|MISSION HOSPITAL SECTION
|Year : 2015 | Volume
| Issue : 3 | Page : 305-307
What happens next? Review of patients referred for further surgical treatment from rural/mission hospitals
Medical Services, Samiti for Education Environment Health and Social Action, Karunya University, Coimbatore, Tamil Nadu, India
|Date of Web Publication||12-Jun-2015|
Dr. J Gnanaraj
Samiti for Education Environment Health and Social Action, Karunya University, Coimbatore 641 114, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Few decades ago, the mission hospital surgeons felt that if they did not operate the patients had no other place to go, and hence attempted a wide variety of surgeries. Now, with the vast improvement in facilities available in urban areas and the improvement in travel capabilities should the mission hospital surgeons be prepared to do a wide variety of procedures? To answer the above question, we followed up the patients who were referred for surgical procedures elsewhere during the last 12 years. Only 24 out of the 128 patients could afford treatment elsewhere. Twenty of them came back to our hospital and had surgery at a much higher risk because they could not afford the treatment elsewhere. The others chose not to have treatment. Hence, is important then for the few surgeons working in rural areas to a "Jack of all trades" and learn a wide variety of surgical skills if they are to treat the poor patients in rural areas.
Keywords: Referrals, mission hospital, surgical patients
|How to cite this article:|
Gnanaraj J. What happens next? Review of patients referred for further surgical treatment from rural/mission hospitals. CHRISMED J Health Res 2015;2:305-7
|How to cite this URL:|
Gnanaraj J. What happens next? Review of patients referred for further surgical treatment from rural/mission hospitals. CHRISMED J Health Res [serial online] 2015 [cited 2020 Jan 24];2:305-7. Available from: http://www.cjhr.org/text.asp?2015/2/3/305/158724
| Introduction|| |
Few decades ago, the mission hospitals played an important role in meeting the heath care needs of the poor and the marginalized in rural areas. They offered surgical care at a subsidized cost. Travel was very difficult for patients and health care at cities were way beyond the reach of poor patients. The mission hospital surgeons were well trained and had the capability of managing a wide variety of surgical conditions.
During the last few decades, several things have changed. Travel has become a lot easier. Health care is affordable at cities too. Highly specialized surgical care with hospitals specializing in various sub specialties of surgical care has become the norm in many places. Unlike the earlier mission-hospital surgeons, the current surgeons do not have many opportunities to learn a variety of surgical skills.
In this context, we wanted to find out what happens to patients whom we refer to the cities for further surgical treatment. We wanted to know whether we still need to train the surgeons working in rural areas in a variety of areas or the model of referring to a specialized place would work in India. In places like UK, , the plan is for moving toward highly specialized care and an efficient referral system.
| Methods|| |
Data from a mission hospital in Northeast India and a charitable non-governmental organization entered in the Hospital Management Software were analyzed from 2003 to 2014. During this period, there were 109 surgical camps at 28 different rural hospitals. The patients who were referred for further treatment were selected from the special referral forms and those requiring surgical treatment were studied. Telephone calls were made to the selected patients if the numbers were available for the survey. Although there is a provision to enter the telephone numbers during registration, it was not made mandatory until the year 2011.
The data do not include the following categories of patients:
- Patients who were diagnosed to have surgical conditions but chose to have treatment elsewhere
- Patients who were given the various treatment options but chose to have an option that is not available at the hospital. For example, some patients chose percutaneous nephrolithotomy over open surgery for Staghorn calculus.
| Results|| |
During the period of 12 years from 2003 to 2014, two hundred and forty-two patients were referred for further surgical procedures. [Table 1] gives some of the details of the referrals from patients from whom information was available. Only 128 patient's information was available while for others their phone numbers were either not active or not available.
Only 24 out of the 128 patients could afford treatment elsewhere. Twenty of them came back to our hospital and had surgery at a higher risk because they could not afford the treatment elsewhere.
From the same database, the outpatient data were analyzed for various surgical diagnosis, and the number of patients who were admitted for treatment at the hospital was found out and it was assumed that the others had treatment elsewhere. By this method, about 17% of the patients (4923 of the 28,944) of the patients diagnosed with surgical conditions did not have treatment at the hospital.
It was difficult to analyze accurately and get the number of patients who were given the various options but chose to have the treatment option available elsewhere.
| Discussion|| |
Of the 1.2 billion people in India, almost 70% of them live in rural areas according to the 2011 census.  Despite the seventeen fold increase in doctor to population ration during the last 6 decades (from 1-6300 to 1-1800 population], most of the doctors are in Urban areas.  According to the National Rural Health Mission publication,  only about 30% of the sanctioned surgeons posts are filled in rural areas. In spite of rising budgetary provision and actual expenditure on the rural health care services, 11% of the rural population die without any medical attention.  In Northeastern states, the filled vacancies of surgeons, posts in rural areas varies from 0% to 15%. 
In India, over 63 million persons are faced with poverty due to health care costs alone. Eighteen percent of all households in India faced catastrophic expenditures due to health in 2011-12.  According to a survey by the Indian Institute of Population Sciences and WHO in six states, more than 40% of low-income families in India have to borrow money from outside the family to meet their healthcare costs. The study found that 16% families had been pushed below the poverty line by this trend. 
Advanced and specialized care offered in the urban areas of India. Unfortunately, they are out of reach of the poor and the marginalized in rural areas. Only 18% of the patients who are referred from rural mission hospitals can have treatment in urban centers. Almost a similar percentage of patients come back to the mission hospitals to have treatment there saying they would rather take the risk of dying there than destroy the finances of the entire family by having treatment in the urban hospitals. Most of them, however, do not even make an attempt to go to the urban areas for treatment. Once they are denied treatment at the mission hospital, they go back home.
The advances in transport system, the advertisements from urban health care institutions, etc., do not seem to have motivated the poor rural patients to go to cities for treatment. However about a fifth of patients who can afford treatment at urban centers did decide to go to the places where better treatment options are available.
It is important then for the few surgeons working in rural areas to a "jack of all trades" and learn a wide variety of surgical skills if they are to treat the poor patients in rural areas. We were blessed with staff from Christian Medical College Vellore, who came to the mission hospital to train the local surgeons in laparoscopic and other surgeries.
| Summary/Take Home Message|| |
The surgeons in rural hospitals should realize that even with the advances in transport facilities more than 80% of the referred patients cannot afford surgery at urban centers. They would be providing greater services if they can perform a wide variety of surgical procedures. The urban counterparts on the other hand can consider taking time off their work to consider helping the poor and the needy by visiting and helping the rural surgeons. Surgical Services Initiative helps in coordinating such mutually beneficial ventures.  By performing greater number of surgeries in the rural hospitals the urban surgeons and the registrars (postgraduate students) in the medical colleges can improve their skills. Postgraduate students of Christian Medical College Vellore (including the author) greatly benefitted by such visits to mission hospitals during the student days. It is a win-win situation for everyone especially the patients.
| References|| |
Deo MG. Doctor population ratio for India - The reality. Indian J Med Res 2013;137:632-5.
Srabanti M, Bandhopadhyay NR, Bhattacharya BK. Reasons for Non-utilization of institutional healthcare service in rural West Bengal: A perspective. Decision 2007;34:113-32.
Gnanaraj J, Jamir S. Surgical Services Initiative: Taking modern surgery to the poor. CHRISMED J Health Res 2014;1:194-7.