Friday, April 10, 2015

Healthcare Challenges for  New Government in Delhi
Delhi health minister Satyender Jain
With the crowning of Aam Aadmi Party’s government in Delhi, there is a renewed interest in public as to how the party will bring about better governance and public good. After all, the expectations are high as Delhi voters catapulted the activist party into power with whopping 67 out of 70 seats, forcing Arvind Kejriwal to admit that it was a ‘scary mandate!’
Healthcare is an integral component of the healthy functioning of a society. Good health indices reflect the vigour and development of a society. Delhi is the capital of India and enjoys the status of a partial state being a union territory, but at the same time, has an elected legislative assembly. Thus, its administrative system is a mixed one, with some of the key portfolios lying with the Center. Spread over a tiny area of 1,483 square km, Delhi’s vast population of 1.7 crore makes it the most densely populated (population density more than 11,000 per square km) area in India. This poses huge challenges in all areas, including healthcare delivery system.
        In addition to a thriving private health sector, the health care services in Delhi are also provided by the central and state government. Some autonomous hospital being run on central government funds like All India Institute of Medical Sciences (a super multi-speciality hospital where 1.5 million outpatients visit in a year) and National Institute of Tuberculosis and Respiratory diseases, some directly run by it like Safdarjang Hospital (a huge 1600-bedded multi-speciality hospital), Dr Ram Manohar Lohia Hospital, Sucheta Kripalani Hospital etc. Central government agency ESI has its own hospitals and numerous dispensaries. The CGHS has similarly hundreds of dispensaries for government employees and Railways too operate its hospitals and dispensaries and also there are military hospitals.

At the national level, government of India spends a measly 4.1 percent of its budget on health. Given that, Delhi’s 10 percent looks healthier, but it still leaves a lot to be desired.
        At the state level, the health ministry of Delhi government is a major player. The state government typically spends about 10 percent of its Rs 37,000 crore annual budget on healthcare. It runs 39 hospitals and about 300 allopathic dispensaries. In addition, the state health department runs mobile dispensaries, school health scheme, Centralized Accident and Trauma Services (CATS); and its AYUSH department administers Ayurveda, Unani and Homeopathic dispensaries and hospitals. The department is also responsible for executing several public health programmes.
        At the national level, government of India spends a measly 4.1 percent of its budget on health. Given that, Delhi’s 10 percent looks healthier, but it still leaves a lot to be desired. Given Delhi’s burgeoning population, large clusters of slums (50 lakh population), the healthcare system remains overwhelmed. Visit any hospital in Delhi and you will see lack of resources, overcrowding, and lack of cleanliness. Poor political will, bureaucratic apathy and inertia have contributed to the sorry state of affairs. Many of the rural healthcare facilities are dysfunctional and a burden on the state exchequer because of the gross under-utilisation.
Delhi’s crumbling health care system needs overhaul and some out of the box ideas. While, increasing budgetary spending on health will definitely help, there could be several other ways to meet the need.                 Affordable primary healthcare access is a major challenge for the poor and middle class people in Delhi. Three hundred odd allopathic dispensaries and 9 Primary Urban Health Centers (PUHCs) are clearly inadequate to meet the demand. There is an immediate need to broaden primary health access points. Rather than opening up more dispensaries (thus, opening more avenues for leakage, corruption and inefficiency), we should look at alternative solutions. The existing government dispensaries can act as poly-clinics where credentialed private doctors can be allowed to come and provide healthcare at the affordable pre-determined prices or they can be reimbursed by the government on the basis of volume of patients seen. Similarly, it may be prudent to open up large number of government-approved primary level clinics owned/maintained and operated by independent healthcare providers. The patients can avail the health care from such avenues and the government would reimburse the bills to the doctors.
        The concept of electronic record keeping and biometrics—a common usage in western world—is non-existent in Delhi health system. An investment on this front will bring down the costs in long term and bring traction in the system.
Rather than opening up more dispensaries (thus, opening more avenues for leakage, corruption and inefficiency), we should look at alternative solutions. The existing government dispensaries can act as poly-clinics where credentialed private doctors can be allowed to come and provide healthcare at the affordable pre-determined prices or they can be reimbursed by the government on the basis of volume of patients seen.
         Unfortunately, the governmental systems in India are known for poor quality of services, sluggish pace, an attitude of indifference and inefficiency. Random checks by health minister and officials and improved oversight will surely bring more efficiency in the system.
        Increasing bed capacity in Delhi hospitals is badly needed. Can we re-examine the existing infrastructure and add more beds rather than necessarily opening up new hospitals? The private medical sector is an important asset for Indian healthcare delivery system. Delhi health ministry should have a collaborative approach towards private sector which will result in better coordination, and less malpractices. If the government acts as a facilitator, there will be an incentive for private medical sector to expand bringing down costs and improving services. Similarly, since AAP claims to be a doer and believes in beefing up systems, corporate social responsibility (CSR) is one area, where a pro-active health minister can bring in a lot of money. Delhi can also be developed as a hub of medical tourism. If we reflect upon why Thailand took over us in this field, answers would be apparent!
        Last, but not the least, increased focus on preventive aspect of healthcare will yield better result. More spending on maternal and child health (MCH) and senior citizens is needed.
        In a recent survey done by Arcadis, a Dutch design group, on most sustainable cities, Delhi comes at poor 49th out of a list of 50. The parameters like health indices, income equality, green spaces, sanitation, business environment and GDP were taken into consideration into this survey. Frankfurt and London occupy the top two spots, Chicago standing at the 19th position. The road to a better Delhi is not easy, but an integrated approach will alleviate some of the problems. (MKR)
(Note: The article was first published in the Lokayat magazine:April, 2015)

