January 29, 2008

Shortage of doctors spells crisis

The growth plans of corporate healthcare players are going to be affected by the absence of adequate medical professionals.

Comparing apples and oranges might seem odd, but the fact remains that airline pilots and medical doctors are increasingly posing a common problem, caused due their acute shortage, to the respective industries.

While the shortage of pilots in the airline industry is already visible, the shortage of doctors is a feared to be ticking time bomb within the corporate healthcare sector.

“The way the Indian healthcare industry is growing, we are bound to see this happen. The healthcare sector is heading towards a huge shortage of not just doctors but also para-medical staff and nurses,” says YP Bhatia, managing director, Astrol Hospital and Healthcare Consultants (P) Ltd.

Drawing parallels between the airline industry and the healthcare sector, Bhatia feels that the sheer size of the healthcare industry could aggravate the problem.

Recent estimates by global consultancy firm Ernst & Young predicts an addition of one million hospital beds in the country by 2012. The bulk of the capacity additions, over 80 per cent, are to come from the private sector.

No wonder, the growth plans of corporate healthcare players are going to be affected by the absence of adequate medical professionals.

“There is an absolute shortage of doctors. This was never the case three to four years ago. The crisis is more evident at the junior level,” says Dharmender Nagar, managing director, Paras Hospitals.

According to Nagar, the crisis is severe in the smaller towns than the metros due to the absence of adequate inflow of junior doctors.

“With corporate hospitals identifying smaller cities as the next growth destination, the shortage of doctors is going to be a problem for all hospital chains in the coming years,” he predicts.

While healthcare analysts put the current country-wide demand-supply gap for doctors between 200,000 and 300,000, E&Y estimates says that the country will need at least 1.2 million doctors (as against 600,000 in 2005) to treat one in thousand population by 2012. Considering the fact that 22,000 doctors are added each year, E&Y estimates the gap (shortage of doctors) to touch 453,785 by 2012.

“The doctors’ availability will be a factor while corporate hospitals plan their expansion programmes. We remain unscathed as Gurgaon remains an attractive destination for doctors,” Nagar says.

While there are no short-term solutions to the problem, the value-added services offered by hospitals might attract more doctors to such organisations, Bhatiya says: “Our hospitals should have in-house training programmes for junior doctors. All entry-level people today need on-job training and the hospitals should develop such facilities,” he opines.

Artemis Hospitals, the healthcare venture of the Apollo Tyres group, is probably taking this path to attract doctors. “Our hospital is fully functional and we have sufficient doctors. The advantage with Artemis is its multi-focus on research, education, healthcare delivery and manufacture of health consumables. The doctors can pursue their research interests by joining us,” explains Asoka Iyer, director, Artemis Health Sciences Pvt Ltd.

However, Bhatia fears that the scarcity of human resources in healthcare industry might compel healthcare providers to compromise on both quality and quantity. “If that should not happen, hospitals should have a very serious manpower plan in place,” he adds.

January 27, 2008

Democratize Health Care in India - Rs.10 lakh Social Entrepreneurship Competition

In an attempt to address growing healthcare problems throughout India, the Piramal Foundation, in coordination with Indian Institute for Management, Ahmedabad has launched the Piramal Prize healthcare business plan competition. The competition seeks to empower bold thinkers to help solve India’s largest health problems through revolutionary ideas.

Currently, India’s population of 1.2 billion people faces a healthcare crisis of epic proportions. While India’s private health system is on par with that of any western country, its public health system is ranked amongst the lowest in the developing world, both in spending and efficacy.

While India’s current health situation is grim, the Piramal Foundation and Piramal Prize believe that there is hope for a cure. They believe that the solution to India’s woes lies not with charity or with the government, but rather with bold ideas that are both entrepreneurial and socially effective. The Piramal Prize competition seeks to bring together the world’s brightest minds to solve aspects of the health crisis while competing for prize awards of Rs. 10 lakh ($25,000) and incubation support at IIM‐A. Contestants will have access to the expertise of prominent business and health leaders through a mentorship program, and will work closely with world‐renowned staff at IIM‐A to fully develop their ideas. Finalists will spend a weekend presenting to a panel of distinguished judges and will showcase their ideas to leading finance firms. The Piramal Prize will produce revolutionary business models and a new generation of changemakers that will be empowered to change the landscape of Indian healthcare. For more information or to enter the competition, please visit: http://www.piramalprize.org.

Contact: Naman Shah, Piramal Foundation, naman@piramalprize.org India: +91 9828386255 U.S.A.: +1 3219178997

18 doctors to get Padma awards

Former Indian Council of Medical Research (ICMR) chief Nirmal Kumar Ganguly was on Friday named for the Padma Bhushan award. He is among 18 doctors selected for the prestigious Padma awards this year.

An epidemiologist, a researcher and professor of medicine Ganguly has been working for decades in several top medical institutes like National Institute of Communicable Diseases (NICD), Central Government Health Services, National Malaria Eradication Programme.

He has also worked with the World Health Organisation to help it develop Integrated Disease Surveillance system. In 1997, he also was an advisor with the government of Sultanate of Oman.

Apart from Ganguly, Jagjit Singh Chopra, a senior doctor from Chandigarh, has also been named for the Padma Bhushan.

Sixteen doctors from Delhi, Bihar, Tamil Nadu, Manipur, Maharashtra, Kerala, Uttar Pradesh and Uttarakhand would receive the Padma Shri awards.

Those who have been named for Padma Shri include Tony Fernadez (Kerala), Indu Bhushan Sinha (Bihar), Randhir Sud (Delhi), Rakesh Kumar Jain (Uttarakhand) and Arjunan Rajasekaran (Tamil Nadu) and Keiki R. Mehta (Maharashtra).

What drives medical tourists?

They come from all over the industrialised world, from countries with relatively poor healthcare infrastructures and, in the case of the U.S., places with exorbitantly expensive health care systems.


The reasons for seeking treatment abroad differ according to country. In Canada and Britain, long waiting times for surgeries encourage those with sufficient financial resources to look for alternatives. In countries with relatively poor healthcare infrastructures, quality is the driving force for those with money.

