After much criticism and delay, the Karnataka government has finally floated tenders for companies to instal, operate and manage the hemodialysis units in the district and taluk levels to handle dialysis centres in the districts.
However, the state government has now stated that nephrologists may physically visit the centres once every 15 days or provide teleconsultation.
This, after it ignored the important issue of the presence of nephrologists in these dialysis centres for the last few years.
Nephrologists in the districts have taken objection to the latest decision of the state government.
“This is detrimental to patients and nephrologists. Dialysis management is a dynamic process. It cannot be managed completely through telenephrology, like CT or MRI reporting done by radiologists remotely,” said Dr Ravi R, a nephrologist from Karnataka.
The plan and its apparent drawbacks
The final draft of the tender floated by Karnataka’s Department of Health and Family Welfare, a copy of which is available with South First, called companies to provide one nephrologist per district, with a qualification of DM (Nephrology or Renal Dialysis Technology or Fellowship in Renal Dialysis from a recognised university.
The draft says, “nephrologist shall conduct physical consultation or teleconsultation fortnightly at the district hospital)”
Nephrologists, in conversation with South First, expressed concerns that so far a majority of the dialysis centres in the state had not even appointed a nephrologist, and the technicians and sometimes even untrained nurses were doing the dialysis.
It may be noted that this was reported by South First.
The Mumbai-based Kidney Warrior Foundation, in its own investigation, found the same situation.
The concern of nephrologists was that if the tender floated for the new company to run the dialysis centres under the PPP (public-private partnership) model was given the option of either visit or teleconsultation by nephrologists, the private agencies might opt for teleconsultation only, and that can be dangerous for the dialysis patient.”
Interestingly, several doctors from districts, whom South First spoke to, were against mentioning their names fearing action from the government and the health department.
A nephrologist from North Karnataka said, “In my opinion, a nephrologist has to compulsorily be appointed by these agencies. Whenever we suggest any options, we need to consider evidence-based trials. There are no studies, to my knowledge, to show that teleconsultation is not inferior to physical consultation. We have to at least show non-inferiority before we suggest this as an option. Even if we are unable to show superiority, that means teleconsultation works in dialysis patients, we have to show non-inferiority, or it is equivalent.”
Another doctor argued that an option like this may be worked out if there were no nephrologists available in the state, but then there is no dearth of nephrologists.
“Why is the state government not appointing them? The reason mainly is they want to hire the nephrologists at a cheaper rate, for as low as ₹10,000-15,000 a month, which is not going to be acceptable to any nephrologist. This option is being worked out by the health ministry in Karnataka to make way for private players to function under the garb of providing teleconsultation to dialysis patients,” he said.
Telemedicine is the way forward?
However, the doctors even argued that considering the fact that telemedicine was being pushed big time in healthcare management in India, the state government should first weigh the pros and cons of providing telemedicine as an option in some portions of disease management.
The doctors argued that as dialysis patients were very sick and needed constant monitoring, physical checks on them were important.
Meanwhile, another nephrologist — from a private hospital in New Delhi — told South First that telemedicine could be considered as an option, provided the nephrologist visited the centre and met the patient at least once in 15 days.
“This means the centre definitely needs to have a nephrologist on board, and an MBBS doctor who has had at least six months of training in the dialysis unit has to be present all the time. Teleconsultation without a nephrologist visiting the centre, seeing the patients, and advising on changes in their dialysis units has to compulsorily happen,” said the doctor.
Meanwhile, a nephrologist from Vijayapura in Karnataka told South First that the system was functioning well when industrialist BR Shetty’s company was managing the dialysis centres well with the appointment of nephrologists, with the maintenance of the machines and RO units as well.
If they could do it, why can’t the new companies, asked the doctor.
“In the last three years, 50 percent of dialysis patients in government hospitals have lost their lives, and the remaining are very ill due to inadequate dialysis in non-supervised, non-serviced dialysis machines and poor-quality water being used from non-serviced RO plants,” he said.
“If the government really intends to do a thorough check, they can do a death audit then the number of patient deaths and the problems they are facing is all very obvious. Who is checking though?” he asked.