Archives

Strike unaffected, OPD free, patient friendly : low cost health care service possible

Prof. Herbert A. Aponso (Emeritus Professor of Paediatrics, Peradeniya Medical Faculty) in an interview with the Health Watch last week on his Family Practitioner - based Health Care System, which he had proposed to the government two years ago (year 2000) which he felt had not been given the due consideration it deserved.

He said he is placing it before the public now for their views on it, as he is going to take it up again with the Health Authorities in the interest of the public this time with the backing of the general public.

Some significant features of the scheme

Objectives

Objectives of the proposed family practitioner based health care service is to attract doctors to the private sector, and set up an extended family practitioner scheme, somewhat like in UK, so that it will obviate the need for people to go the Hospital OPDs initially when sick. The system will also not affect the patients much in case of doctors strikes, and other health sector trade union actions. It will also be a patient- friendly health care service, and also less costly to the government than at present.

The need for a better Family Practitioner Service in Sri Lanka

Most knowledgeable persons are of the opinion that a doctor - population ratio of 1:500 would be ideal to provide proper patient care. However, in Sri Lanka (SL), it is reckoned to be much less satisfactory; it is about 1:2400

(1). With respect to Family Practitioners (FPs), who through the ages have made significant contributions to the community health service, the FP: Population ratio in SL is about 1:24,000 (1) whereas in the United Kingdom it is about 1:2,000. If the Registered Medical Practitioners (RMPs) are taken into consideration, this disparity would be somewhat improved.

While recognising that there are other categories of medical practioners, such as those from the Indigenous and Alternative Medicine systems, this plan is confined to allopathic practitioners. The overall assessment is that there is a dearth of medical practitioners in SL. As a result of this dearth and the inadequate regulation of medical practitioners, there is an alarming number of unqualified practitioners ("quacks") who dupe the public and cause great harm.

The 6 medical schools together with perhaps an additional medical school in the near future will produce about 800-900 doctors each year. Though the needs of the country may justify the training of such a large number of doctors, the government is unlikely to be in a position to offer all of them employment due to shortage of finances. Thus it would be prudent to divert some of them to the private sector.

A World Bank study conducted by the Institute of Policy Studies has reported to the Ministry of Health and Indigenous Medicine that "nearly 60% of the patients prefer treatment at private medical institutions"

(2). A scheme for improving the health services by utilizing the services of private medical practitioners was proposed by the writer as far back as 1961, when working as a private practitioner

(3). The then Dean of the Medical Faculty (only one in the country at the time) commended those proposals as being 'far reaching recommendations which command the attention of every thinking person in the country'

It is known that in the public sector, where Outdoor Patient Department (OPD) doctors work according to a roster, there is often a relative lack of a good doctor-patient relationship. There are several reasons for this.

These posts are transferable and as such do not facilitate good doctor-patient relationships. Furthermore due to the present working conditions, most often there is an unsatisfactory maintenance of records at the OPD. On the other hand, a good doctor-client relationship and good records can be said to be the cornerstones of a Family Practitioner (FP) service.

The President of the Sri Lanka Medical Association has recently made a valuable suggestion that all nationals who wish to be enroled as beneficiaries of the free state health service should be issued a Health Card which would entitle them to seek medical attention, in the first instance, at the clinic, dispensary or hospital closest to their residence, and only if reckoned necessary, be referred to a secondary or tertiary care institution

(4). Such a system would reduce the large number of patients who crowd the hospital OPDs.

It has also been proposed that the present National Health Service which provide free health care for the rich as well as the poor, be revised into an 'Insurance cradled National Health Scheme', in which the State contributes to the Health Insurance of the poor only.

(5 These pragmatic suggestions regarding referrals and insurance could be usefully incorporated into the proposed FP Organisation. Such a scheme would be in keeping with the principles formulated by the SLMA Declaration of Health (6). It is therefore suggested that, in addition to the existing private medical services,

measures should be taken to develop a FP organisation which is affordable, available and accessible to the people.