Medical tourists from the U.S. are usually those seeking procedures not covered by their insurers, those seeking necessary procedures and who are provided with incentives to find lower cost options, and those who cannot secure medical insurance. Where they go depends on the procedures and the physicians. Cosmetic procedures are easily found in South America, while complex heart and orthopaedic procedures are found in India, Thailand and Singapore, and specialists in in-vitro fertilisation can be found in South Africa, Israel and Spain. In the global medical tourism industry, from cosmetic surgery to complex oncology, bargain prices can be found at a medical centre somewhere in the world.

Time and money provide the incentives for seeking healthcare outside the home country. In the case of public health systems with long delays, such as Britain, time is the motivation.

These medical tourists are choosing to pay for a procedure that would be cheap or free in their home environments, but is close to inaccessible due to the rationing of care. For U.S.-based medical tourists, money is usually the motivation. For the uninsured or for cosmetic procedures, savings of 50-90 per cent are common; even when those savings include transportation costs, recovery time, travel and lodging for close family members. For the insured, usually those covered by organisations that self-insure, financial incentives might be offered which for the middle-class worker can be significant.


Quality is a concern for potential medical tourists and what are now being called ‘offshore hospitals’ address these concerns by seeking and obtaining accreditation from bodies such as Joint Commission International (JCI), a subsidiary of the Joint Commission on Accreditation of Healthcare Organisations (JCAHO), which offers accreditation to hospitals in the U.S. Several hospitals that offer medical tourism in India meet or exceed the standards of care of the finest hospitals located in the U.S.

The lower cost structure of these hospitals allows them to be more generous with resources for their well-paying clientele. Nurse-to-patient ratios are higher, private rooms are readily available and family members are often included in the trip and made comfortable in luxury facilities that resemble five-star hotels.

Dr. Milica Bookman, professor of economics at St. Joseph’s University in Philadelphia, US, is author of the book Medical Tourism in Developing Countries. According to her research on the economic impact of medical tourism, 750,000 Americans are expected to have travelled abroad for treatment in 2007 and over six million will do so by 2010.

January 25, 2008

A software that can diagnose diseases!

The Union Health Minister, Dr Anbumani Ramadoss’ plans to make rural postings compulsory for the MBBS students has been dismissed as unworkable by many.

But here is an alternative on offer — a ‘clinical decision support software’ that even minimally trained health workers in remote rural areas can apparently deploy to make ‘intelligent’ diagnosis based on symptoms keyed in by the user.

Tested for accuracy

“We have tested NxOpinion for accuracy, usability and adaptability to local conditions in trials across 200 patients at the Nizam’s Institute of Medical Sciences, Hyderabad. The diagnosis made by the software virtually matched that of fully-qualified physicians. This conforms to the diagnostic accuracy rate of 94 per cent that we have reported across patient encounters in different world locations,” claimed Dr Joel C. Robertson, creator of the software and CEO of the Michigan-based Robertson Technologies.

“We are currently talking to the Central as well as various State Governments about the feasibility of adopting NxOpinion, including its local language versions, under the National Rural Health Programme,” Dr Robertson told Business Line. The software, built on a standard Microsoft.Net platform, can be loaded on to any notebook or desktop computer and run locally without requiring Internet access.

Incorporating a proprietary ‘Bayes theory-derived probabilistic inference engine’ that scans a medical knowledgebase of over 1,000 disease profiles, the NxOpinion software offers likely diagnosis and best treatment options based on the age, sex, general health profile and symptoms displayed by the patient.

Moreover, the technology platform is claimed to be scalable; the disease prevalence data can be changed for more accurate diagnosis by region.

Clinical reasoning

“The software is basically designed to mimic skilled clinical reasoning. Suppose a 45-year-old man complains of chest pain, it then asks him to specify the quality of pain (whether dull or intense; what position or activity aggravates or lessen the pain) and further prompts the health worker to check for pulse rate, blood pressure and cold or sweaty skin. If all these are in the affirmative, then the software would indicate, say 53.70 per cent probability of myocardial infarction. In case, the onset of pain is sudden and radiating to the neck, chest and shoulders, the probability rises to 98.62 per cent or so,” Dr Robertson informed.

But will such a tool really pass muster and gain acceptance with the medical fraternity? “No, we cannot support it. There is no substitute to a doctor, who alone has the knowledge and experience to make proper diagnosis. Tools of this kind will be liable to misuse by the thousands of quacks who illegally dispense treatment,” said Dr M. Abbas, National President, Indian Medical Association (IMA).

Dr Robertson, on his part, clarified that NxOpinion is not a freely marketable product and will be licensed only to health workers specifically approved by the Government. This includes accredited social health activists and informal rural practitioners who would act as an interface between the village community and the public health system.

Dr Abbas, however, maintained that the doctor’s role cannot be replaced by paramedics and neither can there be a simple technology quick fixes for rural healthcare problems. The Government has to provide basic facilities to enable doctors to function in rural areas, he added.

January 24, 2008

The crisis in rural health care

Rural health care in India faces a crisis unmatched by any other sector of the economy. To mention just one dramatic fact, rural medical practitioners (RMPs), who provide 80% of outpatient care, have no formal qualifications for it. They sometimes lack even a high school diploma.

In 2005, the central government launched the National Rural Health Mission (NRHM) under which it proposed to increase public expenditure on health as a proportion of the GDP to 3% from 1%. But increased expenditure without appropriate policy reform is unlikely to suffice. Experience to-date inspires little confidence in the ability of the government to turn the expenditures into effective service.

Rural India consists of approximately 638,000 villages inhabited by more than 740 million individuals. A network of government-owned and -operated sub-centres, primary health centres (PHCs) and community health centres (CHCs) is designed to deliver primary health care to rural folks.

Sub-centre is the first contact point between the community and the primary health care system. It employs one male and one female health worker, with the latter being an auxiliary nurse midwife (ANM). It is responsible for tasks relating to maternal and child health, nutrition, immunisation, diarrhoea control and communicable diseases.

Current norms require one sub-centre per 5,000 persons, one PHC per 30,000 people and one CHC per 120,000 people in the plains. Smaller populations qualify for each of these centres in the tribal and hilly areas. Each PHC serves as a referral unit to six sub-centres and each CHC to four PHCs. A PHC has four to six beds and performs curative, preventive and family welfare services.

