“ There is nothing new in world except the history you do not know.” – Harry Truman

Farooq assesses challenges in medical care in Kashmir

(Dr. Farooq Ahmad Jan, 43, was born in Srinagar, Kashmir. He was schooled at the New Era Public School, Raj Bagh, and attended the Gandhi Memorial College (GMC), Srinagar. He completed his medical degree (M.B.B.S.) from from the University of Kashmir. Dr. Jan completed the 3-year M.D. program in Hospital Administration Under SKIMS Deemed University. Currently, he is an Associate Professor of Hospital Administration and Deputy Medical Superintendent of the Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar. He is a member of the Indian Academy of Hospital Administration, and has published a book on Hospital Care, and numerous technical papers. Dr. Jan has received third best JIMSA article award for year 2010 for the paper titled “Status of Quality Assurances Practices in teaching Hospitals of Kashmir Division,” and has participated in various national and international conferences.)

Health Care: Few Interventions Needed

The Health Care indicators of Jammu and Kashmir are improving but there is much more which needs to be done. Although government is providing health care at nominal registration fee but most of the financing of health care is “Out-of-Pocket”. This form of financing is considered worst form of financing health care. A single episode of ill health consumes a sizeable share of poor household resources leading to financial crisis.

In a study at SKIMS we saw that average “Out-of-Pocket” expenses on cancer care are more than average annual income of family and monetary loss due to inability to go for one’s job is 15.2% of the average annual income of family. More than quarter (27.3%) of families had to sell property or borrow money to meet costs of cancer care. Only 9.09% of patients could get this cost of care reimbursed through reimbursement for government employees, assistance in the form of Chief Minister’s relief fund, exemption by health authorities and insurance. Uninsured adults with chronic conditions are more likely than their counterparts to have unmet medical care needs because of the cost which could contribute to adverse health outcomes.

Health care expenditures have been constantly on the rise. Providing access to all the citizens has long been a corner stone of modern health financing systems in many countries. To ensure that individuals have access to health services one of the functions of health system financing is pooling of resources. Pooling is traditionally known as insurance function. Its main purpose is to share the financial risk associated with health interventions for which the need is uncertain. When people pay out-of-pocket, no pooling occurs. Most of the developed countries have done away with this form of health care financing but out-of-pocket expenses account for more than four-fifths of total health care spending in India. The emerging trend towards nuclear families is exposing people to severe economic and social constraints. The traditional mechanisms of social security and adjustment at times of crisis are fast disappearing.

The transformation has resulted in the creation of several problems for individuals and groups particularly the aged and retired populations. These reasons have led to an increased sense of insecurity among the public and prompt us for the necessity of some sort of health insurance over the years. Many low and middle income countries are considering health insurance for adoption into their social and economic environment or striving to sustain and improve already existing insurance schemes. First small informal voluntary insurance schemes may serve as learning models, but in order to achieve universal coverage government action is needed to formalise these schemes and to introduce principle of compulsion. Once compulsory health insurance exists for some people, incremental expansion of coverage to other social groups may be feasible to achieve universal coverage.

Many efforts have been made in India to start such insurance schemes both at governmental level and by private sector, but private for profit insurers only recently allowed by Government may target better off sections of the society when such schemes are needed more by low and middle income countries. Government can contribute towards the annual premium, so as to ensure the affordability of the scheme to families living below poverty line.

Numerous studies have reported on the ineffectiveness of Indian government health departments in executing their administrative and regulatory roles. Administrators display considerable leniency in implementing guidelines, often preferring persuasion over enforcement. Frequently doctors collide with superiors to circumvent policies while maintaining the outward appearance of compliance. In spite of often possessing perspectives and convictions that differ from sanctioned guidelines, practitioners are not able to effectively communicate these ideas and get them introduced into mainstream policy discourse. Studies have shown that stronger regulations and provisions for accountability in Indian health systems need to be balanced by measures to develop intellectual capital and include voices of frontline practitioners in public health discourse.

In addition to public sector, private sector provides a good percentage of health care especially out patient services. The private sector is largely unregulated and encompasses from small nursing homes to local shopkeepers (Informal Private Providers). These informal private providers (IPP) who practice allopathic medicine but have not been formally trained in it are a significant part of the private sector. Drug vendors are often the first providers of care for many common illnesses such as diarrhoea, fever and cough. Engaging them is a feasible way to ensure that appropriate drug regimes or illness advice reaches the broadest audience possible.

For these entrepreneurs, however training alone may not create the desired effect. Additional strategies such as increased regulatory oversight, establishment of referral system to qualified providers and investigation into balancing the profit motives of most informal private providers with the desired health goals of the public is required.