Dated: November 23rd, 2009 Rajendra Pratap Gupta
Dr. Manmohan Singh
Hon’ble Prime Minister
Government of India
7, Race Course, New Delhi
Shri.Ghulam Nabi Azad
Hon’ble Health Minister
Government of India
Nirman Bhavan, New Delhi -110011
Reference: Healthcare reforms – A detailed agenda for Population Health Improvement
Dear Dr.Singh & Shri Azad ji,
This needs your esteem, kind and personal attention. I am sending a detailed note on what India needs to do to build an effective healthcare system. Over the last 62 years , we have increased the life expectancy by 26 years , reduced the infant mortality and morbidity significantly, eradicated Small pox and Guinea worm and almost eradicated polio and Leprosy.
The government of India has taken up a smart fight against HIV, T.B. , Tobacco. The launch of massive programmes like NRHM & NUHM by the government & the ban on smoking in public places is a proof of the fact that, Indian government is committed to the healthcare of its population. I believe that the healthy population is a prerequisite for an economically vibrant & a healthy nation .
At this juncture, with such a proactive government, I must bring to your kind notice a detailed note on how to transform the healthcare system of the nation. To start with, healthcare has to become the priority sector for the government of India. The Indian healthcare system must have a broader scope and a bigger purpose!
Firstly, let me apprise you of the fact that, higher spending does not mean better healthcare. We have the case of America where 17 % of the GDP goes on healthcare. Still 77 % of Americans have at least one chronic disease, 1 out of 2 Americans have a chronic disease and 7/10 people die of chronic diseases. Despite such a high spending, according to WHO, US Healthcare system ranks 37th amongst nations, at par with Serbia; 31st in life expectancy and 40th in child mortality, worse than Cuba and Croatia . So we must not pursue wrong goal of just doubling the healthcare spends as a percentage of GDP. We need a system that is outcome driven and not that is expense driven !!
Even the French Healthcare system which was ranked as the best by WHO in 2000 is losing USD 28124 every minute and is expected to go bankrupt by 2019.
Taking into consideration the global examples in healthcare , where most of the healthcare systems have failed , India is fortunately better placed. As developed regions like USA & Europe are struggling to correct their system backwards, India is just starting to build its healthcare system. We must embed strong fundamentals in our healthcare system. Though India is better placed not by design but by default and faulty policies over the last six decades, we must use this opportunity to build in our indigenous healthcare system and not import failures by copying anything from abroad .
Let me draw your attention to a few important observations of mine regarding the healthcare system:
Payer model: India has the right payer model , where the user pays. This makes the user as the ‘gatekeeper’ in the healthcare system. The global experience shows that, whenever there is a blanket cover for free healthcare, it is likely to be misused, over used and prone to fraud. Global examples have proven that, whenever healthcare is free, systems collapse. So I must request the policy makers never to change this basic fundamental of the healthcare system, though you must provide free healthcare to BPL families.
Preventive care & Recession: My belief is that healthcare was also one of the main reasons why America faced recession. In 2008, U.S. employers paid an average of USD 9144 per employee for healthcare insurance. Over the last few years, increasing healthcare costs have forced American companies to ship jobs overseas as this presented significant cost savings. Imagine that a computer sold in U.S. was produced in China. So the entire process of building a computer created job and income for Chinese but it was sold in the U.S? So while U.S. kept spending on buying products, U.S. lost its earning & income creation opportunities to China. For each product U.S. citizens purchased, salaries and income moved to China for producing such products. No wonder, China became the biggest lender to America!! American recession was in the making for the last couple of years because of the healthcare costs going up.
Why healthcare costs went up in America? In 1970 preventive medicine specialists represented 2.3 % of the physician work force and by 2002, the preventive medicine specialists were down to 0.8 %. America did not take care of prevention, and today it is home to a population that is more ill than healthy and so is the economy. American economy is a mirror image of its healthcare system. U.S. spent USD 700 billion on the troubled assets relief program (TARP) & USD 568.4 billion on fighting chronic diseases in Medicare and Medicaid. India must learn from USA on the management of chronic diseases early on. We need to build a strong preventive care in the Indian healthcare system.
India is a young nation with more than 60 % of its population below 40 years in age but, in the next thirty years; we will become an aged nation. We will grow ‘Older’ before we grow ‘Wealthier’. Moreover, with the rising incidence of chronic diseases, we are heading towards a problem where even after spending 25 % of our GDP on healthcare, we will never be able to salvage our healthcare system.
