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Establishing a formal Association

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T. Naresh Row, MS, PhD (General Surgery) Consultant Surgeon & Day Surgery Specialist, One Day Surgery Center, Mumbai, India. President, The Indian Association of Day Surgery.
E-mail: nareshrow at hotmail.com



It is important to consider the local politics of medicine and health delivery when considering how to establish a formal association and then link this to the IAAS. I will therefore cover the following aspects of our journey.
  1. Health care system in India.
  2. Need for an Association.
  3. How to go about it.
  4. Challenges faced.
  5. International exposure.
  6. Future plans.

Health care system in India
At the onset, clarity is to be established in the healthcare system followed in India. Broadly, we differentiate them into Public, that is, government funded; it may be local/state/central funding. At present, this is about 1.9% of the GDP. These facilities are utilized by approximately 40% of our population.
Private health care caters to 60% of the patients, which amounts to almost 4% of the GDP.
Medical insurance is still in its initial stages, covering just 5% of the country’s population. About 10% have other means of reimbursement. This means, that, 85% of the patients pay out of their pocket for healthcare, thus, making India one of the most privatized healthcare systems in the world.
The rising cost of living has not spared anyone. With inflation reaching record high, even healthcare is not spared. Therefore, most of the patients are in search of affordable treatment. Situation in India is such that we see a constant rise in numbers of population living below poverty line, being pushed due to health care expenses. Government schemes for the poor have been initiated with some success, but are not without failures, however it is a beginning. Therefore, it is logical to adapt to Day Surgery as a means of providing high quality, affordable, planned surgeries.

Need for an Association
Day surgery, per say, is not new to us. From time immemorial, day surgery in some form or another has always been used across the specialities. However, if an overall view is taken, then we are still utilizing this concept up to somewhere in the range of about 10 % of all elective surgeries.
The main reason for this dismal numbers was lack of awareness. Patients do not know that there is an entity like Day Surgery. Surgeons also, have a perception about Day Surgery that it is limited to minor procedures. Though, there were many individual surgeons, who, by their experience and exposure, are practicing Day Surgery, but, do not have the means to influence patients about the concept. Most surgeons try and give up, the feeling is that if the patient is comfortable in a hospital bed, then so be it, why do you need to push it? However, the number of patients asking to be sent home earlier, for different reasons, is gradually increasing in number. This is a major support for the surgeons, but they are looking for endorsement, they want to establish that what they are doing is correct. They are looking for a platform where they can exchange and share their experiences. Something better, than just a faceless blog or a Facebook page. And that is where the importance of an Association is seen.
The purpose of an Association is to gather like minded people under one banner. It becomes a scientific club for interaction of ideas. You are comfortable in the knowledge that there are several like you who practice Day Surgery and you are not alone, you form a support system. It is your own idea which has gained a form. A legal endorsement in the form of an official body of surgeons practicing Day Surgery, like you. You become a member and have a feeling of belonging, you are different, you can put your ideas into action, and you can use the Association to spread the good word. For something which you have taken tremendous individual effort, can now be converted to collective effort. There can be now awareness. Awareness among the surgeons, awareness among the patients.

How to go about it
When the idea of creating an organization takes form, several questions come to our mind as to how to go about it? What would be our aims? Will we be successful in achieving our aims? The most important decision was to form an Association, having done that, these questions were expected.
So we took one step at a time.
The first step was in the decision to form an Association. Several phone calls and meetings later, we had enthusiastic consensus among 30 surgeons of different specialties, who thought it was a good idea and were eager to for an Association, so a logo was designed and a name given, we had an executive committee of 30 doctors! The second step was to raise funds. We created a membership form, collected membership fees. In India, the fees are one-time payment, not yearly. So, everyone collectively started looking for donors / sponsors. This was tougher than we thought.
The third step was to create a constitution, with the basic aims in place, we decided to look into constitutions of different existing organizations, and adopt one, with modification. This was then circulated among the executive members and appropriate corrections made.
The fourth step was to register The Association. Incorporation of the organization with the relevant authority was easier said than done. Difficult, but not impossible. It was time consuming, a few meeting with the officials, and we were officially incorporated into existence. Now, every member was a trusty. A share holder in a not for profit company.
The fifth step was to create more members. Lists and addresses of members from existing organizations of specialties were acquired and mailers sent to them. Word of mouth method of making members were found to work faster, every executive member was given the responsibility of making at least 5 members.
The sixth step was to create an academic activity. So the first national conference was mooted. Date and venue decided, organizing committee set up and we were ready. At the time of the first conference, we had 100 life members. The inaugural function saw the installation of our mammoth executive committee, along with release of ‘The Day Surgery Journal of India’ and ‘Protocols of a Day Care Surgery Center’ (a hand book on protocols). During the General Body Meeting, we adopted the constitution and passed resolutions giving power to the executive committee for 5 years. This was deemed necessary at that time as there was a lot of work to do and before the committee changed, most of the idea’s and aims were to be put in place, which would be achieved faster with the current team.
During the conference, along with exchange of scientific data, ways and means of increasing awareness among doctors and patients were discussed.

Challenges faced
Long ingrained ideas of the magnitude of ‘surgery’, is so deeply ingrained in the patients and their relatives, that, any change from the norm of 3 to 5 days of hospitalization or even up to the removal of stitches, was severely frowned upon. How do we change the mind set? Was the question.
Establishing the safety and feasibility of Day Surgery was the challenge.
Making more members interested in the concept of Day Surgery, was difficult, as the question of ‘yet another organisation’ was raised time and again. Even, the skeptical, ‘so what’s the big deal? How does it matter if you go home on the same day or the next?’ was very difficult to answer. Awareness of the concept and its utilization to its full extent was the challenge. It was then decided, that, to face these challenging issues, more and more conferences, workshops and awareness programs were to be organized.
Executive members were encouraged to participate in as many conferences as possible and introduce the concept of Day Surgery to their colleagues. Members were coaxed to organize lectures and make more members.
The Day Surgery Journal of India was published every year and released during the conference. Initially, it was challenging to find articles for publication as there was not much work being done as Day surgery. International authors were invited to send in their articles. We got to read about Day Surgery in different parts of the world. This was encouraging. Slowly and surely, articles with enough data on Day Surgery started being sent. We succeeded!
International exposure:
It was an article published in BADS journal that exposed us to world of Day Surgery. International invitation to participate in the IAAS conference and subsequent invited lectures given by members of IAAS, was of tremendous help. The IAAS, through its senior members was very supportive in giving endorsement to the initiative of our national meets.
Joining the IAAS, initially as a corresponding member and then as full member was a challenge in itself. The questions of raising funds to pay the annual fees (which was new to us) and to select two representatives who will participate and bring back material to be shared by our members, was another task.
All in all, the legitimacy of being an organization following the right tract was very important, this was fully afforded by being a member of the IAAS.

Future Plans
Interaction with local and national government bodies in introducing various schemes for establishing Day Surgery as a norm for a few select surgeries is an ongoing process and a challenge.
Regional cooperation with our neighbouring countries in Day Surgery, would create a positive impact on the methodology of delivering surgical management in select patients across the countries.
Medical tourism, a very upcoming and challenging industry, would be benefited by catering uniform surgical deliverance of international standard. It is found that several routine surgeries are made to wait in the many countries as the emergency care takes precedence.
Accreditation body to create uniformity and set standards in patient care as well as optimize the Day Surgery Centres across the nation is essential at this stage. Efforts are now on in creating a board which will comprise of members from the Association and Quality management organization in forming norms for all who are interested in establishing Day Surgery Centres.