By Senthil Nadarajah –

Overhauling Healthcare System 

In Sri Lanka, 95% of physicians and staff are duty-conscious and have been doing their work diligently, even with the constrained environment and limited resources. However, the exiting system has been in place for over a century and the outdated concept with focus on centralized hospital-based health system is showing cracks.

In the 80s, I recall a cartoon in the Island newspaper captioned with the newspaper, stating “Sri Lanka has the best telecommunication system” -Minister of Telecommunication. The picture showed a man talking to himself looking at the phone: “I want to congratulate the minister, but this damn thing is out of order”

Now, about the health system in Sri Lanka, first thing comes to the news is that the Health Minister is in jail for corruption of illegal procurement. However, recently, it’s all about the misdeeds, competing behaviors and name calling with health care workers Strike En-Masse in Chavakacheri is the leading news.

Instead of addressing the local issue and plaster with the false picture that it was an isolated problem, one should look for a broader picture and see if we can change the system collectively so that these kinds of mishaps won’t repeat in the future.

The following suggestions are entirely based on functioning system elsewhere that can be implemented with the complete overhaul of the existing system:

MEDICAL RECORD

One of the first things to do in patient care is to have an organized and widely accessible medical record. In Sri Lanka, patients were asked to carry notebooks as their medical records and every time they see a physician, the book was updated with scribbles. Half of the time, no one was able to read the hand writings.  All citizens and permanent residents of the country should be assigned an eight- or nine-digit number (based on the population of 22 million).

The creation of an Electronic Medical Record (EMR) system may be a tall order for a country just trying to come out of hardship, however, there could be many Sri Lankan expatriates who can work from overseas with a patriotic duty on a voluntary basis and may look for organizations to sponsor the hardware such as computers. This also comes with the training of the staffs and maintaining privacy laws.

A centralized but access restricted through multilayer protection will prevent from repeat and unwanted tests, misdiagnosis and awareness of the urgency in some patients. All lab works and imaging studies as well as major surgeries and the medications they take are the basic information to be entered. Sri Lanka doesn’t need a complex EMR like exist in the US or Canada. It also will help monitor the time stamp for the actions or inaction that was recorded, in an event of auditing

CONCEPT OF PRIMARY CARE

When I was a medical student, I used to go out with the Holy Cross Hospital from Passaiyoor, Jaffna to the remote villages to run medical camps. Since I studied in St. Patrick’s College in Jaffna, I have contacts through the school as the hospital was nonprofit and run by the Catholic bishop and sisters. About three years ago, I visited the hospital and had a chat with the head sister about coming back and working on a volunteer basis to see some poor people in my expert field as Internal Medicine. During the conversation she asked me “if you see a patient, who will be following them?” This question surprised me as I did not realize that there is no primary care system, and everyone goes straight to the specialist and expect them to follow up.

Prevention is better than cure – that’s the mantra every health care person should follow. Health maintenance / Primary care starts from birth. Every person should have a Family Physician or attached to a general practitioner. They are the gate keepers of the health for a community.  These physicians should be in the community and the medical office should not be physically attached to the hospital. Few Grama Serva divisions combined together should create a medical office capable of seeing around 50 patients per day per physician and should also have a computerized medical record system where the registered patients in the community are the only one should have the access to those clinics.  Once a week Specialist visits from various available specialist can also be facilitated through referral system. Each clinic has a referral hospital where patient can be referred to for those who need further assessment or admission by specialist. This is the first step in to decentralize the health system and make the Tertiary care or Teaching hospital to focus of specialty care without overcrowded.

Each district should have a central laboratory system where the primary care centers can collect the blood and transported at the end of the day to have the results available in 24-48h, unless if it’s urgent, in which case the patient can be referred to local hospital with the appropriate referral. Since all the orders are electronic and signed by the physician who should be using a pin or password, outsiders ordering frivolous labs can be avoided. Similarly, a central imaging facility also can be created for those outpatient workups with the strict control of inventory. Ideally, all system should be digitized so that wastage and misuse can be avoided.

At the end of the Internship, few become senior house officers and other were posted in various places. These Primary care centers should be staffed by those coming out of the internship.  The clinic that serves the community can be a place for health education, wound care and someone in need of prolong intravenous antibiotics that can be given while patient is still in their homes and even back to work. Currently, patients are staying in the hospital for extended period for those services such as daily wound care conditions needing prolong antibiotics etc. Finally, the 4^th and 5^th year medical students can be made to rotate through these clinics every month from the medical schools in the province or district as mandatory rotation.

