Blissful Life

Category: mbbshacker.blogspot.com

  • Don’t Jump On Private Healthcare

    People from Koodam asked for opinion on the PIL in Supreme Court regarding fees in private hospitals (and clinical establishments act). They shared a folder collating views of various individuals, including this excellent working paper which I refer to in the text below as Oxfam publication.

    ***

     Hi Gayatri, I went through the whole folder. All I wanted to know was
    what Koodam was. But, lol. Anyhow. What I’m going to write is obviously
    my personal understanding of the transformative nature of law (and the
    limits of it). It is going to be biased by my worldview. I’m going to
    label them explicitly as much as possible.

    Regarding the nature
    of documents in the folder    . The compilation, over all, is very nice.
    That’s mostly because of the excellent documents prepared by JSA. Minus
    that, the arguments and the scholarship is rather weak. Koodam which
    explicitly says “diverse views” has the least diverse of views. The
    Oxfam publication by Abhay Shukla, et al is perhaps all that one needs
    to read.

    Regarding non-additive nature of law, and the paradox of
    how parts are worse than the whole    . I am not sure how well I can
    articulate this. But basically, for law to act in transformative way, a
    series of measures that are all reinforcing each other need to be
    enacted together. This is hinted to in the JSA/Oxfam publication. If
    there’s unbalanced law that’s enacted, it creates all kinds of
    unpredictable troubles. In law, 1 + 1 + 1 is not the same as 3. The
    order of laws, the simultaneousness of it, everything matters.

    If
    there’s unbalanced push for price regulation, without other mechanisms
    that lead to a holistic transformative change (eg: competition
    introduced by well functioning public healthcare, financial support from
    government, in-sourcing of private healthcare providers, control on
    corruption, etc), then there’ll be more failures than success. Examples
    of this generated by AI: https://www.perplexity.ai/search/Give-me-examples-k9aCXE9ERCyq9LnFzWDvZA

    Private
    sector is not a homogenous villain    : Various documents here takes a
    black-and-white opposition to “private”. This is wrong in two ways –
    politically and conceptually.

    Politically, if one were to really
    get this going against the “medical industrial complex” and IMA and so
    on, one has to cleave the opposition (divide and rule). And the easiest
    (?) way to do that is to turn small clinics against big hospitals.
    Putting all private providers in one bucket only helps solidifying them
    as one bloc

    Conceptually, all the accusations against medical
    industrial complex applies only to big hospitals. But the “dominant”
    private healthcare system is not big hospitals, it is the clinics and
    the single practitioners. If the argument is that these are all corrupt,
    it is an unwinnable argument. Firstly, a lot of these clinics and
    single practitioners are not corrupt. They’re just people like you and
    me going about their daily lives, with as much influence of capitalism
    as every other profession has. Secondly, one just can’t call an entire
    class of profession corrupt unless one is also going to radically
    restructure the world and actually thinking of revolution.

    On the
    specifics of fixing price    : Fixing price is a thoroughly impractical,
    de-contextualized solution. Chinu’s very brief response is very
    important. Fixing price might actually cause increase in price. I have
    written about consultation fees in general practice https://mbbshacker.blogspot.com/2019/09/the-curious-case-of-consultation-fees.html
    – the biggest challenge for me as a practitioner is that I’ve to make
    it sustainable while at the same time charging a bit fairly. Fixed price
    almost never works for me. If I’m forced to, I’ll choose a higher
    price. And there’s nothing in the CEA that prevents me from choosing a
    higher price. So, in turn, there’s not much that transparency achieves
    (is this the point that Amar  is making? I read it too fast)

    On
    market    : My father had a sagittal sinus thrombosis a few years back. I
    am thankful that there was an Aster MIMS in Kannur. I didn’t care about
    the money at all. There’s an upper class in India (like my family) that
    prefers to not worry about cost, but only worry about health. This
    market exists.
    I hate capitalism. But one thing I know about the
    world is that when there is a market for something, there’s no
    regulation which can stop that from being capitalized. By hook, or by
    crook, things will happen. This is true for banning alcohol, weed,
    drugs, and so on. This is true for organ trade, human trafficking, and
    so on. This is true for almost everything. We really can’t fight the
    market.

    On the political climate: There’s a section on political
    economy in the Oxfam publication. But what about the political climate?
    What political will is there in the present political scenarios to look
    at deep societal transformation in the areas of health. This is a high
    risk gamble with low rewards for politicians.

    Am I being too
    pessimistic    ?: No, I’m really surprised why the Koodam didn’t take up the
    issue of “right to healthcare” which is much easier to understand, has a
    momentum going for it, and can be used to focus both on public
    healthcare and private healthcare. Taking CEA from a decade ago seems
    ill-timed. Unless of course, this is placed in the larger context of
    right to healthcare and the focus is shifted to the patient rights
    charter. We really need to build an alliance with small private clinics
    and practitioners. Something like patient rights charter is such an easy
    first step

  • What is mfc?

