Under Pressure

In numbers: Maharashtra’s under-funded health services keep its junior doctors in the line of fire

Violence against doctors is not about doctor-patient conflict as much as it is about lack of funds and personnel to attend to the sick.

Since the attack on resident doctor Rohan Mhamunkar in Dhule on March 12, there has been a spate of attacks on frontline doctors working in public hospitals across the state of Maharashtra. The government has treated this purely as a law and order problem and even doctors associations have focussed mostly on providing security to doctors, some even floating extreme demands such as asking that doctors be permitted to bear firearms. What has not been highlighted sufficiently in the public debate so far, is the correlation between understaffed and inadequately resourced public hospitals, and the growing discontent among patients seeking care in these hospitals.

Maharashtra is considered a developed state with among the highest per capita income in the country. The state has a large Gross State Domestic Product per person of Rs 1,48,000. In this context its neglect of public health services in last few decades is surprising.

Maharashtra has among the lowest expenditures per capita on public health, spending just just Rs. 776 per person in 2016-’17 – an amount lower than the expenditure of smaller administrations like Delhi and of less-developed states like Chhattisgarh, Rajasthan, Odisha, Uttar Pradesh and Bihar.

Until the 1980s, public health services in Maharashtra were considered better than many other states, but subsequently public health spending has stagnated in comparison to economic development. The state’s expenditure on public health as a proportion of the Gross State Domestic Product has been halved from an already poor one percent in 1985-’86 to 0.49% for 2017-’18. With major advances in medical technology, a rise in non-communicable and chronic diseases, and rising expectations of the population, these levels of public resources are now grossly inadequate.

Chronically low levels of public health resources and a virtual freeze on regular appointments of medical staff have debilitated the system. Massive, unregulated expansion of private hospitals has further pulled specialists away from public medical service. Currently 60% of posts for surgeons, gynaecologists, paediatricians and other specialists in rural hospitals across the state are vacant. There are practically no specialists in district hospitals such as those of Akola, Nanded and Parbhani. It is unsurprising then, that the trigger for the assault in Dhule was the non-availability of a neurosurgeon to treat a patient with a head injury.

Given this backdrop, it is worrying that the state government has cut Maharashtra’s health budget further for the coming year by Rs 559 crore. Accounting for inflation and population increase, this is a cut of about 10% in real terms.

(2016-'17: Revised estimates)
(2016-'17: Revised estimates)

Moreover, large proportions of these inadequate health budgets remain unspent every year due to delays in sanctioning fund releases at various levels, procedural bottlenecks, and with centre-state financial dynamics.

For example, at the end of the financial year on March 31, only 74% of Maharashtra’s public health budget has been spent. This serious constriction of release of funds amounts to a second, undeclared massive budget cut.

Inadequate staffing and poor resources lead to situations where junior doctors are often overworked. Long working hours and multiple responsibilities limit their ability to spend adequate time with patients. Sometimes there is only one doctor handling more than a hundred patients in an out-patient department. When patients are faced with overworked doctors and inadequate facilities, sometimes violence erupts and these frontline doctors, the most visible face of the system, are made targets.

Large public hospitals that deal with hundreds of patients, many from rural areas and with limited education, have hardly any patient-friendly guidance and grievance redressal systems. This lack of information and dialogue mechanisms adds to the gap between users and the system.

Hospitals need a patient help desk and an accessible, effective grievance redressal cell that might be run a local NGO or citizens’ group.

The Universal Health Coverage system in Thailand has mechanisms such as Independent Complaint Centres run by NGOs to process complaints by patients, and a fund offering “No fault compensation’ to patients who have suffered negative consequences during treatment. These might be adapted to India.

On March 22, the civil society coalition Jan Swasthya Abhiyan in Maharashtra organised a unique public dialogue in Mumbai involving representatives of the health movement, the Mumbai citizen-doctor forum and the nurses union. An organiser of the state’s resident doctors association and the Indian Medical Association’s youth wing also participated. While the need to protect doctors was acknowledged, a strong consensus also emerged on the need to overhaul the system with substantial increases in health budget and better staffing to ensure essential services in public hospitals. The problem can no longer be framed as a doctor against patient conflict, but as a failure of the system. The movement has, therefore, adopted the call “Don’t target the doctors, target the system”.

The writer is a public health physician and health activist associated with Jan Swasthya Abhiyan and Alliance of Doctors for Ethical Healthcare. Ravi Duggal and Richa Chintan helped with budget-related information for this article.

Support our journalism by subscribing to Scroll+ here. We welcome your comments at letters@scroll.in.
Sponsored Content BY 

The next Industrial Revolution is here – driven by the digitalization of manufacturing processes

Technologies such as Industry 4.0, IoT, robotics and Big Data analytics are transforming the manufacturing industry in a big way.

The manufacturing industry across the world is seeing major changes, driven by globalization and increasing consumer demand. As per a report by the World Economic Forum and Deloitte Touche Tohmatsu Ltd on the future of manufacturing, the ability to innovate at a quicker pace will be the major differentiating factor in the success of companies and countries.

This is substantiated by a PWC research which shows that across industries, the most innovative companies in the manufacturing sector grew 38% (2013 - 2016), about 11% year on year, while the least innovative manufacturers posted only a 10% growth over the same period.

Along with innovation in products, the transformation of manufacturing processes will also be essential for companies to remain competitive and maintain their profitability. This is where digital technologies can act as a potential game changer.