Each CHC has four specialists — one each of physician, surgeon, gynaecologist and paediatrician — supported by 21 paramedical and other staff members. It has 30 indoor beds, one operation theatre, X-ray and labour rooms and laboratory facilities. It provides emergency obstetrics care and specialist consultation.

Despite this elaborate network of facilities, only 20% of those seeking outpatient services and 45% of those seeking indoor treatment avail of public services. While the dilapidated state of infrastructure and poor supply of drugs and equipment are partly to blame, the primary culprit is the rampant employee absenteeism. Nation-wide average absentee rate is 40%.

The employees are paid by the state, with the local officials having no authority over them. Not surprisingly, many medical officers visit the PHCs infrequently and run parallel private practice in the nearby town. ANMs are frequently unavailable for childbirths even if the mother is willing to come to the PHC. Though PHCs are supposed to be free, most of them informally charge a fee. Under these circumstances, even many among the poor have concluded in favour of private services.

Sadly, public health services have done poorly even along the income distribution dimension. According to a 2001 study, the poorest 20% of the population captures only 10% of the public health subsidy compared with 30% by the richest 20%. The share in the subsidy rises monotonically as we move from the bottom 20%. The justification for the government provision of health services on income distribution grounds does not find support in the data.

To make improvements in the delivery of health services, at least three reforms are urgently required. First, it is time to accept the fact that the government has at best limited capability to deliver health services and that a radical shift in strategy that gives the poor greater opportunity to choose between private and public providers is needed.

This can be best accomplished by providing the poor cash transfers for out-patient care and insurance for in-patient care. Once this is done, a competitive price must be charged for services provided at public facilities as well. The government should invest in public facilities only in hard to reach regions where private providers may not emerge.

Second, the government must introduce up to one-year long training courses for practitioners engaged in treating routine illnesses. This would be in line with the National Health Policy 2002, which envisages a role for paramedics along the lines of nurse practitioners in the United States.

The existing RMPs may be given priority in the provision of such training with the goal being replacement of all RMPs by qualified nurse practitioners.

Finally, there is urgent need for accelerating the growth of MBBS graduates to replace unqualified “doctors” who operate in both urban and rural areas. Taking into account the evolution of medical colleges and assuming that doctors remain active for 30 years after receiving their degrees, there are at the most 650,000 doctors in India today.

With a population of 1.1 billion, this implies approximately 1,700 people per doctor. In comparison, there are just 400 people per doctor in the United States and 220 in Israel. Whereas private colleges and institutes in engineering, computer applications and business fields have mushroomed in response to the demand, the same has not happened in the medical field.

The Indian Medical Council (IMC) zealously controls the entry of new colleges and keeps the existing medical colleges on a short leash. Recently, it threatened to effectively close down as many as six of the eight medical colleges in Bihar because they were in violation of its guidelines on how many senior positions could be left unfilled at any time.

Given low salaries, colleges face serious difficulties in filling the positions. The result has been extremely slow expansion of capacity in many states. West Bengal has added just two medical colleges since 1969, Rajasthan three since 1965, Punjab three since 1973, Delhi one since 1971 and Bihar two since 1971.

Only Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu have achieved satisfactory progress. This must change. The IMC perhaps needs to relax its norms and the government needs to make salaries competitive to adequately staff the existing colleges and open new ones.

(The author is a professor at Columbia University and Non-resident Senior Fellow at Brookings Institution)

January 23, 2008

Wockhardt Hospitals plans IPO

Wockhardt Hospitals (WHL), one of the largest private healthcare services company, is entering the capital market with an initial public offer (IPO).

The company, which was started with a hospital at Kolkata in 1989, is planning to expand its number of hospitals from 15 to 31 in two years.

“We have already invested about Rs 500 crore for setting up the greenfiled and brownfield facilities, and require another Rs 600 crore for its completion. We will utilise the IPO proceeds to complete these projects, pre-pay some of the short-term loans and meet general corporate expenses,” said Wockhardt chairman Habil Khorakiwala.

Wockhardt will issue 2.5 crore equity shares of Rs 10 each for cash at a price band to be determined through 100 per cent book building process.

The issue will open on January 31, 2008, and close on February 5, 2008. The price band has been fixed between Rs 280 and Rs 310 a share.

The offer comprises a net issue of 24,587,097 equity shares of Rs 10 each to the public and a reservation of up to 5 lakh shares for subscription by eligible employees. The net issue will be allocated to the qualified institutional buyers (QIBs) on a proportionate basis.
Wockhardt Hospitals, part of pharmaceutical and biotechnology company Wockhardt, is setting up new hospitals in the south and north of Mumbai, Delhi, Bangalore and Kolkata, and plans brownfield hospitals in tier-II cities such as Goa, Bhopal, Nashik, Bhavnagar, Ludhiana, Jabalpur, Bhuj, Patna, Hubli and Varanasi.

January 22, 2008

Centre to launch campaign on alternate medical systems

Aimed at generating awareness on the strengths of Ayurveda for the care of elderly people, the Centre will launch a nationwide campaign to sensitise policy makers, professionals and scientists about the contribution that alternate medical systems can make towards Geriatric health.

"Considering the time-tested efficacy of Ayurveda and Siddha systems in preventive and promotive aspects of health care, it is desirable to disseminate the scientific aspects and research findings of these systems for the benefit of the public," Secretary Department, AYUSH, Anita Das told reporters.

About 600 delegates, including Allopathic, Ayurveda and Siddha experts, scientists and NGO representatives are expected to participate to deliberate on the technical and policy issues pertaining to mainstreaming of Ayurveda and Siddha, she said.

The national workshop in the capital would be followed by state and district-level workshops to take the message to the field and facilitate time-bound action from public and private sectors.

"The resolution and recommendations of the national workshop will hold the key in designing the future course of action and implementable strategy," she added

Recognition soon for PG medical degrees from five countries

Over the next two months India will unilaterally recognise postgraduate medical degrees from English-speaking countries, Union Health Minister Anbumani Ramadoss has said.

