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
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 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
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
India needs a holistic care system that is universally accessible, affordable and effective and drastically reduces the out of pocket spending on health. NRHM has failed to meet the objectives and will be radically reformed. BJP accords high priority to health sector, which is crucial for securing the economy.
The overarching goal of healthcare would be to provide, ‘Health Assurance to all Indians and to reduce the out of pocket spending on health care’, with the help of state governments.
The current situation calls for radical reforms in the healthcare system with regards to national healthcare programs and delivery, medical education and training and financing of healthcare. Our government would focus on the following reforms in healthcare:
- the last healthcare policy dates back to 2002. India now needs a comprehensive healthcare policy to address the complex healthcare challenges, keeping in view the developments in the healthcare sector and the changing demographics. BJP will initiate the New Health Policy.
- initiate the ‘National Health Assurance Mission’, with a clear mandate to provide universal healthcare that is not only accessible and affordable, but also effective, and reduces the OOP spending for the common man.
- Education and Training – Will review the role of various professional regulatory bodies in healthcare and consider setting up an overarching lean body for healthcare. High priority will be given to address the shortfall of healthcare professionals.
- Modernize Government hospitals, upgrading infrastructure and latest technologies.
- Reorganize Ministry of Health and Family Welfare in order to converge various departments dealing in healthcare, food and nutrition and pharmaceuticals, for effective delivery of healthcare services.
- Increase the number of medical and para-medical colleges to make India self sufficient in human resources, and set up an AIIMS like institute in every state.
- Yoga and Ayurveda are the gifts of ancient Indian civilization to humanity and we will increase the public investment to promote Yoga and AYUSH. We will start integrated courses for Indian System of Medicine (ISM) and modern science and Ayurgenomics. We will set up institutions and launch a vigorous program to standardize and validate the Ayurvedic medicine.
- Move to pre-emptive care model where the focus and thrust will be on child health and prevention.
- School health program would be a major focus area, and health and hygiene will be made a part of the school curriculum.
- Focus on Rural Health care delivery.
- Senior Citizens healthcare would be a special focus area.
- Give high priority to chronic diseases, and will invest in research and development of solutions for chronic diseases like obesity, diabetes, cancer, CVD etc.
- Occupational health programs will be pursued aggressively.
- Utilize the ubiquitous platform of mobile phones for healthcare delivery and set up the “National eHealth Authority” to leverage telemedicine and mobile healthcare for expanding reach and coverage and to define the standards and legal framework for technology driven care.
- Universalization of emergency medical services-108.
- Re-orientation of herbal plants board to encourage farming of herbal plants.
- Population stabilization would be a major thrust area and would be pursued as a mission mode program.
- Programme for Women Healthcare with emphasis on rural, SC, ST and OBC in a mission mode.
- Mission mode project to eradicate malnutrition.
- Launch National Mosquito Control mission.
Poor Hygiene and Sanitation have a far reaching, cascading impact. We will ensure a “Swachh Bharat” by Gandhi ji’s 150th birth anniversary in 2019, taking it up in mission mode by converging resources and building around jan bhagidari:
- Create an open defecation free India by awareness campaign and enabling people to build toilets in their home as well as in schools and public places.
- Set up modern, scientific sewage and waste management systems.
- We will introduce Sanitation Ratings measuring and ranking our cities and towns on ‘sanitation’; and rewarding the best performers.
- Make potable drinking water available to all thus reducing water–borne diseases, which will automatically translate into Diarrhoea–free India.
Rajendra Pratap Gupta
Authored the BJP Election Manifesto 2014 under the Chairmanship of Dr.Murli Manohar Joshi
Rajendra Pratap Gupta
President & Member
Board of Directors
October 27, 2013
Shri Keshav Desiraju
Secretary to the Government of India
Ministry of Health & Family Welfare
Nirman Bhawan, New Delhi – 110108.
Reference: Need for a National Health Policy – NHP
Dear Shri Keshav ji,
I am writing on behalf of the Disease Management Association of India – The Population Health Improvement Alliance. We have been proactively taking up issues with regards to healthcare policy & reforms in India.
On February 01, 2013, when you were appointed as the Health Secretary, people involved with the health sector felt happy that the nation had got its best health secretary! Expectations are running high!
This communiqué is about the need for setting up a team to draft the National Health Policy. Since the last National Health Policy was drafted more than 10 years ago in 2002, a lot of things have changed, like;
- NRHM was launched in 2005 as a flagship program focused on rural health
- RSBY was launched
- Pandemic outbreaks like H1N1 (Swine Flu) have been a surprise and have shaken the world
- Rise of MDR – T.B.
- Increase in the incidence of chronic diseases & the issues related to child health
- Occupational hazards
- High IMR/MMR & MDGs deadline approaching in 2015
Besides, a lot of other developments have taken place, like;
- UID –Aadhaar number for the entire population have been initiated
- Emergence of mHealth & telemedicine
- Newer technological interventions for diagnostics and treatment
- Emergence of Big Data Analytics
- Also that, India is focusing on transitioning the healthcare system to Universal Coverage
- Emergence of innovative concepts, like Disease Management, ACOs (Accountable Care Organizations), HMOs (Health Management Organizations) & Meaningful use.
