September 30 2015, Wednesday
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Status paper on National Protest Day
![]() ![]() Recently the Supreme Court of India awarded an amount of 11 crore rupees as compensation for medical negligence in a case. This judgment has caused a sense of panic among the medical professionals in our country. Subsequently in three more cases, the compensation awarded has been more than a crore. It has already resulted in a huge increase in the number of cases filed (several of which are on frivolous grounds) as well as a significant increase in the premiums paid to insurance companies. Indian Medical Association (IMA) considers this as a very serious matter and we fear that this may even result in increase in the expenses on medical care. A review of literature by IMA shows that the process of capping of compensation of medical practice law suits has been well established in developed countries, and India needs to adapt the policies being practiced in developed countries to its own requirements and can benefit greatly from their experience. In this regard, to safeguard the interest of the people at large and to avoid unnecessary litigations and to save the precious time of courts as well as medical practitioners, IMA suggests the following:
Indian Medical Association is deeply concerned about the increasing incidences of attacks on doctors and clinical establishments across the country every day even on very flimsy grounds. At least 13 states have acts to punish the perpetrators of such crime through the hospital protection acts. It has been observed that even in such states, no action is taken against the culprits under this act. So IMA requests the Union Government to enact a common act to protect the clinical establishments from vandalism. If more than six states concur for such an act, a common act can be passed in the Parliament. Now more than 14 states have already enacted such an act and under the circumstances IMA feels that it is imperative in the larger interest of public health that a common act is framed and passed in the Parliament to curb this menace. Even in war, hospitals, doctors and paramedics have immunity against attacks. But now we find that on very flimsy grounds, anti-social elements who have a grudge against a hospital, utilise certain situations in the clinical institutions to seek vengeance, perpetuating vandalism. This cannot be allowed in a civilized society. This has to be considered as a crime against the helpless patients who are still in the hospital under treatment. For the sake of public health and to uphold the human rights, IMA urges the government to enact a law to protect the helpless patients, medical and para-medical staffs and clinical establishments. IMA also observes that inspite of the state legislations or because the act is not effectively implemented, violence against clinical establishments and doctors occurs. IMA demands that changes should be made in IPC and CrPC similar to changes made to prevent crime against women. 3. Withdraw plans to start Bachelor of Science in Community Health (BSc Community Health) IMA strongly objects to the Government move to start BSc Community Health course under the National Board, to man subcentres and empowering them to prescribe medicines. Subcenters are the cornerstones of disease prevention activities and implementation of national health programs and not primarily meant to provide curative service except home remedies. The staff pattern in the subcentre consists of one male and one female multipurpose health worker (JPHN/JHI/ANMs). The job description of these staffs is family welfare services, immunization, awareness, household visits, data collection regarding disease prevalence, and coordinating other national disease control programs. These staffs currently work under the supervision of a medical officer posted in primary health centre (PHC). For this purpose, there is no need for a more qualified workforce. Posting the proposed BSc (Community Heath) graduates in subcentre level will be a wrong human resource management. At the subcentre level, a more suitable workforce would be an ASHA worker with basic primary education and training. So the concept of posting paramedics at the subcentre will be a gross waste of human resources and will be counterproductive for the purpose they are meant. The policy proposal on this is not based on ground reality and is conceptually wrong. The deployment of overqualified staff at subcentres will only increase the attrition rate. Entrusting the newly proposed BSc (Community health) graduates to manage very sensitive areas like child health within the health system may even worsen the situation. To leave the health of children and adolescents in the hands of ill-equipped personals is detrimental and may nullify the results of years of hard work that the country has put into reducing child mortality and morbidity Moreover, if the Government’s intention is to produce health workers to work in subcentres, why should such courses be conducted by national board of examination (NBE)?The NBE, in fact, conducts post graduate courses and not even undergraduate courses in modern medicine. Allowing these graduates to be registered under Medical Council will set a wrong practice. IMA therefore, urges the Government to desist from the move to start BSc (Community Health) course 4. Amend PCPNDT Act The PNDT Act came into being in 1994 with the purpose of improving the altered sex ratio in India. It was further amended in 2003 as the PCPNDT act to regulate the technology used in sex selection. The Act banned preconception and prenatal sex determination. Its intent was to curb the actual act of sex selection and female feticide by regulating the use of ultrasound technology. The World Health Organization (WHO) in its recent publication has clearly declared that restricting technology was not the way forward. However, despite the Act having been in existence for over 20 years, the altered sex ratio in India has not changed. Instead, it has had two major negative consequences:
IMA demands the following amendments:
During the pre independence era, the British Government had experimented with various type of health care from licentiate medical practitioners known as LMPs and various other integrated mixture system of practice mixing various systems of medicine. After the independence of India, due to the failure of all these existing types of health care delivery systems, the Government of India decided to re-evaluate the health care delivery system and framed the Indian Medical Council Act 1956, exclusively for the modern system of medicine and the Indian Medicine Central Council Act 1970 for the Indian System of Medicine. The Homeopathic Medical Council Act was framed for the Homeopathic system of medicine. Different qualifications were fixed for the practice of the different systems of medicine. Thereafter, when disputes arose as to the right to practice the systems of medicine, the Supreme Court of India in Poonam Verma Vs Ashwin Patel and others reported in 1996(4)SCC 332, Dr. Mukhtiar Chand and Others Vs State of Punjab and Others reported in AIR.1999(SC) 468, Medical Council of India and another Vs State of Rajasthan reported in AIR 1996 (SC) 2073,categorically held that only persons holding the requisite qualifications prescribed by the respective medical councils and holding registration with the respective medical councils, alone will be entitled to practice the respective systems of medicine. It is also held in Dr. Preeti Srivastava Vs State of Madhya Pradesh reported in AIR-1999(SC) 2894 that dilution of the qualification prescribed by the councils for the practice of medicine cannot be diluted done by the State Government by any orders or legislations. When the qualifications for the practice of modern medicine became rigid under the Indian Medical Council Act and by the various judgments stated herein above, Indian Medicine Central Council for Indian System of medicine and the Homoeopathy Central Council for the Homeopathic system of medicine started issuing circulars and orders permitting the persons registered under the respective councils to practice the modern system of medicine, which was out of the purview of the Indian Medicine Central Council and the Homoeopathy Central Council. These orders and circulars passed by the Indian Medicine Central Council and the Homoeopathy Central Council, for the practice of modern medicine, though out of their purview, are approved by the Central Government without proper verification. Usually the claim of medicine and systems of medicine is sent to the Indian Council for Medical Research for the final opinion before approval by the central Government, but unfortunately the circulars and orders of the Indian Medicine Central Council and the Homoeopathy Central Council for the practice of modern medicine are not properly verified and scrutinized by the Central Government before approval resulting in the practitioners of Indian System of Medicine and Homeopathic System of medicine practicing modern medicine under the guise of these orders and circulars, which are against the existing laws and the spirit of the judgments referred above. The Government of India has to take strict notice of the purpose and contents of the orders and circulars of the Indian Medicine Central Council and the Homoeopathy Central Council for the permission to practice of modern medicine and these circulars and orders will have to be scrutinized by the Indian Medical Council and the Indian Council of Medical Research before approved by the central Government and the failure to do so will promote large scale quackery resulting in the damage to the life of citizens of our country. The permitting of practice of modern medicine directly and indirectly to persons who has not qualified the standards of the Indian Medical Council under the Indian Medical Council Act will result in heavy miscarriage of public health causing dangers to the life of the general public in India. Indian Medical Association demands the government to take note of the fact that various such orders and circulars are put to misuse by various State Governments and the Central Government overriding the provisions of Indian Medical Council Act. Therefore, IMA demands that the ministry should not permit Indian Medicine Central Council or the Homoeopathy Central Council to bring out such circulars and orders which are outside the purview of these councils and ensure that only modern medicine qualified doctors are permitted to practice modern medicine It is noted that various state governments are passing Order/ Circular, permitting the practitioners of Indian System of Medicine registered under the Indian Medicine Central Council Act, 1970 to practice and prescribe modern medicine, under the provisions of the Indian Medicine Central Council Act-1970. In accordance with the law and the judgments of the Supreme Court in the Dr. Preeti Srivastava vs State of Madhya Pradesh case as reported in AIR-1999(SC) 2894, the state Government has no authority or power to pass any order/ circular or legislation to permit the practitioners of Indian System of medicine to prescribe and practice modern system of medicine. Such permissions if at all can be granted, it can only be granted by the Indian Medical Council constituted under the Indian Medical Council Act-1956. The Supreme Court of India in DK Joshi vs State of Utter Pradesh, reported in SCR-2003-3-525 has directed the Utter Pradesh Government, to take action against the unqualified practitioners of modern medicine in the state. Moreover, the Division Bench of High Court of Utter Pradesh in writ petition no 64481 of 2012 in Praveen Kumar vs State of UP has clearly denied the permission for the practitioners of Indian Systems of medicine to practice modern medicine. This being the situation, the orders/circulars of various state Governments permitting