    A year ago, I asked in mfc‘s own e-group this question. You can read that long email and another long email after a week with more ideas of what mfc is here. It ends with an appreciation of what the website presently says about mfc:

    It is an organization which has operated for forty eight years as a
    ’thought current’ without allegiance to a specific ideology. Its only
    commitment has been to intervene in and understand the debates, policies
    and practices of health in Independent India. The understanding that
    our present health service is lopsided and is in the interest of a
    privileged few prevails as a common conviction.  It has critically been
    analyzing the existing health care system and has tried to evolve an
    appropriate approach towards health care which is humane, and which can
    meet the needs of the vast majority of the people in our country.

    [If anyone knows who wrote this, please let me know]

    Of course, this has to be updated to say “50 years” now because mfc just had its 50th annual meet at Sewagram last week.

    In the 49th annual meet during the general body meeting there was a comment by someone that they didn’t want people who ask things like “what is mfc” [in a mocking tone] in their volunteer group for 50th year meet. Funnily enough, the 50th meet and the bulletin released was revolving around exactly this question on identity.

    Ritu Priya’s article was titled “The Debt I Owe to MFC as the ‘Informal University’”

    Anant Phadke’s article was titled “My Reflections on MFC A Consistent Yet Feeble Pro-People Platform in Health care; The Fee-less, Open University of Community Health”

    Sathyamala quoted from their own previous editorial

    MFC is an organization. No, it is a circle of friends. No, it is a thought current. No, it is not even an effective thought current. MFC should debate issues. No, mfc should act. No, mfc is only for Mitra Milan. No, mfc should take stands. MFC has missed the bus. MFC members are unfriendly. MFC is like a family. The Bulletin serves no purpose. Bulletin must continue. Close the Bulletin. The Bulletin is MFC’s life line. Let us decide once and for all what is mfc. How can we decide once and for all what is mfc? MFC is not professional enough. MFC is too elitist. MFC which way to go, which way not to go. (Sathyamala 1998)

    Sathya then goes on to call mfc as an “epistemic community”.

    The rest of the articles are also about what expectations from mfc have been and what mfc have been able to or not able to do.

    Similarly, in the meet, there was a session about mfc and its future. There was the idea of forming a steering group to define a constitution for mfc and decide on questions like maintenance of website, bulletin, etc. The Q&A session here also spent considerable time in the question of what mfc is. This took the form of a debate between mfc defined as a “friend circle” and mfc as defined in the brochure:

    The Medico Friend Circle (mfc) is a nation-wide platform of secular, pluralist, and pro–people, pro-poor health practitioners, scientists and social activists interested in the health problems of the people of India. Since its inception in 1974, mfc has critically analyzed the existing health care system and has tried to evolve an appropriate approach towards health care which is humane and which can meet the needs of the vast majority of the people in our country.

    In this post, I’ll look at this issue once again and try to define what mfc is, or at least what mfc is not (as Ashok Bhargava once suggested).

    ***

    Before we go into that, we need to discuss a couple of things about defining mfc.

    Firstly, defining what mfc is and defining what mfc should be are two different things. What mfc is is a (difficult) question of describing the reality of mfc as close to possible which can be done by anyone who has spent sufficient time observing mfc. What mfc should be is an even more difficult question which requires consensus and vision, and brings up plenty of other operational issues. In this post I’ll focus first on defining mfc, and at the end venture slightly into what mfc should be.

    Secondly, what mfc is and what mfc did are two closely related yet separate questions. Plenty of times people equate these questions and end up in a soup. The answer to what mfc did is indeed useful in understanding what mfc is. But if we just rely on what mfc did to define what mfc is, we will land up in improbable expectations from it.

    And finally, defining mfc is an attempt to seriously engage with mfc and should not be seen as an attempt to diss mfc.

    So, let us first look at what mfc is not:

    …an organisation coming together for collective action at times of a crisis

    Yes, mfc did it. During Bhopal disaster, mfc came together for collective action. During carnage in Gujarat in 2022, mfc came together for collective action. For access to drugs, AIDAN was formed collectively. But these are things that mfc did. There’s no guarantee that mfc will come together at times of a crisis. Manipur and Gaza were made discussion topics at mfc annual meet in Feb 2024 probably in an effort to resume this collective action. But that’s not what mfc is. mfc is not an organization meant for action. It doesn’t have a budget. It doesn’t have any paid staff. It is not meant for any action.

    …an epistemic community influencing health policy

    Yes, many people from mfc did participate in the run up to National Rural Health Mission. Yes, people from mfc have done judiciary activism. Yes, mfc has a big role in JSA. But mfc cannot be an epistemic community because an epistemic community is a network of recognized experts. mfc has always been open to anyone – expert or not. Of course, mfc does include experts who could form an epistemic community of their own. But mfc also includes non-experts. And therefore, by definition it cannot be an epistemic community. 

    …a friend circle

    This is probably the hardest to convince people in mfc that mfc is not. Even people who don’t want to define mfc primarily as a friend circle will say that it is indeed a friend circle, at least secondarily. I believe that this definition of mfc is also in the realm of what mfc did and also what mfc should be, rather than what mfc is. To define mfc as a friend circle, though, would be stretching the definition of friend circle. Sure, I have made and nurture several deep friendships through mfc. But mfc is primarily composed of strangers. In the e-group, as of today, there are 716 members. I barely know 50 of them. Most people in mfc don’t know most people in mfc. There are also people I find annoying within mfc. People I would never call friends. It is very difficult to call mfc a friend circle, no matter how warm the environment is and how friendly people are.

