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

 

 

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Time for a New National Health Policy

DMAI Logo1

 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

CC:

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

Chairperson, UPA

Presidents of all the National Political Parties


Healthcare policies in India: Setting the right priorities | Modernmedicare.co.in

Healthcare policies in India: Setting the right priorities | Modernmedicare.co.in.


Implementing strategies focusing on Child Health through Ministry of Human Resource Development

DMAI                                   

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

 

Dear Dr.Raju,

 

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

following  communications;

 

  1. Communication regarding Child Health dated 11th Feb,11 http://dmai.org.in/sites/default/files/Unhealthy_Promotions_MOHFW.pdf
  2. 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
  3. Communication dated 8th August 2011 regarding, Right to Preventive Care & child health . http://dmai.org.in/sites/default/files/Right%20to%20Preventive%20Care.pdf
  4. 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
  5. 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
  6. 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

  1. 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)
  2. 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.
  3. Each school / college should have a full-time doctor / health educator
  4. Junk foods & associated calorific intake needs adequate attention in school level awareness campaigns
  5. 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

Important).

 

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

 

 

 

 

CC:

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.


Address at the United Nations

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.


UN post the MDG’s – Roundtable dated 13th Februrary , 2013

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

http://www.indianhealthcareblog.com


Auditing of the unused budgetary allocations for Healthcare sector

DMAI

Rajendra Pratap Gupta

President & Board member

 

December 27th, 2012

Dr. Murli Manohar Joshi

Chairman

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

DGHS

President , PHFI