the practitioners of Indian System of Medicine to prescribe and Practice modern Medicine is highly illegal. Medical Council of India (MCI) is the supreme authority regarding modern medical profession and any form of training in Modern Medicine. When this issue came up for the consideration before the ad hoc Committee appointed by the Honourable Supreme Court and the Executive Committee of the MCI, they deliberated the issue at length and noted that as per section 2 of the Indian Medical Degrees Act 1916, the term ‘Western Medical Science’ has been defined as meaning the western methods of Allopathic Medicine, Obstetrics and Surgery, but does not include the Homoeopathic or Ayurveda or Unani system of medicine. Accordingly the MCI and the ad hoc Committee appointed by the Honourable Supreme Court decided that BAMS (Ayurvedic) practitioners, who being Ayurvedic graduates are not graduates trained in Western Medical Science as defined in Section 2 of the Indian Medical Degrees Act, 1916 and hence could not be allowed to practice modern medicine in any form. The CCIM (Central Council of Indian Medicine) has no authority to prescribe training in surgery, obstetrics or in any form of modern medicine practice, unilaterally and suo moto in their syllabus and curriculum without consulting with the MCI. It is pertinent to note here that certain state Governments like in Telengana and Kerala have rejected similar requests of Ayurveda students in their state. Training in modern medicine procedures and postmortem examination are carried out to students of modern medicine as a continuation and culmination of their course, which includes a prolonged study in modern medicine and that training cannot be given to Ayurveda students or internees during one or two months of their internship who do not possess relevant theoretical studies or practical experience. It will be hazardous to the public health and safety and for any modern medicine doctor to indulge in imparting such a namesake training would be unethical as violation of the rules of ethics of modern medicine. Therefore, IMA demands that the state governments are directed not to issue Orders/Circulars permitting the practitioners of Indian System of Medicine to practice modern System of medicine 6. Clinical Establishment Act
It is the obligation of the state to provide free and universal access to quality healthcare services to its citizens. India continues to be among the countries of the world that have a high burden of diseases. The various health programs and policies in the past have not been able to achieve the desired goals and objectives. High-level expert group (HLEG) on Universal Health Coverage (UHC) constituted by Planning Commission of India submitted its report in November 2011 for India by 2022. The recommendations for the provision of UHC pertain to the critical areas such as health financing, health infrastructure, health services norms, skilled human resources, access to medicines and vaccines, management and institutional reforms, and community participation. Planning commission has estimated that 3.30 lakh crores has to be spent in 12th FY period (2012-2017) to achieve the goal of UHC by 2022. We are already into third year of the 12th FYP and yet only a meager proportion of this amount has been budgeted so far on an annual basis. It is believed that an important factor contributing to India‘s poor health status is its low level of public spending on health, which is one of the lowest in the world. In 2007, according to WHO’s World Health Statistics, in per capita terms, India ranked 164 in the sample of 191 countries. This level of per capita public expenditure on health was less than 30 percent of China’s (WHO, 2010). Also, public spending on health as a percent of GDP in India has stagnated in the past two decades, from 1990-91 to 2009-10, varying from 0.9 to 1.2 percent of GDP. Government should increase the public expenditure on health from the current level of 1.1% GDP to at least 2.5% by the end of the 12th plan and to at least 3% of GDP by 2022. Government should ensure that a minimum of 55 percent of health budget is spend on primary, 35 percent on secondary and a maximum of 10 percent on tertiary care services (as proposed by National Health Policy 200), as against the current levels of 49%, 22% and 28% respectively. The Twelfth Finance Commission provided grants to selected states to improve health indicators, but in effect, they recommended that the grants cover only 30 percent of the gap between the state’s per capita health expenditure and the expenditure requirements assessed by them for each of the state. This should go up to at least 50 percent of the gap. Additional transfers from the central government to selected states have to be directed toward primary care and the first level of secondary care by strengthening the related health infrastructure and personnel. This is important not only to facilitate basic primary and secondary care but also to reduce the burden and expenditure share at the tertiary level. The estimated additional expenditure requirement just to provide subcenters, health centers and community health centers according to the norms is estimated at 0.6 percent of GDP. There are additional administrative expenditures and requirements for providing health facilities in urban areas, and these could add up to another 0.4 percent. Thus, a minimum of one percent of GDP will be required in the medium term (next 1 to 2 years) to ensure minimum levels of health care as per the norms. There should be an increase in spending for public procurement of medicines from 0.1% to 0.5% of Gross Domestic Product (GDP). Government should bring in legislation to discourage pharmaceutical firms from using trade names in marketing. Drugs should be available only in chemical name, which will help to bring in uniformity. At the same time there should be strict mechanism to monitor and ensure that drugs available in the market are of good