Initially, the PG degrees of the United States, the United Kingdom, Australia, Canada and New Zealand would be recognised, he clarified, stating this agreement would, over a period of time, become bilateral after issues relating to quality and uniform standards were settled. During his recent visit to the U.K., he explored the possibilities of mutual recognition of medical degrees, which had existed till 1975.

Speaking to journalists at The Hindu here on Saturday, Dr. Ramadoss said the Health Ministry would evolve regulations to control stem cell research and therapy. Admitting that there was a lot of research going on in the private sector, he stressed the need for regulating and monitoring that process. The regulations would be incorporated into the existing guidelines for In-vitro Fertilisation procedures.

Stem cell initiative

The National Stem Cell Initiative would give a fillip to stem cell research, he added. Research need not necessarily happen in the public sector. The Indian Council of Medical Research was funding organisations which undertook research in the area and collaborations were being worked out with the U.K. and Australia. Research would also move towards therapy in the next few years.

Funds for research

The government would pump a lot of money into medical research, with the setting up of a special department of health research, with a yearly allocation of Rs.1000 crore. It was the first time in this part of the world that an exclusive health research unit was being set up, the Minister said. In addition, the ICMR had been upgraded a department by itself.

On the anti-tobacco project, Dr. Ramadoss said that by May 31, the government would put in place a “smoke-free workplace policy.” Smoking would be banned in offices, restaurants, bars and pubs, buildings and discos. “If you want to smoke, do it on the roads, or within home.”

As for mandatory pictorial warnings on tobacco packs, he said the implementation was being delayed due to objections from the industry, but promised that the stipulation would be implemented soon.

Lack of specialists

To tackle the lack of specialists in the northeast, the Ministry was looking to the Army to allow its doctors to work in the region on a short-term basis. Even retired army doctors could serve there. Preliminary discussions had already been held with Army officials, Dr. Ramadoss said.

The Ministry was also looking at involving the private sector, through public-private partnerships, in the northeast. Reputed institutions such as the Sankara Nethralaya; NIMHANS; the Christian Medical College, Vellore; the Tata Memorial Hospital; and the Madras Medical Mission would be invited to handle specialities over a period of 10 years. The government would take care of recurring costs.

January 16, 2008

Indian Doctors In UK Often Face Verbal, Physical Abuse On Duty

Soon after the British Medical Association (BMA) published a report on physical and verbal attacks on doctors in the National Health service (NHS), Indian and Indian-origin doctors admitted that many of their colleagues had been subjected to racial abuse and physical attacks.

BMA research published last week shows that one in three doctors in Britain has been victim of such attacks in clinics. Thousands of Indian doctors and other health professionals work in the NHS, and thousands more apply for jobs in the medical sector here every year.

In the last six months alone, the BMA research reported that there were two horrific cases of violence towards doctors in the Glasgow area. In November, a patient in his consulting room beat up a general practitioner and, in August, another general practitioner was stabbed by a patient in her practice.

In December, Arun Rai, 49, who graduated from Ranchi University, was hospitalised after being assaulted by a patient during an examination in his clinic in Glasgow, prompting other medical staff to carry personal alarm systems at all times.

Speaking for the British Association of Physicians of Indian Origin (BAPI), Joydeep Grover, an Indian origin who works in the Accidents and Emergency sections in the NHS, told IANS: 'We would support the BMA report on violence in the workplace.

'As it points out, medical personnel have a right to work in an unthreatening and dignified environment. Doctors and nurses often have to work in trying circumstances and have the burden of immense responsibility.

'Violence is not always physical in nature, but is more frequently verbal. There is no clear evidence that ethnic minority doctors are more liable to suffer from such abuse, but certainly racial language is still heard in various circumstances'.

Grover said that occasionally patients demand to be seen by white doctors, and some, especially older ones can be overtly abusive. However, he added that most hospital trusts had very well structured policies against racist behaviour by patients, and if the matter is raised the patients are strictly dealt with.

Grover said: 'In my experience there is usually excellent support from colleagues and team members. When doctors/nurses are hit by patients it may or may not have racial

overtones, but there is no study which suggests that ethnic minority doctors are more prone to physical abuse by patients'.

Around 600 doctors from across Great Britain responded to the BMA survey on their experiences of violence in the workplace in the past year. A third had experienced some form of violence - including threats and verbal abuse - and one in ten had been physically attacked, including being stabbed, kicked, punched, bitten and spat at.

Of these, one in three received minor injuries, and one in 20 was seriously injured. More than half (52 percent) of doctors who suffered violence did not report the incident.

The most frequently stated reason for workplace violence was dissatisfaction with the service, including frustration with waiting times and refusal to prescribe medication. This has doubled as a cause of violence since 2003, when the BMA last conducted the survey.

Hamish Meldrum, Chairman of Council at the BMA, said: 'These are worrying figures - both in terms of the potential numbers involved and the fact that so few doctors tend to report violence. We hope that this is not because they feel the problem is not being taken seriously.

'Ministers have repeatedly stated that there should be zero tolerance to violence of any sort in the NHS. We heartily agree. The mechanisms must be there to minimise the likelihood of attacks, to support staff who experience them, and to ensure that anyone who commits an act of violence is dealt with appropriately.'

Other findings from the research include:

--Half of doctors say that violence in the workplace is a problem.

--More than half had witnessed violence against other staff, such as nurses and receptionists.

--Female doctors are more likely to experience violence in the workplace than males (37 percent compared to 27 percent).

--Junior doctors are the most likely to experience violence, followed by GPs.

--Almost two thirds of psychiatrists report that violence in their workplace is a problem, compared with a fifth of surgeons.

--Most doctors have not received any training in dealing with violent patients.

--One in ten doctors has access to a secure facility in which to treat violent patients.

The Criminal Justice and Immigration Bill, currently progressing through the parliament, contains proposals to tackle nuisance behaviour on NHS hospital premises. The BMA is seeking an amendment to the bill so that general practitioner premises are also covered.

World Bank loans misused in five Indian health projects

An internal World Bank inquiry has uncovered a multimillion-dollar scandal involving five health projects in India worth $569 million.

The bank has found significant indicators of fraud and corruption in the projects, which appear to have affected, to varying extents, the projects' implementation and outputs.