    …a think tank

    Think tank is defined as a “group of experts brought together, usually by a government, to develop ideas on a particular subject and to make suggestions for action”. mfc disqualifies for reasons mentioned above under epistemic community.

     …a thought current

    If you read the emails linked above, you’ll see that the word thought-current itself is a buzzword that leaves us no further than what we began with. If you define thought-current as think-tank above, then mfc doesn’t qualify. Basically, it is a circular definition.

    …a platform for exchange of ideas related to people’s health

    This probably would have been a nice definition for mfc in 1970s and 80s assuming there was no other platform for exchange of ideas related to people’s health. But in 2024 when you have plenty of avenues for publishing ideas and exchanging it with the rest of the world and instantly getting feedback thus furthering the exchange, to call mfc a platform would be demeaning the word “platform”. Of note is also the fact that mfc had a barely functioning website till last year. mfc continues to not have a social media presence. It is very difficult to convince someone interested in people’s health in 2024 to join mfc for exchange of ideas.

    What is mfc?

    Let me reiterate what I said above. By discarding these “definitions” I’m not trying to say that mfc has not served these roles or that mfc should not be these things. I’m simply trying to say that mfc needs to be defined more accurately to represent the reality.

    At this point, it would be a disappointment if I didn’t present an alternate definition.

    Let me first document a couple of definitions that I discarded.

    I had tried to draw an analogy to an alumni association. An alumni association is just a group that exists because of some historical coincidence. It doesn’t have particular objectives or structure. It is just a group that exists, have shared nostalgia, etc. This doesn’t accurately describe mfc either.

    Then I thought about saying “mfc is a hashtag”. mfc is like a hashtag people use on twitter where there is not much of a structure, but things could happen sporadically. And there is a lot of discussion around the same hashtag. But then I found something better (thanks to AI)

    mfc is a community of interest

    Wikipedia says the following:

    A community of interest, or interest-based community, is a community of people who share a common interest or passion. These people exchange ideas and thoughts about the given passion, but may know (or care) little about each other outside this area. Participation in a community of interest can be compelling, entertaining and create a community where people return frequently and remain for extended periods. Frequently, they cannot be easily defined by a particular geographical area. 

    The difference from epistemic communities and “community of practice” is that in community of interest, expertise is not a pre-requisite. Anyone can join a community of interest.

    Let’s not forget what a “community” is: “A community is a social unit (a group of living things) with a shared socially significant characteristic, such as place, set of norms, culture, religion, values, customs, or identity.”

    mfc is a community of interest that’s formed around the shared interest of a pro-people, pro-poor health system. Experts and non-experts are welcome to participate. The main mode of exchange of ideas in mfc have been through yearly meeting, publishing a bulletin, and discussing on an e-group, all organized democratically and with a spirit of friendship that transcends ideological divides.

    mfc going forward

    I would have to be the kind of academic I hate to describe something to great detail and do nothing with that.

    Going forward, there are a few things I would like to do with/through the mfc community (that should be the name!):

    1. Tap into the knowledge that is embedded within individuals in the mfc community and make this tacit knowledge more explicit through discussions that are centered around such knowledge — for example, knowledge on how to solve some of the problems encountered while traveling towards Health-for-all.
    2. Surface individuals and groups that are setting good examples into the public consciousness through corrective and creative use of powerful tools like the internet.
    3. Develop the strengths of mfc as a healing community for saving disillusioned medicos from anti-people healthcare system and manifest in them the vision of a pro-people health system and the skillset required to reach there.
    4. Embrace the concept of an open/informal university and bring together all groups/individuals with similar thought-processes (SOCHARA, CMC Vellore, THI/travel fellowship, etc) to double down on the concept of open/informal university and internet based pedagogies.
    5. Nurture the/a community of practice within mfc that serves as a reliable knowledge respository for communities of action like JSA and SAA-K.
    6. …
    7. …
    8. … 
    9. …
    10. …

    References

  • Why Medical College Work Culture is So Horrible

    A number of junior residents at Jipmer have raised allegations of mental and physical harassment against the head of department, medicine, and called for action against the senior faculty.
    In recent complaints lodged with the Jipmer Dean (Academics), the residents alleged they were subjected to various forms of harassment at the hands of the department head during the three-year PG residency. They sought re-examination of the results of the exit examination on December 23 as they suspected they were deliberately failed in the practical segment by the faculty member.

    This is from The Hindu a couple of days ago.

    This is just one among the many thousands of such incidents across medical colleges. It would be really difficult to find a medical college which doesn’t have harassment and bullying.

    When this came up for discussion in a WhatsApp group I am part of, there was an interesting debate. While everyone acknowledged that there is a hierarchical culture in medicine and that this needs to be rectified, there was a slight disagreement on the exacts of how and why.

    One argument was that the medical college culture is an extension of the casteist culture outside and that it will go away only when caste based discrimination disappears. To this some disagreed a bit and said it is not the same in institutions like nursing colleges.

