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View Point Indian Pediatrics 2000;37: 1093-1097 |
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Developing Health Services for Children |
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Children are inheritors of our past and the seeds of our future. It is to them that the world bequeaths its achievements and its treasures, yet they are at the end of the queue when the goodies of governments are being distributed, especially in the developing countries. Howsoever worthwhile a cause may be, someone has to plead for it. Atleast a part of the onus for the inadequate deployment of resources towards child health by the state and the philanthropists therefore belongs to us. Are we ready to do something about it? One need not feel shy of asking help for a good public cause. Infact people are willing to help worthwhile causes and have difficulty in identifying such causes. In order to ask for more, you must ask something, which will touch people's heartstrings; something, which is within their capacity to give; and something, which you possess the capacity to utilize. The demand must be clothed in words that carry conviction and backed by facts and figures. If these conditions are not met, the proposal is likely to be shot down prematurely. I have been persuaded to discuss some of the questions and inquiries on exactly how the Advanced Pediatric Center (APC) project at Postgraduate Institute of Medical Education and Research (PGIMER) came into existence. The narrative is personal and I would not have discussed such a matter in an open session if I were not convinced that there are real lessons to be learnt and our experience may be useful to others. I therefore agreed to tell a bit of the history behind what has happened at the PGIMER and how it was brought about. With due humility I shall like to begin with a "doha" of Bhagat Kabir the 12th Century Saint:
I came to Chandigarh in 1965. An empty ward was handed over to me alongwith two senior lecturers and 8 residents. Everything has been given to me by this team and the Institute and to them this presentation is dedicated. The first important thing is to realize that the duties of a teacher clinician include improving the facilities for treatment of patients as well as for training of his students. This calls for advocacy. If you, who have a place and an image in society do not do this advocacy, who else is going to do it? It was Alex Steigman who taught me that a stage should come in the life of every clinician when auscultating more hearts should be less important than enabling your juniors to work better. According to him Head of Department/Institution is an "enabler" of other people. The first important thing is to dream. All dreams do not turn out to be true, but even if a few do, they would make a significant difference.
All this should be written out, costs worked out and then posted or hand delivered after prior appointment to the dealing officer in the relevant Ministry. And then be prepared that nothing may happen. All your labor may go waste. Don’t despair, begin again! Remember persistence always pays in the end. The story of the King and the spider provides an example. Out of the two major projects undertaken at Chandigarh,
All of you I would concede are first-rate clinicians. But this is not enough when it comes to getting a financial grant - even for a good cause. You must first establish an image in society. If you are known for certain humane values like, coolness, compassion, helpfulness, humility, unselfishness, it is a great help, because before handing over money, the giver likes to be convinced that he is giving his hard earned money to a person who will use it correctly. A nicely done community oriented project is much more likely to enhance your accept-ability in a local community as compared to a piece of internationally recognized research project. Next, you will have to lobby for your cause otherwise some doubting "Thomas" in the committee, whose sole aim is to show how smart he is rather than examine the merit of the issue under consideration, is bound to oppose it. As an example of lobbying, I would like to tell you about the committee, which was set up by the Medical Council of India to review recommendations for undergraduate education. Jon Rohde who was also a member of this committee happened to tell me during a coffee break that many other countries in South East Asia including Pakistan had given pediatrics a separate status in the MBBS examination. I requested him to speak last of all and state that "even" Pakistan had done it. This had a telling effect on the conclusions of the proceedings. The two representatives of Indian Medical Association (IMA) in this committee who had been provided data by me based on Dr. Kaul’s study at Jabalpur stated, that children comprised almost 60 per cent of a general practitioner’s work and therefore an MBBS examinee should be well versed in pediatrics. The committee thus supported a separate examination for pediatrics. Follow up action by Dr. Chapparwal saw the proposal through at the executive committee and general body meetings. The facts and figures, which you present at a meeting, must be accurate and readily verifiable to quench criticism, for this you may carry supportive data along with you. In short, do not just attend a meeting, you must contribute ideas and clarify concepts, if required, show your willingness to accommodate good suggestions!
