Planning Commission’s approach paper on Healthcare

 Rajendra Pratap Gupta

President & Member

Board of Directors

August 21, 2012.

Dr.Manmohan Singh,

Prime Minister

Government of India

7, Race Course road , New Delhi -110001.

Shri. Ghulam Nabi Azad

Union Minister for Health & Family Welfare

Government of India.

Nirman Bhawan, New Delhi – 110108.

Reference: Faster, Sustainable & more inclusive Growth- An approach to the 12th Five year plan – Health

Dear Dr.Singh & Shri Azad ji,

Congratulations on pushing healthcare at the top of the agenda for the 12th five year plan . I am writing this note on behalf of the Disease Management Association of India – 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

Through this note, we wish to draw your attention to the 12th Five Year Plan approach paper dated October’2011, on the Health chapter ( chapter 9, page 87-95) and put forth some suggestions for your kind consideration and action

The approach paper correctly highlights the areas of concern and seven measurable targets like;  IMR- Infant Mortality Rate, MMR- Maternal Mortality Rate, TFR- Total Fertility Rate, Under-nutrition among children, anaemia among women and girls

( According to this plan paper , 55.3 % of the girls are anaemic ) , provision of clean drinking water for all & improving child sex ratio for age group 0-6 years .

Given the formidable challenge that the Indian healthcare system faces, of having 830 million rural population & 6,40,000 villages, we need to be innovative to find solutions that leads to better health outcomes at standards comparable to the best and with least price points that are sustainable in the medium and long term. Also, the role of technology ( Telemedicine and mobile Health) for rural health and chronic disease management, is missing from the plan paper. Without Telemedicine , the goal of ‘Inclusive healthcare’ will remain a distant dream.

Let me take the most critical issue for which India has invested billions of dollars , and still has been facing the flak of all the international bodies and i.e. the issue of Infant mortality and maternal mortality .

We have about 18 million births every year (about 34 per minute), with highest number of still births, according to a study by Lancet . So clearly, there has to be an action plan for 18 million mothers; right from the time of conception which includes awareness , education , sensitization , nutritional & medical support as an Integrated ‘Healthy Baby Mission’ for India . This will cost about Rs. 5000.00 per new born ( not including delivery charges and post natal care ). If we include all , this could reach around Rs.10000.00 to a maximum of Rs. 15000.00 per baby. So , a total budget of Rs. 18000 crores would be needed to fix the problem if we invest Rs.10,000 per new born baby every year . But assuming the number of rural births to be 12.6 million ( 70% of all births i.e 70 % of 18 million per year), of which 80 % i.e. 10.08 million only need financing ; and the number of births in urban India to be 5.4 million ( which is 30 % of all births i.e. 30 % of 18 million), of which 50 % i.e. 2.7 million need financing, the net investment comes to not more than Rs.12,780 crore per year taking an investment of Rs 10,000 per baby per year. To make this happen, a radical change in approach is needed. Also, hoping that population stabilization efforts will contain the cost of financing in the medium and long term.

Without innovating with radical changes, this program or any program that we are building for IMR –MMR, is not going to yield any results ! ICDS has spent thousands of crores for the past 35 years and we are still trying to figure out a new model for ICDS with an inter-ministerial group ! Hoping that the new program will deliver ! Despite the fact that the ICDS has a budget of Rs. 10,000 crore for 2011 / 12, and for the entire 11th five year plan had a budget of Rs. 38980 crore, still our IMR – MMR is amongst the highest in the world.

On page 90, point 9.18, the plan paper states that, “One of the major reasons for the poor quality of health services is the lack of capital investment in health for a prolonged period of time.

The National Rural Health Mission had sought to strengthen the necessary infrastructure in terms of Sub-centres, Primary Health Centres and Community Health Centres. While some of the gaps have been filled, much remains to be done. According to the Rural Health Statistics (RHS), 2010, there is a shortage of 19,590 Sub-centres; 4,252 PHCs and 2,115 CHCs in the country”.

According to point 9.19, “It is essential to complete the basic infrastructure needed for good health services delivery in rural areas by the end of the Twelfth Plan”.

The plan paper rightly talks about lack of human resources and the accountability of people recruited. Given the complexities of the challenges faced and the keenness of the Government to save the Indian healthcare system from the pain & irreversible damage being faced by the healthcare systems in USA, U.K. & Europe , it is imperative to focus on the plan papers note on point 9.34 on ‘Publicly Financed Healthcare’ . This is a very good move and will yield significant positive outcomes

According to the point 9.34, “Public financing of healthcare does not necessarily mean provision of the service by public providers. It is possible to have public financing , while the service itself is provided by private sector players, subject to appropriate regulations and oversight. This type of partnership is common in many areas, but its scope has not been fully explored in the health sector. However, a number of experiments are now in operation, which allow for private sector participation. At the Central level, the Rashtriya Swasthya Bima Yojana (RSBY), is a health insurance scheme available to the poor and other identified target groups where the Central Government and the State Governments share the premium in 75:25 ratio. RSBY covers more than 700 in-patient procedures with a cost of up to Rs. 30,000/-per annum for a nominal registration fee of Rs. 30/-. Cashless coverage, absence of any bar based on pre-existing conditions and age limit are other unique features of this scheme. A total of 2.4 crore families have been covered under RSBY and over 8,600 health care providers are enrolled in the selected districts across 29 States and Union Territories. In several Central Government hospitals, pathology and radiology services are outsourced to private providers”.

“State Governments are also experimenting with various types of PPP arrangements which at times also

include actual provision of healthcare by private practitioners. Public Private Partnership (PPP) as a mode to finance healthcare services, if properly regulated, can be of use to the intended beneficiaries. However, care needs to be taken to ensure proper oversight and regulation including public scrutiny of PPP contracts in the social sector to ensure freedom from potential conflicts of interest and effective accountability”.

