There is a paradigm shift to be made so as to give equal weight to curative medicine, public health/preventive medicine specialties, and Research and Training
Open letter to Hon Minister of Health & Quality of Life,
Dr Anwar Husnoo
Several years ago, as I was on sick leave and therefore couldn’t go through the ‘normal procedures’, I wrote an open letter in this paper to the then Minister of Health & Quality of Life regarding the issue of mismatched blood transfusions. I was threatened with dire consequences, including termination of service. I do not know what risk, if any, I am exposing myself to now in addressing you, as a former colleague who currently has such enormous public responsibilities. However, I am willing to take it because I feel that the situation in the health sector about the oversupply of doctors and the shift system requires an alternative approach which may certainly be not unfamiliar to you, but which may be overlooked because of the multifarious problems that you have to handle.
For the first time the country has a specialist as Minister of Health, who is in a better position to understand and appreciate the complexities of the medical and health scene across the board from primary health care to tertiary health care, and the regulatory aspects, as well as to act on this understanding to formulate more pragmatic and implementable policies. I strongly feel that this is an opportunity that neither you nor the country must miss.
I apologize for the somewhat lengthy preamble which captures the larger perspective about medical and health services which our clinical bias makes us relegate to second place, but which can serve as the basis to guide policy formulation and decisions. The latter can have system-wide impacts.
Evolution of medical practice
In order to appreciate better what will follow, the evolution of medical practice in general will be illustrated by flagging a few basic notions and principles on which modern medicine is founded. Modern medicine is essentially western scientific medicine, which is the predominant form of medical practice in Mauritius. Its basic model is that the sick patient goes to the doctor expecting to get treatment and to be cured of the disease s/he is suffering from. Thus it is called curative medicine, and it can take place outside a hospital – either in the doctor’s consultation or at a health centre (dispensary) – or in a hospital.
Treatment is based on making a correct diagnosis of what the patient is suffering from, which in a number of cases – that is, not all cases – requires that certain additional tests such as blood examination, XRays or scans be done for which the patient may have to be sent to hospital. Many such tests are increasingly sophisticated and therefore costly. Thus, hospital medicine, also called clinical medicine, is very costly – all over the world – and the costs keep rising.
A consequence of this model is that most doctors want to become clinical medicine specialists – or simply clinical specialists – working in hospital, and most patients want to be seen and treated by a specialist. This is even after they would have attended a health centre and been given the appropriate treatment by a competent non-specialist doctor, or by an equivalent private general practitioner, both of whom can handle many cases without resorting to the expensive and at times unnecessary tests.
That is the rationale of having a network of health centres easy of access to patients who live not far away from them where they can go to get primary care for common ailments and minor injuries, and only if necessary be referred to the specialist in hospital. This is known as primary health care which has been and ought to be the backbone of any health service. Properly run and staffed by primary health care specialists, better known as primary health care physicians, the primary health care system (PHC) can handle the bulk of patients, be quite effective and less costly.
Primary Health Care and Preventive Medicine
The strength of PHC is that, besides treatment, it is also concerned with prevention of disease, which involves amongst others vaccinations, screening for early detection of non-communicable diseases in particular, counselling about the associated risk factors (smoking, drinking, food habits, etc) for the latter and following up the cases that have been stabilised at the hospital. PHC is therefore about taking care of the patient in the community in proximity to where s/he resides, and away from the hospital set-up.
The broader dimension of prevention, however, is properly the province of the preventive medicine, which ensures an enabling environment for human existence and a country’s development. In contrast to curative medicine and PHC which essentially deal with individual patients, preventive medicine addresses issues that concern the population as a whole, and that is what the ‘enabling environment’ refers to – an environment free of infection, with water, air and soil of safe quality so as to allow people to live healthily. Together, PHC and preventive medicine make up the larger specialty of Public Health or Community Medicine (the terminology varies according to country preference), and their practitioners are specialists in their own right. So too are specialists in Occupational Medicine, the Occupational Health Physicians who also deal with population issues, and are engaged in preventive medicine related to the hazards of occupations in which human beings work.
What is of significance is that the training of preventive medicine specialists is different from that of clinical specialists, and in general it is of shorter duration for reasons that we can’t go into here. However, they are no less specialists, and play a key role in the prevention and control of epidemics and catastrophes. Unfortunately, there is a tendency to look down upon these specialists as their work is mainly at field level, and doesn’t receive the attention that is given to hospital work, important as that may be. Until there is an outbreak that reminds us of their pivotal role; think AH1N1 pandemic, SARS virus, ebola and we have the picture.
Besides this, though, there are the dimensions of research and training (R &T) that are given short shrift, but whose importance and scope are undeniable and considerable. What is critically lacking in Mauritius is ongoing assessment of the myriad of activities that take place in the health sector, so that decisions can be taken on the basis of solid, objective evidence derived from what is known as operational research.
Reversing the flow towards hospitals
Everywhere in the world, and Mauritius is no exception, there is a bias towards high-tech medicine at the expense of the preventive specialties. Being a clinical specialist myself, I am not by any means denying the importance of clinical specialties and their high-tech requirements and dimensions, which, again, I have myself fought for and implemented. But with an oversupply of medical practitioners (with many more coming every year) and a plethora of specialists, it is time to stem the flow of specialist doctors towards hospital, a trend which has been encouraged by the local career structure and the unplanned, at policy level, development of undergraduate medical education that has swelled the numbers. Since the country never put out an advisory about the capacity of its health sector to absorb medical practitioners, there was an expectation that the public service was bound to provide employment to all of them who had registered with the Medical Council.
However, there is the important fact that, because our public health service is free of cost at the point of service – based on the National Health Service of the UK – up to 80% of the medical workload in the country is handled by the public sector. As such, therefore, there is scope for the employment of more practitioners, but not on the current model. There is a paradigm shift to be made so as to give equal weight to curative medicine, public health/preventive medicine specialties, and Research and Training.
The way forward would be based on certain principles and assumptions rooted in the ground realities of the country, as follows:
- Recognition of the preventive specialties as fundamental to the health of the country; creation of the conducive conditions, including amendments to the law as required, to encourage medical graduates to pursue these specialties. In parallel must be developed a career structure that considers parity in earnings with the clinical specialties. For example, in Japan Primary Health Care Physicians earn higher than their hospital counterparts so as to encourage doctors to take up that field.
- A formal training structure must be set up for this purpose, with help from academics as required.
- This, along with appropriate infrastructure upgrading and the induction of the other required human resources, such as in nursing, physical therapy and so on, will contribute to strengthening of PHC that will take the load off hospitals.
- An additional value added aspect is that patients will have the psychological satisfaction of seeing a specialist, as they are keen to.
- A vast campaign of mass education of the public to create awareness about the shift in emphasis towards PHC for their own benefit.
- Equal emphasis to be given to Research and Training, with appropriate budgetary provision: 2% of the health sector budget is the accepted norm. This will generate alternative employment for medical graduates.
- A complete review of medical and health education in the country by a competent authority in the matter.
- An allocation of the health budget based on per capita rather than as percentage of GDP, vide Singapore.
May I request you, Hon Minister, to view the Health Sector Strategy document that had been prepared with inputs from all stakeholders in the medical and health fields, and which is available at the Health Economist Unit of MOH & QL.
Finally, should you be willing, I am at your disposal to go over the points I have advanced in the interest of all concerned.
* Published in print edition on 18 August 2017