    Today morning I tweeted: “If you apply the corporate workplace harassment standards to medical colleges, you’ll have to fire *all* doctors. That’s how horrible that culture is.”

    I do think there’re more issues that lead to the culture in medical colleges apart from casteism. I list down the potential causative factors here.

    As you might know, I believe in intersectionality and in the contribution of all these causes (including causes that’s not mentioned here) to the problem. The listing here is by no means a suggestion that “X is the reason ABC happens”. If you remove X, you’ll still have Y, Z, and so many other issues.

    There is a lot of work to be done in medical colleges

    A medical college (especially in government settings) has a lot of things happening at once. There’s out patient department and the rush of patients. There are new admissions being made. There are existing in-patients who need follow-up care. There are constantly new developments (new symptoms or worsening of symptoms, new investigation results). There are plenty of learning requirements to be met. There are procedures to be performed. There are resources that need to be mobilized. There is paper work to be done. There are a lot of people talking to each other, lots of communication and miscommunication. There are duty rosters and handovers. There are emotions and sickness playing beneath all of this.

    Almost everything requires to be done as soon as possible too, if not stat.

    There is a lot of gap in resources

    Often (especially in government settings) the resources required for getting a lot of work done is simply not there. This could be things like medicine, dressing equipments, and suturing material. Or this could be human resources like nurses, specialists, doctors, cleaners, attenders, pharmacists, and technicians.

    There is poor spending on healthcare in Indian budget

    As a country, India spends much less than what it should on healthcare.

    The science of medicine is imperfect and the art of medicine is really hard

    Medicine as we practice it has only evolved in the last few decades or so. We still have no idea what’s going on in a lot of situations. It’s an imperfect science. Biology has a lot of secrets.

    Add to that we’re dealing with human beings. The art of handling sickness and patient care is always complicated by the intensity of emotions.

    Who wants to work hard?

    I’ve left hospital based practice long ago. And I’ve not been even doing clinic based practice in the last couple of years. Because it is a lot of work.

    When there’s a lot of work, some people find ways to make it fun. They focus on the learning and growth. Or they focus on the people they’re serving. If you can make hard work fun, you can do it for a while.

    But it is not possible to do it forever.

    Medicine is not fun

    After a point, you get a lot of similar patients. There’s plateau in learning and drudgery in work.

    Even when you find ways to enjoy some of that, you can’t enjoy death. People literally die. Despite all of what we do. How do you make death fun?

    There are not many options for a change in scenery

    It’s the same kind of work from the end of MBBS till retirement. You go to hospital. You see patients. Medical college faculties don’t even get transfer. You’re stuck in the same department of the same building for your entire career.

    Lack of skills leads to insecurities

    We established that medicine is hard. Many doctors lack skills – be it in the clinic, or in their life. They are sometimes aware of their incompetency too. And some of this manifests as insecurities.

    Everyone loves delegation

    The best way to get something done while hating it is to delegate it. Patient care is complicated. If it can be delegated, it is less of a headache.

    Delegation requires power structures

    The easiest way to ensure you can always delegate work is to ensure that there are people “below” you who can do your work at your command. Maintaining a hierarchy is essential for delegation.

    Hierarchies are easy to maintain in a hierarchical society

    How do we build a hierarchy? We just need to belittle others. There are numerous ways to belittle others when the society has trained many people in things like:

    • caste
    • gender
    • language
    • physical appearance

    In medical colleges there is a much easier way to belittle people – using their years of experience. Someone who is “junior” can be belittled easily as they will have that much lesser experience.

    Individuals can’t fight the hierarchy

    Because medicine is hard no individual can do it alone. You can’t run a hospital by yourself. Especially if you’re a junior doctor who is still learning, you absolutely would be terrified of doing patient care without support from seniors. How can you fight someone whose support you need for your work?

    There’s always something more urgent

    There is no space for conflict resolution in medical colleges. Patient care always comes up. There’s no time for cooling down. There’s no time for empathy.

    The individuals who get in are of questionable merit

    Most doctors are doctors who have gotten good marks in an entrance examination. This is a test of their memory and cognitive skills in a very narrow domain. This makes the selection process to medical colleges be highly skewed. The skills in various other domains – like social skills, emotional intelligence, empathy – are not regarded at all.

    Without these other skills, it is very difficult to even acknowledge when something wrong is happening.

    There are not many role models for better culture

    Where does one find examples of good work culture in healthcare in India? Very few “alternative” healthcare institutions provide such an exposure. This is not accessible to a wide variety.

    Medicine is mostly seen as a job, and not as a passion by many

    There aren’t a lot of people who think in terms of quality improvement, safety, etc in medicine. For many it is a job. A way to make money and live.

    And hundred other reasons

    These are what I quickly wrote down. I’ve not gone to a medical college in a powerless position since about 7 years. I do go to medical colleges very often as an “external” “senior” instructor. I’ve used this “power” to understand some of the power structures within medical colleges from up close. That has led to some of the insights above.

    There are possible many other things that contribute to the mess. Some of the ones above could be wrong too. There are possibly many interventions one can do on many of these problems.

