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AIIMS: An ailing model

The government plans to replicate the country's premier medical institute in four states. But in its current form, AIIMS itself is in urgent need of attention

Manavi Kapur & Dhruv Munjal  |  New Delhi 

The light drizzle has made the lush green lawn at New Delhi's All India Institute of Medical Sciences, or AIIMS, look greener. The shrubs and trees are neatly trimmed, and the walkway to the director's office is spotless. Inside, the office is sparkling, with beige tiles, bright LED lights and just-right air-conditioning. The picture in other parts of the building, in contrast, is not so perfect. Patients complain of long queues, unending waits and tiresome paperwork. The waiting area in the out-patient's department (OPD) is large but seems claustrophobic because it lacks good lighting and proper ventilation. The trauma centre, which is the busiest area in the complex, is abuzz with activity. The patients are attended to with quick efficiency, as doctors move from one bed to another, halting for a few minutes to get an update, but the general sense of chaos is hard to miss. Doctors complain of being overworked.

Elsewhere too, things could have been better. The dingy auditorium section is packed with aspirants for the bachelor's course in nursing at the institute. Owing to the poor ventilation, the air is putrid, with a faint smell of urine. Other parts of the hospital-cum-research-institute are riddled with puddles and slushy mud. Though the parking lot has sufficient space, its impractical distance from the main building makes visitors park cars wherever they find space, some right under a "no parking" sign. However, for the government, this is clearly a model that is working well. That's why the Manmohan Singh government in 2012 sought to set up six "AIIMS-like" institutes in Madhya Pradesh, Chhattisgarh, Uttarakhand, Rajasthan, Bihar and Orissa. And in his maiden budget, Finance Minister Arun Jaitley has set aside Rs 500 crore for four new AIIMS in Andhra Pradesh, West Bengal, Maharashtra and Uttar Pradesh.

Experts are less than enthusiastic. They feel the situation at AIIMS should be fixed before anything else. That can be done by improving the infrastructure, streamlining the processes and appointing more faculty. "At a little over 60, AIIMS is prematurely aged and unfit for the stress test," wrote Dipankar Gupta, director, Centre for Public Affairs and Critical Theory, Shiv Nadar University, in The Times of India recently. "Even if further decay is halted, and steady state achieved, it can hardly pose as an institutional stud rearing for reproduction." While admitting that the country desperately needs more - and skilled - doctors, Gupta told Business Standard: "We can't do this blindly and bring the quality of research, education and healthcare down." J S Guleria, former dean of faculty and former head of department for general medicine at AIIMS, suggests that the government should first have a clear objective and roadmap in place before creating new institutes. "No student or doctor wants to join these new centres. Why call them AIIMS at all?" asks Guleria. AIIMS Director M C Misra did not respond to a questionnaire emailed to him.

India has some 450,000 doctors. The strength is woefully short of the standard prescribed by the World Health Organisation: one doctor for every 1,100 people. By one estimate, the country needs to double its army of doctors by 2020. AIIMS, on the other hand, produces about 50 doctors in a year. What went wrong? The foundation stone of AIIMS was laid in 1952. (A generous grant from New Zealand under the Colombo Plan had helped immensely.) It was to serve as a nucleus for nurturing excellence in all aspect of healthcare: teaching, research and patient care. But an overload of patients means that doctors are left with little time for research. This is the primary problem that ails AIIMS.

Thousands of patients travel from distant parts of the country here. The main reason is the near-absence of high quality healthcare in smaller cities and towns. Shweta Shubhdarshini, a dermatology resident at AIIMS Delhi, says: "There are about five doctors for every 28 beds, though this number varies across departments. But the situation in the OPD wing is out of control," she says. "Patients wait for hours just to get a token to see a doctor. They often stand in wrong queues and realise that they have to start the process all over again." It is estimated that over 6,000 people visit the OPD in a day. Shubhdarshini says that though the focus at AIIMS is on research, doctors and residents can't do this at the cost of their patients. Guleria agrees with this. "People come to AIIMS even for treatment of common cold and forget that it is a super-specialty, referral institution. How can you expect doctors to do quality research when they have so many patients to see?"