- Emergence of the prominent role of civil society organizations in healthcare delivery
- Role of social media
The 12th five year plan has often been referred to as the plan for health, and I believe, that it is the right time to set up a committee to draft the new National Health Policy by 2015. Even if the committee is set up in early 2014, it will take at least a year to do the survey and complete the policy and so, most likely, the NHP would be tabled by 2015 and would cover a period of next 10 years (2015-2025).
We are sure that you will consider our request seriously and initiate the process for the new National Health Policy
With best wishes and with warm regards
Rajendra Pratap Gupta
Dr.Manmohan Singh, Prime Minister, Government of India.
Shri. Ghulam Nabi Azad, Union Minister for Health & Family Welfare
Dr.Syeda Hameed, Member, Planning Commission, Government of India
Presidents of all the National Political Parties
I was on a call with a leading political party to discuss the Universal Health Coverage and i raised the following points for them to attend ;
1. Defining the UHC – We need to first define , what is Universal Health Coverage .
2. Focusing on execution – increasing the absorptive capacity on healthcare system – Even 1 % of GDP allocated to healthcare is not being used properly . How will we use 3 % ?
3. Ideating the UHC model – whether it should be pay for use ( except for BPL ) ? Anything free will be worse than what we have today
4. Using technology including telemedicine and mHealth
5. PPP for healthcare outcomes and delivery
Hopefully , this party will be taking care of these points as well . This is the third political party that has sought my views on its Health Policy
Rajendra Pratap Gupta
Rajendra Pratap Gupta
President & Board Member
February 13, 2013.
Dr. M.M. Pallam Raju
Union Minister for Human Resource Development
Government of India
Shastri Bhawan, C- Wing, Dr.Rajendra Prasad road.
New Delhi- 110001
Subject: Implementing strategies focusing on Child Health through Ministry of Human Resource Development
I am sure this finds you doing well.
This note is a follow up on my earlier communications on including health education in school / college curriculum. Please refer
- Communication regarding Child Health dated 11th Feb,11 http://dmai.org.in/sites/default/files/Unhealthy_Promotions_MOHFW.pdf
- Communication dated July 11, 2011 on the UN High level summit for Heads of States. http://dmai.org.in/sites/default/files/Note%20to%20PMO%20for%20UN%20Summit%20on%20NCD’s%20%20September’11.pdf
- Communication dated 8th August 2011 regarding, Right to Preventive Care & child health . http://dmai.org.in/sites/default/files/Right%20to%20Preventive%20Care.pdf
- Communication to Shri Kapil Sibal, Former HRD Minister, for including health in the school curriculum. http://dmai.org.in/sites/default/files/Healthcare%20in%20School%20Curriculam.pdf
- Communication dated October 10th, 2012 to Shri Ghulam Nabi Azad, Union Minister of Health & Family Welfare on ‘Pre-emptive care’ focused on child health. http://dmai.org.in/Pre-emptive-Care-A-new-model-of-care.pdf
- My address at the United Nations, on why we need to focus on Child Health? http://www.youtube.com/watch?v=qCTKC4ndjsc
Implementing strategies to ensure good heath among children would require collaborative working between the
Ministry of Human Resource Development along with Ministry of Health & Family Welfare & the Ministry of
Women & Child Development & the Ministry of IT & Communications . We have been following this issue very
closely, and have sent numerous proposals and met up with various officials from time to time.
The following, if not yet implemented, would be a good step to promote child health ;
1. Start a chapter on hygiene & oral care from class 1 onwards
2. Create animated pictures and videos for children’s health that could be multilingual, and can be screened nationally in classes or using mobile health as a medium to disseminate the audio visuals .
3. Have a chapter and subject called ‘Essentials of health’ , which is exam based
4. Define child health and check-up guidelines on the lines of vaccination charts till the age of 15 years. This can
be done by the Ministry of Health & Family Welfare and incorporated in the school curriculum.
5. Child obesity is a serious issue, and this can be addressed by giving right knowledge about ‘Calorie exchanges’. Since parents teach the children, they will also get educated on the same and impact the family’s health. This must be added in school curriculum from class 3 onwards
6. Work outs or Yoga / mediation must be introduced in all schools
- All schools must have ideal height / weight / age charts in all classes, and every 6 months these must be reported in the half-yearly and annual report card. The same way as attendance, neatness , punctuality etc. are reported in class report cards at the PTMs (Parents Teachers meetings)
- It would be a great move if we start giving out 3 %marks or give a grading of A, B or C ( A for being fit for standards , B for borderline & needs improvement & C for being much below the child health metrics ), for various health indicators like dental hygiene, height and weight (BMI – Body Mass Index ), hemoglobin, Vitamin B & D etc.