Taking into account the recommendations of this plan document, contributions , achievements and learning from other sectors , I would like to highlight the following :

Private sector has clearly made commendable difference to oil exploration , road building , ports , airlines , news and media , education & telecom, besides other sectors. Not only have the services increased & improved drastically, but India has also attained global standards in many fields where private sector participated, bringing in more and better options to the public at affordable price points. In addition, this has created more employment than the public sector. According to the report by the Planning Commission and Directorate General of Employment and Training (DGET ) , Ministry of Labour and Employment, between 1994-2008, the employment has de-grown by -0.65 % in the public sector ,while it has grown by 1.75 % in private sector .

We have achieved a lot by actively engaging the private sector in various segments of the economy. We have also learned a lot during this journey . Now is the time to translate the learning and involve the private sector in government programs for healthcare, and make sure that we have a healthier nation, with investment in healthcare leading to positive outcomes . Not only that PPP’s in health will lead to better health outcomes with accountability but also lead to increased investments and employment generation.

Need of the hour is to implement the recommendations of the Planning Commission . We need to chart out the road map for private sector engagement , and also the guidelines to balance profits with outcomes and not trade one for another !  We lack an economic model for healthcare. If we madly rush for Universal Healthcare in the name of social mandate without a proper implementation roadmap and with checks and balances , we would have embarked on a road of irreversible financial losses to the exchequer with little or no impact on the healthcare outcomes.  Past experience with various government run programs shows us that we have been running ICDS in the health sector for about four decades ,and we still are rated amongst the worst when it comes to Infant mortality and maternal mortality ! Time to immediately introspect and correct as in the approach paper of the 12th five year plan.

Recently, I have been approached by two international organizations ; MAMA Alliance and the MDG Alliance

The MAMA Alliance ( Mobile Alliance for Maternal Action) is a Private Public Partnership launched in May 2011 by the founding partners- United States Agency for International Development , Johnson & Johnson with supporting partners – the United Nations foundation , mHealth Alliance , and  BabyCenter.

MDG Alliance is working with the support of UN Foundation , World Bank, UNICEF, PMNCH , and the Global Compact .

I have accepted to support them by joining them as the advisory board member / partner . Such organizations will do what is easily doable by the PPP models within India !

It is the time to seriously re-consider our approach for each program, and sit & discuss with the sector that brings phenomenal execution capability ( the private sector ) and work together to come out with an economic and health outcomes model for the Indian healthcare system

Without the private sector engagement healthcare will remain a ‘bottomless pit’ for the exchequer and accountability issue will never get addressed . But for sure , with the right PPP models , we will have a faster , sustainable and more inclusive growth in the 12th five year plan ; The goal of the government .

With best regards

Rajendra Pratap Gupta

Member, World Economic Forum’s Global Agenda Council.

Board Member, Care Continuum Alliance , Washington DC.

President & Board Member, DMAI – The Population Health Improvement Alliance

further details

Have we oversold the India story ?

Indian Economy From Aviation, Retail , Healthcare & SEZ Perspective

A lot of experts spoke about the robustness of the Indian economy when the global recession of 2008 did not entirely slow down India’s growth. Experts spoke at length about the pragmatism of India’s central bank leadership and its policies to have evaded the crisis. They even spoke about the sturdiness of the capital market and the role of the regulatory authority.  Today the global crisis is over in most of the nations. United States is back on track with the unemployment figures at a controllable rate and the retail spending picking up. Similarly Japan is expecting the return on investments it made after the Tsunami crisis last year. The amount spent on reconstruction has boosted the economy and it is expected to grow at respectable 2 percent this year. Only Europe seems to be lagging behind, however it must be taken into account that integrating economies of over 30 nations is a daunting task and credit has to be given to EU’s leadership for having dealt with the crisis in a respectable manner.

When compared to the growth rates of these developed nations India’s 7.6 percent growth rate seems to be enviable. So is everything great with the Indian economy? Is it really faring the way it is being projected? Every year fiscal consolidation is the buzzword yet the budget keeps running into deficit. The finance minister keeps promising to bring it under control yet deficit has increased from 4.6 percent last fiscal to 5.9 percent this fiscal year. Most of the deficit is on the account of food, fuel and fertilizer subsidies. The government keeps making provisions for the underprivileged but it is equally true that they are not getting the desired benefits. Most of the provisions are limited to mike & paper.

Let us evaluate the top most (so-called Sunrise )  sectors in India that are consumer driven and how they are faring – Retail , Healthcare , Aviation and also the ‘Oversold & over hyped SEZ story’.

We will have a moment of truth !

Aviation Industry

The India Aviation industry is in a tailspin. Every other day Air India, Kingfisher, Jet Airways etc are making the headlines for all the wrong reason.

Air India the state-owned company has been relying on frequent government bailouts for its existence. Air India alone was responsible for the 10 percent of the global aviation industry losses in the year 2008 while it handled dismal 0.35 percent of the global passenger traffic.  It is also over staffed with over 500 employees per aircraft whereas the industry average is around 120.

Kingfisher airlines owned by the flamboyant liquor baron Vijay Mallya is in troubles. Banks have finally decided to withdraw support in terms of providing further debt.  The only hope which the country’s third largest carrier can have right now is a government bailout. However there is a vehement opposition to such an action by the government. Experts and other industrial groups have strongly advised against such an action as it is a free market economy and it would amount to sheer wastage of taxpayers’ money.