Various Healthcare Models
Indians constitute 5 percent of doctor workforce in USA (and 20 percent of its International Medical Graduates). Indian health workers are also the pillars of medical services in the Middle East. But in India we have to struggle hard to get proper health care.
By Dr Munish Kumar Raizada
India has one doctor for 1,700 citizens (WHO says the optimal number should be 1:1000). Cuba has 6.7 and America 1.5 doctors for their 1000 population. USA spends about 18 percent of its budget on health. However, this is not to say that everything is in perfect shape in USA. In fact, many experts feel that American health system is ‘broken’ due to its inability to provide health care to millions of uninsured people.
      With this background, let us study the basic health care delivery models that are prevalent in the world. The most prevalent service model is ‘Out of Pocket. In India, we may not have any problem in understanding this concept: You are responsible for footing the fee and bills to the doctor and / or hospital. Well, many will say, the government does provide free universal health care to all its citizens through its dispensaries & hospitals. That is true. India claims (unlike USA) that anyone can visit a government healthcare facility and avail treatment literally free of cost. However, in actuality, the government health facilities are dilapidated, over-crowded and dysfunctional thanks to poor work ethics, chronic absenteeism and corruption, thereby limiting the access for a large chunk of population.
      Contrast this with Britain’s National Health System (called Beveridge Model). Here, the government provides you the health care through its government doctors, clinics and hospitals. The private medical sector is negligible. Everyone is eligible to choose a General Practitioner (GP) who is your primary doctor and avail medical care free of cost (the care is free at the point of use).The government will pay your bills. In communist Cuba, hailed by many as the successful model for a developing world, the same system is seen in extreme form: the whole health care system—be it clinic or a pharmacy—is owned by the government. No doctor is allowed to have a private practice.
      However, Canada also provides a universal health care to its citizens, but in a different way. The government provides every citizen a health insurance (National Health Insurance model). The patient can choose to go to a private clinic or a government doctor or facility.
      Germany has a slightly different system. The government mandates a health insurance for everyone, and that is provided by the employer. The employee also contributes a part of premium. But the whole system is created not to make profit and must cover everyone, even if unemployed.
      The above models are typical examples of what we call Socialised Medicine, where government pitches in to provide subsidies through taxation. In other words, these are public-funded health care programme.
      When it comes to USA, the concept of universal health care becomes fuzzy. According to Institute of Medicine, USA is an exception among the developed countries that does not provide a universal health care. Here the government hardly runs any health care centre (except a few county hospitals administered by county governments. One famous example is Cook County hospital in Chicago). For majority of people, health care benefits come through their jobs. In other words, your employer will buy you a private health insurance. But, you also pay a portion of that premium per month. But if you become unemployed or operate your own business, you have to buy your own private health insurance. However, for army men, the government provides healthcare through government-owned and operated facilities. For senior citizens (more than 65 years of age), the government runs Medicare Insurance Scheme and thus bears the cost of their medical bills (Canadian system).
      India has a mixed system where the government pledges to provide health care, but is unable to meet the demands. The private health sector is robust but the poor and the needy may not be able to use the services for want of money. How do we strengthen the health care system in India, then? We need to increase access to affordable and quality health care for everyone. India needs to increase its budget share on health, particularly on preventive and primary health care. In addition, we must produce more doctors and para-medical forces. Instead of running the health facilities itself, the government will do well to broaden health insurance to its citizens and put good regulations in place so that through private sector, it can provide much needed health care to its citizens.
In Britain private medical sector is negligible
In Cuba whole healthcare system is owned by government
In Canada government provides health insurance to all its citizens
In Germany government mandates health insurance for everyone, but it is provided by employers
In USA the government does not provide universal healthcare
India has a mixed system—government healthcare system dilapidated and private sector robust but out of reach to most citizens

