AYUSH
Four important things that ail the health sector did not find place in the budget
As normalcy starts to return, basic health protection for Indians must no longer be bought. It must be assured through participation.
Written by Shailaja Chandra | Updated: February 10, 2021 9:01:02 am
A massive 137 per cent increase in the allocation for health was one of the main highlights of the 2021 Budget announcements. Social media was quick to explain that the surge was not for health alone but included funds for drinking water, sanitation, nutrition, AYUSH, health research, vaccination as well as grants assigned by the 15th Finance Commission. The actual share of Health and Family Welfare was pegged at only a third of the total allocation of Rs 2.24 lakh crore.
Pre-COVID, the health budget was Rs 69,000 crore. An additional Rs 14,000 crore was pumped in to strengthen the National Centre for Disease Control (NCDC) and defray the costs of COVID-related expenditure on research, supplies and vaccination for health and frontline workers. This huge and timely infusion of funds was commendable particularly as, so far, the off-take and implementation have both been efficient. Given the size of the country and its diversity, in handling the pandemic, India, and in particular its health system, have performed beyond expectations. In partial recognition of the sacrifices made, the budget should have set up a corpus fund to aid medical personnel facing unforeseen risks and challenges while confronting health emergencies.
The FM also announced a new centrally-sponsored PM Aatmanirbhar Swasthya Bharat Yojana which would subsume funding for over 18,000 rural and over 11,000 urban health and wellness centres, provide support for public health laboratories, establish critical care hospitals together with five regional branches and 20 metropolitan health surveillance units linked to NCDC. Likewise, the strengthening of health offices at 32 airports, 11 seaports and land crossings will strengthen the capacity to screen arrivals and movement between and across states during epidemics. The announcement will, however, translate into funds only when projects and programmes are formulated.
Four important things go to the root of what ails the health sector but these did not find place in the budget.
First, since Ayushman Bharat was launched in September 2018, crores of beneficiaries from the 50 crore eligible poor have received hospital care through cashless hospitalisation. But now the programme must additionally protect the poor from the uncertainties of doctor hunting, receiving irrational treatment from unqualified medical practitioners, provide drugs and address the inability to pay for high-end diagnostics. Unless the costs of outpatient treatment are catered for under Ayushman Bharat, heavy, out-of-pocket expenditure will continue before a patient needs hospitalisation.
Second, insurance coverage for the middle class remains a gap which should have been addressed through the budget. All citizens, whether employed in unorganised sectors or self-employed, need health cover. Comparisons with other countries do not imply that they are superior, but certainly their experience can be built upon. Among the high performing countries, Germany and France fund health care through contributions which are mandated by law and shared by the employer and employee. The Canadian system pays for all services based on need rather than the ability to pay. The Canada Health Act of 1984 makes federal cost-sharing a government responsibility and unlike the UK’s NHS, where one is linked to a local provider, in Canada healthcare entitlements are portable across the country. Such ideas could work for India’s middle class. The routine response is to dismiss any such suggestion by saying that over 90 per cent of the white-collar workers are in the unorganised sector and health being a state subject, it goes beyond the scope of the central budget.
But undeniably, whether organised or unorganised, everyone who has a job has an employer. After excluding some 50-crore people covered by the Ayushman Bharat health programme for the poor as well as the 10 per cent employee groups falling in the organised sector who are covered by different government or employer generated medical coverage schemes, it still leaves some 30 crore Indians without any state-supported medical insurance. Thanks to Aadhaar and any number of laws starting with the Shops and Establishments Act, 1948, it will not be difficult to collect information on employers and employees in the unorganised sector. All states can be incentivised to mandate the need for all citizens to possess government supported health insurance. If every employer and employee paid even a nominal share, it would cover the costs of essential healthcare to the unorganised sector middle classes.
The Employees State Insurance Corporation scheme created in 1948 through an Act of Parliament could also be modified and used. The then Finance Minister Arun Jaitley, in his 2015-16 budget speech, had announced that the government intended to bring an amending legislation. The ESIC has several shortcomings but nothing prevents government from enlarging its scope to go beyond blue collar workers to cover white collar employees in the unorganised sector. Its linkage with the labour ministry alone needs to be revisited.