Jet Airways has recently been in news when the tax authorities decided to freeze its account as it was about to default on its service tax payments. The Jet Airways spokesperson attributed the problem to rising crude oil prices and the high airport duties and lack of support from government in terms of policies. According to them the delay in service tax payment was a minor operational issue. However the mounting losses over past few years tell an entirely different story.  They were in news few years back for having laid off over 1200 employees and later taking them back next day after intervention from a local politician.

Other airlines in India like Spice jet, Go Air etc. have been on the fringe and have been moving back and forth from black to red.  An only Indigo airline is making profits. Several other have bowed down under pressure. They were either forced to shut down operations like Paramount Airlines or they managed to exit at the right time like Air Deccan and Sahara Airlines.

So what exactly is ailing the airlines in India?  Rising crude oil prices are often quoted as the culprit. In India fuel cost is almost 40 percent of the operational cost of running an airline whereas in other countries it remains around 15 percent. High fuels cost give little margin to maneuver in terms of other aspects like offering attractive tickets rates and other offers. However this is not the entire picture. Even though the crude prices reduced from $ 156 barrel to $70 barrel in 2008 to 2009, the Indian carriers continued to bleed and posted losses.

The real problem is of excess capacity due to overselling of India’s growth story . India’s daily domestic passenger traffic is approximately 1.51 lakh passengers whereas the capacity is around 2.16 lakh passengers. Imagine the revenue loss everyday on account of unused capacity. This has happened only due to the mindless unplanned expansion by the airlines hoping to cash on the Indian Incorporation growth story sold by the gang of politicians right from Sonia , Manmohan & inefficient Pranab and highly promoted Montek !  The airlines promoters were chasing numbers which was arrived on mere speculation & playing a ‘Valuation game to make quick buck’. They went on buying spree and expanded their fleet. Today the aircrafts remain underutilized.  India has the aircraft flying hours of 12 per day compared to 16 per day internationally.

Looking at the complete picture it is difficult fix the responsibility on the airline owners. They are capitalists who are driven by market forces. They anticipated growth in market based on market forecasts and other factors like projected rate of growth of GDP. They expected growth in industrial output and service industry output and subsequent increase in airline travel. However the reality was far removed from it. The India Incorporation failed to deliver and they were left in lurch. Today they are hoping for a miracle to save them from their predicament.

Losses Made by Major Domestic Carriers in India

Carrier Cumulative Loss 3 years (Cr)
Air India 13,000
Kingfisher Airlines 3900
Jet Airways 2400

Retail Industry

According to the experts the retail trade industry in India is having a bright future & is consumption driven due to the ‘reducing poverty due to social schemes and increasing middle class due to India’s growth story ‘. One of the studies by North bride capital expects it reach about USD 850 billion by 2012. Out of which organised retail will be having a share of over 20 percent. In numbers it over USD 175 billion. That is a huge market. According to others this figure will be achieved by 2015. Similarly other reports have painted rosy picture for the entire industry.  Currently it is increasing at a rate of 5% yearly.  A further increase of 7-8% is expected in the industry of retail in India by growth in consumerism in urban areas, rising incomes, and a steep rise in rural consumption.

As per consulting firm KPMG’s findings in a March 2009 report, the organised retail market in India has witnessed steady growth at 15 per cent in fiscal 2009. It will grow much faster, at the rate of 30-35 per cent annually, than the traditional one in the coming years. Fast moving consumer goods (FMCG) and apparel sectors are likely to drive this growth.

According to the 8th Annual Global Retail Development Index (GRDI) of AT Kearney, India retail industry is the most promising emerging market for investment. In 2007, the retail trade in India had a share of 8-10% in the GDP (Gross Domestic Product) of the country. In 2009, it rose to 12%. It is also expected to reach 22% by 2010.

A India’s Retail Market Report by Boston Consulting Group


Total Size ($ Billions)

Organised Retail ($ Billions)








































The true story of the retail industry: It has become a ‘Valuation game’ due to over selling the India story of the growing middle class 

Subhiksha, Vishal Mega Mart, Koutons , Wadhawan group’s Spinach etc; do these names sound familiar and have something in common. Yes these are players in the organised retail industry who have succumbed and failed to deliver at their promoters expectations. These chain stores were at one time case studies of India’s organised retail success. So what actually forced them lower their shutters.   

According to Jagannadham Thunuguntla, head of SMC Global all these cases are classic examples of the retailers getting carried away by the India’s fascinating growth story and the phenomenal rise of the middle class.

The phenomenon is not limited with these cases mentioned above but also with the so-called successful ones in the industry. Country’s largest department store Shoppers Stop for instance posted an overall loss of Rs.4 crore in the last five years, while its debt soared to Rs.390 crore. The Tata group’s retail arm, Trent decided to close down its loss making chain, Fashion Yatra. It was launched in Oct 2008 and it was aiming at low-income shoppers in Tier 2 – 4 towns. Similarly Reliance Retail decided to close its Reliance Wellness format and not only that it scaled its hypermarket format down in some cities. Hypercity closed down its catalogue selling venture and also got rid of its Gourmet City format.

For the modern retailers penetrating further into urban markets has become a challenge. They have no option but to continue to create, preserve and then destroy the store formats they have come up with. Having closed down and revived several formats, most retailers have realised they need to constantly experiment with them to stay afloat.

So we can clearly see that India’s organised retail industry, which has the coveted potential of nearly a billion plus customers with enough cash to spare, has so far claimed a number of players, small and large. These players expanded too soon based on mere speculations.

While these retail stores were expanding and accumulating debts they hoped that the middle class with disposable income would be ready in short time to support them.  Things did not turn out the way they had planned. India Incorporation failed to deliver and along with that came the global economic crisis. These firms ultimately paid the price by closing down their shutters. For instance Subhiksha had expanded to over 1600 stores country-wide entirely on debt. This was a blunder that it committed as it was counting on the rising customer demand which was only on papers.

