making repairs

Violence in hospitals: Three steps towards mending doctor-patient relationships

Delhi’s mohalla clinics and Mumbai’s Swasth clinics have the right idea – make primary healthcare better.

Even after repeated protests, mass leaves and assurances from authorities of better security, incidents of violence against doctors continue unabated. Last week, a man whose critically ill father died at Sion Hospital manhandled a resident doctor, even though several security personnel had been deployed at the hospital since April.

The recent spate of violence against doctors and a resident doctors’ strike in March has brought the fractured doctor-patient relationship in India into the spotlight. The solutions in these emotionally charged situations have been makeshift ones. Increased security, enhanced punishment and patient visitation restrictions, though necessary in the current scenario, are essentially band-aids on larger wounds. They, at best, strain to cover the breadth of the laceration while gnawing further at the tenuous patient-doctor relationship.

The patient-vs-doctor narrative only increases the alienation between the two parties. The patient is, more often than not, venting against the crumbling health system. The hapless resident doctor, who is only a minion representing the chaotic health hierarchy, bears the brunt of a problem that is not of his creation. They are both victims.

The problems afflicting the public health system in India impact almost every aspect of giving care, leading to a benumbing demand-supply gap. The government feels ill-equipped to bring about wholesale change and resorts to temporary expedients. Many solutions suggested, like increasing the number of doctors and building new facilities, though necessary, can show results only after decades. At the same time, training doctors to communicate better can hardly work in situations where they are overworked. Increasing budget allocations to health is necessary. Even more necessary is considered spending on only prioritised solutions in a stepwise manner so that the money spent leads to measurable impact. Let us look at the three areas that need immediate attention and have workable solutions.

Improving primary healthcare

There has been a complete breakdown in the provision of primary healthcare in Mumbai. The importance of primary healthcare is underlined by the fact that 80% of the total expenditure on health in India is out-of-pocket, and approximately 75% of it is spent on primary healthcare. While in some cases prompt treatment could prevent disease or injury escalating into health crises, other services can only be provided at the tertiary level.

Primary healthcare in Mumbai slums is now often the preserve of unqualified quacks who are disconnected from the public health system or residents access healthcare directly at tertiary municipal hospitals. When the base of the pyramid does not work, the secondary and tertiary level health centers are necessarily stretched beyond their capacity. Allocating funds to improving tertiary level facilities before investing in improving primary healthcare is a prime example of the lack of prioritisation that essentially amounts to wasteful expenditure.

Under a World Bank Initiative called Indian Population Project 5, 176 health posts and 168 dispensaries were set up in Mumbai slums between 1988 and 1996. However, staff vacancies, apathy, lack of facilities and lack of prioritisation have caused the health posts and dispensaries to be underutilised – many are non-functional and decrepit.

These health posts can still form the bedrock on which our public health structure stands if the city corporation makes this its priority. They can not only provide treatments for basic ailments, but also antenatal and infancy care to low-risk pregnant women and children as well as medications for tuberculosis under the DOTS program.

There are both public and non-profit sector examples of providing universal access to healthcare in India that are beginning to show credible impact like the mohalla clinics in Delhi. In Mumbai, the Swasth Foundation currently operates 18 clinics across the city’s slums that provide one-stop access to high quality primary healthcare services at half the market rates. Both the mohalla and Swasth clinics make innovative use of technology to maintain quality of care while reducing costs.

A doctor examines Munna Singh, a physically handicapped person, outside the Krishna Nagar mohalla clinic. (Photo: Menaka Rao)
A doctor examines Munna Singh, a physically handicapped person, outside the Krishna Nagar mohalla clinic. (Photo: Menaka Rao)

Regionalisation of care

Regionalisation of care consists of an effective referral or triage system. Low risk patients should be taken care of effectively at the primary health centres, high risk factors should be diagnosed as early as possible and timely referrals should be made to secondary or tertiary level centres. An efficient citywide referral system is essential to ensure effective management of scarce resources and reduce the load at tertiary centres. Various studies attest to the value of an effective referral system. For example, low birth weight or premature infants born in risk appropriate facilities are more likely to survive in these settings.

