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 is a village based economy, as about 68 percent of its population (about 833 million people) live in 6,40,930 villages; the size of the villages varying from a population of less than 100 to about 70,000. Villages are not only the ‘feeder points’ (of providing raw material and manual labour) for urban areas, but are also the majority consumer market for urban industries and hence , ‘Smart Villages’ are essential for sustainability of smart cities project and Make in India. The issue of Smart villages is not about ‘fitment’ but of ‘sustainability’ of the entire economy. Also, when we talk of inclusive growth, villages cannot be left behind, else the growth of the country is not sustainable.
If we look at all the major initiatives of the Modi Government like; the Digital India Mission, Make in India , Swachh Bharat Mission , National Rural Livelihoods Mission, Pradhan Mantri Jan Dhan Yojana and Deen Dayal Gram Jyoti Yojana; all of them dovetail into the ‘Model villages’ / ‘Smart Villages’ mission . The former President of India, Dr. A.P.J. Abdul Kalam had initiated the PURA Project ( Providing Urban Amenities in Rural Areas) to bridge the divide between the have’s and have not’s. All these initiatives clearly indicate that without uplifting villages, India cannot grow sustainably.
Also, let’s rethink on one important future prediction – that by 2050, 60 % of the population will live in towns. I believe that due to the increasing density, pollution and declining quality of life in towns, over the next 20 years, we will see reverse migration starting, i.e. people living in urban and mega metros will start migrating towards hinterland / semi-urban / villages, as these areas will be less polluted and more peaceful and will offer a much better quality of living conditions. We must be prepared for ensuring that the building blocks of managing the living of a modern family are an essential part of the Smart village design as villages will be the main hub of activity in the next three decades.
Building blocks for Smart Villages :
One has to understand that, to make the villages smart, one needs to have the underlying theme of being ‘asset light ‘ & ‘low cost’ and, the over arching theme of digitization. These will be driven by IOT / Sensors. Almost all the challenges in rural areas are an opportunity for deployment of technology as a smart solution. Future of the village lies in adopting ‘idiot proof’, ‘future proof’ and low-cost technologies that can be used and serviced by the residents and can serve them well!
Building blocks of health for Smart Villages :
If 68 % of the population of the country (living in villages) is not healthy, then the growth of the country is at stake. Healthy population is the best insurance against recession and slow growth. We have to ensure that we provide enough options for people to adopt a healthy lifestyle and stay fit to be productive, and for this to happen, we need to leverage technology to its optimum use, integrated seamlessly into the daily life of the residents of the village.
It is expected that in the next 5-7 years, every household will have access to a phone , house , potable water and electricity and road and hence it is good to consider mobile phone as the basic necessity besides food , clothing , water, electricity and shelter. All the services from the government must converge to mobile-based platforms.
For health in a smart village, we need to visualize the following building blocks;
Mobile Electronic health record (m-EHR) is the starting point for health in a Smart village, as without Electronic health record , people cannot deliver healthcare using technology and these electronic health records should not be PC based but mobile based.
Once we have the m-EHR, the next thing we need is a pin-code wise geo tagging of all healthcare facilities and professionals, so that people can reach nearest healthcare provider or professional keeping the golden hour concept as the basis .
Also, one of the major draw back in distant / rural areas is the delay in getting the data and incidence of diseases, and hence, we need live data and electronic event reporting . Live data will not only lead to timely interventions, but also help in demand based supply chain, thereby ensuring appropriate supplies and reducing stock outs
Also, today there are enough point of care, non- invasive diagnostics which can be deployed for Health Screening using mobile platforms . Using these technologies, diseases can be detected on time, leading to appropriate interventions . We all know that tertiary care eats up about 75% of all healthcare costs and major part of the household savings, and hence technology driven POC (Point of care) screening would be the most effective way to manage healthcare from a cost, prevention and outcomes point of view
Also, as long as we focus on the allopathic doctor based healthcare system, we will not be able to address the issue of shortage of doctors in rural areas , and hence , we will need to use technology to its best across the continuum of care. We will need to move from the ‘Golden Hour’ rule of providing critical care in 40 minutes to a ‘Golden minute’ rule of providing health advice over phone in less than four minutes, and this is very much doable. Also, there are enough studies, which prove that, about 65-80 percent of the time, we don’t need a face-to-face consultation with a doctor. Given the fact that majority of the expenditure in healthcare is on infrastructure and salaries, we must empanel practicing doctors to provide services to the rural people and pay them per consultation. This will make healthcare accessible for the population and more affordable to the exchequer.
The next logical building block would be an ePrescription, so that, after the doctor’s tele-consultation with the patient, s/he can send an ePrescription which is digitally authenticated. This will lead to delivery of medicines either though an ATM machine dispensing medicines or routing the same through a local chemist.
I have visited rural areas across the country and found that sub-centres typically cost between Rs.7.00 lacs to more than 14.00 lacs, plus the salaries and maintenance . I think it is time that the government makes a policy to replace sub-centres with mobile health centres – eHealth centres, which can move the direction of healthcare services from the current ‘to the doctor’ to ‘to the household / population’ approach, and moreover, these mobile health centres can also double up as an ambulance as and when needed. Doctors can come from the nearest semi-urban and urban areas, examine the patient, treat them and go back in the evening. This might work better than the sub-centres in one remote part of the village where the patient has to take pains to travel for kilometers to see the so called absentee doctor !
Smart villages have the potential to extensively deploy Digital Tools / IOT, and flip the ‘doctor centric’ & ‘Tertiary care’ model in the coming decade and lead the way for containing the cost of healthcare`
This is a part of the speech delivered at the Vibrant Gujarat summit 2017. Views are personal
The recommendations that i made in 2011 on the invite of Planning Commission , Government of India have been implemented .
Seeing that healthcare in urban India is deplorable , i had asked to convert NRHM into NHM ( National Health Mission ) and this has been implemented along with tax rebate on preventive checks
Thanks to all the policy makers for making it happen !
Rajendra Pratap Gupta