Not only the growth stories are misleading, at the same time the country’s back-end is not developed and huge investments go into developing it.  The vital supply chain required for the retail networks are entirely missing. This leads to a huge inventory cost which the small retailers are unable to cope up with. Take for example, it is estimated that in the food retail business in India, the wastage due to lack of proper storage facility is staggering 40%. This entire situation is largely the result of the lack of proper policy framework from the government.

The Indian retailers like Future group , Reliance and others are backing FDI so that they can get investment and save themselves from the fate of Subhiksha , Koutons , Gini & Jony , Spkykar , Vishal Mega mart , Foodland super markets, Surya Group etc . We have more companies going into CDR – Corporate debt re-structuring post the closure of the financial year 2011 ( March 2012 ). Banks do not wish to announce the failures or NPA’s in this year.

Ideally , retail businesses should have been making money due to consumer demand but the fact remains that India’s income and growth story is limited only to 6-10 towns and impacts less than 10 % of India’s population

 SEZ’s in India

India adopted the concept of zones from as early as 1965. Kandla in Gujarat was the first Asian export processing zone till the advent of the modern SEZ’s as such zones are now known as. With the passing of the SEZ Act in 2005, it was hoped that the Chinese success story would be replicated in India. It was expected that investor’s confidence would be established in the Government’s commitment to a stable policy regime. The real aim was to generate greater economic activity and employment with the establishment of SEZ’s following the Chinese model of economic growth !

There were numerous applications from multiple sources with individuals, indigenous companies, foreign MNC’s all rushing to have a share in the pie. Sadly it was a short phenomenon. The initial excitement was over as the problems started cropping up. Today in the last two years, as many as 60 applications for SEZs have been withdrawn, while 35 developers have applied for de-notification, according to data by CB Richard Ellis (CBRE), the real estate consultants.

Till date, the government has approved 584 SEZs. There are 381 notified SEZs, of which 148 are operational. Of these 148, only 17 are multiproduct SEZs. The remaining ones are SEZs dealing in engineering, electronics, IT/ITeS, hardware, textiles, bio-technology and gems & jewellery.

So what exactly is wrong with the SEZ idea in India which paid its dividends in China, Poland and Philippines?

On the whole the SEZ idea in India seems to be very much the product of the irrational expectation which has been fueled by imagination.

Healthcare Companies :  Most of the healthcare companies are ‘managing profits’ and as i write , a major healthcare ( hospital ) chain and a pharmaceutical conglomerate is about to wind up in the next 3 months . Imagine a healthcare & hospital company winding up ?

So the Congress party has sold the India story purely on ‘Imaginative basis and on speculative data’ numbers , have no idea of what is fueling inflation and what will deliver growth ? With all sunrise sectors on a downslide , it is better to replace these ‘ignorant intellectuals’ and bring in people who can understand the economy and run it efficiently .

Based on the governments high-octane pitches for the India’s growth story , consulting companies have brought out reports supporting government announcements , and  business houses have approached investors or moved to stock market and raised money and have put up expansion plans . But the reality is that, India does not have a growth story with the current fundamentals being very weak and ‘Leaky’ social schemes are making the party rich and not the population !

Also,  that the current stand of the government to raise the tax issue with Vodafone is a clear proof of what i am writing . India is desperate for funds and behaving like a dictator reversing a five decade legislation for just 10,000 crore ( USD 2 billion ). Does it not show the lack of morality and desperation for funds ? Rest will become apparent in April – May-June Quarter !

Lastly , the financial deficit of the government proves the rest ; all is not well with the India ‘bubble’ story ! Tough times are ahead , if we don’t take immediate action !

Rajendra Pratap Gupta

Healthcare I Retail I Rural Economy I Public Policy

Making Personal Health & Hygiene an essential part of the school Curriculum


September 3, 2011.

                                                                Rajendra Pratap Gupta


Shri Kapil Sibal

Minister for HRD

Government of India

New Delhi 110001


Subject: Making Personal Health & Hygiene an essential part of the school Curriculum


Hon’ble Minister,

Greetings from the Disease Management Association of India – DMAI, The Population Health Improvement Alliance.

DMAI – The Population Health Improvement Alliance is a not-for-profit organization, formed by global healthcare leaders. It is the only NGO in India dedicated to chronic disease management in the country, with an objective of overall population health improvement. In the past three years, DMAI has worked at both, International level and within India, to address the issue of India’s healthcare challenges, with the support of patient groups, Industry & policy makers, and wishes to put on record the continuous support DMAI has received from policy makers and the industry.

We are strongly advocating that Child health become the focus area for our policy makers, so that our demographic dividend does not become demographic disaster! This calls for putting child health at the forefront of the health agenda. The starting point for the same, calls for taking healthcare from medical school to primary school i.e. start sensitizing students about healthcare.

During 2009, DMAI conducted the Health Risk Assessment Index (HRAI), and founds that obesity amongst children was alarmingly high, and so was hypertension, which stood at 7 % amongst students. This calls for immediate steps to create awareness and take action right at the school level.

I suggest that the ministry of HRD makes it mandatory to start imparting education on oral health & hygiene from class 2 onwards in pictorial format, and there should

be a separate subject on Personal Health & Hygiene from class four onwards.  I am sure that this one major step would reduce the burden of healthcare over the next 10 years, and will have a lasting impact on younger generation making healthier choices in daily life and reduce the burden of diseases.

