Violence in hospitals: Three steps towards mending doctor-patient relationships

Delhi’s mohalla clinics and Mumbai’s Swasth clinics have the right idea – make primary healthcare better.

Even after repeated protests, mass leaves and assurances from authorities of better security, incidents of violence against doctors continue unabated. Last week, a man whose critically ill father died at Sion Hospital manhandled a resident doctor, even though several security personnel had been deployed at the hospital since April.

The recent spate of violence against doctors and a resident doctors’ strike in March has brought the fractured doctor-patient relationship in India into the spotlight. The solutions in these emotionally charged situations have been makeshift ones. Increased security, enhanced punishment and patient visitation restrictions, though necessary in the current scenario, are essentially band-aids on larger wounds. They, at best, strain to cover the breadth of the laceration while gnawing further at the tenuous patient-doctor relationship.

The patient-vs-doctor narrative only increases the alienation between the two parties. The patient is, more often than not, venting against the crumbling health system. The hapless resident doctor, who is only a minion representing the chaotic health hierarchy, bears the brunt of a problem that is not of his creation. They are both victims.

The problems afflicting the public health system in India impact almost every aspect of giving care, leading to a benumbing demand-supply gap. The government feels ill-equipped to bring about wholesale change and resorts to temporary expedients. Many solutions suggested, like the need to increase the number of doctors and building new facilities, though necessary, can show results only after decades. At the same time, training doctors to communicate better can never work in situations where they are overworked. Increasing budget allocations to health is necessary. Even more necessary is considered spending on only prioritised solutions in a stepwise manner so that the money spent leads to measurable impact. Let us look at the three areas that need immediate attention and have workable solutions.

Improving primary healthcare
There has been a complete breakdown in the provision of primary healthcare in Mumbai. The importance of primary healthcare is underlined by the fact that 80% of the total expenditure on health in India is out-of-pocket, and approximately 75% of it is spent on primary healthcare. While in some cases prompt treatment could prevent disease or injury escalating into health crises, other services can only be provided at the tertiary level.

Primary healthcare in Mumbai slums is now often the preserve of unqualified quacks who are disconnected from the public health system or it is accessed directly at the tertiary municipal hospitals. When the base of the pyramid does not work, the secondary and tertiary level health centers are necessarily stretched beyond their capacity. Allocating funds to improving tertiary level facilities before investing in improving primary healthcare is a prime example of the lack of prioritisation that essentially amounts to wasteful expenditure.

Under a World Bank Initiative called Indian Population Project 5, 176 health posts and 168 dispensaries were set up in Mumbai slums between 1988 and 1996. However, staff vacancies, apathy, lack of facilities and lack of prioritisation have caused the health posts and dispensaries to be underutilised – many are non-functional and decrepit.

The health posts can still form the bedrock on which our public health structure stands if the city corporation makes this its priority. They can not only provide treatments for basic ailments, but also antenatal and infancy care to low-risk pregnant women and children as well as medications for tuberculosis under the DOTS program.

There are both public and non-profit sector examples of providing universal access to healthcare in India that are beginning to show credible impact like the mohalla clinics in Delhi. In Mumbai, the Swasth Foundation currently operates 18 clinics across the city’s slums that provide one-stop access to high quality primary healthcare services at half the market rates. Both the mohalla and Swasth clinics make innovative use of technology to maintain quality of care while reducing costs.

Regionalisation of care
Regionalisation of care consists of an effective referral or triage system. Low risk patients should be taken care of effectively at the primary health centres, high risk factors should be diagnosed as early as possible and timely referrals should be made to secondary or tertiary level centres. An efficient citywide referral system is essential to ensure effective management of scarce resources and reduce the load at tertiary centres. Various studies attest to the value of an effective referral system. 

For example, low birth weight or premature infants born in risk appropriate facilities are more likely to survive in these settings.

Mumbai does have a broad framework in place for a referral system, which is most evident in maternal and child care. There are 28 maternity homes that were meant to be the referral point from the primary health care system in the slums and they in turn are linked to the secondary level centres (Rajawadi hospital, Bandra Bhabha) and tertiary level centres (Sion Hospital, KEM and Nair Hospital). However, the referral system fails too often because there is a lack of equipment, facilities and staff at all three levels. If an urgent case is brought to a secondary hospital, it tends to be transferred to a major tertiary hospital, and due to lack of emergency transportation and problems in ambulatory care, patients have little chance of survival.

Though the three levels of care are linked to each other on paper, in reality, they work in their own silos. For example, if a pregnant woman goes to a health post for prenatal care and a doctor there refers her to a maternity home for antenatal ultrasound, she is forced to stand in lines all over again, register herself at the new hospital and is treated like a new patient and not someone in whom care was started at the health post and continued at the secondary level centre when required.

This is one of the major reasons most Dharavi residents bypass the severely underutilised urban health centre at Chhota Sion Hospital and access care directly at Sion Hospital. The concept of a “continuum of care” needs to be reinforced within the health systems. In this case, the public and healthcare providers need to be aware that the health post in a Ghatkopar slum is actually an outpost of Sion Hospital taking care right to the slum dwellers’ doorstep. A single registration form that works through the health system at every level is a simple step to reinforce this idea.

Better counseling
During my time as a resident and assistant professor at Sion hospital, I became intimately acquainted with how lack of access to simple counseling and preventive care information during pregnancy and infancy led to loss of lives that was completely preventable. There were countless instances of women diagnosed with major high risk factors during their first visits, who never came back for the next scheduled appointments because we did not have time to counsel them about the possible complications. These women often came back only in labour and when they were dying.

Given the severe overloading of hospitals, innovative solutions were needed. That led to the idea of mMitra of my NGO ARMMAN, which is a free voice call service that sends timed and targeted preventive care information weekly or twice a week to women through pregnancy and childhood. The reason mMitra works is that it is complementary to the antenatal and infancy services provided at the municipal health care facilities: health workers are stationed in the municipal hospitals who enroll women in their first antenatal visit. The beneficiaries consider mMitra a part of the services provided at the municipal hospital. These women view services provided at the hospital more favourably and are prepared for every eventuality.

Similar cost effective solutions are needed to counsel patients through treatment of other chronic conditions such as tuberculosis treatment, kidney diseases, diabetes and heart disease. A patient with chronic renal disease is most often brought in late for dialysis due to lack of information regarding care.

Even though the many problems leading to violence against doctors seem overwhelming, effective and scalable solutions are available. What is needed is smart concerted action and will on the part of the government and the medical fraternity.