A visit to the OPD bears out the truth. Umesh Kumar, a small shopkeeper from Chitrakoot in Uttar Pradesh, is camped on a tarpaulin sheet outside the section with his wife, brother and sister-in-law. His wife needs a heart-valve replacement surgery, which will take place a week later. "We came in the morning and stood in a queue for three hours. Now we have to wait another couple of hours before we have proper clarity on the entire process," he says. Twenty-four-year-old Savitri Devi's husband works as a guard at AIIMS. Though she has a card which says she is poor and hence entitled to free treatment, she says they paid a subsidised amount for her obstetric treatment. She waits for her husband outside the pharmacy, next to a pool of stagnant water, just a day after her surgery. "The queues and the waiting are worth it so long as the doctor can treat you properly," she says.

Shubdarshini agrees that cleanliness isn't something that AIIMS can score on, but says that it is an outcome of the patient overload. "Patients who stand in queues for hours don't want to leave in case they miss their turn. So they brush their teeth, eat, drink and sleep wherever they are standing," she says. "The authorities are not entirely at fault, but there is a lot that can be done. For starters, they can launch a toll-free number so people can avoid standing in queues and take their token numbers online." Ashok Seth, the chairman of Fortis Escorts in Delhi, believes the problem of patient overload can only be solved if general hospitals are created parallel to institutes like AIIMS. "An effective way to strengthen primary and secondary healthcare models is through public-private partnership, which has been successful in places like the United Kingdom," he says.

A member of the Medical Council of India (MCI), who does not wish to be named, says that many patients refer themselves to AIIMS for lack of adequate infrastructure at general hospitals. "District-level hospitals are sometimes not even equipped to deal with heart attacks, so all cases come to AIIMS. This overburdens the limited resources," says the MCI member.

To decongest the institute, the Manmohan Singh government set up the AIIMS Outreach Outpatient Department in Haryana's Jhajjar district, around 10 km from Gurgaon's Badli village. Thrown open to the general public in November 2011, it houses eight specialist departments, including gynaecology, paediatrics, psychiatry and radiology.

Located in the Badhsa village, amid the rubble of vast stretches of dug up roads, the centre treats 300 patients daily who get free treatment from specialist doctors who come in from AIIMS every morning. "The nearest government hospital is 30 km away. The entire purpose of this project was to provide quality healthcare to people in need, who cannot afford to travel to Delhi all the time," says a member of the staff. The centre, complete with 80 air-conditioned rooms, two operation theatres for minor surgeries and a canteen, seems to have succeeded in its initial endeavours. Hariprakash, a patient from nearby Devdhar village, explains why. "I had to get my foot operated and travelled to Delhi last week. I was at AIIMS for three days, and couldn't even see the doctor. The entire procedure took just two days here," says the 47-year-old.

Others have different stories to tell. Brahm Singh's wife, a diabetes patient, had to undergo some tests, but had a hard time wriggling through the hospital's unfriendly administrative set-up. "The facilities available are great, but the staff is insensitive," says the Najafgarh resident. "We've been coming here for three days now, and still haven't been able to get the tests done. Now we'll get them done at a private hospital in Najafgarh," says Singh.

More AIIMS-quality hospitals are a noble idea. But that expansion needs to be done in a planned way. Otherwise, it will mimic the frustrations of the new Indian Institutes of Technology or Indian Institutes of Management, which are hamstrung by the lack of teachers. Guleria suggests that the entire system needs an overhaul. "The course needs to be updated and instead of increasing the MBBS degree to six years to incorporate rural training, doctors should spend their year of internship in rural areas," he says. For Gupta, the question of four new AIIMS is irrelevant unless the current model reaches its peak fitness. "It does not make sense to have another AIIMS teetering on the brink of collapse."

First Published: Sat, July 26 2014. 21:10 IST