The bank's Department of Institutional Integrity conducted a Detailed Implementation Review (DIR) of the projects and submitted a report last week, which has been accessed by The Wall Street Journal.

"The probe has revealed unacceptable indicators of fraud and corruption," World Bank President Robert B. Zoellick said in a press release. "The government of India and the World Bank are committed to getting to the bottom of how these problems occurred."

The Indian government said it would prosecute those behind the reported corruption, according to a release by the finance ministry.

In the $54-million "Food and drug capacity building project", for which money is still being disbursed, the investigation found "questionable procurement practices, some of which indicate fraud and corruption, in contracts representing 87 per cent of the number of pieces and 88 per cent of the total value of equipment procured."

For the $194-million "Second national HIV/AIDS control project", the inquiry discovered that "some of the test kits supplied by particular companies often performed poorly by producing erroneous or invalid results, potentially resulting in the further spread of disease."

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In the $114-million "Malaria control project", the review found "numerous indicators of poor product quality in the bed nets supplied by the firms."

In the $125-million "Tuberculosis control project", the bank discovered "bidders sharing the same address and telephone numbers, unit prices showing a common formula, and indicators of intent to split contract awards among several bidders."

And in the $82-million "Orissa Health Systems Development Project", "implementation and procurement of the project's civil works and equipment components exhibited significant indicators of fraud and severe deficiencies in buildings certified as complete," the report said.

Moreover, the DIR, which was initiated in mid-2006, observed inadequate project financial, audit and internal control systems.

These findings will result in a number of investigations by the World Bank into specific cases of possible fraud and corruption, The Wall Street Journal said in its article titled "World Bank Disgrace".

Investigators haven't yet concluded whether the corruption involves World Bank staff, Indian government officials or other parties.

The bank and the Indian authorities have promised stricter oversight of the nine health projects remaining in the bank's India portfolio. Four of the five projects have already been completed.

January 14, 2008

Alarm bell for doctors

It is no longer in the realm of mirth to wonder if doctors are healthy.

Here is scientific proof that doctors’ work and lifestyles take a huge toll on their health, rendering them candidates for a variety of complications.

A recent study conducted among doctors in seven States in the country seems to have rung the alarm bell for healthcare professionals. The results, published in the January 2008 issue of the Journal of Association of Physicians of India (JAPI), indicates that young Indian physicians have a higher prevalence of hypertension, impaired glucose tolerance (pre-diabetic stage), abdominal adiposity (accumulation of fat) and excessive cholesterol than the general population they were compared with.

The study was conducted by the India Diabetes Research Foundation and Dr. A. Ramachandran’s Diabetes Hospitals here, among 2499 physicians aged 25 to 55 years from urban, semi-urban and rural areas, between 2004 and 2006. A total of 1878 men and 621 women, who had a minimum of five years of experience, an MBBS or MD degree, from towns in Tamil Nadu, Kerala, Andhra Pradesh, Gujarat, Orissa, Karnataka and New Delhi participated in the survey.

The control population, against whom the doctors were evaluated, comprised 3278 subjects of a similar age group and socio-economic status from the general populace, Dr. A. Ramachandran, one of the authors of the study, said.

The screening procedures included recording demography, medical history, smoking, alcohol habits, family history of diabetes and cardiovascular diseases.

“It has demonstrated the fact that physicians have a high risk of lifestyle diseases, though they have among the highest levels of awareness of such diseases and are probably treating their patients for the same,” he added.

Metabolic Syndrome, defined by central adiposity, cholesterol, blood sugar and high blood pressure, was more common among doctors. They had a significantly higher prevalence of all abnormalities except diabetes, compared with the general population.

An editorial in the same issue of JAPI by Amit K. Ghosh and Sashank R. Joshi quotes the study and indicate that it is time for physicians to take care of themselves.

“While lack of time, sedentary lifestyle and higher socio-economic status could explain the propensity for increased risk, many [a] physician could lack adequate health care … Physicians now [more] than ever face numerous challenges in balancing personal and professional lives.” They further add, “Altruistic tendencies could result in physicians putting their profession before their personal needs,” calling for a task force to educate and continuously monitor physician health and implement evidence-based strategies to reduce health risk in medical students and physicians.

Though it was long suspected and even proved by studies in developed countries such as Australia, the United States and the United Kingdom that doctors do not take good care of their own health, the findings of the Indian study, touted to be the first of its kind in the country, are in agreement with global findings.

Doctors, made in China

If Russia was the destination of choice in the 1980s and 1990s for Indian students who could not make it into medical colleges in India, China has now emerged as the hot favourite. Last year, for instance, nearly 3,000 Indian students took admission in medical colleges in China.

Still in its relatively early years, the trend has already hit a minor roadblock. After complaints from several students who went in the earlier batches about some of the medical universities not having enough professors to teach them in English and about the curriculum, the Chinese government stepped in this year to specify that only 30 medical colleges identified by it can admit foreign students. The medium of instruction will be English in all these colleges.

Of these 30 colleges, only 24 let in foreign students in 2007-08. The total number of seats in these was just about 2,095 for all foreign students, which would include students from Pakistan, Sri Lanka, Bangladesh, Afghanistan, Saudi Arabia, Ghana and Nigeria, though Indians constitute the bulk.

In 2003, the year after the Delhi High Court ordered that students going abroad would need eligibility certificates issued by the Medical Council of India (MCI), 1,595 certificates were issued. Since then the numbers have been climbing steadily, from 2,500 in 2004 to 4,557 in 2006. MCI admits that the bulk of these students is going to China followed by a dwindling number going to Russia.

Russia is not as popular as it once was since it is far more expensive than China, where an MBBS course costs just Rs 5 lakh to Rs 8 lakh. These apart, Mauritius has just one college and there are six or seven in Nepal that take in Indian students. In 2007, only 3,500 certificates were issued, which could be because of the cut in the number of seats in China.

How good is the medical education these students are getting in China? While MCI expresses concern about the quality of education in some Chinese universities, the fact remains that in the Times Higher Education Supplement's (THES) 2006 listing of top 100 biomedicine universities in the world, three universities from China figure while there is just the IITs from India at 62nd place. Beijing or Peking University is eighth in this list, followed by Tsinghua University at 75th place and Nanjing University at 86th place. Of the top 400 universities listed by THES in 2007, seven are from China and two from India, IIT Bombay and Delhi University. Most of these world-class universities in China figure in the list of 30 universities that China has opened to foreign students.

