Year : 2011 | Volume
: 16 | Issue : 4 | Page : 123--125
Presidential Address at 37 th Annual Conference of the Indian Association of Paediatric Surgeons, Chennai, October 2011; The future - Are we ready?
Ashley L.J D'Cruz
President, Indian Association of Pediatric Surgeons, Director and Sr. Consultant Pediatric Surgeon/Urologist, Narayana Hrudayalaya Woman and Child Institute, 258/A Bommasandra Industrial Area, Anekal Taluk, Bangalore - 560 034, India
Ashley L.J D«SQ»Cruz
President, Indian Association of Pediatric Surgeons, Director and Sr. Consultant Pediatric Surgeon/Urologist, Narayana Hrudayalaya Woman and Child Institute, 258/A Bommasandra Industrial Area, Anekal Taluk, Bangalore - 560 034
|How to cite this article:|
D'Cruz AL. Presidential Address at 37 th Annual Conference of the Indian Association of Paediatric Surgeons, Chennai, October 2011; The future - Are we ready?.J Indian Assoc Pediatr Surg 2011;16:123-125
|How to cite this URL:|
D'Cruz AL. Presidential Address at 37 th Annual Conference of the Indian Association of Paediatric Surgeons, Chennai, October 2011; The future - Are we ready?. J Indian Assoc Pediatr Surg [serial online] 2011 [cited 2019 Dec 11 ];16:123-125
Available from: http://www.jiaps.com/text.asp?2011/16/4/123/86862
Prof. Mayil Vahanan Natarajan, Vice Chancellor, Tamil Nadu Dr MGR Medical University, dignitaries on the dais, Fellow members and Guests, In 1978, as a young house surgeon, I was asked to assist with the repair of a TEF. It was a beautiful operation and we left after the child recovered from anesthesia, as this was done in St. Elsewhere at the request of their pediatric team. The baby did well for a few days but later succumbed. It was my first lesson on the fragility of our young patients and impressed upon me the need to develop the highest standards of care for our babies and their families.
With the support of my family, after a fairly successful career in General Surgery, I returned to my desire to dedicate my time entirely to the care of children. I was fortunate to have my pediatric surgical training at the Postgraduate Institute in Chandigarh and I am eternally grateful to all my teachers, examiners and seniors, who inspired and helped me along the way, many of whom are in the audience today. I thank you for the honor to serve as your President and hope I have served you well in some small way.
It has been a very eventful year not only for our Association as evident from the Secretary's report, but also on the national scene as well. A lone man of advanced age galvanized the young people of our nation by the power of his conviction to stand up against corruption and inspired in them a sense of participation and responsibility for the future. He called upon them to take charge.
On the health front, pertinent to our Association, a few developments have occurred that beg the question, "Are we ready for the future and willing to take responsibility for the demands that will be placed on us as a fraternity?" I would like to highlight developments in three areas undertaken by the Government, Health Industry and our Association that will pose challenges in the near future.
The health Industry is growing at a phenomenal rate of 30% p.a. and will reach US $ 275 billion by 2020. During the year 2009-2010, health care spending in India was 8% of GDP, up from 5.5% the previous year. Health expenditure is mainly out of pocket expenditure ranging from 70 to 80%. Only 3-5% of the country's population has some form of private health insurance. The good news is that the insurance sector is expected to grow at a CAGR of 30% to cross ` 30,000 crores by 2015 up from ` 800 crores a few years earlier and hopefully this may help mitigate the burden of health care in India.
Coupled to this private sector expansion, the government, both at the state and the center, has not lagged behind. It is projected that in the next 5 years, half our population will have some form of social health insurance. Many of us are familiar with these schemes both at the state and center that payout an equitable amount for surgical procedures in children, and ironically, even cover the congenital malformation that the private sector refuses to acknowledge.
In any health system, the two fundamental players are the "care giver" and the "care taker." If the government steps in, health care can be entirely free or subsidized; if not, out of pocket expenditure, expensive as it is, cannot support the costs of health care. Moreover, it is well known that the beneficiaries of state-sponsored health care are often the well to do and the influential and the poor are often marginalized. Therefore, if all are to benefit, the reforms in health insurance and other measures I will refer to later, like standard treatment guidelines (STGs), will have to serve as game changers bringing huge numbers of patients to our doors, now having choice, ability to pay for service and demanding of us the best results.
I have attended many meetings with insurance sector over the year and my sense is that two distinct plans will emerge. About 400 million people will be covered by state-sponsored health insurance in the next 5 years and a further 143 million urbanites will have private health insurance. Insurance for children has grown by 80% in the last 5 years and will continue to grow rapidly. Products are being developed to link the newborn and congenital malformations to the mother's insurance in the corporate group insurance schemes.
What will all this do to the way we work, and the big question before pediatric surgeons is, "Are we ready"? To be ready, we need to address two important issues, namely, STGs and infrastructure development.
Standard Treatment Guideline
Standard treatment guideline (STGs) will be the way of the future. Insurance sector needs them to be able to cost procedures appropriately and children need them to have the best results, diminish the use of unnecessary investigations and avoid expensive complications. Our teams from my institution and many of our IAPS members were involved in an MOH - Government of India project coordinated by FICCI in providing STGs for about 20 index conditions. These guidelines were peer reviewed and will form the basis for licensing hospitals and consultants to undertake certain procedures whilst giving the sponsor (insurance company or agent) a method to arrive at an equitable cost. In time, more such guidelines will be developed and I have asked senior colleagues in our Association to help develop some of them. Needless to say, they will go through rigorous scrutiny before implementation.
