Wednesday, October 31, 2012

Clinical Establishments- Role of government and Healthcare Market

The Kerala Clinical Establishments (Registration, Accreditation and Regulation) Bill, 2009 which was in the news recently has invited the fury of Medical practitioners, clinical institutions, labs, pharmacies, scanning centres and agencies, as it intended to curtail their freedom. The healthcare sector in Kerala which is one of the most lucrative sectors has been contributing to the state’s GDP and providing employment to many people, especially women in Kerala. This includes people who are employed in Specialised Scanning Centres to nursing homes for old aged. With huge demand and high private participation, the sector has grown exponentially in term of numbers, reach and revenue. If you take the number of nurses alone, who constitutes the major part of the sector; the numbers are quite immense, taking into account those working in Kerala or India and those working abroad. Relative figures of people employed in laboratories, Scanning/Detection Centres are not available.

With its high literacy rates and progressive education programmes, Kerala trains a nursing workforce that is highly sought-after in the global labour market. This stands true for persons who are not nurses but possess the qualification or skills to be employed in various labs, pharmacies or clinical centres.  Relatively large number of people work similarly in clinical establishments in other capacities.

In the current scenario the scope and nature of nurses and other non-nursing personnels is determined to a large extent by the situations or market existing in Kerala. The huge potential offered by the healthcare sector through hospitals, nursing homes, clinics and various agencies is the key to the large population of students graduating from various educational institutions imparting training from nursing to pharmacy. Depending on their qualifications (GNM, ANM and BSc for nurses), they are part of the market which is supposed to support the health and well being of the entire population in Kerala and also abroad.

The proposed law throws the questions on whether it will stultify the market opportunities of nurses and others associated in the sector. The legislation requires mandatory registration of all clinical establishments which includes nursing homes, clinics and agencies. Further the Health Department can conduct quality checks and take action against erring institutions. It is a fact that the Healthcare and Nursing sector has become a business which involves millions of rupees. At the same time, it has been providing employment and catering to the requirements of a considerable population, maybe at a cost. The intent of the legislation is genuine, but the manner in which it is undertaken is doubtful. While regulation is required to check lack of quality or unethical issues, mandatory registration does not suffice. This stands true with most of the regulations, especially those related to Health and Environment. The recent Shawarma issue which made headlines is the perfect example of how health authorities failed in executing their mandate of checking and improving quality standards of food. They were more active in closing and sending notices to shops than assisting them to improve the standards or comply with it. A similar situation shall exist once the proposed Bill comes is passed and comes into effect.

The Department of Health and Medical Education and the various institutions like Medical Council and Nursing Council have been involved at various levels in regulating the nursing and other establishments. However, due to lack of personnels and facilities involved, they have not been able to function effectively. This has been one of the major reasons which has caused the sprouting of spurious institutions which has been duping students and people alike. The effect is appearance of unskilled people without means of employment, lack of skilled personnels to handle technologies used in scanning centres or laboratories and overall lack of professionalism in service. This has a larger impact on the persons who take the services of these clinical establishments paying huge cost but get sub-standard service. The issue is graver in case of healthcare services which directly affect the human life such as emergency services, basic life support, infection control etc.  Mandatory registration cannot be an assured manner for preventing let alone reducing such instances, as they can very well function illegally without getting caught by law. Awareness and education of various stakeholders is required to avoid and stop the malpractices which affect the sector.

The current Bill does not address the issue of quality standards demanded by various professions, clinical establishments and those employed in such establishments. The Government can do a monitoring role of checking any malpractices, lack of standards, complaints etc. But it shall not interfere in the day to day functions of these establishments or discourage people from setting up such establishments.  

Unfortunately, the situation in India is that tighter governmental control has only detracted entrepreneurs while on the other hand has created a monopoly for few players who were able to influence the system. In an unregulated environment like healthcare, definitely competition is bound to happen, but for the good. Maybe institutions like Competition Commission can check monopolies and give strictures on unethical practices adopted by various establishments. 

Education, training and skill development of nurses or clinician's employed or seeking employment in clinical establishments is one of the most important areas which the government needs to interfere. Unless we have specialised ITI like institutions for health care professionals, it will be difficult to expect quality from them. The scope of specialised and integrated programmes for  medical practitioners, pharmacists, lab technicians etc is immense and the government should assist private entrepreneurs to impart training. The government can provide funding to such institutions and also build favourable employment opportunities for those graduating and possessing the necessary skills. It is therefore important to provide better facilities and upgrade technologies in the existing colleges or institutions imparting such training. As it has been found that those people passing out does not possess the necessary skill required by the profession. On the job training shall be made a norm with frequent exposure trips and knowledge acquisition. 

Laws like the Kerala Clinical Establishments should be focused on creating standards, educating people, and assisting establishments to build a quality environment for co-creation and co-habitation. Over the years, the healthcare market itself shall break the bad eggs with the help of the monitoring lens of the government.

