Wednesday, March 09, 2011

Out of Bounds for the Poor - Hike in Medical Education & Hospital Rates

This is a guest post from Dr Nadkarni, a very thoughtful observer of the Indian healthcare system. He has some very clever ideas - let's hope the government implements them !


The Maharashtra State Govt. has decided to increase the annual fees for medical education from Rs.18000 p.a. to Rs. 40,000 + Rs. 5000 entrance fee. The government has already raised the charges for various hospital services in the state Hospitals also by 100% or more. “Increasing Costs” is quoted as the reason and as usual, the press-release has stated that the state is spending Rs. 4.8 lakhs per student per annum for his/her education. The hike appears justifiable – or is it? Let us see.

Mumbai Municipal Corporation spends around 500 crores on its four medical institutions, the state government much less, but even the govt. cannot run a medical college without spending 40 to 50 crores. If a college admits 100 students every year, a total of 500 students (100 X 4 + failures) will fetch an additional income of Rs. 1.25 crores at the rate of Rs. 25000 extra from each student. Is it really going to help? The state spends less than 1% of G.D.P on health, so it can easily absorb this 1.25 crore per college without any strain on its budget, and hence will not get any great advantage. Even a large number of students will be unaffected, as they belong to affluent class. The real sufferers will be the poor students whose guardians earn less than Rs. 20,000 per month. An additional burden of Rs. 25000/- is equivalent to a loss of more than one month’s income, when rising costs of food, house-rents, travel and basic education for other children leave no scope of saving even a rupee for these families; and they comprise more than 50% of the population.

A student has to secure around 95% marks in the H.S.C examination (and later (C.E.T.) to secure a seat in the state owned medical colleges which offer this subsidised education. But, with equal talents, it is the Affluent Class students who score better due to better facilities like special tuitions, home coaching and better atmosphere in the house. Therefore, even to-day, more than 50% of the medical students, including those from reserved categories of O.B.C.s and scheduled casts, belong to the economically privileged classes. A bright student from low-income family is virtually denied admission to both govt. and private medical college (which he cannot afford). The increase in fees is going to hit this very class the hardest, and thus the Govt. for the Poor is going to ensure that the poor are totally eliminated from all medical colleges, irrespective of their merits.

But, why should the medical education be subsidised at all? Do these graduates charge less or do they offer to join the government service to serve the poor? Then, why not raise the fees by Rs. 2 lakhs, instead of a mere Rs. 25000? The subsidy can now be justified on the grounds of the financial status of the family and the students getting subsidy can justifiably to bonded to serve the state (in rural areas or otherwise) for at least 10 years. The students with family income of Rs. 75000 per month will have to pay full-fees, while a 50% concession can be offered to those with a monthly income above 40,000 per month (with a bond, of course). Those with income below this may continue to pay the present fee (Rs 18000 p.a.) Nearly 60% of the students belong to the first two groups and each college with 100 admissions will collect 4 to 5 crores, without taxing the poor. Freedom from the bond will induce many parents to pay full fees, irrespective of their (declared) income. The govt. could spend part of this money, for those poor students who score a little less in the state conducted CET and therefore, are eligible to get admission, on merit, to private medical college, by subsidising their fees.

What is true of education fees is even more bitterly true of hike in hospital service charges. It is the poorest population which will be hit the hardest. There was a 20% reduction in the number of poor people attending hospitals, when charges were hiked, between 1999 and 2001. Worse could happen now and it will the old people, women and dependent distant relatives who will suffer most, even amongst these poor, as they will not be able to avail of any medical help. This is also preventable, if the principle of differential payment is adopted here too. “From each according to his ability and to each according to his need” is the motto of any socialist organisation.

The way patients are allowed to attend medical college hospitals is most unorganised. The path to this tertiary centre could be properly regulated, at least for the poor. They will have to attend a primary health centre and/or a secondary hospital before being referred properly to this tertiary centre. Even without a reference, such patients could be allowed to attend here, if they had taken treatment at a primary centre for a stipulated time and were not satisfied or not relieved. If the college hospital keeps a specified time in the O.P.D. STRICTLY for such patients (say 8 a.m. to 11 a.m.) they need not be charged even a rupee more than at present. This system will also help in reducing the unnecessary crowd in medical college hospitals, as many patients will get their full treatment at the peripheral centres. The patients referred will receive better treatment and, may be, even assaults on doctors will be minimised. If any of them need admission, 50% beds in the wards will be strictly reserved for these poor patients—again without any increase in the charges of the hospital.

Yet, some patients would not like to go to primary centres at all and would insist on attending the college hospital directly. The authorities would be justified in charging them 4 to 5 times higher, they are not too poor. Specific separate timing in the O.P.D. (say 11 a.m. to 2 p.m.) and a separate coloured paper will ensure proper segregation of the two groups and 25%beds could be reserved for them in the wards – again with hospital charges 4 to5 times higher than for the poor.

For the more affording or the privileged group, the hospital could profitably start “Pay-Clinic” in the evening hours at FULL CHARGES (about 4 times the charges for the second group). At present, the hospital runs during the morning shift only, and both the space and the equipment lie idle in the evening hours. Being a Pay-Clinic the senior teachers will conduct the O.P.D.s and they will be entitled to incentive payment of “Doctor’s fees”. Another 25% beds can be reserved in the side-rooms of the hospital with FULL CHARGE. These paying patients will be investigated and treated/operated in the evening hours only, thus sparing morning hours entirely for the poor and semi-poor groups. In this way, the senior teachers will be kept busy throughout the day (with incentive payment) and they will have no time spared to indulge in private practice outside. A win-win situation and an income of about 8 to 10 crores for the college. To-gether, the medical college would earn about 12 to 15 crores covering 25% to 33% of the total expenditure of the hospital –without burdening the poor with any extra charge. In general, the poor will pay 5% to 7% of the full charges; and the semi-poor will pay 25% of the actuals.

There are many more advantages in such a scheme of working, like improved medical education, improved services, better maintenance of equipment and scope for self-expansion. I have explained all this in my book, recently published by Vora Medical Publication, Byculla, Tel. 022 – 23754161, titled,



(What Is Wrong - What Can the Done)


Dr. S.V.Nadkarni

Former Dean, L.T.Med.College, Sion,

Tel :- 9320044525

[email protected].

I appeal to the politicians, medical activists, and the intellectuals to study the system and make appropriate changes, so that all the sections of the society benefit. Instead of championing the cause of the poor only, the public sector would do well, if it champions the cause of the Lower middle and the middle-middle class as well.

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