Hoping for a positive response from a responsible government on the this one major step to improve child health in the country

We remain at your disposal for any help / assistance that you might need on this matter of great national interest

Yours Sincerely

Rajendra Pratap Gupta


H.E. Ban Ki Moon, Secretary General, United Nations

H.E. Joseph Diess , President of the UN General Assembly

Hon’ble Deputy Secretary General of the UN General Assembly

Ms. Margaret Chan, Director General, WHO

Shri Ghulam Nabi Azad, Hon’ble Ministry of Health & Family Welfare, GOI

Dr.K. Srinath Reddy, President, PHFI

Dr.Syeda Hameed, Planning Commission, GOI

Sri Sudip Bandopadhyay, MOS- H&FW

Secretary, H&FW , GOI.

K.Desiraju, Additional Secretary, Government of India.

Dr.Sudhir Gupta , ADG, NCD’s. MOHFW.

Board Of Directors , Disease Management Association of India – DMAI , The Population Health Improvement Alliance .

UN Summit on Chronic Diseases in September 2011

July 11 , 2011.

Dr.Manmohan Singh

Prime Minister

Government of India

7, Race Course , New Delhi 110001

Subject: UN High-Level Summit on Non-Communicable Diseases, September 2011

Dear Dr.Singh,

In the above quoted reference , and in continuation to the letter I wrote to you on 8th June 2011; I am connecting with you on my return from the UN session on NCD’s

On 16th June 2011  , on the invitation from the United Nations, I participated  in the informal interactive civil society hearing  & delivered an address at the UN General Assembly Hall . The session was presided by the President of the UN General Assembly , Mr.Joseph Diess

My view was also quoted in the closing remarks by Sir George Alleyne , UN Special Envoy to the Caribbean .

This September, you and your fellow political leaders will have a once-in-a-generation opportunity to halt a global epidemic that is killing and disabling millions of people, impoverishing families and undermining economic progress. The United Nations High-Level Summit on Non-Communicable Diseases (NCDs) is a chance for the Government of India to play a leading global role in confronting this major threat to health, prosperity and security of all of us and future generations.

I wish to assure you of the full support of our organization for the High-Level Summit in September 2011.  We campaigned for such a Summit because the NCD epidemic has reached such proportions that it now constitutes a major risk to global prosperity, development and political stability.

Together the four major NCDs – diabetes, cancer, heart disease and chronic respiratory disease – are the world’s number one killer. It is estimated that some 35 million people die from NCDs each year, and 14 million of these deaths could be averted or delayed.

Recently , Our Hon’ble Health Minister quoted; that every ten seconds two new cases of  diabetes are reported . Further , 14 % people in Bangalore were found to be diabetic , 21 percent had  high blood pressure and 13 % had both diabetes and hypertension. DMAI had conducted the first Health Risk Assessment study in 2009 , and our findings showed that  other NCD’s pose a threat of similar magnitude . We found that 44 % males & 42 % females were Obese , 18 % males and 8 % females were suffering from Hypertension ,  21 % males and 11 % females were suffering from Diabetes , 7% males and 6 % females were suffering from respiratory ailments .

Overall average occurrence across occupations was found to be thus :

Obesity 44 % , Diabetes  20 %, Hypertension 16 % & , alarmingly 7 % of the students suffered from Hypertension

India’s biggest enemy is taking the shape of a multiple headed monster i.e. Chronic diseases .We must be proactive in keeping India prepared for victory against our biggest enemy, Non- Communicable diseases. If we win the war against chronic diseases, rest of the enemies could be easily defeated, but if we lose the war against chronic diseases, we would certainly lose the war against all other enemies

The right word for NCD’s is ‘Irreversible diseases’ or ‘debilitating chronic disorders- DCD’s’ or ‘Life threatening disorders – LTD’s ’ . As a first step, let us address the diseases with the seriousness they need  ! Let’s change the name from NCD’s to LTD’s or DCD’s. Through the same note , I call upon the UN & WHO to redefine the terminology for addressing these disorders .

Dr.Singh , I must highlight you the points of discussions that we had at this special session at the UN on chronic diseases .

President of the General Assembly emphasized the need for a global response to the challenge of non-communicable diseases (NCDs). NCD prevention and control should not be seen as competing with other development and health priorities, and solutions must be integrated with existing initiatives

The Deputy Secretary-General noted that NCDs are a threat to societal well-being, taking

their greatest toll in developing countries. This is an issue that the United Nations is taking very seriously to ensure that there is a global response to the broader social and economic impact of NCDs. Praising the work and commitment of those present at the hearing, who are at the frontline of the fight against NCDs, she encouraged them to learn from and link with those working on other key health development issues – HIV/AIDS, and maternal and child health.

The World Health Organization’s Assistant Director-General for Non communicable Diseases and Mental Health cited key evidence on the scale, distribution and impact of the global NCD epidemic. Reviewing the key achievements of the past decade, he noted the important role that civil society had played in progress of management of chronic diseases to date

The Director-General of the King Hussein Cancer Foundation, Princess Dina Mired of Jordan,

emphasized the need for everybody to be unified in their efforts to get NCDs on the global

agenda and receive the attention they deserve

The first roundtable addressed the health, social and economic scale of the NCD challenge.

There is a fundamental right to good health that is being undermined by the globalization of

NCD risk factors and an insufficient action to date. Thus, a human rights-based approach to

NCD prevention and control is warranted. The global response to NCDs needs to address the

developmental and political aspects of the drivers of the main NCDs, and this will require

collective action – no individual country will be able to deal with the problem alone. Much greater progress can, and must be made in preventing and controlling the NCD epidemic to prevent unnecessary suffering and premature deaths.