Our hospitals and institution in the government sector see a large number of patients, mainly from the poorer sections of our society. Their manpower and resources are often stretched to the limit, making it at times impossible to deliver the ideal care they may aspire to. To address this issue, the government has embarked on an ambitious plan to upgrade all the district hospitals with good infrastructure and will, through the ESI scheme, provide secondary/tertiary level care in the ESI hospitals and clinics. For health, the plan allocation in 2011-2012 has been stepped up by 20% to ` 26,760 crores. The Rashtriya Swasthya Bima Yojana (RSBY) will have more beneficiaries, as many in the unorganized sector of the work force and their families will be included.
The private sector, on the other hand, may have the resources, but because of the financial reasons, I had alluded to earlier that they will cater only to an exclusive population. Nevertheless, this segment is also likely to increase significantly.
The combined effect of having insurance and mandated STGs will spread the patient burden, hence forcing institutions, big and small, to improve their infrastructure. The insurance/sponsoring organization will become the gatekeeper to limit expenses and enforce standards.
So, what is new you may ask. Our demographics show us that India still resides in the rural areas, although this has changed dramatically in recent years. My sense is that with the easy availability of information, rising education standards, our media and NGOs who are active participants in this transformation, these rural patients will demand the highest standards of care from us. We see this happening already in our day-to-day practice.
The third development is that of the health care personnel. At the rate the "industry" - mark you not "service" - is growing, we need millions of medical personnel. It is the only sector that continues to hire in these depressed financial times. We, as pediatric surgeons, often complain that our poor results and follow-up are the result of lack of manpower in the support areas like nursing, outreach staff, trained technicians and junior colleagues. But if you ask someone in the private entrepreneurial sector, he/she will tell you that they have circumvented these problems by hiring unconventionally, and with in-service training in unique ways, they have succeeded in meeting their requirements. It is not far when nurse practitioners and technicians will be able to perform most routine procedures.
Curriculum and Training
India needs about 2500 pediatric surgeons and we have half that number. We have approximately 120 training positions (MCh and DNB) and many are undersubscribed. Our junior colleagues come from the MCh and the DNB streams and we all agree that training standards vary from institution to institution. It is human to be chauvinistic about one's program, but is there harm in following a uniform curriculum and system of accreditation. With the knowledge of the EC and drawing from work done earlier by our senior colleagues and past Presidents, we convened a meeting in Bangalore to develop a uniform curriculum for the DNB 6- and 3-year courses. We consulted with teachers, examiners and researchers, and after due diligence prepared a document that I have personally given to the President and Executive Director of the National Board. In addition to structuring a stepwise learning process, we have suggested visits to other centers for a brief period as a possible option. If all this comes up for discussion, as your President, I request you to support and help improve it so that our students will be benefited.
What about re-certification? Are we willing to have a periodic review of our knowledge and skills? The emerging trend of assigning credit points for our meetings and CME programs is very encouraging. The time has come to address these issues head on and that time is NOW!
As promised, we have updated our website. The Karnataka State Chapter, notably Dr. Sanjay Rao and
Dr. S Ramesh, have worked hard with professionals to give us a means of communication that is interactive and allows scope for vibrant exchange of ideas. On behalf of all of you, I thank and congratulate them on their effort. I hope all the members will use it to address some of the issues I have raised today and work toward a brighter and rewarding future.
To our junior colleagues, I must end on an upbeat and inspiring note. I know there is a sense of despondency in the fraternity; a perception of no jobs, low income and professional status. This has impacted negatively on recruitment; many of our training programs have no trainees. With STGs and insurance, only pediatric surgeons will be allowed to manage children. With 300 million children in India, how can there be lack of opportunity. And if there is, create it! I can give you many examples of young surgeons who have started in smaller cities (of which there are many) and have had successful careers. They Skype or use the mobile connectivity and telemedicine to consult with their seniors for reassurance and advice to produce outstanding results. It is the results that have made them successful. So, the challenge is not to seek help from Associations or the powers that be, but to create centers of excellence, expand your interests, reclaim fields we have lost to others and show by your brilliance that as pediatric surgeons we are the best at what we do. For if you can fix a child with a complex congenital anomaly, do laparoscopy procedures in infants and perform organ transplantation in children, what is it that you cannot do? I call upon the members to appoint a Task Force consisting of eminent persons to prepare a white paper on "Training and research in pediatric surgery - The way forward." It is only by such exercises that we will make progress.
I congratulate all the state chapters on holding excellent meetings and the organizers of many sub-sectional meetings of our Association for furthering progress in their respective fields and apologize to the organizers of those I could not attend. I congratulate Prof. Prasad, Dr Namasivayam and Dr Sripathi and the whole team for their efforts in organizing the Annual Conference in this beautiful setting. I thank our invited faculty from abroad for coming to our meeting at their own expense and for their valuable participation in our conference. I cannot end without thanking my friend Dr Rasik Shah, our Hon. Secretary, and all the members of our EC for their help in running the affairs of the Association, making my tenure a pleasant one.
I thank all our members, those present and those who could not come. Let us repair our relationships, put aside differences and distractions and work toward the common good of our children, for there can be no greater calling. May the IAPS thrive and prosper!