MCI secretary Lt. Col Dr ARN Setalvad (retd.) felt that while in India a medical college would be allowed to take in 100-120 students depending on how much capacity their facilities could handle, in China, they would take 200-300 students or more. "Obviously, if you take in more students you can offer education at cheaper rates as overheads come down. But what about the quality of the education," wonders Dr Setalvad. In the case of colleges in Nepal and Mauritius there are no problems as the medical education in these countries is in English and is modelled after the Indian system.

"The scale of operation in these colleges is beyond what the officials here can imagine. The infrastructure is massive and so they can take more students. They don't build for just a 100 students like we do here, but for 300-400 students or more," says Sanjeev Kumar of Saraswati Online, an agency for nine medical universities in China that sends about 700 students to China every year. Students from India studying in colleges echo his views. "You would be amazed if you see the infrastructure here. It is as good if not better than most private medical colleges in India. In terms of training it might not be as good as AIIMS. But it is not fair to compare it with AIIMS, which is the best in our country. Then why not compare AIIMS with the best in China like Beijing University or Shanghai Medical University? "asks Gautam Singh, a medical student in China.

Of the total number of foreign students in these medical universities, over 90% are said to be from India, with the rest coming from Pakistan, Bangladesh and Sri Lanka. With the surge in demand from Indian students the Chinese universities have been gradually hiking the fee. "In 2004-05, the fee was in the range of $1,700-2,000. Now in many universities it ranges between $3,000-4,000. It is expected to increase further next year," says Kumar. It could also be over $5,000 per year in the best university, Beijing University, which would still amount to just over Rs 10 lakh. Gautam also points out that since the students paid in dollars, with the falling value of dollar, the amount will not increase all that much.

In India, most students hail from Andhra Pradesh, followed by Kerala and Tamil Nadu. There is a big rush from West Bengal, Assam, Jharkhand and the North East too. There is not much rush from Delhi and Punjab, but Uttar Pradesh is fast catching up. Saraswati Online alone has sent about 400 students from UP over the last four years.

"Parents are being taken in by the rosy picture painted by agents of the various Chinese universities. Did any of them bother to find out if they are any good? Did they take the government's permission before sending their children? If things go wrong they have to bear the brunt of it. We even have students studying medicine in Romania and Tanzania. Who knows what the quality of education there is! Our laws say that as long as they can clear the screening test after completing MBBS they can practise in India," explains Setelvad, adding that parents misconstrue any warning issued by the MCI as the council's attempt to help private medical colleges in India.

The hardest hit by Chinese colleges seem be the Indian private medical colleges, some of whom charge Rs 20 lakh per seat. "The medical colleges in China are a blessing for the middle class in India, who cannot afford such a high fee. Many in the government favour private medical colleges. Hence they are trying to run down the medical colleges in China," says Dr N Laddha of UMCS in Maharashtra, another agency sending students to China.

January 12, 2008

Doctors' strikes: Supreme Court seeks reply from medical councils

In a major development in the ongoing public interest litigation seeking a total ban on doctors' strikes in India, the Supreme Court has directed a patients' body led by an India-born American to implead all medical councils in the country.

It has also directed the Kolkata-based petitioner People for Better Treatment (PBT), run by Ohio-based AIDS vaccine researcher Kunal Saha, to issue notices on why councils are not taking disciplinary action against doctors joining "strikes and shutting down hospitals", thus causing misery to innocent patients.

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A division bench of Justices Arijit Pasayat and P Sathasivam issued the directive on Thursday.

Saha, who had lost his wife to alleged medical negligence during a visit to Kolkata in 1998, later formed PBT and launched a legal battle against the "flawed" healthcare system in India.

The court has directed PBT (the petitioner) to "implead" (sue or make them liable) all the state medical councils of the country and issue notices in seven days seeking answers to why the respective state medical councils are not taking disciplinary action under the Medical Council of India (MCI) Rules against the doctors who are joining strikes and shutting down hospitals.

The public interest suit was filed against the MCI and the All-India Institute of Medical Sciences (AIIMS) after several patients allegedly died as a result of "doctors' strike" at the AIIMS hospital in 2006 (to protest against the "quota" system).

"This is a remarkable development in our ongoing battle towards bringing justice for the defenceless patients in India," Saha told IANS from Ohio.

"Doctors joining a strike, disrupting life-saving treatment in hospitals, to satisfy their own demands is unheard of in the rest of the civilised world. But in spite of categorical rules in the MCI Code of Ethics and Regulations that all Indian doctors must follow, strikes by medicos is a frequent affair in our country today," Saha said.

The MCI code mandates that doctors must treat all patients who are in need of emergency medical care.

The counsel for the MCI admitted that doctors in India must follow the existing MCI rules, but submitted that it is the duty of the respective state medical councils to enforce the rules for practising doctors in the state.

Based on this submission by the MCI, the apex court issued the directions.

"Many patients, including several children, died last month in Hyderabad when doctors joined a massive strike to protest alleged attack on some of their medical colleagues by the victims of medical negligence. Now the information must spread so that they cannot be negligent in their duties," Saha said.

Saha has filed the biggest-ever medical compensation case ($17 million) against a hospital and three doctors based in Kolkata after the death of his wife Anuradha Saha, 36, due to alleged wrong treatment.

January 06, 2008

Indian docs row in UK return to centre-stage

Senior British Indian doctors have accused the UK government of unfairly whipping up a fear psychosis of a sort once again by portraying Indian medics as poised to take away thousands of specialist medical training jobs from locals.

The new row comes as 9,000 highly-prized specialist jobs are advertised by Britain's department of health, with the gloomy caveat that at least half of them may go to non-European Union doctors, most of whom belong to India.

The issue of doctor training is seen as increasingly important because without a specialist training job, junior doctors cannot hope to become consultants or general practitioners.

The government warning comes less than two months after it ignominiously lost a legal challenge by Indian doctors in the High Court here, to force the health ministry to treat non-European medics on a par with European.