  • What’s the Most Important Scientific Research?

    Post-facto rationalization. That’s something human beings are good at. If you decide to do research in a specific field, you’ll come up with hundred ways to justify why that research is important, if not the most important.

    I have been listening to Ravikant Kisana the last couple of days. In the podcast episode about Chandrayaan, RK calls Chandrayaan “completely useless”. A summary of the episode is the description of the episode: “Buffalo wonders what the Chandrayaan benefits are, while pondering over the crumbling education system. We take a moment to acknowledge the hot mess that is Gen Z.”

    Palani Kumar makes a very similar point in the talk about manual scavenging in CMC Vellore. “We have too much technology, we have lots of technology, we went to moon also, the other side of the moon, we haven’t saved anyone’s life among manual scavenging people”.

    I’m part of Sarvatrika Arogya Andolana – Karnataka which makes the consistent demand that we need to put more money into primary healthcare and have free medicines in government hospitals and so on.

    That’s the context in which I come across this thread by Nandita Jayaraj about a couple of breakthrough researches. Before I finished reading the thread I tweeted about it: 

    “Reading this thread made me think about how scientists in their lab coat are viewed in a very neutral or positive way by me whereas some of them are quite cunning and will do anything to get funded. 

    There are so many scientists hyping up rare diseases because that is where they get money to play with genes.”

    I hate universities. A lot.

    It is easy to argue with me by saying that universities are important and they create safe space for learning and that I can reject universities because of my privileges, and so on. But my intense hatred for universities has been validated by Ravikant Kisana in the Mind Your Buffalo podcast about institutional murders. The universities and the academia and the intellectual elite of this country are indeed a big part of the problem.

    And that’s where I come from. A position of intense hatred for scientists for their ignorance of how they’re part of the problem.

    And then these people who are held in high regard, in general, by journalists, people, and everyone, talk about research. From their pure and apolitical viewpoints. All I can hear when they open their mouth is “I want money. I am so smart. I do the most important work on Earth. Give me money.”

    Let us set all of that aside and look at this question “objectively”. Isn’t this sort of a trolley problem? You’re forced to choose between space science and sanitation technology. You’re forced to choose between rare diseases and common diseases.

    One could say “let us put some money in everything” because that’s one way of thinking about it.

    One could also think in purely utilitarian ways and calculate the cost (somehow) of each and measure benefit and do some kind of optimization.

    One could operate purely on empathy. But that has its own problems (Malayalam talk).

    Anyhow, answering this question is very hard. But it is indeed possible to look at it from a lens of caste, privilege, etc as seen above in RK’s podcast.

    (more…)

  • What Ails India’s approach to Universal Health Coverage is Elite Solutions That Have No Basis in Reality

    “Poorly maintained registers of doctors”. That’s the first five words of the article What ails India’s approach to Universal Health Coverage in Times of India by four people from Vidhi Centre for Lobbying Legal Policy. Let’s talk about that after we look at universal health coverage.

    “Universal health coverage (UHC) means that all people have access to the
    full range of quality health services they need, when and where they
    need them, without financial hardship. It covers the full continuum of
    essential health services, from health promotion to prevention,
    treatment, rehabilitation, and palliative care across the life course.” ~WHO

    That’s quite an ambitious goal, isn’t it? People having access to a full range of health services where they need them, that too without putting them in poverty.

    The community medicine HoD of PGIMER, Chandigrah ends an article about achieving this as:

    “In summary, to achieve the universal health coverage, major challenge in India is promotion of health, prevention of diseases, and provision of health care in a balanced manner, which will require innovative public policies, strategies, and programs in many sectors. Development and implementation of a multisectoral approach to achieve sustainable development goals is the need of the hour. Establishment of a Public Health Commission will go a long way in achieving coordination of various initiatives not only in the Ministry of Health and Family Welfare but also in many other relevant ministries/sectors. At least 5% of the gross domestic product should be earmarked for public health and a responsive governance mechanism as outlined above should be set up, to achieve universal health coverage by 2030 as envisaged in the United Nations sustainable development goals which are also endorsed by the Government of India.” (emphasis mine)

    Jan Swasthya Abhiyan, the Indian version of People’s Health Movement, suggested in 2012 a national debate, while also saying that “providing entitlements must be accompanied by a clear framework for accountability and grievance redressal” and that “highest priority must be given to significant expansion and improvement of public health services”. (emphasis, again, mine)

    The Lancet lobbying group for “reimagining India’s health system” in a theory of change also talks a bit about accountability.

    “Finally, the fourth proposed intervention relates to creating accountability and trust in public and private health systems. Enhancing the scope of political engagement is a crucial step toward this, along with developing and disseminating performance reports on the functioning of various health systems. Communities should be able to conduct social audits of the health systems they use along principles of Community-Based Management (CBM). Establishing or strengthening the legal framework to protect and empower communities would also be essential, and a robust grievance redressal mechanism should penalize malpractice and negligence. However, care needs to be taken to ensure that caregivers are not unduly penalized.”

    One could indeed say that accountability and grievance redressal forms, or ought to form, a part of the path towards universal health coverage.

