There ain’t no such thing as a free lunch

-Milton Friedman, Nobel-prize winning free market economist

Haroon, a colleague from Panacea asked about FOSS, “Who is marketing it, if it is really so good?”. It is an interesting question with the implication that it may not really be so good, otherwise, why aren’t so many of us already using it!

I strongly feel that FOSS is the next in technology. There was a time when innovation was driven by funding and money. You launch a company, make lots of money and hire the best talent and produce a wonderful software. But, the very nature of the internet and the inherent ‘symmetry of information‘ between the designer, user and the owner of software prevents unreasonable run-away profits! It is not like in health care where the patient and the community have no clue about the surgical process or technique. In the case of software, the community is as well informed, or sometimes better informed than the designer or owner of the software. The only way to make your software best, is to co-opt the community in the development. Of course, it is your choice as to what level of co-opting you would do. The farther you go on that spectrum of involving the community in development, greater are your advantages.

Of course, then Haroon’s logic of why everybody around is not using FOSS still applies. Well, here is the issue. In many countries in the South, the rampant availability of pirated free software like Windows is the problem. It speaks so much of the proprietorship over software, when intuitively, people use software without paying and many are surprised that these actually cost a huge amount! Many of my colleagues are simply ‘used’ to proprietary software, and if faced with paying in retail value for these software, would quickly look for free alternatives. In a world where many would not use IE even if given money, we can see that the transition is beginning.

And it is not as if the big guys do not see this. No company today remains exclusively in software. There is no money in it. Who knows, the next door neighbour may have a better go at an OS than a multi-million dollar corporation! That is how this ‘market’ of software works, not like health care where the asymmetry of information between the provider and the user is phenomenal.

So, there you go, there may not be a free lunch, but FOSS is definitely the recipe to prepare one for yourself! And if you get your recipe in GPL, better inform the recipe owner about that extra salt that you added after the tomatoes!

It is no measure of health to be well adjusted to a profoundly sick society.

- Jiddu Krishnamurti

Gubbi, a Taluka headquaters in Tumkur district

Gubbi is a small town in Tumkur district in Southern Karnataka. Gubbi Veeranna, one of the well-known theatre personalities from Karnataka who started the first Kannada theatre hailed from here. Historically, the town was well-known for its local markets for cotton and areca nut. As early as in 1871, Gubbi was a municipality of its own. The Imperial Gazetteer of India in 1871 talks of the monthly ‘jaatres’ or fairs which were well known for the sale of cotton cloth, blankets, rice and other articles from as far as Malnad (the mountainous monsoon-fed wetlands to the west) to the dry areas of Rayalaseema and the low hills of Arcot to the east and South. Today, Gubbi is a taluka headquarters in Tumkur district and is one of the ten talukas in the district.

Gubbi is about 20 km from Tumkur and is situated along the highway to Honnavar from Bangalore, that passes through Tumkur. The taluka hospital of Gubbi is along the highway passing through the town. The Administrative Medical Officer, the doctor in the hospital tasked with managing this hospital is Dr. NL Dani. The hospital was a Community Health Centre earlier with 30 beds being upgraded now to a 100 bedded hospital.

Dani is one of the participants of the capacity-building programme organised by IPH and its partners in Tumkur. Dani is a paediatrician by training with three decades of experience. He is today managing a 100 bedded Taluka hospital. His hospital sees over 200 patients in a day, is severely understaffed and morbidly overloaded. In these days of panchayati raj, he is answerable not only to his superiors in the hallowed chambers of the directorate in Bangalore, but also to the representatives of the people in the narrow chambers of the Gubbi Taluk Panchayat.

Gubbi Taluka Map

The hospital provides out-patient services to nearly 300 people in a day. At a time when there is a beeline towards corporate hospitals and having busy evening practices, it is heartening to see Dani and his colleagues in Gubbi hospital providing services within the constraints they face; and these are many. Dani conducted a study in his hospital to understand patient satisfaction, as it bothered him that most of the people obtaining the services at Gubbi hospital were reporting that they were not happy with the services. Was there truth to this?

Dani approached it very scientifically. He did not take this for granted. Nor did he cursorily conclude on the reasons for patient dissatisfaction. He conducted a study consisting of exit interviews of through a structured questionnaire. Patients were recruited into the study randomly. He considered the following aspects in his questionnaire:

1. Staff availability of patients
2. Basic amenities like toilets, drinking water, ambulance services and drug availability
3. Patient safety in hospital – infection control, physical safety of women and children
4. Perceptions of cost
5. Administrative and procedural problems

The questionnaire confirmed his hunch about dissatisfaction. Presenting the results in Tumkur, Dani also shared the possible reasons for this. On an average, each doctor in his hospital sees over 70 patients in a day. Many of these, of course are specialists who are supposed to be giving a lot more time than they can to these patients that are referred from primary health centres. However, these patients needing specialist care are clouded by many others who come here for routine health problems. There is no referral system in place.

Dani in his study prepared hospital performance indicators for all departments – in-patients, specialities, CSSD etc. He identified issues in human resources, infrastructure and a few other issues as key reasons for the patient dissatisfaction. He found that staff motivation was poor. Also, he was working in a severely understaffed hospital. Recruitment to the hospital happen in Bangalore. While it is easy to upgrade the beds from 30 to 100, finding the requisite support staff and motivated doctors to work here is another story. The district is helpless to fulfill existing vacancies. In addition, he found that supervision was poor. The doctors and other senior staff could hardly devote time to supervise and hand-hold their non-clinical team. Where is the time for management of the hospital?

In addition to doctors not being available in good numbers, the amenities provided were also poor. Residential quarters were not available for all the staff. The hospital lacked good water and sanitation facilities. A reception counter itself was not there.

This was of course a small study done in a small taluka hospital, one among over a hundred taluka hospitals in the country. However, the issue Dani identified for his study, ‘patient dissatisfaction’ is a universal phenomenon in public health services in the country today. In India today, irrational health practices and expensive health care is becoming a feature rather than a problem. Government-provided health services is the lifeline for millions of poor, who depend on these, and for whom health expenditure is often catastrophic. The reasons Dani identifies through his study are also quite representative of hundreds of other taluka hospitals.

Doctors in government services work with many constraints. Staff are demotivated. There is always pressure from elected representatives, sometimes justified, and other times not. Teamwork is lacking and the work environment is not always cheerful or fulfilling. Yet, there are people such as Dani in many of the small hospitals in the country, whose toils go unheard, and whose stories go unsaid. Yet, we often see the glamour and glory that many a corporate hospital catering to a much smaller proportion of people get.

Here is a doctor who in the middle of taluka meetings, trainings, reviews and visits by superiors, also manages a busy clinic as a paediatrician and is expected to manage a 100-bedded hospital for a taluka. In the midst of this, he keeps his spirit alive and did a study to understand and document patient dissatisfaction. We hope that Gubbi finds more specialists and most importantly, committed people like Dani.

Crossposted on IPH India Blog