EMERGENCY MEDICAL SERVICES (EMS)

Emergency medical services is the lifeline of health system in the developed countries. A phone call to a central number where the distressed family member or a good Samaritan witnesses a health care crisis such as an accident or chest pain – call that number and a nearby Ambulance with Trained Emergency Medical Technicians is dispatched. They attend the situation and communicate with the nearby hospital Accident and Emergency services for advice. A quick transportation to the nearby hospital will save hundreds if not thousands of precious lives. Health care emergency is a race against time where one cannot expect the ambulance to come from the hospital to the scene. It must be nearby to reach the scene in short time.

Sri Lanka does not have a functioning Emergency medical service. EMS services does not mean that it is only an ambulance service. A carefully structured EMS services can do wonders.

For an EMS service to be established, the country needs a new set of trained Emergency Medical Technicians. This can be achieved through opening an opportunity for many young people.  Those Primary care centers can house the EMS services too and the EMT crews can be utilized to attend wound care and other minor nursing care in the periphery. The EMS service need a well-equipped ambulance. This EMS services should be appropriately used only for the emergencies and the ambulance use is only for emergencies and patient transport. A tight mileage control and GPS tracker/ transponder is necessary to prevent the misuse of the Ambulance for personal transportation as many healthcare workers have been using Ambulance for their own transportation. This is a well-known fact.

Whether it is an EMS or at the Base hospital, a patient must be stabilized before the transfer with only few exceptions. There should be adequate training to identify the issue and take the patient to the right hospital if necessary to bypass a Base hospital in cases of Myocardial infarction / Heart attack and acute stroke

APPROPRIATE USE OF BASE HOSPITALS

In an Ideal setting, a patient is seen in the Primary care clinic with few ends up needing to see a specialist as their diagnosis could be complex. If that patient need hospitalization, ideally the base hospital nearby is the first place to go. If that hospital does not offer the specialty that he/ she needed, then referred to if non urgent or transferred to tertiary care where in this case Teaching or National Hospitals. The transfer of patients should be selective based on the available services and the complexity of the diagnosis.

Once the patient is being investigated and started the initial treatment where stability achieved but still need hospitalization, often time those patients can be transfer back to the base hospital. This is a process that has been utilized all over North America called Repatriation. By doing this and utilizing the beds in the base hospital, cluttering of the teaching hospital can be eased up for beds for more sick people. If someone even goes home but need daily wound care or once daily intravenous antibiotics, they could also use the Primary care clinics. This system will effectively utilize all the available resources than burdening the Teaching hospital.

WORK ETHICS, CUTTING THE CORNERS AND PRIVATE WORK

One of the main allegations flying in the social media is that doctors are reporting to duty well off the clock and leaving very much early with many patients were told that doctor is no longer there. Distraught patient ends up or forced to seek the paid option.

Since there are no proper scheduling system in Sri Lanka, most of the patients shows up whenever they have issues. Most of the issues can be tackled at the Primary care centers where as only few needed hospital-based clinics where the immediate blood work or imaging studies needed. Advanced scheduling through the EMR will save plenty of time and over crowed clinics

If a medical officer is assigned to see a follow-up patient and it would be ideal to schedule in advance so that every patient will have their allotted time. A computerized scheduling system either through an app or by phone call in the EMR system will help navigate the flow of the patient. Based on the needs (some patient may need more time while many need standard time with the physician) number patients needs appointment can be calculated  and planned so thst thee will have limits placed. It is the responsibility of the patient to keep the appointment. Once the physician has seen all the assigned patients walk ins or unscheduled patients can be seen up to 4 pm or the allotted time. Individual physician’s efficiency can varies for number of patients seen. Government should have a bonus structure in place of overtime as overtime can be cheated without seeing patients while bonus structure is associated with the patient’s over the stipulated limits. This is in fact an incentive for the physicians to do more work in the hospital than leaving for out side work.

In order to precent cutting the corners a time stamp entry system should be in place using  the badge swipe system.  This is a very sensitive area as each location will have unique issues and a consensus may needed in each location as how to prevent the staffs (both Physicians and non-physicians) showing up in time for work and not leaving early.   

Every physician has the right to work and earn extra in the private sector. However, they are only free to do the work in their spare times. The spare time falls into the time that was not paid to see the patients in the government facilities as it could be a clinic or hospital. Hospitals should also have to come up with the maximum patients one can see in the allotted time as in some places physicians are complaining that they are unjustifiably having to see more patients in the limited time.