Speakers emphasized the need for urgent national and global action as NCDs are increasingly frustrating social and economic development. Some countries already suffer the ‘double burden’ of communicable and non-communicable diseases as well as under- and over nutrition, sometimes in the same household. Health systems in all countries will not be able to cope with the projected burden of NCDs and governments need to be clear that the cost of intervening is much less than the cost of inaction. The economic burden of NCDs is already substantial and will become staggering over the next two decades. Economic policy makers need to better understand that NCDs pose a significant economic threat as they can be expensive to treat, require long-term management and undermine the labour contribution to production. There is also a substantial opportunity cost as the money spent on treating preventable diseases could be spent on other priorities.

Speakers stressed that the economic impact of NCDs is felt disproportionately among the poor and many individuals and families are already tipped into poverty by these diseases; thus NCDs are also a social justice issue. This will only worsen if NCDs are not prioritized in countries’ health and development plans. Health systems strengthening must address the need for social insurance to reduce the potential for ‘catastrophic’ expenditure by individuals who suffer from an NCD.

Given the complexity of the factors driving the NCD epidemic, speakers underscored the need for a response that is ‘whole-of-government’, multi sectoral and spans the life-course.

Both prevention and control are essential, and there is much that can be done by more systematically applying existing knowledge. There are highly cost-effective population and individual interventions for the four main NCD key risk factors – tobacco use, poor diet, inadequate physical activity and harmful use of alcohol – and these should be prioritized.

Focusing on the ‘best buys’ should not be at the expense of the broader range of approaches that is needed to effectively reduce the impact of these risk factors. Speakers noted that this includes the need to consider the broader social, environmental and economic determinants of health, which strongly shape health-related choices and decisions made by communities, families and individuals. Likewise, the cultural, religious and social context should be considered in implementing effective interventions.

Many speakers highlighted the need for a response that is integrated – not competing – with existing initiatives, improving health systems for all conditions regardless of their origin.

There is great potential for synergy with existing health development priorities, including those in the MDGs. The important role of health professionals in both prevention and control was highlighted by speakers. A holistic approach is required that addresses the needs of people and doesn’t treat diseases in isolation. In this sense, other non-communicable conditions such as mental health and substance abuse and oral health disorders should be considered in the health system response to NCDs.

The leadership role of governments was highlighted, which should include a commitment to developing and implementing a national NCD action plan and committing to ‘health in all policies’. It was repeatedly emphasized that all key stakeholders need to be involved in the response, but it was noted that clarity of roles is essential to ensure that potential conflicts of interest are appropriately managed and it was proposed that frameworks be developed to assist countries to do so. It was noted that there are some industrial influences that are in conflict with not just health and social goals but also the goals of other industry and private sector actors; all stakeholders have an interest in dealing with these negative influences.

Speakers agreed on the need for ongoing and improved surveillance of NCDs, their risk factors and outcomes. This will be needed to monitor progress, guide policy decisions and research priorities, and provide information on the effectiveness of different interventions.

There was strong endorsement of the need for a clear monitoring and accountability framework as part of the global response to NCDs, with measurable indicators that countries can report against.

Finally, it was noted that success is possible, and there are many examples of significant and rapid progress in addressing NCDs. Now is the time to scale up collective action on NCDs, and the opportunity must not be lost to avoid the growing negative social and economic consequences of the NCD epidemic.

The second roundtable examined effective ways to address the NCD epidemic. Much is known about effective interventions at both the population and individual levels to both prevent and control NCDs.

These include tobacco control as set out in the Framework Convention on Tobacco Control; reducing the sugar, salt, trans-fats and saturated fats content of processed food; improved diets; increased physical activity; effective policies and programmes to reduce the harmful use of alcohol; and providing low-cost high-quality essential medicines and technologies.

For example, chapters four and five of the WHO Global Status Report on non communicable diseases 2010 summarize the ‘best buys’ in NCD prevention and control

There is little contention about the evidence for the most cost-effective interventions, and the challenge is thus primarily one of ensuring their proper implementation. It was agreed that NCDs are a societal problem, so a range of government departments and societal actors need to be involved in the response. An effective mechanism to achieve this should be a priority for every country. There is an important role for civil society and civil society should be given a formal role in both the development and implementation of each country’s response.

Speakers highlighted that premature deaths from NCDs are largely preventable, and prevention is central to a more effective NCD response at both national and global levels.

Many primary and secondary preventive interventions are highly cost-effective and there are existing tools to support their implementation, including agreed international codes, strategies and Conventions.

Full implementation of the World Health Organization Framework Convention on Tobacco Control (FCTC) was cited by many speakers as being a top priority for action, due to the domination of tobacco-related premature deaths across the NCDs – currently six million per year. The FCTC is now widely ratified by both developing and developed countries, but more can and should be done to support its full implementation in developing countries.

NCD prevention and control should be grounded in a life-course approach, given the fatal and early childhood origins of some NCDs. Children are an important focus for interventions, with the growing impact of risk factors such as obesity on children and adolescents and the opportunity afforded to reach them through schools. Likewise, women are an important target for interventions as child bearers and, frequently, as the ‘gatekeepers’ for food, physical activity and health services for families. Speakers also emphasized the importance of prevention and effective treatment across the life-course, including into older age where much of the burden or diseases falls.

Speakers agreed on the need for an effective health system, which has benefits for all areas of health, not just NCDs. Primary care is the key healthcare setting for cost-effective NCD prevention and control. An important learning from HIV/AIDS is the need for better integration of prevention and treatment services across disease areas – so-called ‘horizontal’ and ‘diagonal’ approaches. In support of this, one participant proposed ’15 by 15′ – namely that by 2015, 15% of funding in all ‘vertical’ programs should be earmarked for strengthening ‘horizontal’ health systems activities. In low-income countries, such approaches should also address the endemic NCDs that affect the so-called ‘bottom billion’, for example sickle cell anemia and rheumatic heart disease, as well as palliative care.

