State Health Policy – Uttar Pradesh

Greetings on Basant Panchmi. it’s an auspicious day. A few months ago, I was here for the workshop on health policy, and I am happy to see that the draft policy has shaped up well and the inputs have been incorporated. I congratulate the team under the leadership of Shri. Sidharth Nath Singh ji, Hon’ble Cabinet Minister for Health, Government of UP for setting the direction for improvement in healthcare in this large state. With 21.3 crore population, and the role of health as a creator of jobs and its role in growth of the economy and most importantly, Healthcare of UP and Economy of the state is critical to India’s sustainable growth, you have the biggest share of challenges and the opportunity. Also, there is no model available anywhere in the world which you can cut, copy and implement. Financial resources will be a challenge and you have factored the same in your document well. You will have to innovate.

Let me first speak about the document and then its contents. “Excellent document” is my first reaction.

I have looked at the document from three perspectives;  Increasing access, improving quality and lowering the cost delivery. this is the overarching theme for SHP and this was same for the NHP

This policy document is actually of 26 pages which makes it really crisp and to the point.  The remaining 30 pages is situational analysis. When I looked at the NHP 2017, I had split the situational analysis into a separate document, so the policy actually is a much shorter document and the role of policy is to give a direction, and this document does it really well.

Now, coming to the positive side: UP has a large population and Uttar Pradesh ranks first in terms of both adolescent and youth population in the country, accounting for 19.3% of total adolescents of the country and 17.5% of India’s youth. Hence the overarching theme of SHP should be ‘Population Health’. This where we have to go beyond the sick care model. Investments in ‘primary care and primary prevention’ will yield the best long-term dividend

Also, there is not much baggage here in terms of legacy of systems, as we need to start afresh in many areas. Also, learning is available from other states and even some countries as to what has worked. We have the success stories of NACO, Pulse polio, RSBY, TMSC.  All these give UP a good chance transform its healthcare.

Coming to the policy issues;

• Sri Lanka with less than 4 % GDP spend on healthcare has much better indicators and we have a lot to learn from the Sri Lanka model
• Data – timely and accurate is a must which will lead to Transparency, outcomes and accountability
• Awareness and sensitization needs investment and an institutional structure like NACO. Set up a State Institute for Health Promotion (SIHP)
• There is an alarmingly high rate of TB and this must be project like Pulse Polio, where pro-active outreach lead to massive results

Not only there is a transition in demographics and between Communicable and Non- Communicable diseases, there is a transition within each of the CDs and NCDs

• Dengue is now responsible for maximum ICU admissions and hence Vector borne diseases must be addressed. Similarly, the JE & AES is endemic to some areas, and it must be addressed
• Within NCDs, there is going to be a transition in a decade due to our life styles and changed food habits . We will have more problems associated with liver related disorders, obesity, joint replacements. Similarly, COPD will be a big challenge due to the deteriorating environment,
• Mental Health will be a big challenge due to unrestricted access to the net, gaming as an addiction, and loosening social values and family bonds. This must be factored in the policy.
• UP has a large section of population into jobs (organized or unorganized) but I did not find the mention about occupational health. Occupational health guidelines need to be framed and enforced. Else, it will cost us dearly
• Nutrition and diet needs to be focused and you need to prepare diet charts and calorie exchange app and popularize It as a part of the awareness campaign. Micro-nutrient deficiency screening is missing in the document and we need to address it
• When it comes to HRH, the long-term goal should be District Level Self-sufficiency. This will also help in retaining locally trained and educated people to work in rural and semi-urban area
• Tribal Population and migrant population’s health needs to be looked into, I did not find a mention about the same
• Children’s health via School based screening must be factored, and is not in this document
• Innovations hold the key ,but I did not find a mention about it
• Given that funding will remain a challenge, UP must look at asset light models of care. Will share the details

Addressing the issue of primary care and gate-keeper:

• It is a fact that sending doctors to rural areas will remain a challenge and will be patchy in its implementation and hence, I suggest the policy to consider
  • Leveraging technology: Set up mobile app based health helpline, where doctors sitting in towns can provide advice and prescriptions for acute ailments based on STPs (standard treatment protocols). Also, symptoms for common ailments can be put in this interactive app. Technology allows you to do it.
  • Pharmacy is the first POC ( Point of care) and Pharmacist is the first responder for acute ailments. Please use this network as a gate-keeper in addition to nurses, as physician assistants.
• Biggest challenge in healthcare is lack of trust. A recent survey has brought to light that 92% of the people don’t trust healthcare. Hence, it is that soft skills program for health professionals is initiated on priority
• I am not sure, if I know the formula for success but for sure, I know the formula for failure. Have the same program implemented in same manner in all the districts. You have 75 districts in the state, some problems are endemic, there are high risk districts with regards to various health issues. Same needs to be factored in planning.