quality. Government should invest in establishing drug-testing laboratories in each state. In addition, government should support and rejuvenate the existing public sector drugs and vaccines manufacturing units. General taxation plus deductions for health-care from salaried individuals and taxpayers as the principal source of health-care financing should be used, and no fees of any kind be levied for the provision of health-care services under UHC. Insurance is not a panacea and government should refrain from promoting health insurance as the best solution for health care problems in the country. Government should introduce a health cess (0.5%) as a component of the existing VAT system and the new Goods and the Services Tax (GST) that is proposed. There should be additional health cess for sweetened beverages, tobacco, alcohol and cars. This will raise revenue for the government on one-side and at the same time will act as a measure to discourage the use of these products Water, hygiene and sanitation are the cornerstones for effective public health protection. Government should not only increase allocation to these areas, but also ensure that the money is spend properly and time-bound. Government should move to a system of ‘purchasing’ secondary care services from private sector until it can provide these services by itself. This will help to prevent out-of-pocket expenses for a large section of population and also can reduce the burden on tertiary care. The reimbursement scheme for health care should be extended to all people working in organised sector and not just to central government employees. This will help to relieve some pressure on the public health systems on one side, and will help to give more options for people in the organized sector. The present schemes such as JSBY, RSBY, JSY etc. are run by different ministries and departments. The Budget should facilitate convergence amongst the various stakeholder ministries/departments so that we can evolve a comprehensive social security package. Public and private sectors should not move as parallel systems, but should complement each other. Public private partnership in health should be promoted. At present, the facilities in private sector are underutilized at one end, whereas public sector lacks in facilities to cater to the needs. Government should design special programs in discussion with professional associations like IMA to optimally utilize the resources- both in public and private sector. This will include sharing the resources in private sector like CT, MRI scans etc. for patient care in public sector. Services of family doctor/single man private clinics should be optimally used on a retainership basis, at least in places where government doctors are not available at PHCs, until government is able to recruit and sustain regular doctors. Government should increase the allocation for health awareness programs. A repository on health information should be created and disseminated using the social media. Non-communicable diseases and health needs of the elderly need urgent attention. Government should increase the allocation to these areas significantly. National programs for NCD and care of elderly should be introduced in all the districts within the next two years. Telemedicine should be given importance, with simultaneous investment in increasing the availability of trained and qualified human resources 8. Strengthen primary health care/rural health service National sample survey, 2014 has shown that 40% of our population depend on single man clinic and small rural hospitals for their health needs. It is observed that these small and medium level hospitals are closing down due to financial non viability. IMA demands that the government should support these hospitals financially through a program of ‘aided hospitals’ To attract modern medicine practitioners to serve in rural areas, IMA suggests the following
As it was clearly established through various studies and as reported by the Planning Commission’s High Level Expert Group (HLEG) report, almost 70% of out-of-pocket expenses incurred in health care is directly due to the cost of drugs and this is more among the poorest quintile. Therefore, the government should spend more resources in making drugs affordable to the population -at least to the tune of 0.5% of GDP. Government should open more Jan Aushadhi stores and establish a drug distribution system catering to both public sector and private sector hospitals. The essential drug list should be revised and published periodically. Drug manufacturing and distribution should be guided by the essential drug list. Very strict laws and penal provisions should be in place to curb irrational combinations and preparations. More drugs should be brought under the price control mechanism. Mechanism of adverse drug reaction monitoring should be made more effective. All the companies should market the drugs in generic name. Government should return to the old system of cost based drug pricing and should do away with the current system of market based pricing. This will rationalize the cost of majority of the drugs and will help to avoid cartel formation. Govt should ensure the quality of each batch of medicine, and this requires adequate funding to establish more testing labs in the country. Drugs should not be allowed to move to the market before the quality is tested for each batch. Govt policy should be to facilitate domestic drug manufacturing companies to undertake drug research and innovation, to invent new molecules to address preferentially the diseases, which are predominantly prevalent in our country. Just like techno parks, govt should invest and facilitate common facilities for drug research and quality control. Govt should also take steps to open and functionalize the closed down vaccine manufacturing units in the public sector and also sick drug manufacturing units in the public sector |
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