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.

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The Fight Against Malaria

Earlier this week I was in Mumbai. Monsoons in Mumbai usually mean unrelenting rain, it drizzles and then suddenly it pours and is again back to the drizzle, it never  appears to stop raining. Weatherman have been unanimous in asserting that this year so far has been one of the wettest in Mumbai in the last 5 years. While the rains have been bountiful, Mumbai has been shivering like never before-it is in the grip of an epidemic of malaria.

The evening broadcast on the television confirmed a few deaths and put the numbers affected by the disease to a few thousands, with over 800 fresh cases reported in the last few days itself. The hospitals are overflowing with the sick. In fact such is the press of patients that Mumbai Hospitals are setting up huge tents on their premises and putting additional beds to cope with the patients. Raj Thackeray the looniest Shiv Sainik has already blamed the North Indians living in Mumbai for the disease. Incredibly he believes that these people living in squalor in Mumbai are spreading the disease and the outbreak will stop if Mumbai was rid of this scourge.

Unknown to Mr. Thackeray, malaria parasite has a history, which dates back to over half  a billion years. The origin of Malaria can be traced to Western and Central Africa. About half a billion years ago the pre parasitic ancestors of the malaria parasite adapted to live in the gut of a some aquatic animals. They subsequently proliferated and evolved to live in insect larvae found in still water bodies. These insects first appeared around 150 million to 200 million years ago. During this period, certain lines of the ancestral malaria parasites achieved two-host life cycles which were adapted to the blood-feeding habits of the insect hosts. In the 150 million years since than, many different lines of malaria and malaria-like parasites evolved and radiated. The malaria parasites of humans evolved on this line with alternate cycles between human and the blood-feeding femaleAnopheles mosquito hosts.

With the advent of agriculture and human settlements, the density of the human population increased. These settlements largely concentrated along inland water bodies. Thus the mosquito population thrived feeding itself on a large and stable supply of human blood. From its origins in Africa Malaria spread rapidly across the globe and became the worst killer disease known to humans. The Chinese knew about Malaria 5000 years ago and Egyptian mummies with enlarged spleens are believed to be the remains of ancient Egyptians who died of Malaria. The disease was rampant in the Indian sub-continent 3000 years ago, Alexander the Great is believed to have died of Malaria in 323 BC, on his way to India.  The disease reached the Mediterranean about 2000 years ago and invaded Europe almost a 1000 years ago. Increasing trade and military conquests spread the disease globally and by the 18th century the scourge was at its peak with half the world’s population at risk. Poor living conditions, famine and poverty contributed to high mortality.

As the western world advanced, living conditions improved contact with the vector declined leading to a spontaneous reduction in Malaria in those parts of the world. By the middle of the 20th century Malaria had been conquered in North America and Europe. However, the fight for eradicating Malaria continues in the tropics.

As the fight against malaria accelerates the world over, an estimated USD 10 bn are being spent in an effort to eradicate it. The goal of this world wide effort is stop all malaria deaths by 2015 and finish the disease by 2035.  The fight is a global effort to improve the living conditions of people in the third world, provide effective protection (such as chemically treated mosquito nets and new generation mosquito repellents) and provide easy access to medical care even in the worst affected and remotest parts of Africa. Global pharmaceutical companies are researching the disease like never before in the hope of finding more effective drugs that can significantly bring down mortality.

Going by what I saw in Mumbai, I shudder to think how ordinary people must be coping with this outbreak in the rural areas, where healthcare services are almost non-existent. The time has now come to take up the fight against Malaria pretty much like the government has been fighting tuberculosis and polio in the country. The government’s flagship health scheme the National Rural Health Mission, must take the lead and orchestrate a nation wide initiative against malaria. A sustained effort should be made in educating people about the perils of Malaria. The government should take preventive steps such as defogging of the vector’s breeding grounds the distribution of medically treated mosquito nets and free distribution of mosquito repellents may help prevent the disease. The Primary Health Care centres must be equipped with kits needed to quickly diagnose and treat the disease. The government health workers should be able to proactively report the likely cases and the PHC doctors should be able to intervene to stymie the disease before it becomes fatal.

All this and more is possible only if there is a will. The money can be found. More than anything else we need dedicated people who feel strongly about this ancient scourge and who are willing to lead in this final battle.