Shortage of General duty medical officers (GDMO) affects the effective management of government health facilities and thus, affects the quality of health care across Tumkur district in southern Karnataka. The Community Health Centres (CHC) and Primary Health Centres (PHC) are the worst hit facilities while the problem is doubled by creating more centres with limited available resources. As a result of this, patients with minor illnesses are also going directly to First Referral Units (FRU) such as CHCs, Taluka hospitals or District hospital where the hospitals are already overloaded with patients.
A GDMO in India is a MBBS graduate. At the primary and secondary level of health services, he/she is mainly responsible for the preventive and promotive work under the national programmes such as Reproductive and Child Health programme, Immunization programme, Revised National Tuberculosis Programme, etc. He/she needs to attend to patients in the outpatient department, inpatient wards and casualty. In the PHC, he/she is additionally responsible for the administration of the PHC and management of the periphery like supervising the staff, monitoring the reporting systems of services provided, financial performance, etc. In Taluka hospitals and the District hospital, the presence of GDMOs allows specialists to attend to cases and conduct operations/procedures within their speciality.
From the above mentioned role and responsibilities, we can therefore understand the importance of having adequate number of GDMOs at the various levels. Now we can see how shortage of GDMOs badly affects not only the functioning of facilities but also the quality of health care available to the community. This is the scenario in Tumkur today but is similar across other districts in Karnataka also.
According to the district records, in 2011, there are 147 total sanctioned posts out of which 133 are filled while 14 are vacant. According to Indian Public Health Standards, there should be at least 407 GDMOs in Tumkur across all facilities(not including AYUSH doctors).This means that the State health department needs to create 260 more posts for GDMOs and recruit at least 274 more doctors. The State health department is trying to bridge this gap through appointment of contractual AYUSH doctors instead. However, the AYUSH doctors are not provided with adequate orientation on their job responsibilities and in some cases, nil. As a result of this, even if they are available at the facilities, they are unable to take an active part in managing these centres. At the end of the day, only the poor patients suffer either by going to private practitioners if they have some money or by staying at home and worsening if they do not.
Thus, there is an urgent need to develop strategies to address this issue. The strategy may be to: i) rethink creation of new PHCs or CHCs, ii) reorganise the PHCs depending on needs of the population rather than numbers, iii) recruit GDMOs on contractual basis to fill in gaps for short term, iv) address the issue of fresh MBBS graduates joining the private sector, or v) address the friction rate of doctors leaving government service to join the private hospitals.
As a trained allopathic practitioner myself, two decades ago I found myself in similar circumstances (1) and appreciate the dilemma of the young doctors. Since this analysis is after the event, it must be read as a tentative explanation of the confusion we often create for ourselves.
Historical influences on a doctor’s professional behaviour
The beginnings of this story must go back to the time when we clinical practitioners, along with the rest of the scientific community, adopted positivism as the way that knowledge was constructed. A positivist approach emphasises “facts” as perceived by the five senses as the basis of empirical evidence. When these facts are shared by a community of “objective observers”, the common ground becomes the basis of “truth” or “real” knowledge. In fact, the positivists would say this is the only truth, proven and set in stone. Interpretation does not play a role here, as the shared observation is considered to be true (1).
However, this knowledge is still from a particular point of view, however closely shared. Western science, in its claim to be objective, separated the observer from the observed and was willy-nilly given pride of place in the hierarchy of knowledge. Medicine, claiming to be a science, needed to be free of “subjective values” (1). This is one limb of a doctor’s training; the attitude imbibed from it has repercussions which we shall see as we proceed.
As a part of Health Inc’s Work Package 1 ‘Capacity building and research network’ led by ITM, the newsletter offers a step-by-step package of support throughout the lifespan of the project (2011-2014). Each Newsletter discusses a specific (sub)topic related to research on social exclusion/inclusion and provides key references for further reading.
Second in a series of three Health Inc Newsletters on focus groups. After having discussed the history of focus group discussions (FGDs) and their particularities in social research (Newsletter 5), the present Newsletter 6 goes for the answer on a practical question: how to get the most out of FGDs?
The fifth newsletter of the Health Inc Capacity Building & Research Network is out. With this edition, the newsletter moves towards discussing qualitative methods esp. focus group discussions and their role in exploring the ‘how’ and ‘why’ of social exclusion.