- Each school / college should have a full-time doctor / health educator
- Junk foods & associated calorific intake needs adequate attention in school level awareness campaigns
- Children do not realize the importance of having adequate quantity of water, and since, in school, they are sometimes restricted to go to toilets, it is high time that the guidelines are issued to all schools for adequate water consumption & availability of drinking water & toilets in school (It might sound trivial, but it is very
Hope this issue will be given the highest priority and attended at the highest level. We will be raising this issue in parliament though members of Parliament from different political parties
For this generation, we are already too late, but we must ensure that the next generation is a healthy one.
In hope of the needful
Rajendra Pratap Gupta
Shri. Ghulam Nabi Azad, Union Minister for Health & Family Welfare.
Shri Kapil Sibal, Minister for Communications & IT
Smt.Krishna Tirath, Minister of state (I/C) for Women & Child Development
Dr.Syeda Hameed, Member, Planning Commission, GOI.
Shri. T.K.A. Nair, Advisor to the Prime Minister.
Shri Keshav Desiraju, Health Secretary, GOI.
Shri Ashok Thakur, Secretary, Min. of HRD.
Shri Prem Narain, Secretary, Min. for Women & Child Development.
Dr.Jagdish Prasad, DGHS, MOHFW
Dr.K.Srinath Reddy, President, PHFI.
Rajendra Pratap Gupta spoke at the United Nations General Assembly Hall on the issue of NCDs ( Chronic Diseases). This was for the Heads of State Summit on NCDs.
Yesterday, i participated in the meeting of what the United Nations must do to the MDG’s ( millenium Development Goals ) post 2015 , when the MDG’s comes to an end in terms of the timeline .
I have suggested that ‘ without sustainable livelihoods for a family’ , MDG’s could never be achieved , so this must come at the forefront .
Access to ICT’s should be made a MDG
Improving life expectancy makes sense seeing the infant mortality and maternal mortality
Further , the MDG’s related to health be ‘clubbed’ and the definition be expanded to provide access to ‘ Preventive health’ as a MDG
Multi-skilling along with education needs to be put than the universal primary education as a MDG
Also, private sector needs to be involved in conceptualization , planning and execution . I further added , that , if the private sector was involved as a partner in MNAREGA and MRHM , things would have been different
Charity is as deep as profits …… time to work as a TEAM ( PPP), else ‘laudable’ goals will become ‘laughable’
Rajendra Pratap Gupta
Rajendra Pratap Gupta
President & Board member
December 27th, 2012
Dr. Murli Manohar Joshi
Public Accounts Committee
6, Raisina road, New Delhi 110001
Ref: Auditing of the unused budgetary allocations for Healthcare sector
Dear Dr. Joshi,
Greetings from the Disease Management Association of India (DMAI).
This has reference to the meeting at your residence on 25th December 2012, and the discussions that we had on the Public Accounts Committee report on NRHM (PAC NO. 1939). I have gone through the PAC report submitted by your good self to the Parliament. I wish to draw attention to the following references in your report;
Page 9: Mission Steering Group (MSG) was required to periodically monitor progress of the mission and to meet twice a year. Audit scrutiny revealed that MSG met only four times in four years instead of 8 times as per the laid guidelines.
The delegation of powers to the MSG and EPC (Empowered Programme Committee) was subject to the condition that a progress report regarding NRHM, also indicating deviation from the financial norms and modifications in ongoing schemes, would be placed before the cabinet on an annual basis. However, during the past four years, the Mission had submitted a progress report to the Cabinet only once in August 2008 (as per the PAC report).
Page 12: Public Private Partnerships (PPP) in RCH services is not up to the expected levels
Page 18: Regarding composition & functioning of the VHSC (Village Health & Sanitation Committee)
Secretary Health’s statement,
“To be very honest with you, we have got a survey done recently by the Institute of Population Sciences, and yesterday they gave us a presentation. It is not a very happy picture on the village health societies. In many of them, people did not know if they existed; they did not know who the members are; they did not know if they are functioning; that was the finding of the planning Commission’s mid-term review also, when they had gone round the country and seen… that is VHND. There is certainly a vision in the NRHM when it was designed. That has not been fructified……….
“ Our experience with Panchayat raj is not good. They also complained about it. Half of the fund is not spent because he is the co-signatory – either he is not living in the village or if he is, he harasses her and why should she sign? The entire Panchayat raj system, with due respect, has not really worked; the ideal is one thing, but practically it is not; those who take interest, have got excellent experience, but those who are not interested, it is not good. It is very difficult for these people; it has not worked out well”.
Page 19: Health Secretary’s response on, “how the ministry ensures that the disbursal of funds by the state health societies to VHSCs is monitored”?