Speakers referred to the roles that civil society organizations can play in NCD prevention and control. There is a significant opportunity to use information and communication technologies to promote health awareness and increase empowerment of individuals and communities to reduce their exposure to NCD risk factors and supporting self care.

Many speakers emphasized that access to essential medicines and technologies for prevention and treatment of NCDs is critical. The cost of the essential medicines is low, and these should be included in readily available ‘packages’ of essential care; this will require increasing manufacturing capacity of essential drugs to ensure quick access to high quality generic pharmaceuticals. The specific need for better access to adequate pain relief, especially morphine, as part of palliative care was raised by several speakers. It was noted that late presentation is all too common in developing countries, partly because of a lack of universal social insurance, as well as lack of awareness; both need to be addressed to avoid unnecessary suffering and premature deaths. Patient and ‘survivor’ groups should be engaged in policy and implementation and can play a significant role in influencing the public, politicians and the media with their stories.

Speakers noted that governments need to set the pace for change and utilize their power to ensure appropriate regulation to achieve public health goals. This may require regulation at both national and international levels to address significant health threats such as the obesity epidemic, for example to support the effective implementation of standards on marketing of unhealthy foods to children and agreed targets for salt reduction. Children and the public should be protected from commercial marketing that encourages unhealthy actions and, exposed to educational messages in schools and in their communities that encourage healthy action. The use of social media to deliver such messages needs to be greatly expanded. The role of physical activity was raised by a number of speakers. The benefits of physical activity are wider than NCD prevention and national and local policies should create an environment that encourages and supports people to be physically active.

Regarding the resources required to prevent and control NCDs, speakers noted that the majority of funding for health comes from within countries, and States need to mobilize their own resources. Health needs to be a higher priority for government spending, and NCDs a higher priority in health spending – this is the only way that funding will be sustainable in the long term. Likewise, current spending on NCD prevention and control needs to be carefully scrutinized to ensure the best possible value for money. NCD prevention and control should also be considered in decisions about ODA for health, in particular through integration with existing health development priorities. In addition, innovative funding mechanisms will need to be explored.

Many speakers emphasized that one important source of funding for NCD prevention and control is through increasing taxation of tobacco products. Tobacco taxation is also irrefutably one of the most effective ways to decrease tobacco consumption, particularly among young people, and is fundamental to an effective tobacco control programme.

Speakers endorsed the need to build capacity and capability to address NCDs among health professionals. This will require concerted efforts to revised training curricula, dealing with ‘brain drain’ of trained professionals from low income to higher income countries, and greatly strengthening research capacity in developing countries to monitor trends and evaluate interventions.

 The final roundtable examined ways to scale up action at the global level to collectively address NCD prevention and control. The full range of stakeholders, including all those present at the debate, was identified as been essential to a more effective response. It is vital to carefully examine previous international experiences to draw out the key lessons.

The value of international instruments such as the FCTC was emphasized, and it was noted that other such instruments may be needed in the future to support effective international action.

Speakers provided specific examples of enabling mechanisms to support global cooperation, including a ‘clearing house’ function to facilitate knowledge sharing, a global forum, and bilateral and multilateral partnerships to support technology and knowledge transfer.

The need for appropriate monitoring and accountability was reiterated, noting that accountability is a national responsibility that can be supported by appropriate international monitoring.

It was acknowledged that the funding environment is currently challenging, but there is much that can be done with existing funding. At the national level, there are opportunities to generate or ‘free up’ resources, for example through taxation of tobacco, alcohol and foods high in fat or sugar, and reprioritizing spending on ineffective and expensive health care interventions. Reducing donor ‘silos’ will help to ensure that health development occurs in a much more integrated way that will benefit NCDs as well as other priority areas. There is a need to expand the donor base, and opportunities to do so through linking with other related issues such as climate change.

International federations of NGOs, private sector and other organizations have a useful role to play in promoting global cooperation. Representatives of the research-based pharmaceutical industry and the food and non-alcoholic beverage industries outlined pledges they have made to contribute to NCD prevention and control. There is potential to expand new partnerships, for example with the sporting goods industries to promote physical activity. The private sector can bring a range of capabilities to support NCD prevention and control; for example, its global reach, and experience with global brands and global marketing campaigns. With respect to NGOs, speakers identified the value of greater collaboration, which has been realized over the past two years. This has greatly enhanced their ability to mobilize resources, advocate and generate social and political momentum. This collaboration will need to be further developed to support and monitor the implementation of the outcome document that is to be adopted in September.

 Sir George Alleyne, Director Emeritus of the Pan American Health Organization,summarized many of the key points canvassed during the day’s discussions. He noted a strong degree of coherence in the day’s discussion and agreement on the need to act urgently, while acknowledging the different views within and between the different stakeholder groups on some key issues. Underscoring the need to use proven tools and the value of strong partnerships within the UN and across broader society, Sir George urged all stakeholders to work together for the global public good of reduced suffering and early deaths from NCDs. He echoed the comments of many speakers on the need to integrate NCD prevention and control with action on other key health priorities, notably HIV/AIDS and maternal and child health.

In concluding, Sir George Alleyne exhorted participants to increase their efforts to stimulate political action on NCDs. Civil Society has the resources and passion to overcome the apparent inertia and it must use its unique ability to ‘agitate’ for change. The wider public needs to be informed of the size of the problem and of the consequences of inaction. He emphasized that the High-level Meeting is an important milestone but that sustained action will be needed beyond September.

In closing, the President of the General Assembly emphasized that, as with other key health and development issues, all stakeholders need to act collectively to address the global challenge of non-communicable diseases. He noted that the global community can act decisively and effectively on important global health issues, and we must learn from these prior experiences. It is in our common interest to act now.

