On December 28, 2013, I was made the health minister. After becoming the health minister, I went to the emergency department of Lok Nayak Jai Prakash Narayan Hospital. There I was a bit surprised to see that patients were praising doctors very much. This was a kind of discovery for me. What the people really complained about was one bed was being occupied by 2-3 patients, medicines were not available, there was no cleanliness, bedsheet was torn etc. I realised these were administrative problems. I also realised people were happy with doctors!
There are two aspects of healthcare – healthcare provider and service user. Whatever I am doing I am doing from the user’s perspective.
When I was young, in our neighbourhood there used to be a doctor and a compounder and the system worked very well. After becoming the minister, I thought why can’t the government do something like this?
Once I visited a government dispensary in Delhi, which was being run by a staff of 19 people. And when I asked them what was the biggest problem there they said it was staff shortage. Surprisingly, out of the 19 staff members, there was only one doctor. I found there was a lady who in a day had just made 36 entries in a register. There was another lady who had also made 36 entries but in a different register. I realised we have not been using the manpower efficiently. The current thinking is that the solution to any problem is put some more money and put some more people into it. Then things will improve. I am often asked how much more money you spent, how many more people you employed. I am never asked how much more work you got out of your current manpower or what did you do with the money already spent?
If a normal delivery in a government hospital is being done at a cost of Rs 1 lakh, there should be a big question mark. There was a 30-bedded hospital only for MCH (Maternal and Child Healthcare) in Kanti Nagar. The hospital had 18-20 doctors. There were many other staff too and in a month there were only 18-20 deliveries being done in the hospital in a month. And these were all normal deliveries, as the hospital didn’t do caesarean. And no one was asking why only 20 deliveries were being done and not 200? And the cost for each delivery on an average was more than Rs 1 lakh. I am only asked, ‘Why are you not spending more on health?’ I closed that hospital, actually converted it into a polyclinic. In that polyclinic today 1500 people go who get free treatment and get free medicines and get their tests done for free. And we have attached this polyclinic with a nearby hospital.
During a government hospital visit, I was shown a machine which the doctor told me was the best in India, he said the gas pipeline was so advanced not even private hospitals had such a system in India, even the OTs were very modern and modular, I was very much surprised to such an OT. Then I asked, ‘Where are the patients?’ And the doctor said, ‘Sir, we don’t have them.’
In a 500-bed private hospital, where most of the beds are private, per patient area would be around 500 square feet. In our government hospitals, where there are very few private beds, per patient area is 2,000 square feet. And still there are beds put together. I asked, ‘Where are the other areas?’ And I found they had built too many stores. In government hospitals the room of a medical superintendent is sometimes so big that we can play football there. I said please adjust instead with a badminton court. So, the fact is we think of patients in the last. Recently, I visited Apollo and was shocked to see the hospital head was sitting in a small room in a gallery. I thought in such a room in a government hospital even an office superintendent would not like to sit. I asked the lady at Apollo, ‘How come you are sitting in such a small room?’ She said, ‘We are working for patients and not for ourselves.’
Even now when a list of demands are submitted to me, it often talks about things like how to improve internal co-ordination and no one talks about what they want to do about the problems of patients.
If you go to any emergency ward of a government hospital in Delhi, be it under the Delhi government, the union government or under the MCD, you will see 3-4 doctors are sitting on one side of a table and on the other side would be patients standing in a queue. And each of these patients would be prescribed medicines in about 30-45 seconds. The doctors would not even try to touch the patients. They will just ask the patients about the symptoms and then prescribe the medicines or send them for tests. I am often told about the latest technology and I say please use the technology gifted to us by the God. You have got two ears, please listen to the patient for just a couple of minutes. I am not asking for 20-25 minutes, not even five minutes. Please talk with the patient nicely for a minute. You have got hands, just touch the patient with your hand. And just see how this technology does wonders. The government is working in this direction, this is called human technology.
Today, we have brought down the status of doctors to such a level that we have made them only prescribers of medicines. Doctors think, ‘If a patient has visited me and I don’t prescribe medicines, I have not done my job.’ But that should not be the case. I think doctors are not meant to only prescribe medicines, they are there to give advice and the advice may or may not include medicines.