“This is a huge task for the states. They are finding it very difficult to keep a track of so many small accounts. But we have given them accountant at every block level. In a block there will be some 100 VHSCs. He should have been able to get these accounts and see what they have spent on and do the auditing. We will have to streamline it further and get them to do the auditing. But we suspect about Rs.100-200 Crore lying unspent. That is our present assessment”
Page 20: Table 3 highlights the gap between the funds released and expenditure.
Page 23: Point 55, “ However, the Ministry have clarified that actual utilization of the funds allocated shall depend upon a number of factors in particular the absorptive capacity of the system. In fact, one of the argument put forward by many is that while the actual allocation in the Eleventh Plan was lower than the original plan allocation, the actual expenditure has still been lower i.e. the system has not been able to utilize the curtailed outlay”
Page 28: “It may be observed that rural households account for around 55 % of the total out of pocket expenditure within the country”
Page 31: Audit examination revealed that 71 PHCs (11 per cent) in 15 states were functioning without an allopathic doctor. In 518 PHCs (86 per cent) of 28 States / UTs, an AYUSH doctor had never been appointed. 69 test checked PHCs were functioning without an allopathic doctor or an AYUSH doctor. This meant that population residing in their sphere of coverage had no doctor available at all in the public domain. In Andhra Pradesh, Haryana, Himachal Pradesh, Kerala, Madhya Pradesh, Mizoram, Punjab, Sikkim, Tripura and Lakshadweep, none of the test checked centres had an AYUSH doctor.
Page 33: “As per norms, Specialists are appointed only at CHCs level and not at PHCs level. As per the data available in Bulletin on Rural Health Statistics in India (Updated up to March 09), a total of 5789 specialists are in a position at CHCs across the country, as against the sanctioned posts of 9028 specialists…………”
Dr. Joshi, as discussed during our meeting, it is imperative that the PAC / CAG, or any competent independent regulator, starts the audit of unspent funds allocated for each social sector so that the benefit of the plan reaches the targeted population. As DMAI, we would be interested in pursuing this issue further with the concerned authorities. Also, a clear and enabling policy framework is required, so that the bureaucrats can take decisions without fear on fund allocation utilization, and the absorptive capacity of the system increases to 100 %.
I have been visiting the rural sub-centres and have been gathering first hand information about the impact of NRHM. This communiqué is marked to the PMO and MOHFW for information. Will meet you shortly with more details
Thanks for your continued support
Best wishes for a great year ahead, & tons of good wishes for your birthday, in advance. Wish you good health & long life.
With best regards
Rajendra Pratap Gupta
CC: Dr.Manmohan Singh, Prime Minister,
Shri Ghulam Nabi Azad, MOHFW
Dr.Syeda Hameed, Member, Planning Commission
Secretary – MOHFW
President , PHFI
Rajendra Pratap Gupta
President & Member
Board of Directors
September 22, 2012.
Government of India
7, Race Course road, New Delhi -110001.
Reference: National Digital Health Plan (NDHP)
Dear Dr. Singh,
I am sending this note on behalf of DMAI – The Population Health Improvement Alliance.
About Disease Management Association of India (DMAI) Disease Management Association of India (DMAI – The Population Health Improvement Alliance), was formed by Executives from the Global Healthcare industry to bring all the stake holders of healthcare on one platform. DMAI has been successful in establishing an intellectual pool of top healthcare executives to become an enabler in building a robust healthcare system in India. India is on the verge of building its healthcare system, and it has a long way to go. DMAI is building the knowledge pool to contribute & convert ‘Ideas’ into ‘Reality’, for healthcare in India. DMAI is the only not-for-profit organization focused on population health improvement in India
Let me start by quoting Kathleen Sebelius, Health Secretary of the United States, “Mobile Healthcare is the biggest technology break-through of our time to address our greatest national challenge”. Ms. Sebelius said this last year at the mHealth summit in Washington DC. This statement is more relevant to our country as, though for the developed world, mHealth is another option for healthcare delivery but for a developing country like India, mHealth is the only option!
We urge upon your good selves to initiate the National Digital Health plan – NDHP (Digital Health means Telemedicine, mHealth & technology backed healthcare delivery) for India, and may be, consider to form an inter-ministerial group to give this a definite shape. According to WHO review in 2010, only a quarter of countries worldwide had drawn up a national telemedicine policy or strategy. Let us take the lead in setting up the National Digital Health Plan (NDHP).
With 6 billion mobile phones globally at the end of 2011 and about 960 million cell phones in India, mobile phones provide a matchless platform for delivering change at the grass roots and are a tool
To deliver programs aimed at economic & social inclusion & more importantly, inclusive healthcare.
We must think seriously & act now about incorporating Telemedicine & mHealth (mobile healthcare) in our healthcare system and building a road map of Digital Health for India. With over 800 million people living in rural India and about 640,000 villages as per the latest data of planning commission’s approach paper for the 12th five year plan, it is imperative that we build a national roadmap for telemedicine in India to address the issue of accessibility & affordability with sustainability on one side, and on the other side, for leveraging a global business opportunity for Indian entrepreneurs, like what IT (Information Technology) did to India’s growth story. It is time to replicate the IT success story this time using mHealth and help the industry build a few multi-billion dollar global corporations
Telemedicine is needed for delivering ‘Inclusive healthcare’ to India & also to serve across various sectors like in defence, help in job creation, veterans’ health and disaster management.