Governance and leadership:

 Reforms are needed in

Clinical, logistics, manpower and administration and governance

Transforming Governance should be ‘qualified’ in its statement as “making healthcare system data driven, transparent and outcome oriented”. You need to engage community representatives in the planning, monitoring and evaluation to make meaningful changes.

Governance reforms are desired in administration, financing and in delivery, and at the ministry level, at the administration level and in the last mile delivery of service and service providers.

• The Department of health, family welfare, department of medical education must be merged, I would even say that ICDS be brought under the health ministry to make a meaningful difference to the healthcare delivery and to improve the health indicators.
• Not just Multi-sectorial approach but we need a unified Ministry for Population Health, which includes every department that deals in health directly like, medical education, health, family welfare, AYUSH, nutrition, Pharma FDA to address the continuum of care

Siloed working will never deliver as we will not have convergence and synergy in our efforts. We will continue with duplication and the populations will continue to suffer. Breaking the silos is the biggest disruption

Monitoring and evaluation needs to aim at “Implementation and enforcement”.  Also, if you want to transform, please ensure that there is a ‘spot inspection’ of healthcare providers. There is no other way you can see the ground reality. Please ensure a role of community in planning and execution of programs, it will make a big difference in effective delivery of healthcare services

Delayed payments have led to deaths. Please ensure payment within a defined period, and levy a fine on the approving official for delay.

Implementation framework is missing and we need to mention about the same in the policy , and it should be developed alongside the policy

 Private sector:

Role of private sector is going to be important and hence, there needs to be frame-works for pricing, STPs, EWS beds, oversight mechanisms for ensuring quality, affordable and outcome driven care delivery. Hospital costs account constitute a major chunk of healthcare spending and chronic co-morbidities consume majority of healthcare spending. I would love to see effective steps taken for secondary prevention. The word secondary prevention is missing in SHP.

Please sit with private sector and arrive at a rate for treatments packages. Given that insurance will happen sooner or later, this must be done so that there is transparency in treatment

Both private and public facilities should mandatorily disclose diagnosis and treatment data via health information exchange. Also, this will help understand the treatment and success rates across public and private facilities for corrective action

AYUSH:

AYUSH professionals have their own place in the healthcare system and this system has served our country for 1000s of years. Let us work towards clinical validation and effective utilization of their strengths rather than making them subservient to the allopathic system

Sanitation: A week back, I visited the Kumbh Mela site with Shri Sidharth ji, and in my view, the model for sanitation is available for replication across the state

New Models:

Initiate “Janta clinic” model and go beyond the Jan Aushadhi and AMRIT pharmacies. Where POCD, Physician assistant and medicines should be available at 20-30 rupees for people who can pay and free for the marginalized and poor, and let us take this model to marketplace, and ensure that people don’t have to go beyond 30 mins to reach the nearest first clinical responder by walking

Gradually, transition or supplement sub-centres to mobile clinic model with primary care and testing facilities, which can double as an ambulance in the times of need.

Number of households in UP 33.4 million in 2011. Do a GIS mapping of households and healthcare providers. Please use IOT, big data, AI and cloud and do a periodic epidemiology survey through mobiles, and even factor the use of block chain technology if you are drafting a health policy that will impact this state for the next 10-20 years. Remember, we are taking of SMART cities and health is an integral component. I did not find a mention in the document about epidemiology and SMART cities.

Households be linked to health risk assessment tools which could be made available online and are clinically validated. This will help us in addressing issues at the right time.

Population control is missing and needs to be addressed. UP is a big state and it has a large chunk of population which is poor, and hence, we have to ensure quality care for all, but not free for all. Steps have to be taken with inbuilt mechanisms, that those who can afford to pay should not seek free healthcare at the cost of poor. Insurance model needs to developed with time bound – progressive scaling up in terms of entitlements, beneficiaries & benefits

A note to those who are drafting the document, please avoid mentioning brand names of medicines, and statements like ‘consumption of supplements and vitamins etc. are inessential, inappropriate and irrational’.

Health of the people is directly proportional to the economy of the state

UP has all the elements of challenges and opportunities which makes it a fertile ground to find the solution the world is looking for, and I am confident that we will turnaround Uttar Pradesh into Uttam Pradesh

These are the key points from the speech delivered by Mr.Rajendra Pratap Gupta , a leading public policy expert at the Consultation workshop organized by the Government of Uttar Pradesh for drafting the State Health Policy on 22nd January 2018 @ Lucknow