Most dissatisfaction in patients is not there because they didn’t get good medicines or their tests were not done well, but that they were not treated sympathetically.
Once a man came to a Mohalla Clinic. He had visited many private and government hospitals and after that he had come to a Mohalla Clinic to get treatment for his child. He said he had heard a lot about Mohalla Clinic and his child was not becoming any better and he asked the doctor to treat his child. The doctor patiently listened to him and told him that the child could not be treated but added that he could any time come to the clinic and that he should keep some lifestyle things in mind. He was satisfied. He said no one before explained this to him. Till then he was just being referred from one place to another.
The concept of Mohalla Clinic was there should be a touch and feel between the doctor and the patients; some sort of a relation should be developed between them.
Today, in a typical 200-bed government hospital there are about 200 patients. Even if there are 3-4 attendants with each patient the total footfall would be around 1000. In the emergency department 300-400 patients would come in a day, and if each patient has 4-5 attendants so this would mean a footfall of around 2000 in emergency. There is also an OPD where 3500-4000 patients visit in a day. Each of these patients is normally accompanied by two more people. So, on the one side the critical footfall is 3000 and on the other side there is a footfall of 12,000 which is in OPD. So, a hospital, which is visited by 15,000 people in a day, has actually become a very large OPD. If you visit a hospital after 4 pm you will feel like the hospital has been closed. But hospitals actually don’t run like this. Today, even junior doctors are demanding the round the clock presence of senior doctors in the emergency. Most of the emergencies are being run by JRs and SRs, not a single senior doctor is present there. We are trying to change this. We are trying to reduce the number of footfalls in the OPD so that more resources could be devoted to take care of the critical in-house patients.
I don’t agree that we are short of resources, though I agree that lots of resources are being wasted. We are using doctors, who become doctors after studying medicine for more than 5-8 years, for non-clinical works. In the Delhi government, there are about 10,000 doctors. In Delhi, there are about 50,000 doctors. And by any international norms, 50,000 doctors are not less for a city like Delhi. And more than half of these 50,000 doctors are in government. So, we are not short of resources, even not of money. We spend enough money. In a government hospital, the cost of one hospital bed per day is between Rs 7,000 and Rs 13,000, the average is Rs 10,000 per day, and this is when we are providing only secondary care and not super-speciality care. I think this cost is very exorbitant. If a patient stays in a government hospital for 10 days, it means the government has spent Rs 1 lakh on him. The need is how to economise the use of these resources. In a 100-bed government hospital, there are departments like orthopaedic, paediatric, gynaecology, medicine, and there are 120 full time doctors, and still most of the patients are being referred from the emergency department.
I was once told by a gentle man that the government should take the responsibility of all diseases, including kidney transplant. When I asked about the estimated expenses for a year, I was told it would take around Rs 10,000 crore. And I said if we spend so much on one disease and our budget is of Rs 40,000 crore then our entire budget would be spent on only 4-5 diseases. So, I felt this is not the right way. The challenge is how to best use the given resources. The average cost of attending one OPD patient in a Delhi government hospital is Rs 600. And assuming the patient has to visit the hospital twice including for test and has to travel for a distance, for treating him, the government on an average spends Rs 1200 and the patient spends Rs 200-300 on travel, and also loses his daily income for two days. So, we thought about bringing healthcare to the doorsteps of people, and the concept of Mohalla Clinic came.
We are currently running 105 Mohalla Clinics in Delhi where we are providing free treatment, free medicines and free tests. The average cost for seeing one patient in a Mohalla Clinic is around Rs 100-110. So, we have brought down the average cost of seeing a patient in an OPD from Rs 900 to Rs 100 and the hassle that the public had to face in visiting a doctor has been removed.
Most of the people visiting the Mohalla Clinics are ladies, aged people, and children. After talking with these people we have found that now people are not hesitating in visiting a doctor, which was not the case earlier. We had thought that perhaps we would be able to treat 80 percent of the people visiting in Mohalla Clinics there itself, and we would have to refer 20 percent of the people to other hospitals. But our experience of running these clinics for about five months shows that we have to refer only 5 percent of the patients; 95 percent of the patients are getting treated in the Mohalla Clinics itself.
