Shopping for monthly provisions is a great exercise in management. Before setting off, we go through the following stock-taking and planning motions, more or less:
- what we have
- what we don’t, and what we need
- where to get from
- how to get
- budget
- once done, have we got what we wanted
This goes on and on, every few weeks. Necessity drives some contingency purchases as well. When the same simple set of tasks is applied to nationwide health implementation, there are no answers. Disappointing is an understatement.
At the core are the twin issues: numbers that exist and that don’t. Rehabilitation services in India, as an extension of health care in general, have been traditionally provided to those who seek them. Paltry number of centers providing such services to over a billion people makes a mockery of all modern day healthcare targets. This gross mismatch places a huge burden on existing rehabilitation service providers and users, the people.
What make the matters worse is that currently there is hardly any scientifically sound nationwide data on any health condition, probably with the understandable exception of polio related statistics. It therefore is impossible to know the actual incidence and prevalence of most conditions that cause significant physical impairments. We do not know what we have, and hence cannot know what we don’t and what we need. This could render arbitrary all the healthcare policies of the state, since meaningful solutions cannot be planned for problems that are not fully defined and assessed. As a result, a high percentage of persons that would potentially benefit from a structured program never get a whiff of rehabilitation in their lifetime. And those that do get are those that are fortunate to know and access necessary resources.
If the system needs to become better, a few significant changes in the basic structure of healthcare and, as an extension, rehabilitation services might be in order. Those changes, which would need to be initiated and effected by each of us, as part of the community of healthcare professionals involved in this work.
Create National Registries
We need to get the numbers. Factual ones, not just the samples which are extrapolated, as is the current practice. From these real numbers would emanate epidemiological datasets that could serve as starting points for us to fathom the actual impact of health conditions and care provision (what we have). That could lead us to better decisions on priorities and interventions (what we need).
Generate useful evidence
Clinically relevant evidence comes by asking the right questions. The first step always should be to aggregate what the world already knows (literature review) about that question, and get the essence of the answer (the evidence base). If we need to enamor ourselves with knowledge of the available literature, we need to step outside of book-based learning, and engage in regular, critical reading of scientific literature, the right way. Not just going through abstracts and taking them for granted, but by questioning logically everything that comes our way.(1) Evidence is needed not as ready-made decisions, but as clinically relevant information that would help us make better decisions.
Guidelines for healthcare that are regularly updated
Based on evidence generated by us, of us, for us, there should be common-minimum care guidelines. These should not just mirror what the western world does; what works there might not/might work here. Also, the guidelines should direct us towards focusing interventions on outcomes that matter. Hard end points that mean something to the patients should take precedence over surrogate lab measurements. (2) What seems clinically appropriate may not be what the patients prefer. Let there be an end to treating the symptoms and signs. People should matter, not just what they come with. A corollary to this would be an end to one-size-fits-all type of treatment plans. The right type of guidelines are capable of inspiring changes even in deep rooted practices.(3) Key to implementation would be assigning justifiable accountability wherever necessary- including researchers, policymakers, healthcare professionals.
‘User’ to ‘Provider’ shift
Probably, the most important of all. The onus of provision of health needs should be on the provider, who by default should be the state. We should cease being content with the tunnel vision tradition of providing care to those who seek them.(4) Paraphrasing the fictional Albus Dumbledore, quality healthcare should be provided to all who deserve it, not just to those who ask for it. Such an achievement would need a modern miracle in changing mindsets of all stakeholders- the people, everyone working in healthcare ‘industry’ (can there be a more derogatory term?), researchers, and policy makers. Such a welfare state model may have its own predicaments, but there are not many humane alternatives, are they? The ‘other’ model, inflationary insurance-driven healthcare (cue: USA) is not doing particularly well. The American healthcare dream has fizzled out to a (probably) never-ending nightmare, nobody having any idea what it would turn out to be.(5) The only worse thing we could do would be continuing to embrace inaction and maintaining current course.
Disclaimer Views expressed in this article are not solely mine, and they might just be plain wishful thinking.
Competing Interests: Notwithstanding what is written here, I hold a current subscription to an Indian health insurance scheme which I intend to continue for some time to come. No other competing interests.
References
- Lehman RS. Nullius in verba: Don’t take anyone’s word for it. Jama Intern Med. 2013 Jun 24;173(12):1049–50.
- Ioannidis JA. Appropriate vs clinically useful diagnostic tests. Jama Intern Med. 2013 Jul 22;-.
- Thornhill MH, Dayer MJ, Forde JM, Corey GR, Chu VH, Couper DJ, et al. Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study. BMJ. 2011 May 3;342(may03 1):d2392–d2392.
- Gray JAM. The shift to personalised and population medicine. The Lancet. 2013 Jul;382(9888):200–1.
- Oberlander J. The Future of Obamacare. N Engl J Med. 2012;367(23):2165–7.
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