The key components of the proposed plan

The success of the proposed plan is dependent on addressing several important provisions. Some of them are:

1. Formation of a state-aided organisation

2. Providing incentives to doctors to join the private sector

3. Provision of an efficient FP service that is affordable to a large number

4. Providing a state subsidy for establishment of FP services

Formation of a state-aided organisation, such as the Central Transport Board, would facilitate the implementation and monitoring of the scheme.

Incentives to doctors

To attract doctors to join the scheme it is proposed that the organisation provide them with a suitable place for the practice, basic requirements such as furniture, telephone and essential medical equipment (eg., BP apparatus, diagnostic set, weighing scales, etc) initially.

They should also be granted an annual health insurance for a period of three years and a loan, of a reasonable amount, to pay for a Life Insurance policy, so that they would have some financial security till they establish themselves. Furthermore, they should also be given the privileges and concessions that are given to state medical officers with respect to treatment in state hospitals.

In order to encourage and facilitate home visits they should be offered a loan, of a reasonable amount, to purchase a motor vehicle and the duty concession granted to the state medical officers. This concession (but not the loan) may be granted once in six years. The loans, referred to above, are to be gradually recovered after a period of three years.

The above-mentioned incentives, which can be provided by insurance policies that are now available, could be sponsored by the Organisation.

Remuneration for FPs and ancillary staff

They should be paid an allowance, equivalent to the state sector salary, for a period of 3m to 1 year, depending on the location (urban/rural) of the practice.

It is proposed that they be appointed to the posts of Registrar of Births and Deaths in their respective areas, as and when vacancies occur. Such appointments would promote accurate records, especially with respect to the causes of deaths; accurate records are necessary for compiling medical statistics and the planning of National Health programmes.

The income of FPs from the medical practice and from the post of Registrar should be exempted from income tax, for the first three years. It would be the responsibility of the FPs to employ, at their expense, the necessary ancillary staff.

It is reckoned that each doctor would need, to begin with, a staff of at least three workers - one dispenser, one nurse-aide and one multiple-purpose worker.

The monthly remuneration for this staff, including EPF and ETF, would amount to about Rs. 18,000, initially. It is suggested that each FP should be paid Rs. 12,000 in the first 6m and Rs. 6,000 in the next 6m to subsidise the payment of the staff. These workers would be trained by the doctors to perform their various duties, such as maintenance of records and Accounts, and carrying out simple lab tests (eg, urine for sugar, albumen and bile). These tests (at the clinic) should be done without an extra charge (see below).

Advantages to the public

The following features make this scheme affordable, available and accessible to the public) a The low cost of Rs. 70 per visit for consultation, including investigations (if necessary), and medicines. The long term plan should be to develop a National Health Insurance Scheme to cover, in the first instance, the above-mentioned charge of Rs. 70.

b) The availability of a FP, of one's choice, with whom they can develop a good doctor-patient relationship c) Maintenance of a reliable health record system.

Advantages to the state

This scheme will assist in providing employment to all medical graduates and improve health service to the community by supporting a low-cost FP organisation, without having to incur the total extra expenditure of meeting the primary health care needs of all the people. It should be pointed that the state would incur the initial expenditure of establishing the group practices listed.

This expenditure would be for a period of one to three years only.

The long-term expenditure would be for the building, for drugs and medical investigations. However, it should be noted that these items of expenditure are those that the state would, in any case, have to incur in the present free health service.

Furthermore, there would be no payment to doctors except the salary in the first year, payment for health insurance in the first 3 years and the payment to the ancillary staff for one year as suggested above. As alluded to earlier it is envisaged that these expenses could be recovered eventually from the diminishing expenditure on an entirely free OPD service.

This proposal is initially a basis for critical examination by doctors, the people, the government and opposition. It is hoped that a workable scheme could eventually be adopted, in view of the need expressed and the fact that this proposal seems to be consistent with the prevailing policy of the Government as well as of the Opposition.

Herbert A. Aponso, Emeritus Professor of Paediatrics, University of Peradeniya Address for Correspondence: 454/10B, Piachaud Gardens, Kandy.

Nutrition for adults and the elderly... 

