It is time to experiment with “health out-reach  program” to rationalize patient traffic  across three tiers of healthcare.

Billions of rupees have been spend on the health care in the State of Jammu & Kashmir over the last few decades and considerable expansion has been done in this area. However, the State has yet to experience a health care delivery of the type, which would suffice the needs of the community. There are a number of reasons for this; most significant being the conflict state is going through since last two decades. This has directly affected healthcare in many ways which include higher incidence of diseases, changing epidemiology of diseases with trauma and mental health disorders as front runners, breakdown of law enforcing agencies, easy access of unethical and unlicensed business agencies to health care facilities, exodus of the medical personal for security reasons and excessive pressure on the existing skeletal staff. While this was so, medical community has shown apathy to take position on many vital issues of healthcare planning and society has accepted sub-optimum healthcare facility. Administration has shown inability to adapt to rapid changes in healthcare planning so avidly seen in systems outside State and in the West.

Health care policy and planning is an ever-changing vibrant area of overall administration and has to be addressed in view of the changing national and international health policy and planning.  The changes in such policies have to be done keeping in view the cultural and socio-economic environment of the society. Health-care in the state of Jammu & Kashmir (J&K) has taken a severe beating over the last 2 decades and methods of its revival as practiced today need to be intensified.

Optimum health-care for State of Jammu & Kashmir should be defined under following headings:

1. There should be a clear-cut health policy and planning with clear objectives. This should be widely known, debated and constantly updated with new information in such area.
2. Each unit of health-care (primary, secondary and tertiary) should have clear overall mission statement and yearly goals which need to be monitored and achieved.
3. All three tiers of health system must be integrated and a clear-cut referral policy to and back should be available for continuity of care. Tertiary care unit must use an outreach policy to support primary health care developments.
4. Health care should address the needs of the community health- may be preventive, primary health, secondary level care, and tertiary health problems. Practices, procedures and therapies not available should be made available to the needy through a coordinated mechanism and in the last decade a number of such means are being practiced in many places at national and international level.
5. An initial and continuous in-service (on the job training) to health care givers must be done to prepare them to serve the community as care givers, physicians, advisors and important people in the community.
6. Of great importance is the fact that health care givers must respect every human being, keeping in view his beliefs and social status. A “bill of rights” needs to be adopted which gives patient following rights: (i) Right to dignity, and  respect, (ii) Right to information, (iii) Right to take decision on his health matters, (iv)  Right to have “second opinion”, (v)  Right to address his concerns. Physicians are generally against asking for a “Second Opinion” when needed, patients feel apprehensive to divulge to their physicians that they want a “Second Opinion”. This has created a peculiar phenomenon in our society and patients do talk about the need for rushing to other cities for medical help.
7. Health care giver must not do any harm to those under his care and he must make every effort within him to prevent such harm being done by the system to which he (physician) exposes him (patient). Medical error and negligence should be addressed through a transparent, credible and evidence based systematic policy.
8. At no cost health care giver must exercise personal bias-monetary or otherwise in identifying the health delivery including medication to his patients.
9. Health care giver must have high standard of ethics, morals and discipline. He must follow health care rules and regulations and teach everybody to follow these to the ultimate.
10. All treatments must be cost effective, current and evidence based. Modern practices being experimented and proved to be of benefit must be carefully introduced under close monitoring.

Health care in the State of Jammu & Kashmir must be addressed at multiple levels.   One issue which has been haunting our tertiary health care is overcrowding and massive overstretching of its facilities. Our tertiary centres accept and report on attendance of millions of patients with exceptionally large number of laboratories tests, procedures, surgeries and hospital admissions done over short periods.  This overstretches these facilities and makes these centres inefficient and reduces patient satisfaction and brings poor rating of our health care. There are many reasons for unusual rush of patients to these centres which include: (i) poor development of primary health care system; (ii) lack of confidence of society in primary health care; (iii) lack of application of tertiary centres to streamline their work load conducive to their capacity; (iv) lack of a strong referral system across 3 tiers of healthcare. Our tertiary centres were built up very thoughtfully for managing patients with advanced and complicated disease states and given responsibility to conduct highly sophisticated patient care management available anywhere in the world. By accepting and managing patients with simple disorders (which can be managed in the primary care as well), these centres are diluting their activities and wasting their otherwise precious time to give basic health care. Other than making these centres in-efficient, the basic purpose of these centres is lost and this is a waste of huge ex-chequer budget utilised to build and maintain these centres.