It is high time we converted our slogan from Food, Clothing and Shelter to: Food, Clothing and Healthcare. Health care needs to become the fundamental right of every Indian
Disease burden in India: India has to first asses the health burden in India. The figures released by the top consulting firms are not reliable given the wide disparities. Let me give you a glimpse of the ‘potential’ disease burden in India.
A. According to WHO, India has 14 % of its population suffering from Arthritis. This takes the Arthritis patients to approximately 140 million
B. According to WHO, India has 10 % of its population suffering from Hypertension. This takes the Hypertension patients to 100 million
C. According to the International Diabetes Federation , approximately 5 % of the Indian population suffers from Diabetes i.e. 50 million
D. India has at least 40 million CVD patients
E. Cancer patients in India are about 2.5 million
F. Elderly people in India are about 150 million
So, by any conservative estimates, we have about more than 400 million patients suffering from one or more chronic disease.
ABCDE of Indian healthcare system . I coined this Acronym , where A stands for Arthritis , B – Blood Pressure , C- Cardiac diseases & Cancer, D- Diabetes , E – Epilepsy or Elderly. My belief is that the prevalence of chronic diseases is such that today every family if India has one or more members of either of ABCDE .
Due to out of pocket spending on health, about 40 million people go below the poverty line every year.
If we see the population dynamics & demographics , it calls for a serious planning and implementation on healthcare reforms so that we don’t face what America is passing through today! We need to build low cost, user friendly & accessible healthcare system so that people enter the healthcare system earlier and leave it earlier and it does not cost more!! I have changed the centuries old saying ‘Prevention is better than cure’ to ‘Prevention is better than death ™’ Since chronic diseases, if not controlled, lead to disability and finally , death
Problem of distribution: India has a serious problem with the focus & allocation of health resources ; we are quite urban centric. A survey by the Indian Medical Society had found that 75 % of the qualified consulting doctors practice in urban centers, 23 % in semi-urban areas and only 2 % in rural areas, where about 65 % of the population lives
Acute model of care: Though over the past 60 years the disease patterns have shifted from acute and infectious diseases to chronic or life style diseases, still Indian healthcare system emphasizes on acute care and medical care model. This needs an immediate correction. The problem of not adopting preventive care is that aging population requires more healthcare treatments with a lower earning and paying capacity. Earnings reduce with age but healthcare problems increase. This will put our ‘Young’ nation of today into a serious economic, social and development crises in the next 25 years. The ‘baby boomers’ of today will become ‘Patient boomers’ of tomorrow.
A study done by Kaiser Family Foundation revealed that, the healthiest 50 % of Americans account for just 3 % of the annual spending; the sickest 15 % represent nearly 75 %. This should help India understand the importance of preventive measure to keep our population healthy.
I believe that we have already been late for this generation, but we must build a robust healthcare model for the coming generation. We need to bring a change in government policies, medical curriculum, medical practice and channels of delivery of care across the healthcare spectrum. Without an integrated care system, we cannot have results, and without preventive care we cannot have an integrated healthcare system.
We must seriously consider that it might be cheaper to provide free preventive care than to absorb the high cost of chronic care. Preventive care must become the minimum standard of healthcare.
New paradigm of care: We must work towards building a strong support system for our healthcare infrastructure to build an effective healthcare system. This calls for a strong:
• Self control & Self care : Individuals must take to self care and self control and become health conscious individuals. This is where the government can play an important part and sensitize the population on health issues , so that the healthcare becomes effective
• Education system: The Prevention must move from the ‘Medical school’ to ‘Primary school’. It should be ingrained in our school text books and Preventive care is more important than the sex education for which too many efforts are being made too fast! Yoga & Meditation should be taught for at least 30 minutes / day from class 1 onwards
• Occupational health: Work place wellness is not established in India. I would expect that the proactive private sector gets active on providing preventive care to its employees at the work site
Why should a person approach the doctor directly for every small / routine issue?
