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  Presidential address
ARSICON-2005, Ujjain
23th September 2005

Dr. R.D.Prabhu

  The Association of Rural Surgeons of India is now 12 years old and come November, it will be 13years old. I believe that we have done satisfactorily well in these 12 years and am sure that we will do even better in the future.

However and sadly though, every time the authorities take a step meaning to improve health care, that step affects rural surgeons adversely; first it was blood bank rules now it is the proposed Medical Establishment Act. National Council of Applied Economic Research (NCAER) made a survey of India between 1986 and 1994. It found that people belonging to lower middle class and below constitute 83% of the Indian population; a total of 760 million at that time and 830 million now. These are mostly the people, who, we believe are served by Rural Surgeons. But the government elected by these very people is about to bring in the new act, which may affect them adversely.

The Reason, as per Shri. Javed Chowdhury, Union Health Secretary in 2000, is that "in the recent past health care sector has also become commercialised and it is therefore necessary to prescribe standards and evolve modalities for implementing the same." He further said "Union Government is clear in its mind that expansion of private health care through the insurance system be accompanied by a strict scientific determination of standards and enforcement of the standards."

That I do not believe is the whole story. This must be a part of liberalisation, which is a cunning way of exploiting developing world and the poor by those who have economic might.

By this act:
   a. The government will gradually withdraw from its health care responsibility.
   b. Health care will be more and more privately managed, and
   c. Insurance companies and health care industries will be major players in that private

Similar changes were brought in by liberalisation, in a South American country and a cardiac surgeon who had brought cardiac surgery within the reach of the poor committed suicide because the liberalisation suddenly made the same treatment unaffordable by the poor. But our politicians do not seem to learn from others' experience.

Aim is Quality improvement and control.
I have seen the draft of the bill for Karnataka State. According to it, the government is stipulating "minimum standards for quality of service". That of course is a noble thought. But unfortunately, these standards are primarily in relation to physical aspects of hospital and to qualification of staff only. If quality were its true aim, then it ought to have included more important indicators of quality, besides physical standards, like:
   1. effectiveness,
   2. efficacy,
   3. equity,
   4. efficiency,
   5. accessibility,
   6. acceptability,
   7. adequacy

All of these may be achieved with unqualified but trained personnel, and are certainly achievable without most of the equipment. Many of us are working with unqualified but trained personnel and have found them to be at par and some of them even better than the qualified persons. Our services have not displeased any patients because of lack of qualifications and in fact are appreciated very much. We believe, physical standards and qualifications alone cannot guarantee quality. So, the noble thought is not all that noble after all.

There are other and better yardsticks for evaluating the quality of a health care:
   1. Low incidence of post operative infection,
   2. Avoiding unnecessary investigations, and costly medications,
   3. Performing only indicated surgeries and interventions, and
   4. The most important, satisfaction of the patients.

These have not been accounted for in the act either. Besides, even these are not dependent on equipment or qualification of paramedical staff. Currently, the patient satisfaction appears to be more important than qualifications. In U.K. the G.M.C. has listed the duties of a doctor as follows:
   1. Be polite and considerate
   2. Respect patient's dignity and privacy
   3. Listen to patient's views
   4. Give patient information
   5. Respect their right
   6. Keep your professional knowledge up to date.

Thus professional adequacy, in other words the qualification, comes a poor 6th after the 5 other duties to satisfy a patient.
The impact

To implement this new foreign concept of health care, state governments will have to borrow money from World Bank. The Karnataka Government has already decided to borrow about 570 crores of rupees for it. That is where, in liberalisation, the World Bank plays its cunning role; it first creates borrowers with bait, e.g. idea that managed health care is better. It is said that World Bank always keeps a hook in its bait. The hook is that, the World Bank will dictate the way the programme is implemented. You may read that as "you are free to do what ever you want to do as long as it is what we told you". Its usual condition is that "the state governments play an active role in creating an environment for greater private participation in the health sector". Private participation invariably means involvement of foreign health care industries; like insurance and equipment companies. Once in its grip, World Bank behaves like our moneylenders. Borrowers invariably end up losing their lands and property. Christian Aid estimates that Africa has lost $272 Billion in the last 20 years from being forced to promote liberalisation, for receiving World Bank loans. (Mark Curtis, in The Hindu 24-8-05). Uganda could get only US$ 2 million for a property that was worth US$500 million, to qualify to get World Bank funding (George Monbiot, in The Hindu 15-6-05). We in India may lose more than our gains, if there are any gains at all.

Therefore, we in ARSI do not believe in such standardisation, and we believe that if the act has to be enacted at all the rural hospitals and tribal hospitals must be excluded from the act. Because, the act and such standardisation will only make health care costlier to the poor without making any significant difference in quality. Needs of the majority must have a priority over those of a minority, that is the rich.

We the Indians have always prayed for happiness of all; our own emblem says, "let every one be happy". We have been praying like that over 5000 years and we continue to pray like that even now because we know that many are still not happy. They say that India is shining. What is the use if India shines, when its majority is not happy? Great industrialist, late Shri J.R.D.Tata after he was honoured with the Bharata Ratna award in 1992 said, and I quote:

"An American economist predicts that India will be an economic superpower in the next (21st) century. I do not want India to be an economic super power; I want India to be a happy country." I strongly support that view. I wish every one to be happy by our own standards of happiness. That, we need not always follow western standards, is nicely shown by Dr. Brahma Reddy who introduced ordinary mosquito net as a good alternative to the imported costly proline mesh, for hernia repairs.

Happy news for all of us is that National Board of Examinations has decided to train MBBS doctors in to Rural Surgery. That has been our wish for a long time. As early as 1996 late Dr. B. Ramamurthy, past president of N.B.E. had written to the, then president of N.B.E. to take up rural surgery as a Board's programme. We are happy that our dreams are finally materialising. Interesting aspect of this training is that candidates will be trained in rural hospitals and not in the High-Tec teaching hospitals. Our members will have to help this programme in this area. I sincerely hope that India will soon have a strong force of rural surgeons to care for rural folk. ARSI thanks Dr. Shyamprasad, Dr. Rajshekharan, Dr. Sood, and others in N.B.E, and our own Dr. Toor for their initiative in this.

Over the years, I have come to realise that even developed countries have a section of people who do not get adequate medical and surgical care. Those countries too have started focussing on the needs of rural surgeons. So now we have decided to bring all or as many as possible, groups of rural surgeons from around the world under one banner, The International Federation of Rural Surgeons. This I believe is an idea that was initiated by Dr. Thomas Moch of German Society for Tropical Surgery and Dr. J.K.Banerjee, our current vice president. I congratulate them both and sincerely hope that this federation grows fast and strong so that appropriate health care is available in all corners the world. Then our prayer will have been truly answered.

I like to thank the management of the R.D.Gardi Medical College and in particular Prof. V.K. Mehta for organising and hosting this nice conference here in this fantastic city of Ujjain whose early history is lost in antiquity. This city is named in Buddhist literature of 6th century BC. Wars have been fought here and the city has been looted and vandalised again and again by foreign invaders. Famous and proverbial king Vikramaditya, poet king Bhartrahari and emperor Ashoka had ruled it. Famous Sanskrit poet Kalidasa, one of the nine gems of king's court wrote the monumental classic poem, his masterpiece, Meghadoota in this city. From 4th century B.C Ujjain was the Greenwich of India, long before Greenwich of U.K. was established. We are proud to have our conference in this historic city. I welcome all the delegates and especially all those who have come from far away countries. I sincerely hope that you all will benefit from the deliberations and meetings.