Third, the absence of any mention of medical regulation based on the 2017 National Health Policy has once again left consumers without protection. The health policy had recognised that grading of clinical establishments would give protection to patient rights. The states have been tardy, even remiss, in not implementing the model Clinical Establishments Act 2010. The Indian Medical Association has successfully thwarted efforts to instil accountability in medical establishments for eleven long years. The Fifteenth Finance Commission’s recommendation to start a debate on bringing public health and hospitals on the concurrent list of the Constitution (like population control, food adulteration and drugs already are,) is a bold initiative. It merited a mention in the budget.
Fourth, the Health Policy 2017 had also recommended the establishment of a separate Empowered Medical Tribunal. The Consumer Protection Act 1986 was never mandated to address the complexities of medical negligence or malpractice. The health sector badly needs a regulator on the lines of the State and Central Regulatory Commissions, say, for electricity. Having been embedded in the Health Policy 2017, it behoved a mention of the need for health regulation.
As normalcy starts to return, basic health protection for Indians must no longer be bought. It must be assured through participation.
This article first appeared in the print edition on February 9, 2021, under the title “Closing the health gap”. The writer is former secretary, AYUSH Government of India, and health secretary, Delhi government
Standards must not be lowered to certify Ayurveda postgraduates surgeons
This conundrum of different standards for surgical training must be solved because patient safety is far more important than the career progression of Ayurvedic postgraduates.
Written by Shailaja Chandra | Updated: December 15, 2020 8:45:06 am
A three-decade-old wrangle between the allopathic and AYUSH fraternities has been resurrected following a recent clarification on a 2016 notification. This time, the clash is not about the AYUSH practitioners’ right to treat using allopathic drugs, but their “right” to conduct surgeries.
Three important groups affected by this order have this to say: The Ayurvedic fraternity maintains postgraduates in Shalya and Shalakya (two surgical streams among 14 post-graduate courses) are taught procedures listed in the curriculum; that the oldest-known surgical specialist was, in fact, an Ayurvedic surgeon/sage Sushrut (600 BC) who wrote the Sushrut Samhita — a profound exposition on conducting human surgery which continues to receive worldwide acclaim. Surgery was practised by Ayurvedic surgeons long before the advent of western medicine.
Allopaths question the logic of this claim. Can Sushrut’s millennia-old pre-eminence bestow the right to practise modern surgery? Do these Ayurvedic surgeons know the hidden risks of every surgical procedure and how to surmount sudden mishaps?
The Ministry of AYUSH justifies its notification on the ground that not all vaidyas but only postgraduates qualifying from two surgical streams have been authorised to perform selected surgeries. And none of this is new. But the moot point is who decides whether Ayurvedic surgeons possess sufficient proficiency to conduct these surgeries safely? By what standard are their skills judged? Surgical proficiency cannot be judged by different standards in one country — particularly when less-educated patients would rather save money than question a surgeon’s qualifications.
The statutory regulatory body for AYUSH education is the Central Council of Indian Medicine (CCIM). Over the last 20 years, it has become a clone of the erstwhile Medical Council of India. For decades, stalwarts of Ayurveda have lamented that CCIM has only promoted what private college managements demand, propelled, in turn, by students’ need to earn a stable income as medical professionals. In this misplaced zeal to give better earnings to the Ayurvedic vaidyas, CCIM has sidelined many skills that Ayurveda could have included, which are relevant even today.
Even the Ayurvedic fraternity laments that the statutory body that sets standards for Ayurvedic education has subjugated the curriculum to nurture more and more replicas of doctors of modern medicine. Thereby, an ancient, time-honoured system and its wealth of empirical knowledge has been substituted by teaching students to imbibe as much allopathy as possible. This has killed the knowledge, purity and goodness of classical Ayurveda, which ironically is the Ayurveda in high demand in Europe, Russia and America.
Until now, the debate was riveted on Ayurvedic vaidyas using allopathic drugs to treat symptoms. But now it has expanded to encompass surgery. And two facts make the case for Ayurvedic surgeon-vaidyas weak. When it comes to surgery, it is not knowledge but rigorous training and continuous practice which makes for perfection. Both require clinical material and most Ayurvedic hospitals do not have a fraction of the surgical patients found in allopathic general hospitals. Allopathic students of surgery learn first by watching and then performing scores of surgeries under supervision. In over 400 Ayurvedic hospitals, it is reported that, perhaps, only 10 have attached allopathic hospitals. Surgical skills are by no means impossible to learn but they become difficult to master without continuous training and supervision. Due to the paucity of patients, limited scope for training and access to gaining hands-on practice, it is hazardous to allow all Shalya and Shalakya postgraduates to undertake surgical procedures.