In an innovation, our doctors of Mohalla Clinics have formed a WhatsApp group with the doctors of G B Pant Hospital and they regularly consult the senior doctors about their patients.
Most of the patients visiting Mohalla Clinics are suffering from cold, cough, fever, and then for hypertension and diabetes. These two diseases (hypertension and diabetes) are more prevalent than what we could have imagined. Most of the time patients get diagnosed for diabetes for the first time, they had gone for something else and after test it was found they were suffering from diabetes. Since our focus at Mohalla Clinic is on women’s and children’s health we are planning to make a gynaecologist sit in Mohalla Clinics for a day in a week. Similarly, we will send a paediatrician on a day in a week. This would be in addition to our regular doctor. Our other priorities are diabetes and hypertension. For these diseases, we are planning to train our existing doctors and may be initially we can also send the experts for a day in a week. We are also planning to connect our doctors of Mohalla Clinics with specialist doctors through telemedicine.
Currently, about one lakh patients visit in OPDs of Delhi government hospitals in a day and there is no system to get any idea of the patients or diseases. So, we are computerising the healthcare system in Delhi, starting from Mohalla Clinics. We will do 100 percent computerisation so that we could know what kinds of diseases are more prevalent and which disease started from where so that we could take timely action.
I am often asked, ‘How will you manage the 1000 Mohall Clinics?’ But I think we will manage little and support more. Why should I become a boss of a doctor who is sitting there with 10-20 years of experience? My job is to provide adequate medicines, facilities for tests, the infrastructure should be good and these will be taken care of by professional managers but they will not be over doctors. For ensuring quality of care, we will outsource this to senior doctors in a medical college or a hospital who would guide and monitor our doctors in Mohalla Clinics. We will not do this on our own. We will allow our doctors in Mohalla Clinics to work independently.
Today there are too many managers who are actually doctors. Recently, I got a list of LNJP (Lok Nayak Jai Prakash Narayan Hospital) doctors and I found 50 doctors are in full-time managerial work. Someone is looking after the laundry; another is looking after the cleanliness. I asked them, ‘Did you study this? Are you interested in this?’ They said, ‘No’. Then I asked them, ‘Then why do you do this?’ They say, ‘We are helpless.’ On the one hand we say we are short of doctors and on the other hand we put doctors into those jobs in which they are not interested. And why should they be interested? Why should a surgeon be involved in laundry work? Doctors should be devoted to the area of their core competence. Delhi government will gradually remove all doctors from non-clinical works, like purchase; we are now centralising this. We have already setup Delhi Health Corporation.
After a study, we found that we are spending Rs 87 crore on just salary to manage our medicine stores. Transportation expense is extra. We asked professional logistics companies, ‘How much it would cost if we privatise this?’ They said, ‘It would cost at most Rs 20 crore.’ We asked them, ‘If we set up a central warehouse and you have to send medicines at a clinic how much time you would take?’ They said, ‘Four hours.’ Currently, it can take even a month. So, we are working on a lot of things to make the system smart and efficient and simultaneously reduce the cost.
We will open 1000 Mohalla Clinics by the end of December 2016. Then in the next phase we would be opening 100 polyclinics where all consultants will sit and these polyclinics would be equipped with X-ray and ultrasound machines. But these will be after Mohalla clinics. We have already opened 23 polyclinics on trail basis. Our experience shows that unless there are Mohalla Clinics and the proper referral system, the polyclinics would not be very helpful. At the third level, there would be hospitals.
We would be dividing the hospital services in three parts: day-care hospital, secondary care hospital, which will focus on emergency care and MCH (mother and child health).
On a day in a government hospital emergency department, 32 patients were admitted and at the midnight only two were left as the other 30 were referred to other hospitals. We will change that. Emergency care will be provided at all hospitals.
At the next level, we would have five super-speciality hospitals in Delhi for planned work like knee replacement. Unplanned work will be done at all hospitals. I think the government should focus more on primary and basic care and leave the super-specialist care for the private sector because we are very inefficient in providing super-speciality care. In government hospitals, we have full time specialists for everything whereas in private hospitals they have a panel and when a patient comes they call a doctor from their panel.