    And that’s indeed what Vidhi set out to study as per the three reports they released on Dec 5 all of which start with “Holding Healthcare Providers Accountable”:

    And the next paragraph in the TOI article makes it abundantly clear that they’re indeed talking about these: “Healthcare providers in India are held accountable by the state through four primary mechanisms — courts, consumer fora, medical councils that regulate healthcare professionals, and regulators of clinical establishments”

    This is where I begin to disagree (and this is probably where my shock comes from in reading that “poorly maintained registers of doctors” ails the approach to UHC).

    When the rest of the world is talking about holding healthcare providers accountable, they’re talking about the healthcare providers being held accountable by people, society, or basically healthcare consumers. For example, in the Lancet group’s article above, they talk about social audits. But when Vidhi is studying this, they put on an irrelevant criteria — “by the state”.

    If they meant state in a larger scope wherein state includes citizens (people, society, and healthcare consumers), then they’ve gravely erred on the “four primary mechanisms” through which healthcare providers are held accountable in India.

    When one glances through the report this becomes obvious as they have very nicely documented the numerous reasons why all of these fail to hold healthcare providers accountable. Here’re some statements from their three report landing pages:

    • “the apparent reluctance of courts to convict healthcare providers of medical negligence under criminal law raises questions as to the role of this mechanism as a tool of accountability in the healthcare space”
    • “However, SMCs fail to perform their adjudicatory functions effectively. Very few complaints are instituted, and even when instituted, the most common disciplinary actions are warnings or mandating attendance of continuing medical education (CME), with very few instances of an RMP being removed from the register either temporarily or permanently.”
    • “Enforcement has continued to be unsatisfactory in various states that have adopted it. The Act also has various gaps, like the absence of grievance redressal systems, that prevent it from being an effective and patient-centric healthcare regulation. “

    Yet they have persisted in their belief that these are the “primary mechanisms” of holding healthcare providers accountable.

    If their argument is that they’re only researching how the “state” can hold providers accountable, then there is a case to be made that “holding accountable” is not a function of the “state” — which in many cases is the “provider”. The state itself has to be held accountable (at least in the case of public healthcare system). “Holding accountable” is almost always the function of consumers and citizens.

    If their argument is indeed that these are the main mechanisms, and they’re wrong, then what are the real primary mechanisms of holding healthcare providers accountable?

    I have written about this before where I talk about avoiding legal system altogether. I write in that that we could focus on activism, politics, journalism, and research.

    But what are the “primary” mechanisms?

    Let’s put ourselves in the shoes of a healthcare provider.

    An independent private healthcare provider running a clinic. What they’re the most afraid of is a patient dying and people thrashing their clinic. The mechanism of accountability here is direct physical action.

    An HCP inside a private hospital. They’re most worried about the person who pays them salary. And that person is most worried about the reputation of the hospital being ruined by reports of inadequate care there. The mechanism of accountability here is social messaging.

    An HCP inside a public hospital. They’re mostly not worried about anything. But they are indeed answerable to their medical superintendent and district level officers (like the DHO) who have the power to transfer them. And these higher officials are most worried about politicians (minister, MLA, etc). And they’re the most worried about their political image being tampered by journalists writing up a series of negligent care in government hospitals.

    Through this exercise in empathy what I’m trying to say is that the biggest (primary) mechanism of holding healthcare providers accountable is “social pressure”.

    But Vidhi is a group of lawyers. The four authors of the TOI article are lawyers. And all they can see this is as a problem of law. They can look at it only in terms of clinical establishments act, and tort law, and NMC act, and so on.

    That’s absolutely fine. It is very much required to have well functioning regulatory mechanisms through law.

    The problem is when they claim they know more than what they know. You don’t reach Universal Health Coverage by focusing on law alone. And I don’t even want to go into how “poorly maintained register of doctors” has relatively little to do with holding healthcare providers accountable through law.

    But all I want to say is that Vidhi should stop writing TOI articles that help Nandan Nilekani build data maximization projects like the NDHM.

  • Repeated Names in NSQ Manufacturing

     There’s a 2014-2016 survey of drugs.

    That’s followed up with smaller surveys by CDSCO.

    We will compare with March 2023 report.

    Let’s look for repeated offenders.

    Skymap Pharmaceuticals Uttarakhand. In the old survey they had 14.04% samples NSQ. In March 2023, they’re NSQ again in 2 samples. (We do not know how many samples from Skymap were tested, so we cannot reproduce a percentage).

    There are two samples without manufacturer specified (of Ritonavir and Rivastigmine).

    There is Karnataka Antibiotics & Pharmaceuticals Limited coming up 4 times within the March list.

    Ridley Life Sciences Delhi shows up twice. They were in the 2014-16 list for 11/52 samples (21%) being NSQ.

    Neon Laboratories Maharashtra shows up once. They were in the 2014-16 list for 2/42 samples, that is 4% being NSQ.

    Preet Remedies Himachal shows up once. They were in the 2014-16 list for 2/47 that is 4% being NSQ.

    Shiva Biogenetic Himachal shows up once. They were in the 2014-16 list for 25/62 that is 40% samples being NSQ.

    Let’s take the October 2022 list to see if we can find more common names.

