Date : June 30th , 2010.
Mr. Debasish Panda
Ministry of Health & Family Welfare
Government of India
Nirman Bhawan , New Delhi 110108
Ref: D.O. V.11025/10/2009-ME(P-1) dated 8th June 2010
Thanks for the invite for the regional consultation on NCHRH . Unfortunately, I could not attend the meeting at Mumbai on 18th June due to a prior commitment at Bangalore for the India Innovation Summit on the same date.
I had sent you an email on the NCHRH with two recommendations. Since then, I have dwelled on the issue at length and wish to submit some recommendations for your kind consideration
Before I start on the specific recommendations, let us consider a few important points that need to be kept in mind for the National Council for Human Resources for Health – NCHRH
- India has 1.2 Billion population out of which about 1/3rd is illiterate population
- In the next 10 years, India will add 120 million people in the working age category
- Currently, India has about 2/3rd of the population below 35 years in age
- Currently , 2/3rd of India lives in rural India and probably, in that category, healthcare does not figure in the list of priorities
- 2/3rd of India does not have adequate access to healthcare
- Awareness and sensitization about healthcare is missing . People will go and splurge money on dining outside , but will not spend a fraction in wellness .
- India believes more on religion , spirituality and charity than wellness
- Healthcare professionals available are not willing to work in the so called rural India . At max, they are willing to work in semi urban India
- The incidence of diseases is not vastly different in rural India from that of urban India for most of the ailments
- Status of urban poor is deplorable when it comes to healthcare
- PPP’s in healthcare are not going to work in rural India
- Those who study for healthcare in urban areas, majority of them are not willing to adjust to the rural lifestyle for professional or family reasons . Gives us a reason to think to start medical colleges in rural settings !!
- The entire healthcare system is focused on medicine , doctors, clinics and hospitals etc. This has created a fear & suspicion amongst the healthcare users that healthcare means pills, surgery and hospitalization
- New models of care are evolving for addressing the changing disease patterns and Indian healthcare system is ill prepared to handle the same
- Time has come to take health ( not medical ! ) education from medical school to primary school. Basic healthcare education should be made compulsory at the school level.
- 3G has now become a reality , so mHealth will not just re-define the healthcare delivery but also healthcare education
In short , I would say that , the world over , no healthcare system has answers for our problems, as all the systems are already failed or heading towards a collapse . This provides a unique challenge and an
opportunity to build a robust healthcare system for India that is low cost, agile , protocol driven, and evidence based and not eminence based system; one that avoids errors , trails and wastage . Then only we can have an outcome driven health system that cares !
Here is what I submit for your kind consideration :
NCHRH ( National Council for Human Resources for Health ) has been set up with the goals to overcome the acute shortage and uneven distribution of human resources in public health delivery system & aims at overhauling the current regulatory framework. Toward this end, it is proposed to set up a National Council
for Human Resources for Health as an overarching regulatory body to achieve the objective of enhancing the supply of skilled personnel in the health sector
What I can understand from the above stated purpose for NCHRH is that NCHRH will ;
- Regulate the current set up
- Identify the current need gap
- Project the future requirement for the next 10, 20 & 30 years
- Asses the population mix and the disease patterns and address the issues in a proactive manner
- Create a resource pool & knowledge pool ( not just impart knowledge but create it as well )
- Human resources for disaster management in healthcare is missing from the draft that I have gone through . It needs to be incorporated
Health in India has to be looked regionally and planned at the district level: It would be wrong to just limit it to five members headed by a chairman. I would suggest that you must create an “Indian Health & Wellness Service (IHWS )” for the entire nation on the lines of IAS . Today , if I have to complain against deficiency of healthcare services or standards or care at a hospital, there is no grievance redressal mechanism !! Because the system is ambiguous and there is no demarcation for people to look at health and wellness services. For erring police , I can go to SP City , DIG –Range or IGP or the DGP; for an erring postman , I can go to the Post master general etc., and the same for most of the services ; but if there is a deficiency in a hospital service provider where does a common man go ? Another hospital, I suppose !!
So when you are planning for NCHRH , You must consider having an all India service to tackle the multi headed monster called healthcare.
