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Wednesday, March 08, 2006

Trends in public health

Read this old post written in 2000 at by Arun Bal

It is still very relevant, even today

Resident doctors of public hospitals in Mahaharashtra were on strike again, demanding parity in their stipend with other states. This was their sixth strike in two decades. The usual pattern is that the strike is carried forward for two to three weeks and then withdrawn in the face of government coercion. The government does little to prevent such strikes, or to hold any meaningful discussion with the agitators once they begin. This is primarily because the people affected by the strike are poor and unorganised, and cannot put much pressure on the government. Also, the public’s health is a low priority for all political parties.

Resident doctors make up the backbone of public hospitals affiliated to teaching hospitals, and the government‘s assertion that the strike did not affect services in these hospitals is completely false. Resident doctors are post- graduate medical students who work as resident doctors as a part of their post- graduation. Keen on completing their post- graduate studies, they are usually up-to- date on recent developments in their subject. They are responsible for the efficient work culture and relatively high quality patient care in these hospitals — a contrast to district hospitals with facilities similar to teaching hospitals but with full- time doctors who are government employees.

Demands justified
There is a big gap in the stipend paid by the government of Maharashtra and that paid by other states. The government expects resident doctors to work 24 hours a day without the protection of any service rules because they are students. At the same time, it charges them hefty teaching fees for post- graduate courses.

The government also argues that resident doctors in Bombay are working in the best hospitals in the country, and will go on to earn lakhs in their private practices based on the experience they receive at these hospitals. This ‘good will’ justifies the low stipend that they receive. The government’s contribution towards this ‘good will’ is zero.

Resident doctors in Maharashtra work and live in abysmal conditions which are bound to affect patient care adversely. In times of medical crisis, they must depend on archaic communication systems. Discharge cards are still hand written, though computerising the record system would save significant time for patient care. Essentially, the government has always looked upon resident doctors as cheap labour for its public teaching hospitals.

In short, the demands of resident doctors in Maharashtra were justified.

Why the strikes fail
However, resident doctors have failed to garner public support for any of their strikes in the last 25 years. The reasons: the inherent weakness of the Maharashtra Association of Resident Doctors (MARD) as an organisation whose members and leadership change every three years, and the lack of social awareness about the critical role that resident doctors play in public teaching hospitals. The government has always exploited these facts to break the strike.

Both MARD and the medical profession at large have failed to create public awareness about the importance of resident doctors for public teaching hospitals. The medical profession’s general lack of political awareness contributes significantly to the current situation. The main demand in residents’ strikes has always been monetary. Instead, the focus of any negotiation should be the poor working conditions which affect patient care.

Any strike by health professionals which deprives people of basic care is unethical. MARD should have allied with other medical and social organisations to lobby the government, negotiate and arrive at an amicable solution. They should also have focused on the trends in health care responsible for the situation today.

Trends in public health
Investment in the care of seriously- ill patients as a percentage of investment in public health has been decreasing over the years, particularly after the World Bank / IMF’s structural adjustment programme pushed for privatisation of the public health system. The Maharshtra government’s recent Rs 771 crore loan from the World Bank to modernise the district and sub-district level health- care system is conditional on starting user fees and increasing the involvement of the private sector in the public health system. The government has already announced that private doctors will be hired on contract to improve the functioning of public hospitals. It is surrendering public hospitals to private medical colleges which don't have a hospital of their own, in order that these understaffed institutions run by politicians meet the Medical Council of India’s requirements. Finally, the entry of private health insurance companies is likely to reduce the importance of public teaching hospitals.

While these trends are not directly related to the resident doctors’ strike, the government is likely to use the strike as a excuse to take privatisation one step further. Its move to reduce the importance of resident doctors by reducing the seats for open category post- graduate registration, reserving some for full- time government doctors, will, in the long run, adversely affect patient care in public hospitals. Neither MARD nor other professional organisations in the state have taken note of this fact.
National standardisation of stipends to post- graduate students and resident doctors is unlikely unless the medical profession realises the political and social implications of health care privatisation and joins hands with like minded organisations to create public awareness on the issue. Such public protest — with the support of professional organisations — forced the British government to abandon similar plans in some National Health Service hospitals.

The recent resident doctors’ strike in Maharashtra is a symptom of a crumbling public health system. The medical profession’s ignorance of this fact will only help the government break the strikes.


Arun Bal,Flat 6, Mallika, Makranth Housing Society, SVS Marg, Mahim, Mumbai 400016

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