    Ridley is there once in this list too.

    Zee Laboratories of Himachal Pradesh makes one entry. Zee has an entry in the 2014-2016 list for having 40/222 (18%) samples NSQ.

    Mercury Laboratories Gujarat makes it to the list too with one entry. Mercury Gujarat was the topper in 2014-2016 list 

    Shiva Biogenetic Himachal Pradesh is back here too.

    Pure & Cure Healthcare Uttarakhand makes one entry. They were in the 2014-16 list with the misname Pure & Care for 3/38 samples (7.8%) NSQ.

     

    This is emerging to be a good tech project to track each pharma and their NSQ detections. Maybe for another day. 

    One challenge is that we do not know the denominator on the smaller surveys.

  • Engaging with the System – A Visit to IISc

    When Prasanna heard John and I were leaving Hari’s farewell party to join Ravi in the trip to Indian Institute of Science, PS let out a characteristic sigh and said “all the best”. It probably comes from experience of how incorrigible people in elite institutions are when it comes to thinking about broader determinants of health and communities.

    After all, I wasn’t wearing my usual grey short pants either. I had to dress for the “vibe” of the place. I was wearing a long pant and a full sleeve shirt. Even Ravi was wearing a shoe. And when we reached the place, we were welcomed by Dr H Paramesh who was wearing a suit. The only person who was under-dressed (relative to their usual) was Pruthvish who was at the venue too, but didn’t wear a suit today.

    Places and events like these have a way of making you uncomfortable in your skin. There’s a level of “sophistication” that’s expected in the way you carry yourself. Is it written down anywhere? No. It’s just the air. You won’t be able to breathe if you’re not walking and talking the way everyone around you is.

    Gender non-conforming people have stated how in public places, it is sometimes overwhelming for them when everyone is looking at them like “they don’t belong here”. Trans women feel unwelcome in healthcare clinics for similar reasons. 

    Perhaps what I feel is a bit like what they feel.

    Would you expect a trans woman to speak about “Health for All” at Indian Institute of Science? Or a garment factory worker? Or a manual scavenger?

    I wouldn’t. Because they would always be under-dressed. No matter how expensive their clothing is.

    It affects the content of the discussion too. There are certain “sophisticated” ways you would give a talk in a place like IISc. You can talk about things like “equity”. Even “gender equality” is fashionable. But words like “caste”, “transgender”, etc would not pass the vibe check.

    That’s the trouble I frequently have when “engaging with the system”. The system has certain methods. And certain taboos. It is often the taboos that are at the heart of the problem. 

    It is only if we talk about the terrible lived experience of the caste oppressed, or the gender minorities, or the poor that we can start to expose how unjustifiable the position of scientists in ivory towers are. When lived experience of discrimination and oppression and ill-health is put on the table, people will have only two options – either turn their faces away and ignore it, or accept how they are part of the problem. They can no longer sleep comfortably saying “we’re also doing our bit”. Because nobody is doing their bit as long as people are suffering.

    And those who are suffering will never be invited to talk to the system.

    The responsibility then falls up on those who are invited. To give a second hand account from their experience of the lived experience of suffering. To amplify the voices of the marginalized. To pass the recording, when they can’t pass the microphone.

    But that won’t pass the vibe check.

  • A Community for Online Action in Community Health

    Today Guru, John, Swamy, Ravi, and I met in the Health for All – Learning Center workspace at SOCHARA. We discussed an action plan for the next 3 years (with a focus on 2023-24) for the Digital Archives Platform unit at SOCHARA. The archives becomes a core activity for a community of community health activist-scholars and activist-professionals to do study, reflection, action, and experiment online towards “Health for All”. 

    The larger hypothesis is that when we flood the internet with content related to community health, the second order and third order effects of that will lead to a massive movement by narrative building and discourse shaping towards community health.

    The DAP at SOCHARA is going to focus on SOCHARA’s own reports, publications, presentations, videos, audios, etc for the first year (along with medico friend circle’s archive). This comprises items from Appendix A of Silver Jubilee Museum Archive Project that happened between 2016 and 2022. The year after that we will focus on Appendix B (which includes networks and organizations SOCHARA is connected to) and Appendix C (which has special focus themes and topics). What to do in year 3 will emerge by the end of 2023.

    While this is just the Digital Archives part of it (which many organizations are now entering – NCBS, AICTU, APU, WIPRO, etc), there are many many other activities that this community can do:

    • Communications for community health with things like podcasts, memes, reels, and so on need to be built.
    • Stories of people and organizations need to be captured on wiki.sochara.org (which communityhealth.in now redirects to).
    • A public discussion forum needs to be created (either as part of something like Azad Maidan or independently).
    • Content of high quality and relevance like mfc bulletins and health taskforce report need to be modernized by conversion into web pages with hyperlinks.
    • Effective sharing of resources with other similar efforts in the network has to be accomplished.
    • The team at SOCHARA itself has to become comfortable with and active on these public documentation efforts.
    • … (your idea here)

    There’s plenty of interesting work that lies ahead. This month we will be focusing on the website and SOCHARA’s evolution story, physical clean up of the unused sections of the library, and getting “systems of sustainability” available for use of the team.