The fourth newsletter contains two interesting articles on conducting research among the socially excluded. Both articles talk about why and how should excluded people be involved in planning and implementing the study. This is important if one is to conduct ethical research that makes exclusionary processes visible and affects policy.
Discussing social inclusion, the twinned concept of social exclusion, with illustrations from Senegal, Ghana and India. Peru’s president is given the last word (actually his first); the turtle keeps quiet.
An overview of the term social exclusion traveling South, and concrete examples from the Health Inc study countries: India, Ghana and Senegal. Food for thought from BR Ambedkar to conclude, and the turtle’s name revealed.
An introduction to the Health Inc research consortium, to the Health Inc newsletter, and a very first introduction to the concept of social exclusion. A quote of Bertrand Russell to complete, and an unidentified turtle on top.
The Rashtriya Swasthya Bima Yojna (RSBY), along with the National Rural Health Mission (NRHM), is a flagship programme introduced by the central government in April 2008, to increase the breadth, depth and height of coverage so that ultimately universal coverage can be achieved.
Key features of this scheme are a systematic focus on the poor with an aim to try and cover all BPL families within a period of five years, covering more than 700 hospitalisation packages, thereby protecting the poor from major health shocks, and finally a cashless mechanism through the “smart card”. The RSBY is an excellent attempt at providing social protection in health for the vulnerable and poor in India.The scale of RSBY, its clear social purpose, as well as its original design also make the scheme a tremendous learning opportunity for social policy-makers in India and all over the world.
Hence, there is a need to study the RSBY in more detail and identify what works and what does not work, and also understand why. This is also an excellent opportunity to provide feedback to policy makers and managers of this scheme, so that the scheme can be further strengthened.
To study the impact of the RSBY scheme in Patan district of Gujarat state in terms of enrolment rates, access to quality hospital care and financial protection
To list and understand the issues with governance, enrolment, utilisation and monitoring of the scheme
Two dimensions are being studied and hence, two distinct methodologies are used:
To look at what is happening, a household survey will be conducted using a structured, closed ended questionnaire.
To understand why certain events are happening, qualitative methods like key informant interviews and focus group discussions will be conducted.
This study will assess the performance of the RSBY vis-a-vis enrolment, access to quality hospital care and financial protection. .All the three dimensions of universal coverage – the coverage of the BPL families, the depth of the RSBY package and the out-of-pocket payments will be considered during analysis and interpretation of results. The study results are expected to provide an explanation to policy makers and managers to enable them to make necessary corrective actions to improve the effectiveness and efficiency of the RSBY. The results will hence, be disseminated to stakeholders from district to national levels through a workshop and also to academicians, activists and policy makers via publications in peer reviewed journals.
Title – Socially inclusive health care financing in West Africa and India
Short title – Financing health care for inclusion
Project Acronym – Health Inc
Duration – 36 months
In most low- and middle- income countries (LMIC), out-of-pocket payments make up a large proportion of total health expenditure (on average 75% in Asia and 50% in Africa). At the international level, there is now a consensus that out-of-pocket payments for health care increase inequity and as a result, increased risk pooling is necessary. There has been a recent proliferation of health financing reforms in LMIC which aim to introduce prepayment at affordable prices for low socio-economic groups and targeted subsidies for indigents and other vulnerable groups. However, while such reforms have led to increased utilization of health care, it is often the case that the poor and informal sector continue to be excluded from coverage.
The research project Health Inc. (Financing health care for inclusion) puts forward the hypothesis that social exclusion is an important cause of the limited success of recent health financing reforms.
In four countries/states (Ghana, Karnataka, Maharashtra and Senegal), Health Inc. will employ mixed methods to analyse whether different types of financing arrangements not only overcome social exclusion to successfully cover poorer population groups but, crucially, also increase social inclusion by empowering socially marginalised groups. A multi-sectoral stakeholder analysis will additionally explore whether vulnerable population groups participate in policy making and whether their needs are represented and understood. Health Inc. will also identify and test policy recommendations.
This will be done through a process of comparing and contrasting policies across contexts in order to elicit lessons. Following this, local policy makers and population groups will be consulted in a feasibility analysis.
Using a wide range of media, Health Inc. will disseminate those lessons learnt among different target populations: local, national and international public health authorities, researchers and health and development cooperation actors in general. Health Inc. will also consolidate and expand international research networks and build the capacity of the partners in the consortium.