(Note: The article was first published in the Lokayat magazine:April, 2015)

Food hygiene for disease prevention
The World Health Day on April 7 was celebrated around the globe this year focussing on the issue of food safety. The slogan for the occasion given was: From farm to plate, make food safe. Everybody knows that healthy food is an important requirement for health. But today food production has been industrialised and distribution is globalised. These changes have introduced multiple opportunities for food to become contaminated with harmful bacteria, viruses, parasites, or chemicals, which are known to cause more than 200 diseases—ranging from diarrhoea to cancers. Microbial contamination of the food contributes to communicable disease burden. The rise even in the non-communicable diseases has links to the consumption of food high in fats, sugars, salts, residues of pesticides, food additives and contaminants. The WHO has commissioned a study to know the global burden of foodborne diseases. The results are expected to be released in October 2015. The health communication drive is needed to encourage people to practise food hygiene.
(Note: The article was first published in the Lokayat magazine:April, 2015)

Social movement for health
Individuals, families and communities can do a lot to prevent diseases and promote good health. Development of good and efficacious medicines, advanced diagnostic tools and good hospitals cannot reduce disease burden, if the root causes are not addressed. Diseases depend on the social, economic and physical environment where people live and work. Social and employment security can reduce disease burdens. Measures to reduce stress in life and improved safety in the work place should also find place in government policies. People should be encouraged to lead a healthy life style. Preventive measures like practicing Yoga and doing exercises etc should be promoted. Proper efforts should be made to see indoor and outdoor air pollution is reduced. Similarly adequate public investment must be done to make water safe for drinking. For health promotion schools are the ideal places and adequate efforts should be made to create awareness for healthy living. With the help of media, NGOs, schools and colleges and professional organisations and corporates, social responsibility wing should be used to launch a ‘Social Movement for Health’.
(Note: The article was first published in the Lokayat magazine:April, 2015)

Indian System of Medicine
The previous NDA government had adopted a policy in 2002 for meaningful integration of Indian System of Medicine and Homeopathy and a department called AYUSH was created for giving impetus to the new policy. Now again the NDA is enthusiastic about AYUSH services. Last year in October it launched National AYUSH Mission to promote AYUSH medical systems. The mission will be implemented in cooperation with states and union territories. Interestingly, there has been a global trend of integrative medicine. India can contribute immensely in this integration and emerge a global leader in this provided the government allocates sufficient funds for research and development. The incidence of non-communicable disease is increasing and AYUSH has shown better results in tackling this. Indian system of medicine is capable of offering many preventive solutions which could be cost-effective and make the national health system cost-effective.
(Note: The article was first published in the Lokayat magazine:April, 2015)