    Two tables put together with half a dozen chairs around it. Bookshelves filled with books are all around.
    The workspace in HFA-LC, after the meeting. I forgot to take a photo while the meeting was happening. The empty chairs symbolize the space for anyone reading this to come in and be part of the community.

  • Personal Is Political in Professional Practice

    “Should a doctor treat an alcoholic who is injured due to drunk driving? Would your opinion change if it were just a solo accident v/s injuring/killing other people on the road?” asked @arshiet. The regular controversy. Should doctors judge their patients? Is it ethical to even ask the question of whether it is ethical for doctors to withhold treatment to anyone? What are the social determinants of alcohol use?

    The issue is straightforward in the emergency room. You save life first and worry about alcohol and justice later.

    But what about elective issues? If you are an obstetrician and you are pro-life, do you avoid elective abortions? If you are a pediatric surgeon and you consider circumcision as genital mutilation, do you avoid ritual circumcisions? Conscientious Objection – apparently that’s what it is called.

    One of the solutions offered is that the healthcare provider can be upfront about the moral position and arrange a different provider. This helps the patient to retain autonomy and the provider to retain moral clarity.

    Basically, doctors can’t simply cancel patients.

    If we refuse to see the doctor-patient relationship as special, we can see that what’s at play here is the tension between “personal is political”, cancel culture, etc on one side and the practical realities of the world on the other side. I’ve personally gone through the self-isolation of ideological purism and come out with the ideology that it is okay to be altruistically pragmatic.

    The world is full of people with incompatible ideas, values, and norms. If we start cancelling, we end up cancelling almost everyone. If we don’t cancel, we become an apolitical mess. The point is then about finding alternatives to canceling everyone. You cancel some, you strategically avoid some, you engage sincerely with some others.

    That intelligent, “nuanced”, intersectional approach to politics is called life.

  • History is to Practice

    I’ve been in many debates where “science” is accused of being wrong. As if science is a set of things written down in a book or a set of ideas that are arrived at by a group of people. Something that has to be consumed by others. I’m baffled by this argument because, to me, science is a tool available for every human being to practice. It is my use of science to understand the world that matters to me. When I say “scientific method” I am talking about the method *I* use to arrive at the truth. It might be the same method that a professional scientist used, but I have to replicate that method and arrive at the truth on my own.

    When chatting with Ravi Narayan (RN) yesterday about the SOCHARA archives, I had a very interesting realization. The way I used to look at history was the way these people looked at science. I thought about history as a set of facts written down in many books, as a scholarly consensus available to those who are in the elite universities. The thought I had was this: What if, like I practice science instead of consuming it, I start practicing history instead of just cataloguing it?

    I can’t say that this thought had nothing to do with the discussion I was having with Upendra Bhojani about a Masters in History that UB was pursuing. History is a science. It is the science of the past. And without knowing the methods of studying history, I was basically being less effective as a historian.

    And without being a historian, it is difficult to be an archivist!

    So, I’m doing two things now:

    1. Take on the identity of a health historian seriously and consciously.
    2. Start practicing history.

    Another insight I had about myself was that I learn a subject the best when I have a framework that fully encapsulates the topics in it. The more there are unknown unknowns in a subject, the less I’m interested in studying it. But when I have a complete and comprehensive “table of contents”, my brain feels comfortable in taking on that skeleton, slowly going through all of the actual contents and attaching things one by one into that skeleton. I need to first have the big picture before I let in even one of the finer details.

    So, I made RN sit down and help me build that framework of how to think about the history of community health in India. After the discussion there’s a rough framework that is now emerging in my mind:

    • Prehistoric times of British India
    • Bhore committee and the first 25 years of independence. 
    • The search for alternatives in the 70s and 80s
    • Whatever happened in the 90s towards “Health for All by 2000”
    • People’s Health Movement
    • NRHM and NHM
    • Ayushman Bharat and so on…

    Much of the discussion with RN yesterday was about the 70s and 80s. RN took out 4 books on to the table:

    • Health for All – An Alternative Strategy (ICMR/ICSSR)
    • Alternative approaches to meeting basic health needs in developing countries (UNICEF/WHO)
    • Health and Family Planning Services in India (D Banerji)
    • Community Health – In Search of Alternate Processes (CHC)

    I swiped them into my bag for weekend reading.

    The NRHM bit was interesting. In my mind, the people’s health movement, the alternatives, all of these were failures. But, RN was like, “25 people out of this movement, who had by then (by NRHM formation time) formed the Jan Swasthya Abhiyan, are (were) consultants to the NRHM”. That was a light bulb moment for me. NRHM, in the biomedical colleges is taught like just another chapter, without giving it the emphasis that it deserves. That ASHAs who represent the shift into decentralization came through NRHM and how significant that is, is kind of forgotten. For me who started medicine in 2011, the idea of ASHA that was passed on to me was that of a healthcare worker like nurse or doctor, working with a very small population. But that’s totally missing the spirit and heritage of ASHAs and NRHM.

    The story of ASHAs and the story of NRHM is thus the story of evolution of community health in India. And that’s the story we’re interested in.