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If Hospitals No Longer Make Sense, India is Ahead of the Game

Keeping Community-Based Care a Priority

In the field of maternal health there has been a big shift towards increasing access to tertiary care. This was important as the majority of maternal deaths were due to causes that could only be dealt with by specialists. But, increasing access to hospital-based care can seem like a fraught enterprise in public health. Everyone has a story of care gone wrong: a misdiagnosis; expensive tests; hospital-based infections; callous doctors and nurses.

globally, prescription drugs constitute the third leading cause of adult mortality

In the US, medical error is the third highest cause of deaths. The incidence of hospital-based infection is also high, with 1 in 25 hospital patients getting at least one health-care-associated infection (a similar risk profile to getting an injury from bungee jumping). I haven’t seen similar data for India, but I would guess rates are higher. Doctors in the US work on insufficient sleep over many hours in a brutal competitive culture. They over-prescribe and order extensive tests – because they simply don’t have time to treat more comprehensively. In a fee for service system that rewards hospitals for any care they provide, there is simply nothing to limit the amount of care prescribed. This just increases risk.

This is not just in the US. The head of the Nordic Cochrane collaboration estimates that globally, prescription drugs constitute the third leading cause of adult mortality (after heart disease and cancer).

Photo Credit: Baneen Karachiwala

A typical coping approach seems to be “gallows” humour, where empathy is stripped and jokes are made at the patients’ expense. A colleague (Baneen Karachiwala) conducting QoC facility observations in a tertiary care hospital in Bangalore saw a woman experiencing a difficult labour plead for water, being accidentally given methylated spirits from a Bisleri (water) bottle. She gulped it down and then gasped, her distress increasing manifold. The response: the doctors and nurses all had a good laugh, joking that the baby would emerge drunk. While this anecdote is extreme, we’ve all seen similar scenarios. It seems empathy is barely possible the way facilities’ and patient care is managed.

I recently saw this article “Do Hospitals Still Make Sense” by Wiler, Harish and Zane – it questions the hub-based model that hospitals are supposed to provide. They suggest this simply isn’t working, and instead suggest a more decentralized model – with lay health workers, digital tools, telemedicine and care coordinated through primary care physicians. Diagnostics can be provided at home with portable equipment. Hospitals would still be present – but there would be a much greater emphasis on home-based and community-based care and less on inpatient care.

Do you know what this reminded me of? The ASHAs, their mHealth tools and the many other community-based workarounds that have been developed in low resource settings to deal with the shortage of health workers (including doctors and nurses). For example, Swasthya Slate – a comprehensive diagnostic tool for community health workers currently being deployed in Jammu & Kashmir. While we may not have all the technologies in place, India definitely has the human infrastructure to make such a model work. It’s inspiring to think India could be ahead of the game, and maybe instead of trying to catch up by establishing more hospitals – it should invest in different and improved models of community-based care.

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