One Problem

The Paradox of Plenty: How Misuse of Free Services is Paralyzing Kerala's Healthcare

Original Article written and edited by Dr. Anoop Prathapan and published online on 8/1/2024

The Kerala healthcare sector is justifiably recognized as a global benchmark. Our physicians are in perennial demand worldwide, a testament to the quality of our medical ecosystem. Yet, a critical paradox lies at the heart of this success: the system's laudable accessibility has inadvertently created a debilitating dysfunction. While government medical service offers a secure and pensionable career, an alarming rise in physician burnout and suicide points to profound stressors within the department. This essay will dissect one such cardinal issue: the systemic paralysis caused by the inappropriate utilization of state-provided resources, particularly within our emergency departments.

The perennial complaint across most government health establishments is that of being understaffed. While this appears true at a cursory glance, it is a diagnosis that mistakes the symptom for the disease. A workplace becomes understaffed when the personnel are insufficient for the client volume. The conventional, yet myopic, solution is always to demand an increase in staff. However, to genuinely enhance the quality of our health services, the more cogent strategy is to curtail the influx of non-essential patient presentations that strain our finite resources.

The epicentre of this resource misappropriation is the Accident & Emergency (A&E) department. An A&E is designed for acute, time-sensitive medical crises: myocardial infarctions, cerebrovascular accidents, major trauma, or sudden, severe respiratory distress. Instead, our emergency rooms are inundated with low-acuity conditions—coughs, colds, and fevers—that are the proper domain of a General Outpatient (OP) clinic. These are trivial cases that could often wait for primary care consultation, yet they flood the A&E at all hours, creating a volatile and inefficient environment. These patients, often impatient from a wait they shouldn't be undertaking in an emergency setting, can become confrontational, leading to incidents of verbal abuse and aggression. Such behaviour is a grave indignation to the medical profession and, more importantly, a dangerous distraction from genuine emergencies.

This phenomenon intensifies on holidays and weekends when primary care clinics are closed, transforming the A&E into a default walk-in clinic. The long waits are tolerated because the visit serves a secondary purpose beyond medical care. In what must be a global anomaly, the government hospital is sometimes perceived as a social venue. In the year 2024, where else on the planet can one consult a doctor, receive parenteral medications, and obtain a full course of take-home medicines for a nominal fee of just ₹5 (USD 0.06)? The state’s noble intention—to ensure no deserving person suffers due to poverty—has been contorted by a failure to update the terms of service in line with modern socio-economic realities. The result is a system that inadvertently encourages its own misuse.

The Solutions: A Three-Pronged Approach

To rectify this, a paradigm shift is required, moving from merely augmenting resources to managing demand. The goal must be to make the hospital a less attractive destination for non-urgent matters.

1. Implement a Tiered Tariff System

The most effective deterrent to frivolous utilization is a sensible financial structure. The current tariff, or lack thereof, should be retained strictly for the Below Poverty Line (BPL) category. All other patients (APL category) should be required to pay a nominal, subsidized fee for consultations, services, and medications. This fee, while significantly less than private sector charges, would introduce a crucial element of cost-consciousness, effectively curtailing casual and unnecessary visits. The revenue generated could be reinvested into the health service for infrastructure, equipment, and staffing. The public has already demonstrated a willingness to pay for charged services like ECGs; extending this principle is the logical next step.

2. Empower Patients Through Education and Technology

A substantial percentage of A&E presentations are for common ailments that can be safely self-managed. The Health Department should launch a robust public education campaign to:

• Publicise a list of essential OTC medications and medical equipment (like thermometers and pulse oximeters) that every household should maintain.

• Distribute learning cards and digital resources on the correct dosages and usage for these common medications.

• Educate the public on the fundamental difference between an emergency and a non-urgent condition, clarifying the designated purpose of the A&E.

Furthermore, we must leverage technology. Drug vending machines could be installed in hospitals, allowing individuals to procure essential OTC drugs using their e-Health card. Such systems can be programmed to prevent overuse by limiting disbursals within a specific timeframe, thereby also mitigating the risk of antibiotic misuse. This would divert a significant caseload of trivial complaints away from the doctor, freeing up invaluable time for patients with genuine medical needs.

3. Enforce Rigorous Triage and Security

While patient education and tariffs are long-term solutions, the immediate implementation of a strict, uncompromising triage system is non-negotiable. This must be supported by clear signboards and, crucially, a 24/7 security presence in high-pressure areas like the A&E. Security personnel are essential not only to prevent assaults but also to assist in professional crowd management, allowing medical staff to focus on clinical duties. These conventional methods are often subverted when the public uses local political influence to bypass queues. Therefore, triage protocols must be institutionally protected from such interference to be effective.

Conclusion

The state's healthcare apparatus has myriad other challenges, but the one discussed here is foundational. Continuously adding doctors, nurses, and equipment into a system with a foundational leak is an exercise in futility. The primary focus must shift from endlessly pouring resources in from the top to preventing their haemorrhage at the bottom. We must contain the spillage to save the resources. Once this systemic wastage is controlled, the Kerala State Health Service can finally fulfill its potential to be the world's finest, providing exemplary, quality-driven care to those who truly need it. Disclaimer: This is a reflection on systemic challenges in healthcare service delivery. It is not aimed at any individual or government authority, but at the system and practices that we as professionals can engage with to improve outcomes. Opinions expressed are personal and do not constitute the position of the State.

Dr. Anoop Prathapan

09400643477 (phone and WhatsApp)