For Preventive care , we must have two goals :
A. Preventive care has to be the mainstay of the stable healthcare system
B. Preventive care becomes the minimum standard of care
Government: Action points:
• The government must set up an inter-ministerial task force under the Prime Minister’s office or mandate the National Knowledge Commission to make recommendations every five years on healthcare reforms needed , based on the fast changing dynamics and demographics of the Indian population. The ministries to be included are Ministry of health & family welfare, Ministry of labour , Ministry of sports, Ministry of finance , Ministry of defense , Ministry of rural development , Ministry of child & social development ,and
Ministry of tourism .We must look at Brazil’s healthcare system where the health provisions are under the state & municipalities , but the Federal government continues to be responsible for the quality of care
• Health should be a federal subject
• Department of pharmaceuticals ( currently under the Ministry of Chemicals and Fertilizers) must be brought under the Ministry of Health & Family Welfare
• Central Health Authority : We need a central health authority along with similar state health authorities in every state to focus on Health Risk Assessment , Healthcare forecasting, Health Awareness , Immunization , Mother & Child care , Geriatric care , Primary prevention , Occupational health , Disease management , Organ transplants , Emergency care & Palliative care
• Government must take the sole responsibility for awareness creation about wellness and diseases separately, and both should be handled by different heads with proper coordination
• India immediately needs an epidemiological survey. As of now, there is neither an epidemiological survey nor a health risk assessment index to find the actual disease burden. Without that, anything we are doing amounts to Adhocism. We need to be more scientific in whatever we do to have an outcome. The data given for various disease states are thrown by various organizations and the data is hard to believe! Health Census must be done along with the population census.
• Government must take the responsibility for mass screening and mandate the employers to do mass screenings for their employees based on the guidelines for each sector
• Government must issue industry & sector specific recommendatory daily allowance (RDA) for food intake or calorie intake , health & wellness guidelines for employers and employees. If need be, government must appoint a employee health regulator to enforce the guidelines
• All the admissions after high school should have a basic health check as a prerequisite
• People above the age group of 21 should go for a yearly basic health check up
• Marriage certificate should only be issued after a comprehensive risk assessment
• Those with BMI above 23 should be put on annual preventive check
• Those with a family history of any chronic ailment should be kept on OPC – Observatory preventive checks at an early age ( 16 years )
• Government must come out with a health status report on its national leaders and set up a separate health department for political leaders both at national & state level
• Government must focus more on Geriatric care
• Government must address the issue of mental health deficiencies & encourage TeleHealth in Psychiatry seeing the ratio between Psychiatrist and population being 1:1 Million
• Government must start ‘Day Care’ centers for minor surgeries across the nation
• There are thousands of lives lost every year in road accidents. Government must work out organ transplant centers and frame guidelines for cadaver implants.
• The government must start a 24 hour health channel.
• Local governments must start a IVR – Toll free health helpline for the local population with Frequently asked questions on health put in IVR format
Special guidelines to treat chronic diseases:
• The government must immediately start a Central Disease Registry (CDR). All the
chronic disease patients must be registered under the same by the path labs itself
• Once the person is diagnosed with a chronic disease, the entire family must undergo a health risk assessment covering basic checks like BMI, B.P., Sugar, Cholesterol etc. This will be an effective way to monitor and control the chronic disease incidence. Such families should be advised to undergo a yearly basic check to avoid chronic diseases
• Chronic diseases cannot be controlled by prescription alone. It involves a behavioral change. This calls for counseling. Counseling should be made mandatory for chronic diseases. Doctors , Pharmacists and Nurses should be trained in the management of chronic diseases
• Patient’s family must be involved in the management of chronic diseases. Chronic diseases cannot be managed alone; it needs proactive support from the family members. Guidelines should be issued for the same
• Based on the disease state , the patients must be put on the appropriate disease
• The doctors practicing in the field of chronic diseases should not be allowed to practice without a counselor , dietician , Phlebotomist and a fitness trainer
• The local municipality must encourage the formation of patient groups at a local level to help in the self management through ‘role model’ approach and via experience sharing amongst patients. This can be quite effective in the management of chronic diseases
• Nurses & Pharmacists have not been effectively utilized in the management of chronic diseases. These health professionals should be effectively used. In fact, the pharmacists should become the first local touch point for health information dissemination
• Pharmacies must be mandated to provide instant checking like BMI, Sugar, and B.P., Cholesterol etc.
• Pharmacists must be mandated to counsel all chronic patients
• Government must encourage generic prescription in all government hospitals and allow patients to seek generic substitution at the pharmacies.
• All doctors must seek patients nod before prescribing products other than generics
• The government must implement Disease management in the PSU’s immediately to
study the amount of money & lives that can be saved. Also that this can lead to better
outcomes and increased productivity
• Religious leaders must be used to tackle health issues as they can prove really very
• The government must ban Junk foods in schools
• Special emphasis needs to be on Geriatric care and a separate set of guidelines needs to be worked out on the same
• Government must mandate the insurance companies to pay for routine health checks and
preventive care. Home based self diagnostics should be re-imbursed under insurance
• Gram Panchayats must be starting points for information dissemination for rural India.