Mumbai does have a broad framework in place for a referral system, which is most evident in maternal and child care. There are 28 maternity homes that were meant to be the referral point from the primary health care system in the slums and they in turn are linked to the secondary level centres (Rajawadi hospital, Bandra Bhabha) and tertiary level centres (Sion Hospital, KEM and Nair Hospital). However, the referral system fails too often because there is a lack of equipment, facilities and staff at all three levels. If an urgent case is brought to a secondary hospital, it tends to be transferred to a major tertiary hospital, and due to lack of emergency transportation and problems in ambulatory care, patients have little chance of survival.

Doctors stage a silent protest outside the OPD of Mumbai's Sion hospital after a resident doctor Rohit Kumar of Sion Hospital was allegedly beaten up by angry relatives of a patient, who lost his life, in Mumbai on March 20, 2017. (Photo: IANS)
Doctors stage a silent protest outside the OPD of Mumbai's Sion hospital after a resident doctor Rohit Kumar of Sion Hospital was allegedly beaten up by angry relatives of a patient, who lost his life, in Mumbai on March 20, 2017. (Photo: IANS)

Though the three levels of care are linked to each other on paper, in reality, they work in their own silos. For example, if a pregnant woman goes to a health post for prenatal care and a doctor there refers her to a maternity home for antenatal ultrasound, she is forced to stand in lines all over again, register herself at the new hospital and is treated like a new patient and not someone in whom care was started at the health post and continued at the secondary level centre when required.

This is one of the major reasons most Dharavi residents bypass the severely underutilised urban health centre at Chhota Sion Hospital and access care directly at Sion Hospital. The concept of a “continuum of care” needs to be reinforced within the health systems. In this case, the public and healthcare providers need to be aware that the health post in a Ghatkopar slum is actually an outpost of Sion Hospital taking care right to the slum dwellers’ doorstep. A single registration form that works through the health system at every level is a simple step to reinforce this idea.

Better counseling

During my time as a resident and assistant professor at Sion hospital, I became intimately acquainted with how lack of access to simple counseling and preventive care information during pregnancy and infancy led to loss of lives that was completely preventable. There were countless instances of women diagnosed with major high risk factors during their first visits, who never came back for the next scheduled appointments because we did not have time to counsel them about the possible complications. These women often came back only in labour and when they were dying.

Given the severe overloading of hospitals, innovative solutions were needed. That led to the idea of mMitra of my NGO ARMMAN, which is a free voice call service that sends timed and targeted preventive care information weekly or twice a week to women through pregnancy and childhood. The reason mMitra works is that it is complementary to the antenatal and infancy services provided at the municipal health care facilities: health workers are stationed in the municipal hospitals who enroll women in their first antenatal visit. The beneficiaries consider mMitra a part of the services provided at the municipal hospital. These women view services provided at the hospital more favourably and are prepared for every eventuality.

Dr Aparna Hegde with women using the mMitra free voice call service. (Photo: Aparna Hegde)
Dr Aparna Hegde with women using the mMitra free voice call service. (Photo: Aparna Hegde)

Similar cost effective solutions are needed to counsel patients through treatment of other chronic conditions such as tuberculosis treatment, kidney diseases, diabetes and heart disease. A patient with chronic renal disease is most often brought in late for dialysis due to lack of information regarding care.

Even though the many problems leading to violence against doctors seem overwhelming, effective and scalable solutions are available. What is needed is smart concerted action and will on the part of the government and the medical fraternity.

The writer is a urogynecologist, researcher and social entrepreneur. She is the founder of the Center for Urogynecology and Pelvic Health, New Delhi and of the NGO ARMMAN, Mumbai which works in the field of maternal and child health in seven states of India.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

Relying on the power of habits to solve India’s mammoth sanitation problem

Adopting three simple habits can help maximise the benefits of existing sanitation infrastructure.

India’s sanitation problem is well documented – the country was recently declared as having the highest number of people living without basic sanitation facilities. Sanitation encompasses all conditions relating to public health - especially sewage disposal and access to clean drinking water. Due to associated losses in productivity caused by sickness, increased healthcare costs and increased mortality, India recorded a loss of 5.2% of its GDP to poor sanitation in 2015. As tremendous as the economic losses are, the on-ground, human consequences of poor sanitation are grim - about one in 10 deaths, according to the World Bank.