Have separate members in NCHRH, each having a clear role and responsibility for capacity building for the following :
- Urban Health
- Rural Health
- Tribal Health
- Health in hilly areas
- Health in Armed forces
- Health for retired government employees
- Health for private sector
- Work Place wellness
- Healthcare amongst Minorities
- Expatriates working in India
- Geriatric care in urban & rural health should be handled separately by different members
- Split ‘Mother and Child care’ under separate heads, each under a separate member . It is glaring to note that According to International Institute of Population Sciences , Mumbai , 56 % of the Indian women in the age group of 15-49 suffer from anemia
- Mental Health
- Telehealth should be a strong focus area for Urban & rural health. It should also be a part of the Medical curriculum and a 3 month internship should be made mandatory for telehealth
- Medical Education
- Home health & care technicians
- Healthcare counselors and Physiotherapists
- Health administrators for clinics , hospitals other wellness providers
- Gyms & Wellness centers
- Diet and Nutrition
- Acute care
- Awareness & Education about wellness
- Awareness & Education about diseases
- NGO’s capacity building
- Disaster management in healthcare including outbreaks & epidemics
- Epidemiology & research on regional requirements . One example I will quote here. In north eastern part of India , in tea gardens , people take black ( known as red tea in NE ) with salt and so there is a very high incidence of Hypertension and stroke . Same applies to other belts in India which have very specific requirements that cannot be tackled with centralized planning and execution
- Technical up-gradation & training of the workforce on latest developments in equipments and technology
- CME for each level of workforce
- Nurses should be renamed as Physician’s Assistant (PA’s ) or Health & Wellness Officer (HWO’s ) . There should be a plan to create enough specialized resources under this head for rural health, geriatric care , telehealth , chronic diseases etc. We need not make our healthcare system doctor & hospital centric . The number of PA’s / HWO’s should at least be double of that of the doctors in the next 10 years
- For medical education ( all streams ), behavioral psychology should be added in the curriculum . This is one of the most important change that we need in the medical curriculum . Doctors have just been reduced to diagnosis & prescription machines . Whilst we might be imparting the best of medical knowledge, but patient care and handling is missing totally from the curriculum . Writing prescriptions does not deliver care . Patient friendly care is a must . Because of the lack of understanding of the behavioral psychology amongst doctors , the patients fear and suspect the doctors . Even the doctors do not go beyond prescriptions !! This needs an immediate change to ensure compliance and outcome from the treatment , most importantly, regain ‘Trust’ in the system by the users
- Put a separate head for innovation in healthcare education
- Separate head for guidelines, standards , treatment protocols , assessment & accreditation for each aspect of medical & health education and research
Further , each member should be responsible for research , planning & execution for his department. It is clear that if we do not plan for human resources , it will not just lead to deficiency in healthcare services but also increase the cost of healthcare . Limited number of healthcare professionals would be available for jobs and that will definitely lead to unrealistic inflation of salaries amongst health professionals
Since this note is about the healthcare in the country , I would also like to add that, we must look at setting up a TAB ( Technology Adoption Board ). India must not import technologies simply because GE / Siemens have
produced it and it is the latest. Technology is one of the major cost drivers for healthcare . TAB must ensure that the technologies that have demonstrated positive impact on the treatment compared to its cost and accuracy of diagnosis should only be allowed in practice . In 2007 , a 64 slice CT Scan was the most advanced , now it is 914 slide CT scan . The question is what is the difference in cost and accuracy of diagnosis compared to the earlier versions ?
Also, MOHFW should set up ICE – Insitute of Clinical Excellence to formulate and work on clinical pathways & protocol based treatment for all major illnesses , so that the doctors do not resort to expensive and arbitrary line of treatment at the cost & care of patient . A protocol based treatment would let all the stake holders in the continuum of care to work in close coordination
Also, the time has come to move to a greener healthcare system. I hope that we will learn from the MEA ( Ministry of External Affairs ). When you apply for a passport , the passport office gives you two or three receipts , one for the passport application fees, second for jumbo passport ( if you opt for ) and a third one for tatkal category ( if you fall under that category) . I fail to understand that, would it not be better to have one receipt with multiple options for ticking !! It wastes paper , ink and generates three times the heat and noise printing three receipts . MOHFW needs to ensure that we move to a Mobile Health Record system (MHR ) that does not depend on paper . Mobile phones could carry all the records, and more so , when most of the people are likely to carry mobiles. Providers could sync all the medical records with SIM cards. But the success of this depends on the will of the policy makers, honesty and efficiency of implementers ( bureaucrats ) and literacy amongst users
Lastly, it is high time to check migration of our best brains & highly skilled manpower. We can build six AIIMS like buildings, but building institutions will be an onerous task in the current scheme of things, and this could well be the first test for NCHRH.
With some good leaders at the helm of affairs in healthcare , I am quite confident of the changes in healthcare for the benefit of the common man
I do hope that the recommendations are of some help. Incase, you need some clarifications or assistance , I remain at your disposal .
With best wishes
Rajendra Pratap Gupta
Email : President@dmai.org.in
Shri Ghulam Nabi Azad, Union Minister for Health Family Welfare, Govt. of India
Dr.Syeda Hameed, Member , Planning Commission , Government of India
Shri Dinesh Trivedi, Minister of State for Health , Government of India
Sam Pitroda, Advisor , Prime Minister of India & Chairman, National Knowledge Commission .
Ms.K.Sujatha Rao, Health Secretary, MOHFW, Govt. of India
Dr.K.Srinath Reddy, President , PHFI, Government of India
Dr.Murli Manohar Joshi, MP.
Mrs.Sonia Gandhi , Chairperson ,NAC , UPA.
Encl: note on healthcare reforms sent on 23rd November 2009.