But Dr Ramesh Mehta, president of the British Association of Physicians of Indian Origin (BAPIO), which was the lead appellant in the 16-month case, told TOI on Saturday that it was an absolute "nonsense that the Department of Health is spreading because the number of doctors coming here from the Indian sub-continent has dwindled in the last year".

Senior Indian doctors, however, allege the British government has embarked on a smear campaign against non-European medics in an attempt to prejudice public opinion because it is seeking to overturn their November 9 High Court victory in the highest court of the land.

The British government lodged an appeal to the House of Lords in mid-December in an attempt to stress the fairness of its attempt to give UK medical graduates priority in the recruitment process in 2008. The case will be heard in the Lords on February 28.

Mehta insisted that the Indian doctors expected to apply for the prized training posts were "those who are in the country already and rightfully have the expectation they would be treated on merit".

BAPIO claims that barely 300 Indian doctors entered Britain to work from April 2007, compared to nearly 9,000 in 2005.

But the British government has already issued a defensive statement to say "Doctors from outside Europe have made and continue to make a huge contribution to the NHS. The issue is not, and never has been, whether they can continue to work as NHS doctors - which they can - but whether the taxpayer should be investing in training them instead of UK medical graduates."

The November 9 High Court ruling upheld BAPIO's appeal against the British health ministry unlawfully decreeing that it was right to discriminate against non-European Union doctors when it comes to jobs.

In a sign that at least some of the scaremongering – with Indian doctors as the villains of the piece – is having an effect, local doctors have already started to protest against unfair and unsustainable levels of competition for a limited number of National Health Service training jobs.

The lead NHS employers' body has warned there may be an average of three applicants per post, many of them non-European. It says there may be as many as 23,000 applications.

But with a rhetorical flourish, Mehta says, "Why are they so worried about competition? They should train the best doctors they have, be they Indian or British."

He added that Britain would actually benefit every time it chose an Indian doctor for further training because it had paid nothing to get a fully-qualified medic, while it costs the UK taxpayer £ 250,000 to educate a single doctor.

January 04, 2008

Giving birth becomes the latest job outsourced to India as commercial surrogacy takes off

Every night in this quiet western Indian city, 15 pregnant women prepare for sleep in the spacious house they share, ascending the stairs in a procession of ballooned bellies, to bedrooms that become a landscape of soft hills.

A team of maids, cooks and doctors looks after the women, whose pregnancies would be unusual anywhere else but are common here. The young mothers of Anand, a place famous for its milk, are pregnant with the children of infertile couples from around the world.

The small clinic at Kaival Hospital matches infertile couples with local women, cares for the women during pregnancy and delivery, and counsels them afterward. Anand's surrogate mothers, pioneers in the growing field of outsourced pregnancies, have given birth to roughly 40 babies.

More than 50 women in this city are now pregnant with the children of couples from the United States, Taiwan, Britain and beyond. The women earn more than many would make in 15 years. But the program raises a host of uncomfortable questions that touch on morals and modern science, exploitation and globalization, and that most natural of desires: to have a family.

Dr. Nayna Patel, the woman behind Anand's baby boom, defends her work as meaningful for everyone involved.

``There is this one woman who desperately needs a baby and cannot have her own child without the help of a surrogate. And at the other end there is this woman who badly wants to help her (own) family,'' Patel said. ``If this female wants to help the other one ... why not allow that? ... It's not for any bad cause. They're helping one another to have a new life in this world.''

Experts say commercial surrogacy _ or what has been called ``wombs for rent'' _ is growing in India. While no reliable numbers track such pregnancies nationwide, doctors work with surrogates in virtually every major city. The women are impregnated in-vitro with the egg and sperm of couples unable to conceive on their own.

Commercial surrogacy has been legal in India since 2002, as it is in many other countries, including the United States. But India is the leader in making it a viable industry rather than a rare fertility treatment. Experts say it could take off for the same reasons outsourcing in other industries has been successful: a wide labor pool working for relatively low rates.

Critics say the couples are exploiting poor women in India _ a country with an alarmingly high maternal death rate _ by hiring them at a cut-rate cost to undergo the hardship, pain and risks of labor.

``It raises the factor of baby farms in developing countries,'' said Dr. John Lantos of the Center for Practical Bioethics in Kansas City, Missouri. ``It comes down to questions of voluntariness and risk.''

Patel's surrogates are aware of the risks because they've watched others go through them. Many of the mothers know one another, or are even related. Three sisters have all borne strangers' children, and their sister-in-law is pregnant with a second surrogate baby. Nearly half the babies have been born to foreign couples while the rest have gone to Indians.

Ritu Sodhi, a furniture importer from Los Angeles who was born in India, spent US$200,000 (euro138,910) trying to get pregnant through in-vitro fertilization, and was considering spending another US$80,000 (euro55,563) to hire a surrogate mother in the United States.

``We were so desperate,'' she said. ``It was emotionally and financially exhausting.''

Then, on the Internet, Sodhi found Patel's clinic. After spending about US$20,000 (euro13,890) _ more than many couples because it took the surrogate mother several cycles to conceive _ Sodhi and her husband are now back home with their 4-month-old baby, Neel. They plan to return to Anand for a second child.

``Even if it cost $1 million (euro690,000), the joy that they had delivered to me is so much more than any money that I have given them,'' said Sodhi. ``They're godsends to deliver something so special.''

Patel's center is believed to be unique in offering one-stop service. Other clinics may request that the couple bring in their own surrogate, often a family member or friend, and some place classified ads. But in Anand the couple just provides the egg and sperm and the clinic does the rest, drawing from a waiting list of tested and ready surrogates.

Young women are flocking to the clinic to sign up for the list. Suman Dodia, a pregnant, baby-faced 26-year-old, said she will buy a house with the US$4,500 (euro3,125) she receives from the British couple whose child she's carrying. It would have taken her 15 years to earn that on her maid's monthly salary of US$25 (euro17).

Dodia's own three children were delivered at home and she said she never visited a doctor during those pregnancies.

``It's very different with medicine,'' Dodia said, resting her hands on her hugely pregnant belly. ``I'm being more careful now than I was with my own pregnancy.''