Continued from 14.2.2003

T.W. Wikramanayake, professor emeritus, University of Peradeniya.

By culture engineering is meant an effort to develop, in cell dimension, the environment in which the human genome finds its optimal expression. This concept has been referred to as "euphencis".

For prevention of obesity, diabetes and ischaemic heart disease, the euphenic approach is the "Palaeolithic Prescription". In the interests of health, in the 21st century there should be a return to aspects of the Palaeolithic Prescription that provide an objective background against which we could consider modifications in our current lifestyle.

If we accept the Prescription, certain initial decisions have to be taken:

A. Which population to target, in the interests of efficiency and cost-effectiveness?

i. All inclusive, general population approach, similar to the campaign against cigarette smoking or alcohol consumption.

ii. Target the predisposed, especially children of parents that have the metabolic syndrome.

iii. The preventive approach, focusing on a particular phenotype, e.g. obesity, which is easily diagnosed and could result in diabetes or hypertension.

B. What constitutes an acceptable and feasible Prescription in contemporary society? An over ambitious programme might demand unacceptable lifestyle modifications, or an unacceptable impact on the food industry.

C. At which age to implement the Prescription? There are benefits of restricting dietary energy intake in early life, as obesity and food intake patterns are familial.

Controlling the environment

Society is unlikely to return to a hunter-gatherer lifestyle. Efforts have therefore to be directed towards preventing the toxic environment acting as a risk factor.

One principal action is health education, of the school child and of the general population.

However, health education alone is insufficient. People need opportunities for good eating.

The Food Industry should be encouraged to -

i. Reduce advertising energy dense food directed at children. Energy-dense food distribution in schools should be limited, especially in urban areas.

ii. Develop tasty, nutritious, high-fibre, low-energy foods.

iii. Reduce or eliminate advertising fast foods, candy, soft drinks, sugared cereals.

The Government should:

i. Subsidise vegetable sand fruits grown locally. ii. levy a special tax on energy dense foods, beef, ham, cheese and chicken Bergers, KFC, pizzas.

Changes in diet

1. We should return to the rice diet of pre-World-War II era: rice flour for hoppers, string hoppers, pittu and roti, rice and curry for lunch and/ or dinner, rice flour in any other food prepared for dinner, noodles and pasta of rice and kurakkan flour.

2. Use the wide variety of yams available in the country, to supplement energy intake from rice, and make greater use of starchy fruits such as jak and bread fruit.

3. Eat a variety of vegetables and plenty of green leafty sambals, mallumas and curries, with as many servings of vegetables as of rice.

4. Eat more of fruits such as nelli and guava, which are richer in vitamin C than any other fruit, local or foreign. Agriculture department should distribute one plant of each kind to every household.

Physical activity should be encouraged by

i. Introducing mandatory exercise programmes in schools

ii. By designing highways and roads to induce safe walking and cycling, maintaining discipline among road users.

iii. Encouraging cycling to school and work

iv. Providing community recreation centres

v. Insist on buses stopping only at halting places vi. Encourage walking down stairs, by having lifts stopping only at every third floor on the downward journey. Encourage self-monitoring of one's life-style.

The subjects keep daily records of their food intake, physical activity and of their body weight. Such records provided information that help then to identify components of their behaviour that may be detrimental to their health.

For exercise, any activity is better than none. Exercise could be programmed: aerobic exercise (walking, running, hiking, swimming) engaged in for set period of time (20 to 110 min) at a relatively high intensity level that is planned.

Lifestyle activities involve being more active during one's daily routine:

Taking stairs instead of the lift or escalator,

Standing while telephoning

Putting away remote controls, moving during commercials.

Getting off a bus a stop earlier

Making several trips upstairs

Going out for entertainment rather than sitting in front of the TV,

Washing car at home

Here energy expenditure is increased without concern for the intensity of the activity.

The need for self-discipline in many other aspects of human behaviour is increasingly evident. How we undertake to manage these syndromes will indicate how well we cope with the larger issues of population and resources.

If we cannot summon the self-discipline to improve our personal health, it is unlikely that society can summon the discipline to meet the many problems created by expanding populations and diminishing resources.