More focus on comprehensive primary health care
Proposed National Health Policy has highlighted a major change in health care service delivery system. More emphasis would be put on high quality comprehensive primary health care services that would be free, universally accessible and provided as close to where people live and work. Comprehensive primary health care would mean primary care to all in reproductive and child health, communicable and non-communicable diseases. With this enhanced package they would greatly be called health and wellness centre. It has been rightly argued that quality primary health care services would reduce morbidity and mortality at much lower costs to the system and the individual than any other approach. It would reduce the need for costly stay in hospitals. It has been suggested that every family should be given a health card, which should be eligible for a well-defined package of services. This system would help in checking self-medication as well as protect the patient from unnecessary medicalisation. The health and wellness centre teams would be trained to play an important role in counseling, guiding and educating people to avert diseases. Most elements of primary care can be so designed that a nurse or paramedical with suitable training is able to provide the desired care. Several elements of the continuity of care required for chronic illness may also be provided in these centres, thus preventing overcrowding at the hospitals. For providing quality medical services use of Information and Communication Technology would be used which should be possible in the rural areas as well with the ongoing efforts to connect most villages with the broadband connectivity through optical fibre cables. This concept of health and wellness centres should be extended to all urban areas also. For secondary healthcare services the government would have to upgrade all district level government hospitals to the medical college level hospitals. An efficient emergency transport system would also be needed to connect health and wellness centres to these district hospitals where all diagnostic services and medicines can be provided for free. These hospitals would work on a pre-paid system like health insurance.
(Note: The article was first published in the Lokayat magazine:April, 2015)

Government would expand its hospital network
Government will have to expand its own capacity to provide tertiary care services. It can strengthen 58 medical colleges in the first phase, then upgrade 58 district hospitals to become medical colleges and in the third phase build close to 15 more new All India Institutes of Medical Sciences (AIIMS). The centre has six AIIMS which would soon be functioning at full capacity.  This apart a number of national tertiary care hospitals have been declared national centers of excellence. But seeing the growing demand, the need for further expansion of infrastructure for specialty and super specialty services at state level would remain. It is hoped state governments would also pay due attention in this regard. The draft National Health Policy has also indicated that the government would purchase tertiary care in private hospitals to fulfil its obligations created through public insurance policies which may be made universal in coming years.
(Note: The article was first published in the Lokayat magazine:April, 2015)

Thursday, April 9, 2015

National Policy Soon to Ensure Good Health

Will Nadda Deliver ?

 By Bodhi Shri
Union Health Minister J P Nadda

Health and happiness is not only a driver of economic growth but also necessary for evolution of a harmonious society, and thus it should be a goal in itself for any governance system. India currently finds that despite so much advancement in medical technology, discoveries of new medicines and development of new high-tech based diagnostic tools and coming into existence of so many big government and corporate hospitals, people are still suffering from so many diseases and proper health care is not available to them. 
     Government currently endeavours to give final shape to the new National Health Policy to determine how all countrymen can be provided health care at an affordable cost. Currently, the ground reality is that healthcare services are catastrophically high, much because more than seventy percent healthcare facilities are in the private sector, who assumes healthcare only as a business rather than an humanitarian enterprise. Massive growth of tertiary care hospitals in the private sector has no doubt contributed to national growth by way of medical tourism, but for the common people this has only made tertiary health care even more prohibitive. Will the new National Health Policy take care of all these concerns?    

Previous two national health policies of 1983 and 2002 have been successful to achieve their targets to some moderate extent. They contributed in raising life expectancy in the country; also helped reduce population growth rate. A few diseases like polio have been eliminated. Incidence of Leprosy is getting reduced. There are signs of success in controlling AIDS, kala-azar, lymphatic filariasis, malaria, but the situation on the front of TB, dengue, viral encephalitis, chikungunya is not satisfactory. This apart the new phenomenon is that non-communicable diseases are on the rise. The draft National Health Policy mentions that 75 percent of all communicable diseases are not covered into any national health programme. The overall disease burden of non-communicable diseases is 39 percent and of injury-related around 11 percent. And the bigger issue amidst continuing ill health, diseases, premature death is inaccessibility of health care facilities in many parts of the country and unaffordable to majority of Indians, no matter they are in rural or urban areas.  
     A new phenomenon is increasing urbanisation as people from rural areas migrate in large numbers, but a very large percent of such people live in slums. Today, about 31 percent of our population lives in urban areas and 17 percent of this urban population lives in slums. They might be living in cities with big corporate hospitals, but for them modern health care facilities remain out of bound. Realising this, perhaps, the outgoing UPA government had launched National Urban Health Mission (NUHM) in 2013 with special focus on urban poor and marginalised population groups like rickshaw pullers, street vendors, railway and bus station coolies, homeless people, street children, and construction workers. 
     Modi government’s proposed National Health Policy seems to retain this focus. But to implement this policy would require huge funding from the Centre. The health comes in the concurrent list and the Centre would be obliged to contribute to the extent of 75 percent and the rest would be provided by states and union territories. In Uttarakhand, Himachal Pradesh and Jammu & Kashmir Centre’s contribution under NUHM was fixed at 90 percent.