Primary Healthcare centers should add Telehealth to its faculties to take the health to the rural population. Building and maintaining healthcare faculties in rural India is not viable. But Telehealth is an option worth trying to provide boost to rural health
Standards & protocols in Medical Practice : Due to absence of medical establishment standards , lack of treatment guidelines and protocols ; substandard facilities are mushrooming and malpractices are leading to ‘Over Diagnosis’ and ‘Over Treatment’ The government must play an effective role for the formulation of guidelines and enforce the same effectively . Also , despite having the best of brains and facilities , we are still
using the JCI / Australian accreditation . The government must recognize only the NABH / NABL accreditation for its healthcare facilities and take it international through support and incentives .
The detailed guidelines are expected on:
• Guidelines for screening.
• Guidelines for diagnostics
• Guidelines for treatment of various disease and the line of treatment along with the diagnostic requirements
• Government must come out with grading norms for facilities based on the treatment outcomes, number of beds , clinical staff, facilities , accreditations offered , town class and treatments offered
• Government must decide the price / rate for various treatments & procedures in facilities based on the infrastructure , town class , outcomes data for treating patients & grade of the facility
• Referral protocols for higher diagnosis and treatment
• Rural health guidelines should be formulated
Financial Incentives for the health sector:
• Rapid or instant diagnostic kits should be entitled for lower taxes & duties. Ideally, it should be duty free. But we must also encourage local production
• Telemedicine or Telehealth hold a promise when it comes to healthcare delivery in more than 6.20 lac villages. Such companies should be given a tax holiday for the next 10 years
• Medical imports under PPP must be tax free
• Clinics & Hospitals in rural areas must be given a tax holiday for 10 & 20 years
• Government must give a tax holiday for 3, 5, 7 & 10 years for healthcare facilities in tier 1.2. 3.& 4 class towns
• Preventive checks should be made tax free
• Currently government gives rebate in income tax for medical insurance. The same should be given for preventive check and the amount for such checks should be Rs. 2500 per family member per year. For senior citizens, it should be Rs. 3000 per member per year. Gyms & Yoga club memberships should be included in the preventive check category
• Health professionals working in designated rural areas should be given 50 or 100 % tax free income based on the regional disparities
• Companies that do preventive checkups for employees must be entitled to a tax rebate on such expenses to an extent of 100 %
• Pharmaceutical & other companies that sponsor health checks in communities should be given 50 or 100 % tax rebate for the amount spent.
Health Minister’s Fund – (HMF). The government must create a health minister’s fund to encourage donations from individuals and corporates with 100 % tax exemptions on donations. This fund must be used for providing healthcare to BPL families
Compulsory Health Savings Account(CHSA) & Health Cess: We need to look at innovative ways to fund healthcare. Levying 1 % health cess on taxes would collect Rs.4000 crore.
The government can draft a CHSA under three classifications and people can opt under the scheme as per their entitlement. The people enroll in CHSA at an age of 25-30 years and contribute a monthly amount for 30 years. Say, for example, a category A person pays Rs. 1250 per month per family for the first 10 years, Rs. 1500 per month for the next 10 years and Rs. 2000 per month for the last 10 years. So in 30 years the family saves USD 31000 and can get free healthcare for the rest of his life. Also, if we assume that the dollar is at an exchange rate of Rs. 45 & an annual interest rate of 7 % is accrued on this ; the middle class which is assumed to be 150 million now, grows to 200 million in the next 20 years and 250 million in the next 30 years. The government will stand to collect USD 1 trillion after 10 years, USD 2 Trillion after 20 years and USD 6 Trillion after thirty years. . The money thus collected can be used to make the best of healthcare facilities.
Indigenous research: We have sent Chandrayaan to the moon and made our own sub marine. But we have not done great research in medical technology and pharmaceuticals. Technology and equipment import constitute a major cost in a healthcare facility set up cost. These costs are passed on to the patients. This can only come down if we can have our own technology. Irony is that, we export our brains and then import technology at an exorbitant cost!! We have the best institutes & best brains to train them but we are not able to retain them! The government must frame strict deterrents to avoid brain drain. Healthcare will only become affordable if the cost of set up comes down. This can happen if we have indigenous technology. Going forward, healthcare will be totally technology driven.
AYUSH Professionals: The government must integrate and effectively utilize AYUSH professionals in mainstream healthcare & rural health. This could be the best way to make use of the resources at hand.
Medical Curriculum: Far reaching changes are required in medical curriculum
• The government must not allow M.B.B.S. to do Post graduation till they spend 3 months each into rural health, telemedicine, pharmacies and Panchayat health centers.
• Private medical college students should also undergo the same internship as is for students of government medical colleges.