Paper read before the Nutrition Society of Sri Lanka.

On orthopaedics : Will I get arthritis?

Let Dr. Mandeep S Dhillon (Senior Consultant Orthopaedics Colombo Apollo Hospital) explain it to you.

With an aging population, the incidence of patients with joint pains is increasing. This has lead to many queries coming to me, from young active people, especially in their mid-thirties, who ask the very simple, but taxing question. Will I get arthritis if I overuse my joint? Is this inevitable? The question to be answered is truly complex, but for the laymen the simplest answer is NO. Arthritis of the joints is not inevitable, although some wear and tear is. If you use your joints for sports or other activities, unless significant jerks are given to it, the warranty on your joints will not run out.

Moderate regular exercise in middle-aged and older people who are in good health and have no previous joint problems does not increase their risk of developing osteoarthritis. These facts are corroborated by a University of Iowa professor and Sports physician, Joseph Buckwalter, who explains it very simply in a current issue of The American Journal of Sports Medicine.

Joint is a living structure

"Joints aren't like the bearings on your car which wear out after a certain number of miles. The joint is a living structure; the cells are continually renewing themselves, and adapting to the load placed on them. Using the joints doesn't necessarily hurt them, in fact, the more you use them, the better off you may be".

The literature on this subject is often conflicting, with various views on the relationship between athletics and osteoarthritis. osteoarthritis is a degenerative process of the joints where the articular cartilage is lost, producing stiffness and joint pain. The condition is age related (most people show signs of osteoarthritis by the time they are 45) but not caused by age.

Athletes at high risk

Each bone of the joint is lined with a cartilage layer called articular cartilage. The articular cartilage contains fluid. When force, or stress, is put on the joint, through an activity such as jumping or running, the fluid moves to evenly distribute the impact.

When the force is suddenly, repetitive and when there is torsional loading (a twisting motion) the articular cartilage and muscles don't have time to properly absorb the shock, increasing the likelihood of a joint injury. Football and soccer players and baseball pitchers and catchers are examples of athletes at high risk for damaging their joints. However, lifelong participation in sports and exercise don't necessarily result in osteoarthritis. Studies of long-distance runners show that runners don't have a higher incidence of osteoarthritis than non-runners.

Don't think negative

Thus the message which should go out to sports enthusiasts is simple. Regular sports, provided no injury is involved, will NOT damage your joints; sporting activities are actually recommended. Regarding whether arthritis is inevitable or not, the question can again be answered in the negative.

There are many more elderly people without major arthritis than there are cases with arthritis. This should give hope to all. Another fact is the finding of x-ray changes in joints with tendency for arthritis. All people with x-ray changes of wear and tear, or even some kind of arthritis do NOT necessarily have pain! This is important to understand.

Unfortunately the converse is also true, as many people with no changes on x-ray, especially middle aged females, will have significant pain. This may be dictated by your genetic structure, your pain tolerance level, your fitness levels and many more factors. So don't think negative - go out there and be active. Your joints will not wear out unless there is a specific predisposing element involved.

Next week : Backpain myths

Health Watch Letter Box

Food for thought and Hath Maluwa

A controversy seems to be raging among nutritionists, dieticians, doctors of medicines, doctors of philosophy and laymen over some food items suitable for certain ailments. I am not an expert in any of these fields or any other fields for that matter and depend solely on the guidance of the experts in the area of food and nutrition.

Man and all other animals depend on plants or other animals which depend on plants for their sustenance. There is not a single food item of plant or animal origin which could be labelled as ideal for humans except perhaps the mother's milk during the first few months of a baby's life. In rare instances even the mother's milk may not agree with her baby.

Rice seed contains the nutrients needed for the growth and development of the rice seedling. Similarly cashew or other nuts contain the nutrients needed for the growth and development of their seedlings. It is the same with eggs. The flesh of animals contain proteins, fats, minerals and other nutrients to serve the various needs of the respective animals. Cow's milk meets the nutritional needs of the calf.