Defence services: We need Telemedicine through dedicated satellites for armed forces posted on Naval Ships and remote areas at the border and at Siachen. Also, the ECHS for ex-servicemen could have a healthcare facility through Telemedicine at various polyclinics .This must be initiated and the ECHS clinics must be connected with Army referral centers. US Veterans administration, for e.g., found that overall the practice of telemedicine / mHealth cuts hospitalization by 30 % & admissions for heart failure by 40 %
Disaster Management: During national disasters, Telemedicine & mHealth can be the only healthcare delivery channel for the affected areas and this calls for a Telemedicine road map under National Disaster Management Authority (NDMA), at the Prime Minister’s office. During Tsunami in Japan, Continua Health Alliance members came together and gave a solution in a record time. It would have been a double catastrophe, if such a Tsunami ever destroyed paper medical records and the patients had to be moved to a remote place for treatment. Nothing could have been worked without medical devices which were interoperable and an EMR hosted over a cloud. This calls for immediate planning to avoid healthcare disaster along with a natural disaster!
Chronic Diseases: In the USA, FDA (Food & Drugs Administration) has started approving mHealth applications and two of the insurance companies recently agreed to pay for mHealth applications for diabetic patients. mHealth holds the promise to address the biggest challenge facing our nation i.e. chronic diseases & the implementation of secondary prevention program
With approximately 960+ million cell phone users; healthcare in India will converge to mHealth, and ultimately, this is where all practitioners, payers and users will converge too! It is time to look at mHealth as a tool for ‘Inclusive Healthcare’. With mHealth, ‘Universal Healthcare’ will move faster from a dream to reality!
Earlier, it was said that, ‘An apple a day keeps a doctor away’, and now it is being said rightly that, ‘An app ( mobile application ) a day keeps a doctor away’.
According to the PWC & Economist Intelligence Unit (EIU) recent study – 2012, conducted in 10 countries including India, Patients believe that convenience, cost and quality of health in the next three years will change due to mhealth
According to this study;
59 % of the doctors and payers believe that the wide spread adoption of mhealth in their countries is inevitable
In the next 3 years,
57 % of the patients in emerging markets believe that mHealth apps / services will make healthcare more convenient
54 % of the patients in emerging markets believe that mHealth apps / services will improve the quality of care
53 % of the patients believe that mHealth apps / services will substantially reduce the overall cost of care
59 % of the emerging-market patients use at least one mHealth application or service.
The Department of Health, U.K. had set up a WSD (Whole System Denominator) program to help provide an evidence base for setting further policy in this field. This was claimed to be the largest randomized control trial of Telehealth & telecare in the world. The program was launched in May 2008 involving around 6200 patients and 238 GP practices. Early indications from WSD show that, if used correctly, Telehealth can deliver a 15 % reduction in accident & emergency visits, a 20 % reduction in emergency admissions, a 14 % reduction in elective admissions, a 14 % reduction in bed days and an 8 % reduction in tariff costs. They also demonstrate a 45 % reduction in mortality rates
According to Lord Nigel Crisp, Former CEO of NHS, U.K. (National Health Service) and Member, House of Lords, ‘In UK, NHS direct started free health advice service over phone. It has over 6 million subscribers, over 10% of the country’s population’.
For chronic disease patients, Home care based ‘Nuvola It Home Doctor system’ was developed by Telecom Italia in the Piedmont region. As a part of the policy to bring health services closer to the community, patients suffering from chronic diseases monitor certain biological parameters using traditional electro-medical devices and send them to the Telecom Italia data center, using a dedicated mobile phone provided by the hospital. Home-based care is estimated to cost 180 euros compared to 700-1000 euros in hospital. mHealth based home care can provide tremendous relief to geriatric patients in India, in addition to psychiatric patients with the existing ratio of psychiatrists: population nearing 1: 10, 00000
OPD workload in Government district hospitals: In India, the biggest problem in district hospitals is the patient overload in OPD (Outdoor patients department).
By using mHealth / telemedicine, we can provide right timely interventions at the point of care and cut this OPD overload anywhere by 30-60 %.
mHealth as a tool for diplomacy: A few years ago, ISRO had taken up some key initiatives along with the Ministry of External affairs for setting up the ‘PAN network’. It is time to revive that actively, and provide remote consultations, not just in India but in developing countries of Asia & Africa. Telemedicine can be a good tool for diplomacy. I had made a keynote presentation at Lahore, Pakistan under Aman-ki-Asha in May 2012, and telemedicine and mhealth was a key point of discussion to increase collaboration between the two countries. Healthcare is the most impactful tool for political diplomacy with our neighbours who have similar challenges when it comes to healthcare.