We are also renovating all Delhi government hospitals, making all the hospitals fully air-conditioned, upgrading the basic care and we will remove private rooms from the government hospitals which will only have general wards.
We are planning to introduce incentive scheme in Delhi government hospitals to reward more efficient doctors and staff. We will also ensure proper training of staff. Recently, we sent 35 managers, who are doctors, to IIM Ahmadabad for training.
Currently, there is only one MRI machine in the Delhi Government hospitals. But we have already issued tenders for 5 MRI and 10 CT scan machines. But we will run them on PPP (public private partnership) model. Because we have realised we cannot run them efficiently. And these services will be available to our patients for free. Earlier one MRI test was done for Rs 4,000 and the waiting period was one year. Now they are being done for free and the waiting time is two years.
In Mohalla Clinics, the tests are being done by the private sector and this model has been very successful. We have realised the management cost is very high so we will focus on key functions like patient care and outsource the non-key functions.
We are working on an app where public can share their opinion about Mohalla Clinics. We are also setting Mohalla Clinics Management Committee which will have 10 people from the locality and the doctor of the clinic will also be one of its members. The committee will provide its feedback to the government. There will also be a committee of MLAs which will make weekly visit to the clinics.
We are not giving salary to any staff of Mohalla Clinics, we are only giving per patient salary with minimum guarantee to doctors, which is currently Rs 68,000 per month but it can go to Rs 1 lakh or even Rs 1.25 lakh. This ensures they behave with patients very well. They are not government employees, they are on a panel. There is a proper process of selecting candidates and providing them training and after training only those who are successful can be appointed on the panel.
We will also launch a universal healthcare scheme where we will provide health insurance to all the people of Delhi. The first part would be accidental insurance. It will be free for all. It could be around Rs 10 lakh. Then there will be medical insurance. It will again have two parts. Medical Insurance will be family insurance in which the government will pay the premium for the EWS (Economically Weaker Sections) category people, and the rest will pay their own premium, but since it will be on a huge scale the premium will be low. This medical insurance will also include OPD (Out Patient Department). This scheme will also be available to private hospitals, where we will set the standard rates. But the services will be provided on the basis of a no-frill insurance system and will be available at the basic level; there will be no private wards available under this scheme.
Right now our focus is on diseases. If a man is healthy he would not even get water for free because you are healthy. But if you are ill we can spend even Rs 5 lakh on you. But I think if people are keeping themselves healthy we should also do something for them.
The cost of doing one MRI in Delhi Government hospital currently is around Rs 25,000-30,000. So, we have realised we can’t do everything efficiently and we will go for PPP where necessary. Even lab tests and medicine distribution will be done through private partners.
I am health minister of Delhi and not of Delhi Government’s hospitals, even private hospitals I consider them as my own. We are going to use vacant beds in private hospitals and also provide them new customers through our health scheme.
We will also launch Health Card for all. This card will have all the medical records of the cardholder and the data will be accessible to even private hospitals. We will start from Delhi government hospitals and gradually we will include even private hospitals. Initially, it will be optional but after, may be, five years this can become compulsory. Data will be patient’s data. He can take it anywhere and just swipe it. In an accident case, just taking the victim’s thumb impression would be enough to get all the relevant data.
I am surprised to see people are not treating MBBS graduates as doctors. Everyone is looking for experts, degrees.
One night at LNJP hospital, I asked an old lady, ‘Amma, has the doctor seen you?’ She said, ‘Doctor will come day after tomorrow.’ I asked a doctor who was standing nearby, if he had seen the lady. He said, ‘Yes, I have.’ I asked him about his designation. He said, ‘I am SR (Senior Resident Doctor).’ So, someone who had done PG two years ago, the patient is not treating him as a doctor! Where are we taking this system?
I think first of all the senior doctors should start respecting their juniors and then patients will also start respecting them. Right now, they (senior doctors) are asking people to respect them that ‘I am a big doctor’. In government hospitals, a senior doctor goes on a round, accompanied by 20 juniors, and the patient thinks only he is a doctor and others are not doctors.
Note: This article is based on a speech delivered by Delhi Health Minister Satyendar Jain at the India Health Forum 2016 organised by ETHealthWorld on July 23 in New Delhi.