News
Doctors urge clear directive for optimal patient care
View(s):- Shortage of essential life-saving meds, consumables & devices
By Kumudini Hettiarachchi
Numerous patients who seek healing in state hospitals are in serious jeopardy, as doctors spread across Sri Lanka face the quandary and confusion whether “to do or not to do”.
The quandary for these doctors is – if a life-saving essential medicine, consumable or device is not available in the state hospitals, should they or shouldn’t they issue a prescription for this item to be bought from the private sector. Consumables range from bandages to gauze to gloves to needles and more, while devices cover stents and pacemakers for the heart, replacements for joints, lenses for the eyes and much more.
Now the burning issue among doctors is that if patients who need such essentials do not get them, they would go into severe disease or die or be compelled to seek treatment in the private sector which many cannot afford, so they would die anyway!
It is no secret that the government supply over the years has been challenged by severe shortfalls or not been consistent. Health experts were of the view that authorities sometimes go for “big” things which would benefit a few patients, while neglecting the basics needed by the majority. Health sector development has also been ad hoc.
Many doctors were adamant that a clear directive should be issued by the Health Ministry, enabling them to give prescriptions to patients so that there is “absolute” transparency for their action. Others were planning to stop urgent surgeries including trauma, orthopaedic, heart and eye operations, if there was a shortage of consumables and devices, until such time as the shortfall was met which could take long months or even years.
The Association of Medical Specialists (AMS), in a letter dated June 22 to the Health Minister copied to all high officials of the ministry, has sought urgent clarification on the “official stand” with regard to requesting patients to make such purchases. It has also stressed that there are many misconceptions and allegations against medical personnel who are working in good faith in the state sector.
While requesting a meeting with the Minister and a “very clear written directive”, the AMS has also sought other clarifications:
Is it permitted to inform patients/their next of kin the specific places where these items are available? The AMS has explained that this is important in certain cases where these items are only available with a few sellers and if this information is not provided to patients, they will have difficulty in finding the correct place to purchase such items. It also becomes relevant when there is an urgency to institute treatment as can happen in cardiology, orthopaedics and trauma surgery.
As local purchases of items is not possible in outpatients’ clinics, is it permitted to issue prescriptions for unavailable items for outside purchases, without the medical administrator’s (hospital director) permission or is it mandatory to obtain his/her permission in every case?
Are we permitted to issue requests for certain laboratory investigations to be done outside the hospital when such investigations are not available at state hospitals?
Is it permitted to inform the patients/their next of kin about the non-availability of medicines, devices, consumables and tests needed for optimal treatment?
If medical personnel do not inform the actual shortage or unavailability of treatment options to patients or relatives in state hospitals, accusations of negligence and non-disclosure of the real situation could be raised.
When the Sunday Times contacted the College of Surgeons of Sri Lanka (CSSL), its President Dr. Duminda Ariyaratne explained how the state sector doctors, along with the other staff including nurses, work under trying conditions to provide the best of care for the poorest of the poor.
“We do understand how the country has been impacted by the pandemic followed soon after by the economic crisis and are managing to the best of our ability to maintain an uninterrupted and good service to our patients,” he said.
Referring to how these doctors have not left the country in search of greener pastures, how they work long hours in six-day weeks and how they see or operate on many patients a day, whereas in developed countries it would be just two or three patients, he said it has led to good health indices and no waiting lists, all in a low-resource setting.
Dr. Ariyaratne appealed to people not to launch virulent and vicious attacks on social media against doctors without any basis.
Conceding that there may be a “very few” bad eggs among the hundreds of doctors who are providing an excellent service to patients, he urged anyone who has a valid grievance to complain to the Sri Lanka Medical Council (SLMC) or the Health Ministry.
Dr. Ariyaratne said that non-availability of essential medicines, consumables and devices has been a recurrent problem over many years. The ‘local purchase’ option is tedious – when stocks are not available, the Specialist has to inform the hospital Director, who then checks with the Chief Pharmacist, who in turn gets in touch with the Medical Supplies Division (MSD), which then checks its stocks as well as those in other hospitals. If not available, the hospital Director has to float tenders to get it.
All this while, the patient is “waiting and waiting”. In many such instances, the patient’s family offers to get it from outside. Some Specialists would then get the family to write their request on the bedhead ticket, as a safeguard, inform the Director of the request and then issue a prescription to the family, he said, asking whether if there is only one supplier, they should allow the family to go round in circles, wasting valuable time.
“Then we are compelled to direct the family towards the supplier because this is not like buying paracetamol which is freely available,” he added.
The President of the Ceylon College of Physicians (CCP), Prof. Prasad Katulanda’s earnest request was that if there are medicine shortages, the health authorities should somehow enable life-saving optimal patient care and not place doctors under duress. Essential life-saving medicines such as antibiotics, insulin, furosemide and other cardiovascular drugs should not be in short supply.
“If the supply chain gets disrupted there should be clear instructions and processes for doctors and hospital administrators to save their patients without getting into legal or other difficulties,” he said, adding that if doctors are in a dilemma, unsure what to do or not to do, optimal patient care would be in danger and the best interests of the patients would not be met. .
Other doctors explained how if a knee replacement has to be done and the device is not available, the family would have to ask the supplier to bring different sizes on the day of the surgery, for doctors to be able to get the right fit for that particular patient.
With regard to lenses for the eyes and stents for the heart, many patients tell doctors that they would like to bring “quality” products from outside the hospital. Isn’t it the patient’s right to do that, some asked, explaining that the patients are very grateful to the state health system for providing the treatment and care because they simply cannot afford exorbitant private hospital bills.
“We manage, we try very hard to get stuff from other hospitals and it is only when there is no option that we ask the patients to buy the stuff from outside and then too we direct them to the President’s Fund to get some financial relief,” one added.
| Don’t fear – Minister Health Minister Dr. Nalinda Jayatissa, in response to a query at Wednesday’s Cabinet media briefing said that the state health sector requires 862 medicines and 12,414 devices, of which the State Pharmaceuticals Corporation (SPC) tenders for 432 medicines and 5,906 devices. “Sometimes there are issues in getting them,” he said, explaining that hospitals could resort to local purchases. If there is a further urgent need, doctors could give a chit to families but not tell them the exact pharmacy they should go to. There is nothing to fear.
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| She would have had to pay half-a-million in the private sectorHere is just one example of a patient without health insurance or a fat bank balance who underwent a joint replacement procedure. Thousands like her, either middle class or even poor, are those who seek help at state hospitals. This 68-year-old, who had been a victim of polio as a child, had had a fall and fractured her femur. She needed an urgent femur-head replacement and when her family checked, doctors had told her that in the private sector, the operation would cost a minimum of Rs. 400,000, chances being it would be much more, while the ball-shaped device would be an additional Rs. 50,000. Advised by a friend to go to a teaching hospital close to her home, there she had been asked whether she could afford to buy the device from outside as it was not available at the hospital. When she said yes, it had been explained that the metal device costs Rs. 18,000 and the biochemical device Rs. 38,000, which was the suitable one for her. Given the contact details for the supplier, her family had made the payment online and on the day of her operation, May 19, the supplier had brought seven sizes so that the doctor could choose the right fit for her. “The treatment was excellent and the staff very good,” says this patient who is home and walking now, with follow-up hospital visits scheduled. “I just could not afford a private hospital bill and may have ended up in a wheelchair for the rest of my life if not for the state health sector,” is her view.
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