Rural Health: With over 640,000 villages where doctors are not willing to work, technology seems to be the best solution and mHealth appears to be the best technology
In Turkey, Acibadem Mobile runs a mHealth nutrition service with 450,000 members. Also, in less than two years, an emergency healthcare service offered in conjunction with Turkish Telecom has grown to 100,000 members. . In Mexico, Medicall Home has five million subscribers who pay US $5 a month on their phone bills in order to access medical advice
Across the border, in Bangladesh, Grameenphone has set up Healthlink to allow its customers to talk to the doctors 24 X 7. This service has fielded 3.5 million calls in the last six years
Strengthening India’s healthcare system: Also, India is presently building on its healthcare system, and the 12th Five Year Plan has been referred to as the ‘Plan for Health’! Now is the right time for the policy makers to ensure that technology is embedded in all programs that the Government is planning to rollout for healthcare delivery. In specific, mHealth has tremendous potential to reduce costs, improve the reach and access to Health Care, make the healthcare system more outcomes driven, and more importantly, help in establishing an ‘empowered patient’.
According to the EIU PWC report 2012, USA has been at the forefront of mobile health deployments in the world. Almost 40 % of the solutions deployed work towards strengthening the healthcare systems. mHealth is not just promising but truly transformative to healthcare. From pill reminder, training of health workers, reducing IM / MMR, T.B. – DOTS, HIV treatment compliance to quitting smoking to managing diabetes, obesity & emergency surgeries, mHealth is becoming an integral part of healthcare delivery. It is time for the best brains to work on mHealth with all stake holders in healthcare delivery
In my view, mHealth is the only option in India, where people pay 2/3rd of the healthcare costs and only 1/3rd get healthcare in the real sense.
Seeing the potential of telemedicine, & mHealth in particular, India needs a roadmap for mHealth / Telemedicine encompassing areas of rural health, tribal health, chronic disease management, disaster management, defense services, coastal healthcare services etc.
Following might be helpful in building the digital health road map for India
Focus areas that need to be considered in the NDHP Ministry / Deptt / Org. involved
- Incorporating Digital Health in Medical education / training MCI, NIFW, MOHFW
- ESIC clinics connected via Telemedicine & home care
facilities provided through mHealth for ex-servicemen MOD / ISRO
- Sub-centers in rural areas to be replaced gradually
with mobile health Units (MHU’s & this could Consider under MNAREGA,
also double as medical ambulances at the time NRHM – MOHFW
- of emergency in rural areas)
- mHealth national grid MOHFW/ML&E/ MOD/MIT
- National / Regional IVR Health helplines on the lines of 108 MOHFW / State Govts
- mHealth for Chronic disease management MOHFW
- Skills Development for Digital Health NSDC / MHRD
- Telemedicine / mHealth under Disaster Management – NDMA PMO
- Regulation of tariffs ( special tariffs for mHealth services) TRAI
- Mental health Telemedicine Network MOHFW
- Checking counterfeit & Spurious medicines using mHealth Deptt. of Pharmaceuticals
- Healthcare facilities in Jails Min. of Home Affairs
- National IT policy 2011 & health as a mission mode project Min. of Comm. & IT
- National Institute of telemedicine & mHealth MOHFW
- DST- TDB could set up ‘mHealth innovation village’
like the Startup village in Kochi DST, TDB / CHA
- Electronic Health Record – RSBY MOL & E / HIMSS / CHA
- ECHS / Naval Telemedicine / Siachen / borders MOD / MHA / ISRO
- mHealth for Tribal health & North Eastern states MDONER / MTA
- Civil Aviation / airports MOCA / ISRO
- Social media strategy for health Min. of Comm & IT / HIMSS
- Medical Devices standards & Interoperability Min. of Comm. & IT /CHA
- Electronic Health records for all new born’s MOCWD / CHA /HIMSS
- Treatment protocols for various diseases ICMR / PHFI / AIIMS
- Enactment National Telemedicine / Digital Health Act MOHFW/Min. of Legal Affairs
- Applications Venture fund for telemedicine TDB / DST
- Digital adoption lifecycle benchmarking of different states Planning Commission /HIMSS
- National Cloud computing policy for healthcare MIT / MOHFW / HIMSS
- Privacy / data security issues of patients MOHFW / BIS / CHA
- e-Prescription policy ( Electronic / digital prescription) MOHFW / MIT /HIMSS
On the acceptability & adoption front for telemedicine & mHealth, let me quote examples; a rural telemedicine service provider in Indi has done about 200,000 consultations with 30-40 % repeat visits, across states of U.P. , Bihar, Karnataka & Maharashtra . A leading eye care hospital does over 2.5 lac telemedicine consultations every year and another eye care hospital does over 1.5 lac telemedicine consultations in a year in India.
