. For the moment, the government must provide roads and communication infrastructure, which allows patients to be quickly transported to urban centres, where relatively better healthcare is available. The government must offer incentives such as an option for subsidised post graduate education, health insurance and guaranteed employment for doctors, who choose to serve a year or more in rural hospitals. 

Last but not the least the government must improve its healthcare infrastructure. It must invest in better equipped facilities, ensure better hygiene and provide a better professional work environment. It can even experiment by involving private players in a model which guarantees minimum returns on private capital and the franchisee will guarantee far better and more efficient care.

At the end of the day, the government must try and attract young doctors rather than force them into rural postings.