Healthcare sector in India is growing very fast 

India has succeeded in absorbing latest medical technologies developed anywhere in the world quite rapidly, but their affordability to most of the population is suspect due to high costs. There is tremendous increase in number of hospitals in the private sector, , of all types, big and small,  contributing in the growth rate of the country, making India a hub for medical tourism, but for the countrymen due to high costs they remain inaccessible. In emergency even poor people do go to them but to find ultimately their savings and assets badly dented. 

     The new National Health Policy has to look at this aspect seriously while making efforts to help health care sector remain as an engine of growth and job-creation. The health care industry is growing at 15 percent compounded annual growth rate and this has been estimated to reach 21 percent in the next decade. Recently with the passage of the Insurance Bill which has increased the FDI limit to 49 percent from 26 percent in the insurance sector, the growth of health sector may even be better than estimated.
     The private health care industry is valued today at Rs 240,000 crore and it is expected to become twice bigger by the start of the next decade. Half of this amount is related to hospital and clinical care. The private health care constitutes nearly 80 percent of outpatient care and about 60 percent of inpatient care. An interesting feature of this is that 72 percent health care enterprises are owned by single professional (a doctor), but the situation has started changing and number of employing enterprises in private sector is increasing. However, the National Sample Survey Organisation in its 60th round revealed that public sector health units were more efficient and truly the value for money. Will the present government in the Centre would pay attention to this aspect and allocate sufficient money in this sector? This definitely will go a long way in improving efficiency of the money spent on health care.  
     No matter what Congress detractors might say, the fact is that the ten year average growth rate had been the highest ever recorded in the country during the UPA regime. Despite this high growth in economy, share in healthcare spend in the country did not improve. Total spend in healthcare is 4.1 percent of the GDP and in this government spending is only 1.04 percent of the GDP though the National Health Policy, 2002 had envisioned it to increase it to 2-3 percent. This shows government spending is only one fourth and the rest comes from individuals’ pockets. Central government spends only Rs 325 per person in a year on health while states spend Rs 632 per person. Individuals on an average have to spend Rs 3,700 per year out of his own pocket to get health services. 
     In India government’s share in health expenditure is 30 percent of the total while developed countries like UK, Japan, Sweden, France and Germany spend more than 76 percent, a few countries upto 86 percent. Health activists have demanded the public health expenditure should be raised to minimum 4 percent of the GDP. Seeing the target of NHP-2002 of 2 percent of GDP could not be met, the current draft policy has proposed to raise it to 2.5 percent of the GDP. 
     The paradox is the good health of people contribute in economic growth, but this is not reciprocated in higher healthcare spend. The result is in 2011-12, people in rural areas were spending 6.9 percent of their household expenditure on healthcare alone which is quite high seeing the income levels in rural areas. It was 5.5 percent in urban areas also. Since government hospitals and dispensaries are fewer than needed and remain over-crowed, people per force go to private hospitals or clinics. 
     There are eight states like Andhra Pradesh, Karnataka, Tamilnadu, Maharashtra etc, where the state governments have introduced health insurance schemes for people living below poverty line to meet their hospitalisation expenditure to the extent of Rs 30,000. With this insurance they can afford to enter in private hospitals also to seek treatment. Central government also launched a similar Rashtriya Swasthya Bima Yojna in 2008 under which a family was required to pay a maximum sum up to Rs 750 per year. The biometric enabled smart card ensured that only real beneficiaries got the benefit. The scheme was unique in the sense it could be used in any RSBY-empanelled hospital across India. Yet 75 percent population of the country is out of such insurance coverage. Not all people below poverty line have been included under this government insurance scheme. The situation becomes even more pathetic when it is found that the RSBY card-holders do not know about how to use the card and in what circumstances. 
     Meanwhile there are suggestions from several quarters to merge all state and central schemes into one and improve the delivery of healthcare services under this public insurance system.
(Note: The article was first published in the Lokayat magazine:April, 2015)