EMRI – 108 services in Andhra Pradesh is on a PPP model, and this service receives 58000+ calls per day with 4800+ emergencies a day and has saved 20165 lives. A true example of successful mHealth / telemedicine in our own country!
HMRI -104 (Health Management Research Institute, A.P.), is about providing information on health, counseling and healthcare services via health helpline. Till May, 2008, it received 51000 calls per day. Medical advice given to 40860, counseling attended- 7493, information of health facilities provided- 6331 & complaint calls received on healthcare facilities- 253. Top 10 ailments attended were recurrent abdominal pain, back pain, knee pain, cough, hair loss, chest pain, and eye pain or problems with eyelids, rash, pain in ankles or feet, belching, growing stomach or gas.
I had a chance to visit these facilities personally and observe the calls from patients / public, and I must say that this is something every Indian must have access to, rich or poor ! With an average cost per call of Rs.9, this is definitely a successful telemedicine & mhealth model for implementation in India. http://nrhm-mis.nic.in/UI/MEActivities/goa_web/PDFs/02-05-08_pdf/Pre%20Lunch/Goa%20presentation_AP.pdf
Also, I have visited remote places in Wardha district of Maharashtra, where mHealth has been used by rural health workers and has helped reduce maternal mortality from 91 per lac to 51 per lac in a period of about 1 ½ years with an approximate investment of Rs.4000 per village . There was a 43.95 % reduction in MMR using simple phones, through text messaging and covering high risk expectant mothers with the existing network of anganwadi workers
According to the GSMA deployment tracker, currently there are around 300 commercial deployments globally. (http://apps.wirelessintelligence.com/tracker/, extracted in Dec 2011).
So clearly, mHealth & telemedicine is fast pervading and showing its impact on the healthcare system in India
Digital Health & Medical tourism: India is fast losing to other South East Asian nations as a centre of excellence for medical tourism due to lack of IT usage in its hospitals and dismal usage of mhealth / telemedicine. International patients follow the international electronic data / medical records standards , and also would like to connect with their care givers using telemedicine , and if we do not promote EMR & telemedicine through hospitals , India is likely to lose billions of dollars in revenue which otherwise could accrue through foreign patients seeking treatment in Indian facilities
Healthcare program reporting, review & timely interventions: Currently, the healthcare data is reaching after months and in some cases well over two years. This could become live and actionable for timely interventions by using GPS enabled devices & e-reporting. Solutions are already available and are scalable. It is the right time to adopt the same in NRHM, and create a national household medical record (NHMR) for the families in rural / urban India. This will help us study the epidemiology & family health risk assessment. May be, we must make it compulsory to ensure that all the 18 million new born’s must have the electronic health record and then move upwards to put an electronic health record for all Indians, post the national screening program. At least, the next generation must be having a digital health record right from birth so we do not have to change the system backwards for them in future.
So, for sure, mHealth & Telemedicine is a proven model for care delivery, and we need to support it in a more structured and institutional manner for the next 5 years .
It is beyond doubt that , mhealth will add efficiency to affordability , acceptability , accessibility & efficiency on one hand , and create about 2 million jobs and also add about 0 .5 % of growth in the GDP at a minimum in the next 5 years .
Inclusive innovation & inclusive growth have now added a new dimension, i.e. ‘inclusive healthcare’, with digital health being the starting point. mHealth is the fastest solution to the oldest problem of reaching the unreachable! We must seriously consider deploying at least 3 % of our total healthcare budget on ICT, and this will certainly make the data live and lead to timely interventions and thus saving lives, establishing accountability of the service provider through periodic reviews and bring transparency in functioning of the various programs
US FDA has approved mobile health applications for diabetes management besides others, and two insurance companies have agreed to reimburse mobile health applications for treatment of diabetes. This development indicates that the big multi-billion untapped market of the developed world is waiting to be tapped and the government needs to step in, like it did to develop multi-billion dollar corporations in the field of Information Technology. According to the Economist Intelligence Unit (EIU) & Pricewaterhouse Coopers (PwC )report 2012, mHealth market is likely to be USD 23 Billion by 2017, and Asia Pacific market will be 30 % at USD 6.8 Billion .If we work towards setting the right enabling policies for mHealth, Indian companies would grab a major portion of this market, like we did for IT industry a few decades ago. Besides, given the technical & competent manpower in India, mHealth & telemedicine can do for country what IT revolution has done for India! This calls for a dedicated action group on Digital Health (mHealth & telemedicine) .
mHealth & Telemedicine is becoming the focus area for all the major healthcare systems across the world, and given India’s expertise in this area, India can become a global provider of products and services in the field of Telemedicine & mHealth. We believe mHealth can add at least 0.5 % to country’s GDP in the next 3 – 5 years, create at least 5 billion dollar companies in mHealth, and lead to creation of over 20,00,000 (2 million) jobs directly by becoming a Global leader in this space. If two persons are deployed in every village for Telemedicine, and considering that India has over 6,40,000 villages, we will create over 1.2 million jobs directly just in rural India and this could be a worthwhile project to be considered for funding under MNAREGA scheme that will not only create jobs, but also lead to better health for rural India and lead to tremendous savings under NRHM expense head!