Are there any loop holes which support this overcrowding? First loop hole is that we cannot implement a strict legal referral system in our society because of its political and social implications. It shall need a very strong political will to streamline patient traffic on a defined law and I am sure we are not ready for that as of today. Second is we encourage rush to our centres by exposing our highly trained super-specialists to private practice which allows private visits by routine walk-in patients. These walk-in patients find easy access to our tertiary centres and even are pampered and preferred to those who attend these centres through direct registration. Third we have failed to define missions of our health units and thus cannot limit our activities to tertiary work. For example if we give a mission slogan that our speciality maternity centres only cater to complicated and high risk pregnancies,   it shall reduce the load of these centres by 90 percent. Yes, all other pregnancies need to be taken care in the primary care. Similarly, speciality departments dealing with cardiac, neurology, gastroenterology etc can define the type of patients acceptable for treatment and this shall streamline their load and activities. You might think these ideas are not practical; however, I have personally experimented these while I worked in SKIMS and abroad in KFSH, Riyadh and have worked without any problems and markedly improved patient care and patient satisfaction. Society either here or in Middle East has never objected to this arrangement.

Over and above this, one program which has markedly improved patient care and patient satisfaction in the Middle East is called “Health Outreach program”. This program is run by KFSH Riyadh and I have personally been a part of it over a decade.  This service is based on a partnership between tertiary health centres (KFSH Riyadh) and primary health centres (primary centres all over the country) for improvement in healthcare by enhancing clinical practice, promoting education and training and standardizing management of specific diseases. Through this program tertiary centre adopts primary outreach centre for developing its activities in a number of important areas. Main focus is regular visits of senior faculty to these centres usually on weekly or in some cases monthly rota. Usually one senior faculty in a speciality adopts one centre and this way a service can adopt multiple centres all over the region. The protocol for each visit is drafted by mutual discussion. Faculty can run a clinic and extend consultation to patients booked for him, take rounds on in-patients, help develop diagnostic facilities, and do in-service teaching. Staff, medical and Para-medical can makes short visits to tertiary centres for in-service.
Apart from what faculty visits, patients from primary centres can be referred to tertiary centre and those discharged from tertiary centres can be followed up in primary centres. This program helps society to develop confidence in primary healthcare and markedly reduces rush to tertiary centres. It also helps tertiary centres to accept a defined optimum specific load for its activities. KFSH Riyadh has now expanded this program for e-health and all educational programs in KFSH are being transmitted through telemedicine facility throughout these centres. Also KFSH extends patient consultation and management admitted to primary health centres through its telemedicine program. It is believed that “Health Outreach Program” is one of the most important health care activities in improving patient care in developing countries and improves patient satisfaction and has been greatly applauded by World Health Organization. If such a program is successful in our community, it shall become a base for starting a stricter referral system between three tiers of healthcare in future.

(Prof Muhammad Sultan Khuroo, MBBS, MD, DM, FRCP (Edin.), FACP (USA), Master of the American College of Physicians is Director Digestive Diseases Centre, Dr. Khuroo’s Medical Clinic Sector 1, Sher-e-Kashmir Colony, Qamarwari, Srinagar, Kashmir. Mail at khuroo@yahoo.com or visit at www.drkhuroo.org)

Lastupdate on : Fri, 8 Jan 2010 21:30:00 Makkah time
Lastupdate on : Fri, 8 Jan 2010 18:30:00 GMT
Lastupdate on : Sat, 9 Jan 2010 00:00:00 IST