The digitalization of the manufacturing industry involves the integration of digital technologies in manufacturing processes across the value chain. Also referred to as Industry 4.0, digitalization is poised to reshape all aspects of the manufacturing industry and is being hailed as the next Industrial Revolution. Integral to Industry 4.0 is the ‘smart factory’, where devices are inter-connected, and processes are streamlined, thus ensuring greater productivity across the value chain, from design and development, to engineering and manufacturing and finally to service and logistics.

Internet of Things (IoT), robotics, artificial intelligence and Big Data analytics are some of the key technologies powering Industry 4.0. According to a report, Industry 4.0 will prompt manufacturers globally to invest $267 billion in technologies like IoT by 2020. Investments in digitalization can lead to excellent returns. Companies that have implemented digitalization solutions have almost halved their manufacturing cycle time through more efficient use of their production lines. With a single line now able to produce more than double the number of product variants as three lines in the conventional model, end to end digitalization has led to an almost 20% jump in productivity.

Digitalization and the Indian manufacturing industry

The Make in India program aims to increase the contribution of the manufacturing industry to the country’s GDP from 16% to 25% by 2022. India’s manufacturing sector could also potentially touch $1 trillion by 2025. However, to achieve these goals and for the industry to reach its potential, it must overcome the several internal and external obstacles that impede its growth. These include competition from other Asian countries, infrastructural deficiencies and lack of skilled manpower.

There is a common sentiment across big manufacturers that India lacks the eco-system for making sophisticated components. According to FICCI’s report on the readiness of Indian manufacturing to adopt advanced manufacturing trends, only 10% of companies have adopted new technologies for manufacturing, while 80% plan to adopt the same by 2020. This indicates a significant gap between the potential and the reality of India’s manufacturing industry.

The ‘Make in India’ vision of positioning India as a global manufacturing hub requires the industry to adopt innovative technologies. Digitalization can give the Indian industry an impetus to deliver products and services that match global standards, thereby getting access to global markets.

The policy, thus far, has received a favourable response as global tech giants have either set up or are in the process of setting up hi-tech manufacturing plants in India. Siemens, for instance, is helping companies in India gain a competitive advantage by integrating industry-specific software applications that optimise performance across the entire value chain.

The Digital Enterprise is Siemens’ solution portfolio for the digitalization of industries. It comprises of powerful software and future-proof automation solutions for industries and companies of all sizes. For the discrete industries, the Digital Enterprise Suite offers software and hardware solutions to seamlessly integrate and digitalize their entire value chain – including suppliers – from product design to service, all based on one data model. The result of this is a perfect digital copy of the value chain: the digital twin. This enables companies to perform simulation, testing, and optimization in a completely virtual environment.

The process industries benefit from Integrated Engineering to Integrated Operations by utilizing a continuous data model of the entire lifecycle of a plant that helps to increase flexibility and efficiency. Both offerings can be easily customized to meet the individual requirements of each sector and company, like specific simulation software for machines or entire plants.

Siemens has identified projects across industries and plans to upgrade these industries by connecting hardware, software and data. This seamless integration of state-of-the-art digital technologies to provide sustainable growth that benefits everyone is what Siemens calls ‘Ingenuity for Life’.

Case studies for technology-led changes

An example of the implementation of digitalization solutions from Siemens can be seen in the case of pharma major Cipla Ltd’s Kurkumbh factory.

Cipla needed a robust and flexible distributed control system to dispense and manage solvents for the manufacture of its APIs (active pharmaceutical ingredients used in many medicines). As part of the project, Siemens partnered with Cipla to install the DCS-SIMATIC PCS 7 control system and migrate from batch manufacturing to continuous manufacturing. By establishing the first ever flow Chemistry based API production system in India, Siemens has helped Cipla in significantly lowering floor space, time, wastage, energy and utility costs. This has also improved safety and product quality.

In yet another example, technology provided by Siemens helped a cement plant maximise its production capacity. Wonder Cement, a greenfield project set up by RK Marbles in Rajasthan, needed an automated system to improve productivity. Siemens’ solution called CEMAT used actual plant data to make precise predictions for quality parameters which were previously manually entered by operators. As a result, production efficiency was increased and operators were also freed up to work on other critical tasks. Additionally, emissions and energy consumption were lowered – a significant achievement for a typically energy intensive cement plant.

In the case of automobile major, Mahindra & Mahindra, Siemens’ involvement involved digitalizing the whole product development system. Siemens has partnered with the manufacturer to provide a holistic solution across the entire value chain, from design and planning to engineering and execution. This includes design and software solutions for Product Lifecycle Management, Siemens Technology for Powertrain (STP) and Integrated Automation. For Powertrain, the solutions include SINUMERIK, SINAMICS, SIMOTICS and SIMATIC controls and drives, besides CNC and PLC-controlled machines linked via the Profinet interface.

The above solutions helped the company puts its entire product lifecycle on a digital platform. This has led to multi-fold benefits – better time optimization, higher productivity, improved vehicle performance and quicker response to market requirements.

Siemens is using its global expertise to guide Indian industries through their digital transformation. With the right technologies in place, India can see a significant improvement in design and engineering, cutting product development time by as much as 30%. Besides, digital technologies driven by ‘Ingenuity for Life’ can help Indian manufacturers achieve energy efficiency and ensure variety and flexibility in their product offerings while maintaining quality.

Play

The above examples of successful implementation of digitalization are just some of the examples of ‘Ingenuity for Life’ in action. To learn more about Siemens’ push to digitalize India’s manufacturing sector, see here.

This article was produced on behalf of Siemens by the Scroll.in marketing team and not by the Scroll.in editorial staff.