Ironically, even an MS Surgery (allopathy) or a surgeon who has passed one of the world’s toughest examinations to become a fellow of the Royal College of Surgeons (FRCS) is not permitted to conduct even comparatively simple operations like tonsillitis. In the last three decades, specialisation has excluded general surgeons from performing what was once considered routine. For example, only an ENT surgeon can perform a tonsillectomy. Therefore, to notify that Ayurvedic postgraduates in surgery can perform omnibus operations runs counter to the norm in India and in other countries.
In performing surgery, the only benchmark should be the duration of hands-on training received — counted by surgeries under supervision, and being judged through external evaluation. Every surgeon’s skills and competence must be tested by applying exactly the same standards before she/he can operate. This conundrum of different standards for surgical training must be solved because patient safety is far more important than the career progression of Ayurvedic postgraduates.
This article first appeared in the print edition on December 15, 2020 under the title ‘Surgical Mis-strike’. The writer is former secretary, AYUSH Government of India, and health secretary, Delhi government
Shailaja Chandra.The Indian Express Author Profile
STATUS OF INDIAN MEDICINE AND FOLK HEALING, Part I
With a focus on benefits that the systems have given to the public
Shailaja Chandra
Former Secretary, Government of India
Ministry of Health & Family Welfare
Department of AYUSH
and
Former Chief Secretary, Government of Delhi
Under the aegis of
Department of Ayurveda, Yoga & Naturopathy,
Unani, Siddha and Homoeopathy (AYUSH)
Ministry of Health & Family Welfare
Government of India
AUGUST 2011
Post DU, Ayush moots longer course
Monday, 20 May 2013 | Archana Jyoti | New Delhi
Amid the hullabaloo over the four-year DU course, a Government report prepared by Shailaja Chandra, former health secretary (Ayush) has recommended a 10-year MBBS/MD/PhD in integrative medicine as a long-term measure to boost alternate medical system in the country.
The essentials of all major healthcare systems can be incorporated, says the extensive report “Status of Indian Medicine and Folk Healing in India” prepared by Shailaja Chandra, former health secretary, Ayush Department in the Health Ministry.
The report extensively focus on the current status as well as gaps that need to be bridged with the aim of improving public awareness and access to identified health benefits that each system offers.
The recommendations also include strengthening postgraduate education both quantitatively and qualitatively and to increase a requirement for rigorous and independent research the quality of which needs to be judged by publications in reputed journals.
“Instead of leaving the students to find their own feet, it would be better to expose them in the very first year to the work of good practitioners so that they understand how the public is accessing ASU medicine and for what conditions.”
“It would be useful to send the students to visit reputed ASU teaching institutions and private clinics so that they observe actual treatment in progress,” the report says.
The four-year degree course introduced by Delhi University from the new academic session beginning July to replace the existing three-year BA/BSc (General/Hons) course has sparked a major controversy with the DU faculty splitting into two factions.
The report recognises that both under National Rural Health Mission (NRHM) and by virtue of special orders issued by certain State Governments, ASU practitioners are permitted to prescribe modern medicine; but no one has spelt out whether that includes prescription of all Scheduled drugs and other interventions.
“Since there is no domain expertise on the functional requirements of Ayush available with the NRHM managers there is a recommendation to use the extensive human resource capacity available in the existing non-NRHM facilities to provide oversight for the NRHM related Ayush work,” the report says.
Likewise, the need for supervision of Ayush drug supplies which were found to be universally in short supply has been dwelt upon. The near absence of interaction between modern medicine and AYUSH doctors has been described bringing out what is essentially needed if the patient’s welfare is to be kept uppermost in view.
Referring to a recent case of an injured and incapacitated NSG commando who was paralyzed and received
Ayurvedic treatment but failed to get reimbursement for the expenses incurred, the report has stressed on the need for the Department of Ayush to convince all ministries to reimburse medical expenses on AYUSH treatment of employees.
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