Your first task is to form a team capable of working harmoniously and whole heartedly towards the goals of the department. Personal rivalries are minimized by giving each member an area for which he has exclusive charge. For anything good happening in his area he must get the total credit. Prof. Pohowalla used to say "a pat on the back carries a person further than a kick on his backside". A genuine well-deserved compliment is never forgotten. I give you an example. At AIIMS, an infant died of Congestive Cardiac failure. Clinical diagnosis was uncertain. A young intern went to mortuary and got a heart biopsy with Vim Silverman needle. It proved a diagnosis of fibroelastosis. When the report was presented in the mortality conference, I was so pleased, that I searched all my pockets and found a single rupee note. I offered it to the intern as a prize, expressing my regret at the same time that this was all I had at that moment. The boy said, "Sir for me this is equal to a hundred thousand". I forgot all about the incident. Almost 25 years later, his vote in a meeting helped to tilt an important agenda in our favor. When I thanked him for his support, he recounted the story! Those of you who are heads of departments please remember that your prime tasks are to: (i) Enable people to work smoothly by providing them adequate facilities and congenial environment for work; and (ii) To develop the services, as well as careers of your team members. Our team undertook the latter task by renewing our contacts with the institutions like University of New Castle, Radcliffe Infirmary, Oxford and Great Ormond Street Hospital where someone amongst us had worked. The generous support of these institutions for training some of our young consultants was an important step to see that the Pediatric Center was not merely walls of concrete, but a center where specialized skills are available. It helps to join some well established organizations like Child Welfare Council, Red Cross Society, Rotary Club, Lions Club and other similar organizations. Your participation can help such organizations to focus their welfare programs on children rather than on some hair-brained projects, for which these organisations are often responsible. Without unity, a department can not grow. When I was Director of the Institute, the local Lions club wanted to fund a big project for a particular department. The number two man in the Department torpedoed it by telling the organization that the Department is being maladministered.
Strategy A key element of the strategy should be to avoid as many hurdles as you can. Why climb a hurdle, if you can bypass it? This principle was well illustrated by the strategy adopted in operation "Desert Storm". The initial plan of the APC gave emphasis to neonatology, pediatric intensive care, genetic and metabolic diseases, allergy, immunology, hematology and oncology, developmental psychology, developmental neurology, pharmacology and the investigative departments. As these depart-ments did not exist in the hospital, it was surmised that lesser objections to their creation were likely, as we were not going to tread into someone’s territory. The next principle is make friends, not enemies. Keep your friends close to your bosom - especially if they are the opposite gender! Humans don’t easily forget harsh words or a humiliation. Remember Sheikh Farid who said:
The golden rule for making friends is help everyone you can and for not making enemies is not to criticise anyone, if it is avoidable. A famous bureacrat once advised me that for whatever you want from the government, get a file created. He added that "you may die, but a file never dies". It can always be made to resurface under more favorable circumstances! Our project though filed in 1978, found a sympathizer in 1985. The second advice was to get the project sanctioned in principle with a small outlay. Balance of the money can be asked in supplementary grants because nobody wants that the money already expended is wasted. I don’t believe that bureacrats are hurdles. If a case is properly prepared and presented, they are most helpful. More often it is jealous colleagues who are a greater hurdle. Friends were of great help to us on numerous occasions. An area of 18 acres of land along with buildings adjacent to PGIMER was handed over by the Institute to army in 1962 for using as base hospital. In 1991, even though the army hospital had shifted to its new building at Chandimandir, our land was not being vacated. A letter written to the then defence secretary, explaining how important the restoration of land was to PGIMER did the trick. The army vacated the site on which the new OPD block has been constructed. Recruit the help of your friends for worthwhile public causes. Some of them will be happy to help you. Peter Drucker, the Guru of Management tells us that an enterprise is always the result of a courageous decision. Don’t hesitate to ask for a public cause. There is no embarrassment if such a request is refused. As an example I shall like to tell you how IAP got representation in the planning commission committees. In 1983, I read a newspaper report indicating the names of members of a committee formed to formulate the next national 5-year plan. I sent a simple letter to the Hon’ble Minister of Health, who I did not know at all, that when such an important plan is to be made, some representatives of the Indian Academy of Pediatrics may be invited. The Minister nominated Dr. Bhargava and me to the panel and the practice continued for the 7th and 8th plan. This gave us a chance to introduce several new programs like the ARI program, control of diarrheal diseases, introduction of measles vaccine, school health check ups and neonatology services at district level. It is my firm belief, that child advocacy is as important an area of work as clinical practice, teaching or research. What we have been able to do here is to create a tiny island for children in an ocean of neglect, where children continue to die from preventable and easily treatable diseases. Everyone may not be able to build an institution, but everyone can and should work earnestly for improving the services and facilities for children, at his /her place of work. I would like to close this narrative by acknowledging the unstinted support and the warmth and affection, which everyone in the department gave me. They are the real pillars of this center. We walked hand in hand. It is incorrect to say that I was leading them. No, infact they were pushing me, supporting me, and sustaining me, all the time.
Thanks are due to Prof. I.C. Pathak and Prof. P.L. Wahi former Directors of PGIMER and the faculty and staff of the Department of Pediatrics especially Professor O.N. Bhakoo, Lata Kumar and Anil Narang for their unstinted support.
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