The country and the people cannot continue to face a catch-22 situation regarding the choice between a patchy government medical service and an unaffordable private medical service
‘I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures which are required…
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know… Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability… if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure…’
– Large extract from the modern version of the Hippocratic Oath taken by physicians
For the general public, the test to ascertain the quality of medical services offered to people occurs when somebody close is ill and is urgently in need of treatment. The Health Ministry has the third largest estimated 2015-16 budget of Rs 9.720 billion after those of Social Security and Education. Free public health service is one of the pillars of our welfare state. Are we getting value for money? Is the medical service provided to the sick and ailing up to the mark and patient friendly? Are the sick being tended for properly and efficiently? Are those suffering from serious ailments finding relief, hope and cure?
We must remember that the vast majority of Mauritians depend on the public health services to be tended and cured whenever they are ill as most of them including the retired cannot afford the costly medical services available in private or in private clinics, the more so as they are not covered by medical insurance schemes provided to employees of the corporate sector.
Too often sick people taken to hospital for treatment return home not knowing what they suffered from or the name of the doctor who treated them. In more complicated cases, it can be un parcours de combattant for the patient and their relatives and can lead to serious consequences if the patient is not treated competently by capable physicians. Have the high benchmarks of public medical service the country started up with been allowed in some instances to be watered down?
At the outset, after independence, the best doctors and specialists qualified in the UK, France or India have manned the public health services and provided a high quality and high standard of medical service to the public. Private clinics were principally used by the well-to-do. The nursing personnel and other hospital support staff were also efficiently trained. Over time the required investments have been made by government in state of the art facilities and equipment to upgrade the medical services provided in hospital to the highest benchmarks prevalent in the world. The care and facilities provided for example in the cardiac, neurosurgery or dialysis services offered by the government health services at great cost are world class and in some respects better than those in the private sector.
A patient centric approach
A correct diagnosis, an apt medical treatment and communication with the patient or his family members to reassure and share information on the prognosis are essential elements of the therapy and the management of illnesses, however serious these are. For this to happen and for the standard and quality of the government medical services provided to the public to be as high and efficient as possible, it is essential that there is a necessary mise à niveau of the medical staff recruited or allowed to exercise in our hospitals and the public health services. Is there an essential and rigorous peer review by an independent and internationally recognised body of the medical colleges and universities across the world from where doctors and specialists who wish to practice in Mauritius have qualified before they are registered and allowed to practice in the country? Not to do so is to short-change the public. The standard and quality of medical services provided to the public will necessarily suffer if this is not the case. It will lead to pervasive public dissatisfaction and risks of mishaps.
The quality of medical service provided to the public is further complicated by the fact that specialists working on government roll are also allowed to practise in the private sector outside working hours and when they are not on call. However, as is generally known, this dual responsibility makes specialists continuously shunt from their rounds of patients in private clinics to their place of work in hospitals and back to their private practice. Emergencies and time encroachment into working hours at the hospital obviously impacts on the quality of the medical service provided to the public and the standard of medical care obtained at the hospital. This duality can, if the grapevine is to be believed, lead to abuse in the absence of rigorous administrative control, a well-demarcated line between public service and hospital facilities and private practice and rigorous rules of good governance.
The access to medical services in the private sector and in particular in the private clinics has been rendered even more inaccessible now for the average Mauritian by the high costs charged for treatment which only the well-to-do or those covered by a comprehensive medical insurance cover can afford. The substantial costs and length of medical studies in the top universities of say the United Kingdom and the high and periodically increased ceilings of medical insurance cover offered by insurance companies to the corporate sector and its employees have combined to hike the charges and costs of treatment of patients in private clinics. From the medical grapevine, the cost of a normal delivery of a child can be between Rs30-40,000 whereas a delivery by caesarean could cost Rs70-75,000. A heart bypass could cost some Rs 450,000 all inclusive. This gives an inkling into the scale of the costs of medical treatment for different ailments especially those requiring surgery in the private clinics which only the insured and the well-off can afford.
Honouring the Hippocratic Oath
There is therefore a clear divide and inequality in respect of access to personalised medical service and treatment in the private sector and in private clinics between those that benefit from medical insurance cover and the multitude that do not. It is therefore probably time to accommodate, as is the case abroad, a private wing with reasonably priced top class medical and surgical services within the state hospitals open to the public. There would also be merit for government to negotiate the terms and conditions of a contributory medical insurance scheme covering medical and surgical treatment for all civil servants open to the wider public. Apart from providing the critical mass and an actuarial base for competitive and affordable insurance premium, this measure will also help broaden access to private medical services and private clinics as well as relieve the daily pressure of patients on the public medical services. Such a development would enable the medical staff in hospitals to provide a more efficient and swifter service to patients.
Isn’t it also time for a re-think and an overhaul of the government medical services to ensure that they first and foremost provide through efficient care and treatment full customer satisfaction to the patients and to the public at large? A few simple steps would help attain this objective. The medical authorities must first ensure that there is a necessary mise à niveau of all doctors in the service and who practise locally with the help of an international peer review body and if required supplementary training.
The doctor must take time to examine, properly diagnose each patient and communicate the diagnosis and prognosis of the ailment and the treatment protocol to be followed to the patient (and if that is not possible, to an accompanying family member). Specialists must as usual be called in when required. In the case of more difficult cases specialists must consult with their colleagues to define the way forward. The central objective of the government medical services must be the relief, recovery and cure of patients at all times, which are key to public satisfaction
It is equally time, to start practising preventive medicine on a national scale. Thus, as is the case in the UK, the senior citizens and the middle aged could be called at prescribed ages for preventive screening of ailments likely to afflict them such as blood pressure, colorectal or prostate cancer, eye, hearing or cholesterol testing or in the case of women for mammography, bone density tests and pap smears. Similarly, shouldn’t government control the sale of some highly fatty street foods which have rapidly taken hold among the growing fast food consumers, given the high incidence of cardio-vascular diseases in the country?
Another way to significantly reduce the pressure on the overstretched public medical services would be to examine the cost benefit and feasibility of having a UK National Health Service based approach to government medical services. Such an approach would shift the first contact and treatment of the patient from the health centres or hospitals to a local GP (general practitioner) remunerated by the State. A number of the doctors working in government medical services would thus be posted to work as local GPs in this new approach aimed at providing a more efficient, personalised and patient friendly government medical service. The GP would as required refer the more serious cases to specialists in hospitals.
It is also time to professionalise, as is the case abroad, the administration of hospitals and the health services with the employment of professional hospital Directors and Health Directors qualified in these specialized fields. Doctors have so far assumed these responsibilities. In this more modern approach, senior doctors would be made to focus on medicine and all its technical aspects and advise the government accordingly.
The country and the people cannot continue to face a catch-22 situation regarding the choice between a patchy government medical service and an unaffordable private medical service. Instead, they must be able to have the choice between quality, uniformly efficient and patient friendly public medical services and private medical services accessible and affordable to a broader cross-section of the population. It is only such a sea change in the medical landscape which will live up to the lofty Hippocratic Oath taken by physicians.
* Published in print edition on 4 March 2015