Shahid Akhter, editor, ETHealthworld spoke to Dr Dinesh Pendharkar, President, Indian Society of Oncology, to know more about his model of cancer care (District Cancer Care Programme) and his association with the programme.
With your experience in Cancer care, where do you find the major road blocks and challenges ?
The biggest challenge in cancer care world over is access to care. Access implies multiple things; physical access- that you have to travel to some distance to get the treatment, financial access- patient cannot afford cancer treatment as it is really costly today. Access also means, cultural barriers because if a patient from far off travels to Delhi, he might have a challenge staying in Delhi with cultural and language problems, so there are multiple access issues. And the biggest problem in cancer care in access is that the patient doesn’t travel alone, he has to go with a family. Then there are two to three people required to take a decision on the next line of treatment, so that is also an access issue. So there are multiple access issues which actually makes cancer care more complex. So even if patient has an access to a physical facility and a financial capacity, still cancer care is a difficult issue. If you want to solve a cancer care problem we should probably solve the issue of access at every level: financial, social, economical, cultural, or government system so, all these areas need to be considered to solve the access issue.
Your suggestions to overcome them ?
The biggest challenge is physical and finance. The physical issue can only be solved by bringing care to the periphery, and if you have to bring care to the periphery it should be close to the patient, that is a physical access. And financial access is about the government to come out and fortunately they are coming out with lot of financial solutions to assist the cancer patients financially in his treatment, in his journey of cancer care. If these two issues are resolved, I think the policy has to bring the care to the periphery and in India the periphery actually means the district that is a place which a patient is absolutely comfortable to visit. So if a person from Jaisalmer has to visit a hospital, Jaisalmer District Hospital will be the closest place for him and at the same time the district headquarter —administrative headquarter, every person is familiar to go to the district Hospital. He doesn’t feel any challenges. So probably District Hospital should be the unit which should be empowered in specialized care.
Please elaborate on the model of care ( District Cancer Care Programme ) that you have rolled out at various places ?
Fortunately I have the experience of working at multiple places in the country. I started my journey with Tata Hospital in Mumbai. I worked at AIIMS, Delhi. I did practice in Indore, Bombay, Delhi, again in Delhi, presently at ICD Healthcare. So the learning from this entire journey was that the patient is not able to access the care. He can come to the Cancer Hospital once but he cannot come again and again. This needs a solution and we cannot have cancer hospitals in all the districts. So we started working on this issue long back when I was in Delhi and the first issue we tried to resolve was for Railway Hospital. Same problem was with the Railway Hospital, the patients who are supposed to be taken care by Railway Hospital were not always willing to go out of Railway Hospital for treatment. We started the unit of Cancer Care in Central Hospital Railway, Delhi with a general duty medical officer taking care of cancer patients, I gained experience from that and it became so successful that in the same fashion it is being run for last 14 years. This shows that the model works and you can use a general practitioner for cancer care.
So if we have to bring care closer to the patient we have to empower the District Hospitals. We know that we cannot increase the number of doctors; we know we cannot bring a specialist to the district Hospitals. So we have to create such a system which will still offer help to the cancer patient in the District Hospital. So I rolled out one model of experiment in Ratlam District Hospital where I empowered a doctor to do chemotherapy and with my backup they started looking after cancer patients offering free anti cancer drugs on government schemes.
Then government of Madhya Pradesh came with an idea that we would like to do free cancer drug in all the district hospitals. Because every care in the government district hospital is free. So I sat with the government of Madhya Pradesh and we evolved a programme which is now known as District Cancer Care Programme. It is functioning in 4 states of India: Madhya Pradesh, Orissa, Rajasthan and Himachal. This programme has been coined as District Cancer Care Programme by which we have taken one existing general duty medical officer who is a general physician has been retrained into looking after cancer patients over one month by me. He goes back to the districts and starts seeing cancer patients. Two nurses have been trained in doing chemotherapy. So today what is happening is, a cancer patient from the district is free to visit any hospital but when he lands up in a district Hospital he is being seen by this doctor. The doctor examines the patient, takes the review of the patient and the patient is brought to a tumor board which comprises of me as an Oncologist, two of my colleagues and the group of the doctors from the state and then we decide the next course of action for the patient.
Generally, when the doctor puts this information on a group, he is replied as fast as half an hour and if he doesn’t get a reply within half an hour he is supposed to call and get an answer depending on the emergency of the situation. This doctor may not be well trained in a month but with every patient he is seeing he is being trained and you can imagine if there is a doctor who has being continuously trained with every patient seen, his skills are going to be improve. The government has chipped with phenomenal input into this programme. All these doctors have been designated as district model cancer officers… All the states have included anti cancer drugs in the list of essential drugs. Drugs are available in district hospitals and all these services are free, including, investigations being done for cancer patients. So a patient can walk into the districts and take cancer care.
If a patient requires services which cannot be offered in district, the patient is counselled appropriately by a local doctor who knows local cultural things, who knows local language, who can be visited frequently by this local person, he counsels this patient appropriately to go for surgery and tells about the benefit from surgery. So now you have a person in district who is explaining you why surgery is important for you. It is running well, it has been audited by multiple agencies. So, as I said the major issue in cancer is an access issue and here government is pitching it with free support, free anti cancer drugs and free services. Patient has to travel a smaller distance and patient is still being referred to appropriate cancer hospitals as and when required. So probably this is a model of cancer care delivery which was exercised in 125 districts close to 17% of districts of India. Government District hospitals are working in cancer and can serve as a model for all diseases where government considers it as a priority.