Although these items are not produced specifically to meet out nutritional needs we have been using them as food for ages. There is a story among rural folk about a native doctor who visited a market to buy vegetables. He found that a vegetable good for phlegm was not good for bile. What was good for bile was not good for windy complaints or phlegm and so on. Ultimately he has come back only with a snake gourd (pathola). If he visit a market these days he is sure to come back empty handed because now even Pathola is loaded with pesticides.

This story reveals a fundamental truth about food items. Any food item would contain a number of chemicals, sometimes running even to hundreds. Many of them are integral parts of the plant or animal and perform some specific functions. There are others which are not needed for the organism but have entered its body from the environment through air, water or food. In the course of production, processing and storage of food, man himself adds pesticides, antibiotics, hormones, preservatives and various other chemicals.

Even under natural conditions, without any interference from man, the chemical composition of plants and animals we use as food could vary from place to place, season to season and organism to organism even in the same locality.

With the nutritional wisdom developed mostly through trial and error during thousands of years of man's existence he has learnt to select the food items that are palatable and appear to be safe. In recent years with the advancement of food science, biochemistry, human physiology and other allied subjects scientists are augmenting this knowledge base.

However, we have to accept the fact that it is humanly impossible to do a complete analysis of all the food items that we commonly consume and test how each of them interacts with each individual when taken as food. Each is unique and food for one could be poison for another.

The body of every organism whether man, animal or plant is perpetually in a state of flux and as such what is good for an individual at one time could be harmful to him at another time. It could also interact with other food items taken by him and produce undesirable results. We could understand this situation if we go through the literature of medicinal drugs such as an antibiotic or a steroid. Even if it is a single chemical substance. When we read its possible side effects, contra-indications and interaction with other drugs we feel rather nervous to take it.

Through long experience man has learnt to avoid food items which are identified as causing undesirable effects. He also has learnt to remove undesirable effects of some food items during their preparation. But it is not easy for him to identify the long-term harmful effects of some food items when taken regularly or in combination with other items. It is not easy even for the scientists to do it due to the vast number of variables in any selected human sample.

During our school days we were told that meat, fish, eggs, butter and milk should be in our diet regularly and that food items of plant origin are poor cousins because they lack some essential amino-acids and vitamins or something to that effect. Later on we were told that animal fats are saturated fats and are not good because they contribute to hypertension, heart diseases and bowel cancer.

The virtues of unsaturated fats and oils of plant origin were highlighted. Then it was the ratio between HDL and LDL that was important. Coconut oil was accused as the biggest culprit responsible for the high incidence of cardiovascular diseases in the country. Then we were made to understand that coconut is not the villain after all and it is OK when taken in moderation.

Any way the debate is continuing. We are also told that vegetables such as tomatoes and carrots are good to prevent cancer because they have something called antioxidants which fight free radicals which are responsible for causing cancer and other diseases. That tea decreases the absorption of iron in the diet and the fibre in vegetables is very good to prevent bowel cancer and to reduce the absorption of fats into the body.

Anyway we have to admit the fact that food science, so to say, is still in its infancy. Lots of things about food and nutrition still remain to be discovered.

With all these pronouncements we are somewhat in a state of confusion.

In this scenario what can we, the ordinary citizens do? It looks as if where our diet, is concerned the best policy to follow till these controversies are resolved is to believe in the two sayings "Variety is the spice of life" and "Too much of anything is good for nothing".

Eat anything and everything in moderation but not the same thing every time. Have as many varieties of food items as practically possible. It might be good to have variety in the methods of food preparation as well. This should help to reduce deficiency diseases and other nutrition related ailments.

The importance of variety in our diet was highlighted in Sri Lankan homes during the Sinhala New Year celebrations in the past.

An important item in the traditional New Year lunch was the Hath Maluwa (The seven in one curry) consisting of seven types of food items including green leaves, nuts and yams.

G. Dharmawardhana, Kotte.

News | Business | Features | Editorial | Security
Politics | World | Letters | Sports | Obituaries |

Produced by Lake House
Copyright 2001 The Associated Newspapers of Ceylon Ltd.
Comments and suggestions to :Web Manager