Poor sanitation contributes to about 10% of the world’s disease burden and is linked to even those diseases that may not present any correlation at first. For example, while lack of nutrition is a direct cause of anaemia, poor sanitation can contribute to the problem by causing intestinal diseases which prevent people from absorbing nutrition from their food. In fact, a study found a correlation between improved sanitation and reduced prevalence of anaemia in 14 Indian states. Diarrhoeal diseases, the most well-known consequence of poor sanitation, are the third largest cause of child mortality in India. They are also linked to undernutrition and stunting in children - 38% of Indian children exhibit stunted growth. Improved sanitation can also help reduce prevalence of neglected tropical diseases (NTDs). Though not a cause of high mortality rate, NTDs impair physical and cognitive development, contribute to mother and child illness and death and affect overall productivity. NTDs caused by parasitic worms - such as hookworms, whipworms etc. - infect millions every year and spread through open defecation. Improving toilet access and access to clean drinking water can significantly boost disease control programmes for diarrhoea, NTDs and other correlated conditions.

Unfortunately, with about 732 million people who have no access to toilets, India currently accounts for more than half of the world population that defecates in the open. India also accounts for the largest rural population living without access to clean water. Only 16% of India’s rural population is currently served by piped water.

However, there is cause for optimism. In the three years of Swachh Bharat Abhiyan, the country’s sanitation coverage has risen from 39% to 65% and eight states and Union Territories have been declared open defecation free. But lasting change cannot be ensured by the proliferation of sanitation infrastructure alone. Ensuring the usage of toilets is as important as building them, more so due to the cultural preference for open defecation in rural India.

According to the World Bank, hygiene promotion is essential to realise the potential of infrastructure investments in sanitation. Behavioural intervention is most successful when it targets few behaviours with the most potential for impact. An area of public health where behavioural training has made an impact is WASH - water, sanitation and hygiene - a key issue of UN Sustainable Development Goal 6. Compliance to WASH practices has the potential to reduce illness and death, poverty and improve overall socio-economic development. The UN has even marked observance days for each - World Water Day for water (22 March), World Toilet Day for sanitation (19 November) and Global Handwashing Day for hygiene (15 October).

At its simplest, the benefits of WASH can be availed through three simple habits that safeguard against disease - washing hands before eating, drinking clean water and using a clean toilet. Handwashing and use of toilets are some of the most important behavioural interventions that keep diarrhoeal diseases from spreading, while clean drinking water is essential to prevent water-borne diseases and adverse health effects of toxic contaminants. In India, Hindustan Unilever Limited launched the Swachh Aadat Swachh Bharat initiative, a WASH behaviour change programme, to complement the Swachh Bharat Abhiyan. Through its on-ground behaviour change model, SASB seeks to promote the three basic WASH habits to create long-lasting personal hygiene compliance among the populations it serves.

This touching film made as a part of SASB’s awareness campaign shows how lack of knowledge of basic hygiene practices means children miss out on developmental milestones due to preventable diseases.

Play

SASB created the Swachhata curriculum, a textbook to encourage adoption of personal hygiene among school going children. It makes use of conceptual learning to teach primary school students about cleanliness, germs and clean habits in an engaging manner. Swachh Basti is an extensive urban outreach programme for sensitising urban slum residents about WASH habits through demos, skits and etc. in partnership with key local stakeholders such as doctors, anganwadi workers and support groups. In Ghatkopar, Mumbai, HUL built the first-of-its-kind Suvidha Centre - an urban water, hygiene and sanitation community centre. It provides toilets, handwashing and shower facilities, safe drinking water and state-of-the-art laundry operations at an affordable cost to about 1,500 residents of the area.

HUL’s factory workers also act as Swachhata Doots, or messengers of change who teach the three habits of WASH in their own villages. This mobile-led rural behaviour change communication model also provides a volunteering opportunity to those who are busy but wish to make a difference. A toolkit especially designed for this purpose helps volunteers approach, explain and teach people in their immediate vicinity - their drivers, cooks, domestic helps etc. - about the three simple habits for better hygiene. This helps cast the net of awareness wider as regular interaction is conducive to habit formation. To learn more about their volunteering programme, click here. To learn more about the Swachh Aadat Swachh Bharat initiative, click here.

This article was produced by the Scroll marketing team on behalf of Hindustan Unilever and not by the Scroll editorial team.