The good point is that, we have a least complex healthcare system in India, and we are building it up. Also, we have quite receptive and friendly policy makers who are willing to try initiatives.
Hopefully, we will lead and show the world an outcome driven & a self-sustainable healthcare delivery model built on strong foundations.
Over the past few years, I had a good experience working with policy makers across geographies and it has been a wonderful experience, especially in India, working with different stake holders to discuss new ideas and policies aimed at better healthcare options for the common man.
This is not a complete or a reference document but just to initiate a few discussion points. Should your office or any concerned organization, department or ministry need more inputs or support, my colleagues at the World Economic Forum, The Telemedicine Society of India, HIMSS & Continua Health Alliance, would be more than glad to volunteer and assist. I am sure that this submission will also be considered positively by the various stake holders in the Government and acted upon, so that we can see large scale deployment of mHealth & telemedicine projects in all major departments and programs of the Government making healthcare accessible and affordable to provide timely advice & right interventions for the common man 24 X 7.
Yours in good health
Rajendra Pratap GuptaMember, World Economic Forum’s Global Agenda Council – Digital Health Board Member, Care Continuum Alliance, Washington DC. USA Executive Council member, Telemedicine Society of India President & Member of the Board, Disease Management Association of India (DMAI).
Mrs.Sonia Gandhi, Chairperson , NAC.
Dr.M.M.Joshi, Chairman, Parliamentary Accounts Committee .
Dr.Sam Pitroda, Chairman, National Innovation Council, GOI.
Shri A.K. Antony, Hon’ble Minister of Defence , GOI.
Shri Ghulam Nabi Azad, Hon’ble Minister for Health & Family Welfare, GOI
Shri Kapil Sibal, Union Minister for HRD/ Comm & IT, GOI
Shri Jairam Ramesh, Union Minister for Rural Development, GOI.
Shri Ajit Singh, Union Minister for Civil Aviation, GOI
Shri Salman Khurshid, Union Minister for Law, GOI
Smt. Krishna Tirath, Union Minister of state (I/C) for Women & Child Development, GOI
Shri Jitendra Singh, Union Minister of state for home affairs, GOI.
Shri Sachin Pilot, Union Minister of State for Comm. & IT, GOI
Dr.Syeda Hameed, Member, Planning Commission, GOI
Dr.K.Srinath Reddy, President, PHFI.
Shri. P.K.Pradhan, Secretary – HFW, GOI
Shri. Keshav Desiraju, Addl Secy – HFW, GOI
Shri. Anil Swarup, Joint – Secretary, Ministry of Labour & Employment, GOI
Mrs. Anu Garg, Joint Secretary – HFW, GOI
Shri Harkesh Mittal, Secretary, Technology Development Board, GOI
Shri Rajeev Aggarwal, Secretary, TRAI, GOI
Shri Shankar Aggarwal, Addl Secy, MOD, GOI
Dr.Jagdish Prasad, DGHS, GOI
Dr.V.M.Katoch, Secretary DHR & DG, ICMR. GOI
Director, NIFW, MOHFW, GOI
Dilip Chenoy, Managing Director, NSCDCL,
Board of HIMSS Asia Pacific India chapter
President, Continua Health Alliance
Board, Telemedicine Society of India
Board members, Disease Management Association of India.
NDHP: National Digital Health Plan
MOHFW: Ministry of Health & Family Welfare
MHA: Ministry of Home Affairs
PHFI: Public Health Foundation of India
HFW: Health & Family Welfare
DGHS: Director General of Health Services
MCI: Medical council of India
TDB: Technology Development Board
DST: Department of Science & Technology
NIFW: National Institute of Family Welfare
TRAI: Telecom Regulatory Authority of India
MOD: Ministry of defence
MNAREGA: Mahatma Gandhi National Rural Employment Guarantee Act
NRHM: National Rural Health mission
MOL & E: Ministry of Labour & Employment
MCWD: Ministry of Child & Women Development
MIT: Ministry of Information Technology
MHRD: Ministry of Human Resource Development
MDONER: Ministry of Development for North East Region
MTA: Minister of Tribal Affairs
PMO: Prime Minister’s office
MOCA: Ministry of Civil Aviation
ICMR: Indian Council of Medical Research
BIS: Bureau of Indian Standards
CHA: Continua Health Alliance
HIMSS: Healthcare Information Management & Systems Society
NSDC: National Skills Development Corporation
EMR: Electronic Medical Records
ISRO: Indian Space Research Organization
Reports referred in this note:
Touching lives through mobile health by PWC
A Better insight to mHealth adoption
Telehealth Report 2011 by Telemedicine Society of India ( www.telemedicinecongress.com )
Emerging mHealth: paths for growth by PWC