• Those health professionals ( doctors , nurses and pharmacists ) working in rural areas for three & five years must be given special quota / guaranteed admission in P.G. courses or given fast track promotion in government jobs
• Government must provide higher pay and perks ( including tax free income ) and more paid leaves to doctors working in rural areas
• Doctors who working in rural areas should be given loans at a cheaper rates from the ‘Central Health Fund’ to set up medical clinic / facilities
In Mexico, absence of proper planning during the 70’s lead to oversupply of physicians in the 80’s. India should avoid the same and plan carefully.
Rural health needs a special consideration. In rural India, whenever a patient is taken to the nearest urban center for treatment, at least two family members accompany him. That’s the reason why even the 20 % beds mandated free for BPL families remain unused. Government must provide for free accommodation to these two attendants of the rural population who travel to urban areas for treatment including free train & bus travel. Telemedicine should be the core to rural health model in India
New Models : The government must ideate and try new low costs model where the primary preventive care can be availed at Rs.2 per day. Imagine, if we get 5000 people to pay Rs. 2 a day , we can have Rs.3 Lac per month per facility .This can be used to have two full time doctors , two nurses , two counselors to provide basic care to the population of 5000 people round the clock. I believe these are the models to be tried and implemented
The government’s role must logically move from a provider of care to payer and a regulator. Though government must be responsible for primary care,disaster management & sudden outbreaks but it must also focus on
• Awareness and education about health & wellness for the common man
• Primary care and prevention
• Rural health
• Regulation and standardization
The government must follow the chart mentioned below when approving secondary & tertiary care facilities in any place based on the population size as the standard for population health improvement. Government must not approve the higher end facilities for a geography till the facilities are existing for the levels below ,for which the approvals are sought. The government must also encourage private players by incentivizing them for providing primary care before approving them for secondary and tertiary care
Level of care Population Size Facilities Services provided
1 1000 Telemedicine, Panchayat level dissemination of info. Basic health services must be provided
2 10,000+ PHC – Panchayat Health Center Trained Nurse Practitioner
3 50,000+ Primary Hospital with 25 beds Primary Care
4 100,000 + Secondary Care Hospital 100 beds Secondary Care
5 500,000+ Multi Specialty Care hospital 250 beds Tertiary Care
6 10,000,00+ Institute of Medical Sciences Centers of Excellence
Private Public Partnerships (PPP): I have been actively involved from the very beginning in the PPP document authored by CII. I have already written in detail about the success factors for PPP in healthcare. The government must enter into PPP only for secondary and tertiary care. There is a lack of trust, transparency, speed and continuity in the government policies. Government does not trust the private players and Vice Versa. All PPP’s must pass the test on the four parameters
• Scientific credibility
• Operational stability & scalability
• Financial feasibility
• Political viability
Medical Tourism: Medical tourism can be a big revenue earner for the Indian healthcare system. But there should be a segregation of DHSP – Domestic healthcare service providers and IHSP – International Healthcare Service providers
Government must provide land at highly subsidized rates or free, at or near the airports, for hospitals and facilities catering to medical tourism ,and take the profits as a sleeping partner
For private players entering into IHSP, for each IHSP facility they set up, they should set up three DHSP.
Government must come up with an insurance scheme for international medical tourists coming to India for medical treatments to encourage and promote medical tourism
We have the best of tertiary care in India but what we lack is the basic primary & preventive care in the country .If we don’t start healthcare with preventive care and continue with chronic care management; one day, the entire healthcare system will become over burdened, under- funded and outdated – no matter what we do !
We have to move from being a ‘Disease focused’ and a ‘Doctor centric’ system to a system that revolves around younger populations, and where nurse and a pharmacist play the role of a health coach
The government has to be careful in our healthcare capacity building. One side, we need to increase the healthcare service providers, on the other hand, we have to work to reduce the burden of ‘Killer’ diseases. A very strong primary and preventive care model needs to be embedded in the system.
Healthcare is the largest service industry in terms of revenue and the 2nd largest after education in terms of employment
‘World Class’ standards in India is not the goal, ‘India Class’ standards for the world should be our goal. We can teach the world how to run an effective healthcare system
I am quite convinced that committed leadership will take cognizance of this note and take measures to implement the suggestions after a debate with all the stake holders in the continuum of care . Should you need any assistance at my end , feel free to connect.
With best regards
Rajendra Pratap Gupta
Dr.Murli Mahohar Joshi
Montek Singh Ahluwalia
Smt. Sushma Swaraj
Shri Dinesh Trivedi
Members of Parliament
Secy , Health & Family Welfare , GOI
Chief Minister’s of States
Dr.Salim Hebayeb, WHO
Gerard M La Forgia , World Bank