Prepared by Madhu.S, Team Lead, Centre for Public Policy Research (

Friday, October 19, 2012

Tryst with Indian Railways....

by D.Dhanuraj

Couple of months ago, I had applied for Shubh Yatra card issued by Indian railways. Within a few days, the card was delivered at my office. Then I realized that I should be a frequent 2 tier (at least) passenger to make use of the benefits offered by the card. But I am happy with one aspect of the Shubh Yatra card which is nothing but, I don’t have to take platform tickets any more, while I am card member. 

These days, I have travelled extensively in Indian Railways and many times I could reserve tickets using online Tatkal system thanks to some changes in the rules in the game.

Yesterday, I wanted to book online another Tatkal ticket between Trichy and Ernakulam. I waited for an hour before I could realize that IRCTC server is down. It happens so most of those precious times for an online  tatkal booking passenger. 

Since I was staying very near to Chennai Central Station (irctc code: MAS), I thought of walk into the reservation counter before the Tatkal quota gets over. I was walking to railway counter to reserve Tatkal tickets after many years (I suspect the last one was in 2009). So I was timid and tensed in my approach. As usual, almost all the counters (I believe there are 25 counters) at MAS had long queues. I joined one of those to test my luck this time. Then I noticed that every counter has exhibited timings for Tatkal booking as 10 am to 11 am. “What does it mean?” I asked my fellow ticket seeker.  He said there would have been separate queues for Tatkal booking between 10 am and 11 am. Another person remarked that after 11 am, there would not be any Tatkal Booking. “How can it be?” I asked myself though I did not share it with others. After 15 to 20 minutes, it was my turn to reserve my ticket. I handed over the filled up form to the officer at the desk.  I was so happy to hear him that tickets were still available in Tatkal quota. But in the very next moment, I was thrown into a deep well, when he asked me for a photo copy of the ID card I am carrying. I pleaded with him showing my original ID card (my driving license) which carries my photograph also. He said without a photo copy, he could not issue the ticket.  I did not have the choice to argue on this account so I had to leave the counter. He asked me to get a photocopy of the ID card so that he could issue the ticket. 

I am sure that those who are frequent to MAS can imagine where are those photocopy shops!! They are across the street on busy Poonamallee high road. Rushing out of the MAS building, I gave up my interest to take Tatkal ticket as I was not sure whether I should stand in a queue again to approach the ticket counter. Later, I tried it again online… This time I was lucky and I got it.. I think the particular route between Trichy and Ernakulam is not so busy these days… But the questions remain answered for me;

1.       What is the point for asking a photocopy of the ID when the original ID is presented and the holder himself is present at the counter?

2.       Does it mean that Railways cross check thousands of Tatkal tickets issued everyday against the photocopy? Even if they do, how do they ensure that they are not bogus?

3.       While Indian Railways insists on reducing the paper print, why do they insist on a photocopy?

4.       If this is the case, the TTE should also ask for photocopy. Otherwise, how does he ensure the passenger is genuine?

5.       There was no information exhibited on this regard at the counter!! Why can’t they do it so that I would have taken a photocopy as an obliging citizen..

I feel sorry for the fellow passengers who do not have access to internet and smartphones. They would have terrible times with these kinds of unsavory policies.
 I am yet to understand the intent of this policy? What do they want to achieve? If you know, please email me or comment below…

I thought my bad experience with Railways is over. But no…. Last night, I had to board the train from Egmore to Trichy at 10.30 pm. The train was supposed to start at 10.30 pm from Chennai Egmore Station (MS). The train came to the platform only by 10.40 pm which surprised everyone as it was the station of origin. Then we had another shock waiting for us. My ticket was in 3 tier (B2). There was no B2 compartment (“we could not  find it”, that is the better expression) but only an extra sleeper class (SL) compartment. All the passengers boarded that SL coach which was in the position of B2. Later we are informed that there are changes in the berth numbers.. in the middle of night TTE woke me up and gave the refund chellan… He explained that both B1 and B2 had malfunctions so that there were no other choice but to replace them with SL.
Today afternoon, I went to Trichy station to know more about the refund rules. I was more curious about the procedures than the refund money. As I expected I had to move from counter to counter and from officer to officer. At the end, I was directed to Claims and Refund session in Divisional Manager’s office. Since mine was an e-ticket, I was asked to take print out and send it to Claims officer sitting in Southern Railway office in Chennai by post. I was wondering the cost involved including the time and resources in all these processes. Who is bothered? Anyway, I will try this out as I am curious to know how the system works…

While coming out of the claims office, I noticed a Malayali couple sharing their grievances to a police officer. Hearing them, I approached them. They were on the way to VELANKANNI from KOLLAM in Kerala. On the way, they were pick pocketed. I gave them some money.  Receiving the money, they told me that they would pray for me in the church tomorrow. They have strong belief in The Mother of  Velankanny.

I wish they (in fact, all of us) pray to The Mother to improve the Indian Railway System……………….