A physicians should have the ability to choose between seeing more patients for bonus Vs seeing the minimum number of patients within the working hours and proceeded to see private patients in an outside facility after the working hours are over. This is where the conflicts of interest should be applied carefully as the physician’s primary interest is performing his duty in the hospital or clinic and should not overlap his secondary interest of his private practice. As long as the physician fulfil the duty for which he was paid, no one has any right to question his/ her private practice.  When they violate the rule by leaving the hospital with the patients stranded, they are violating work ethics, and they should be subjected to disciplinary action.

One major way by which government can minimize the need for the physicians to seek extra income is by increasing the salary proportional to the work load.

PRIVATE WORK FOR THE NON-MEDICAL STAFFS

Patient often complains that some nursing and many attendant levels people are asking money to do favors including necessary care. I think those attendants who can form a work force to be available as Personal Support workers (PSW) or Nursing aids to be available for paid service on the days they are not working. Some families may need extra help to care their loved ones both in the hospitals as well as in their homes and these types of services where they can reach out for a paid services are a win-win situation. Those people can decide to have the minimum number of hours worked in the facility they are paid to work and leave for a private work in the afterhours or non-working days. An electronic Photo badge entry system is needed to make sure that they are not cutting the corners.

TACKLE THE SHORTAGE OF PHYSICIANS

With the IMF stipulation and the change of the retirement age, there were many specialists that planned to stay for a longer period were forced to retire. Government may have a choice of using those specialists or even regular medical officers in some remote areas on a free-standing contract such as 1-3 years without extra benefit and fixed pay schedule.

On the other hand, Sri Lanka Medical council should allow the expatriate physicians to provide services here.

For example if a community welfare society was able to find some physicians or surgeons who are willing to provide limited services between 1-6 months or a year of service coming on sabbatical leave, those Sri Lanka educated and foreign trained physician or surgeon should be able to obtain a limited license in his field of work provided the physician or surgeon also has certified and has clean record both in the area as well as legally. There are too many red taped placed by the hierarchy and once I was told that Sri Lanka has not recognized US trained physicians.

This attitude should be changed to have inclusive mentality.  When over 1500 specialist left the country, few expatriates willing to serve back are holding back to the obstructionist attitude by the people in position.

POWER AND ENERGY CRISIS

One of the concerns for opening and running the operation theater or Labor room are tied to the lack of backup generator. In this day and age, instead of going back to fossil fuel generators, we should be looking for clean energy alternatives.

Each hospital has plenty of sun exposed area and therefore the best option would be to have solar energy from two different sources with battery backup during the power failure times.

Solar panel can wire both to the grid as well as directly will also save more operating expenses as many rooms needed Air conditions. Community welfare projects can undertake or sponsor such projects to install Solar systems as an active participation in their own benefit. There are plenty of places now purely depends on solar only energy. A fossil fuel generator can be second back up in an event the backup battery drains earlier than anticipated specially in the night

NEED OF FURTHER TRAINING

Our medical education does not include the ethics of all sorts, cost analysis and effective use of the available tools, areas of management of as well as conflict resolution. Instead, many have learned from bad examples set by corrupt and inefficient leaders or people in position. We cannot expect a clean slate of people running the administration as they will be branded as outcast a trouble maker when they don’t go along with the unethical practices.

All of the medical professionals should go through mandatory training in these issues and every administrative position need internship to have job training prior to undertake the responsibility. All clinical medical professionals working in the hospital setting/ clinics should hold an active Advanced Cardiac Life Support (ACLS) training card as a requirement.

Health care also need outside independent auditing system for everything from time card to purchase of medicine, equipment, and construction cost and the use of ambulances.

CONCLUSION

The country needs visionary leaders with future vision and transparency and should emphasize in developing and improving the existing system or complete overhauling for a new system without corruption, nepotism and name calling. It is the nation that will benefit from such change and not selective few.

When a group of British University of Jaffna Alumni doctors did a survey to find out the issues related to the suicides amongst the medical students, all the students participated with enthusiasm but the administration did not want any suggestions coming from outside.

This is not the first time I heard such story that any suggestions from overseas alumni to improve the system will always fell on deaf ears. This mentality existed for very long time. Well wishers of the country are making suggestions because they are seeing it from outside as the ship is sinking and where the holes are. They have exposed to a different functioning system that some of the methods can be incorporated or implemented in their birth country. If the people in power cannot change the system or improve the system, then they must move aside to give a chance to younger generation to take the torch forward for a functioning corruption free system.   

I myself am looking to return to provide medical service free of charge if the circumstance and time permits. I hope this opinion can serve as an eye opener for some and give my perspective to others as what I see as an outsider to the system in the existing chaotic climate.