Patel said she carefully chooses which couples to help and which women to hire as surrogates. She only accepts couples with serious fertility issues, like survivors of uterine cancer. The surrogate mothers have to be between 18 and 45, have at least one child of their own, and be in good medical shape.

Like some fertility reality show, a rotating cast of surrogate mothers live together in a home rented by the clinic and overseen by a former surrogate mother. They receive their children and husbands as visitors during the day, when they're not busy with English or computer classes.

``They feel like my family,'' said Rubina Mandul, 32, the surrogate house's den mother. ``The first 10 days are hard, but then they don't want to go home.''

Mandul, who has two sons of her own, gave birth to a child for an American couple in February. She said she misses the baby, but she stays in touch with the parents over the Internet. A photo of the American couple with the child hangs over the sofa.

``They need a baby more than me,'' she said. The surrogate mothers and the parents sign a contract that promises the couple will cover all medical expenses in addition to the woman's payment, and the surrogate mother will hand over the baby after birth. The couples fly to Anand for the in-vitro fertilization and again for the birth. Most couples end up paying the clinic less than US$10,000 (euro6,945) for the entire procedure, including fertilization, the fee to the mother and medical expenses.

Counseling is a major part of the process and Patel tells the women to think of the pregnancy as ``someone's child comes to stay at your place for nine months.''

Kailas Gheewala, 25, said she doesn't think of the pregnancy as her own.

``The fetus is theirs, so I'm not sad to give it back,'' said Gheewala, who plans to save the US$6,250 (euro4,340) she's earning for her two daughters' education. ``The child will go to the U.S. and lead a better life and I'll be happy.''

Patel said none of the surrogate mothers has had especially difficult births or serious medical problems, but risks are inescapable.

``We have to be very careful,'' she said. ``We overdo all the health investigations. We do not take any chances.''

Health experts expect to see more Indian commercial surrogacy programs in coming years. Dr. Indira Hinduja, a prominent fertility specialist who was behind India's first test-tube baby two decades ago, receives several surrogacy inquiries a month from couples overseas.

``People are accepting it,'' said Hinduja. ``Earlier they used to be ashamed but now they are becoming more broadminded.''

But if commercial surrogacy keeps growing, some fear it could change from a medical necessity for infertile women to a convenience for the rich.

``You can picture the wealthy couples of the West deciding that pregnancy is just not worth the trouble anymore and the whole industry will be farmed out,'' said Lantos.

Or, Lantos said, competition among clinics could lead to compromised safety measures and ``the clinic across the street offers it for 20 percent less and one in Bangladesh undercuts that and pretty soon conditions get bad.''

The industry is not regulated by the government. Health officials have issued nonbinding ethical guidelines and called for legislation to protect the surrogates and the children.

For now, the surrogate mothers in Anand seem as pleased with the arrangement as the new parents.

``I know this isn't mine,'' said Jagrudi Sharma, 34, pointing to her belly. ``But I'm giving happiness to another couple. And it's great for me.''

January 01, 2008

Hospitals should display treatment costs: Consumer Commission

Hospitals in the capital should display the cost of treatment for the patients to see and decide whether it is affordable to them, the Delhi Consumer Commission has observed.

Concerned over the spurt in consumer complaints accusing the hospitals of keeping them in dark about the expenses, the Commission has also asked the medical facilities to give a minimum estimate of treatment at the time of admission.

"The basic expenses for every disease and its treatment should have been displayed outside for the information of each and every patient so that he may at the time of admission know whether he has the capacity to get the treatment in such a hospital or nursing home or not," it said.

Noting the pamphlets often published by the hospitals served no purpose as far as a consumer's knowledge regarding the possible treatmet cost was concerned, the Commission's President Justice J D Kapoor said that in such cases, they may be asked to compensate for their "unfair trade practice".

"At the time of admission, at least minimum estimate has to be given to the patient in order to see whether he would like to get the treatment from the said hospital or not," the Commission noted in a recent decision.

In no way a patient should be put on treatment without being informed as to the minimum expenses to be incurred as any poor person, if put in ICU for long, would definitely suffer mental agony and physical discomfort if he does not know as to how much amount he has to shell out, it noted.

The Commission while observing that the hospitals put out the treatment cost, asked Shanti Mukund Hospital in East Delhi here to pay Rs 25,000 to Nathu Ram Bansal, who was treated for asthma but was not given an estimate of the medical expenses at the time of his admission.

According to the patient, he was never informed about the cost he had to incur on his treatment and the hospital had subsequently raised a hefty bill of over Rs one lakh.

Allowing the appeal of Bansal, a resident of Shahdara here, the Commission said that the hospital was liable to pay for its deficiency in service in not informing the charges of the treatment to him

AP doctors to get Rs 1 lakh to teach

Faced with the embarrassing situation of having medical colleges full of students but no faculty to teach, the state government has finally decided to act. It now intends to offer professors a salary of Rs 1 lakh a month to lure them to the classroom.

Finance minister K Rosaiah has accorded approval to the proposal put forth by the medical, health and family health department to hire professors with high salaries in government medical colleges at Kadapa, Ongole and Srikakulam. Apart from professors, associate and assistant professors are also to be recruited with appropriate hike in salaries, the quantum of which is still being worked out. At present, the professors are paid a monthly salary of Rs 35,000 as per the University Grants Commission (UGC) scales. In order to give them a salary three times that amount, the state has decided to make these colleges autonomous. The new recruitments are likely to be made to these institutions from the academic year 2008-09.

But all professors recruited under the scheme would be hired only on contract. “It will be on contract and without any pension benefits. Under the autonomous system, the college can hire the services of any experienced professional,” a source in the department said.

At present, there are 220 vacancies for professors in the various medical colleges in the state out of a sanctioned strength of 687 posts. There are around 100 vacancies at the associate professor level and 362 vacancies at the assistant professor level as per a notification issued in November 2007.

But it was not exactly the shortage of teaching staff that made the government act. According to sources, the state woke up after the Medical Council of India (MCI) threatened to de-recognise the colleges due to lack of faculty and infrastructure. The MCI has already de-recognised the government medical college in Anantapur due to lack of infrastructure and faculty. Consequently, admissions have stood suspended since the academic year 2003-04. The Anantapur college was set up in 2000.



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