Thanking all those who participated in the hearing, the President noted his optimism that the  High-level Meeting and the subsequent response will make a real difference to the global NCD epidemic. This optimism had been strengthened by quality of the discussion and range of ideas canvassed during the hearing and the obvious energy and sense of purpose from all stakeholder groups.

Principal conclusions

 The key conclusions of the hearing include the following:

Countries should move urgently to prevent and control NCDs to alleviate the significant social, economic and health impact these diseases are having, which is now compromising development gains. The last decade has seen some progress at the global level in NCD prevention and control and it is clear that concerted action and leadership by governments can result in significant and rapid progress. However, efforts need to be greatly scaled up to avert unsustainable increases in the costs of treating NCDs, which no country can afford.

There is a strong consensus that NCDs are a development issue and urgently need to be afforded greater priority in national health and development plans, and a higher priority in government funding decision. NCDs also need to be incorporated into the global development agenda in ways that complement rather than compete with existing health development priorities, and innovative funding mechanisms need to be rapidly identified and implemented.

The complex drivers of NCDs require multi-stakeholder action, and countries should put in place a mechanism to engage all the sectors needed for an effective response. Governments should ‘set the pace’ of the response and must show political courage and leadership.

Addressing the key risk factors for NCDs will require involvement of government, communities, civil society, non-government organizations, academia and the private sector. It is important that potential conflicts of interest are appropriately managed so that effective action is not compromised.

NCDs disproportionately affect the poor at global and, in many cases, national levels and lead to ‘catastrophic’ expenditure that forces people below the poverty line. Universal social insurance schemes are essential to avoid this and their implementation should be a priority, with attendant benefits for health care that go beyond just NCDs.

Countries should prioritize the implementation of the most cost-effective population and individual level interventions to prevent NCDs, some of which are in fact cost saving, to ensure they are getting the best value for money from existing expenditure. These interventions should be the priority for new spending on NCD prevention and control.

A renewed commitment to full implementation of the FCTC is essential to prevent a huge burden of suffering and many millions of premature deaths among working age people.

Countries should honour their commitment not just to full implementation nationally, but to international cooperation to support low-income countries to implement the FCTC.

Countries should continue to strengthen NCD surveillance and monitoring to inform and guide NCD policy and action at both national and international levels.

The health system response to NCDs must be fully integrated with programmes that address other key health issues, to ensure that services are delivered around the needs of the people who use them. Access to high-quality and affordable essential medicines is an essential component, and the implantation of programmes to deliver them effectively in low resource settings.

The outcome document for the High-level Meeting must have clear objectives and measurable indicators, supported by a monitoring and evaluation function, to support national accountability for scaling up NCD prevention and control. Civil society organizations should play a role in independently monitoring and reporting on progress.

It is essential the Heads of State and Government attend the High-level Meeting, to ensure that there is the high-level political commitment to scale up NCD prevention and control.

Countries should consider including NGOs on their delegations to the High-level Meeting, as they can bring technical expertise, can help to mobilize political support, and will be essential actors in implementing the agreed outcomes of the High-level Meeting.

Health workers are key to an effective national response to NCDS, but many are not trained to prevent, detect and manage NCDs. Training curricula should be reviewed to ensure that health workers receive relevant training in both NCD prevention and control.

Governments should look to tobacco taxation as a key way of raising revenue to prevent and control NCDs – in addition, this is a highly effective way to reduce smoking rates, particularly among young people.

DMAI – The Population Health Improvement Alliance asks you to attend the UN Summit and in person and make this a high priority for the Ministry of Health & Family Welfare . We are also calling for the establishment of a NCDs partnership to lead multi- sectoral and coordinated action, and a UN Decade of Action on NCDs to implement the commitments governments will make at the UN Summit in New York

DMAI – The Population Health Improvement Alliance would be pleased to provide your office with any further information in preparation for the UN Summit.

NCDs have the power to affect us all. Increasingly NCD’s strike people in younger age groups, including children, threatening international economic progress. But we are not powerless.

We have achievable cost-effective solutions. We need political leadership now to make them a reality. Please be a champion for NCDs by attending the UN Summit in September and safeguard the health and prosperity of future generations in India

We sincerely hope that the country will take leadership and set an example for the world on how to manage chronic diseases through early interventions

DMAI – The Population Health Improvement Alliance Recommends that:

Indian government establishes an NGO-Private Healthcare Players – Government  Alliance . An  India NCDs Alliance , linked to WHO, to coordinate follow up action with member states, other UN and multilateral agencies, foundations, NGOs and private sector

  • We must look at enacting a Chronic Care bill 2011 in the parliament in the winter session that addresses this biggest healthcare challenge (NCD’s) .
  • Create a high level committee for creating an actionable plan for identification , enrolment and treatment of chronically ill populations or move them under a primary prevention plan for people at the risk of chronic diseases . This plan should be implemented on ground before end of this year
  • As written in my comprehensive healthcare reforms document  in 2009, we must set up a CDR ( Central Disease Registry ). Details available at .
  • Come out with protocols for the treatment of chronic diseases
  • Come out with mandatory guidelines for work force wellness
  • Enforce child health guidelines in all primary schools & dietary guidelines . Please refer DMAI’s note on Healthy Foods & An Appeal at for details
  • Include general & basic information on nutrition and physical activity in school curriculum from class VI onwards . Have a compulsory paper on health & Wellness for  class 10th exam for all educational boards in India
  • Adopt an open minded and outcome driven approach of roping in private healthcare players to improve preventive care & treatment of identified populations
  • Include preventive checks and health clubs ( Gyms & Yoga ) under tax benefits
  • Levy additional premium on insurance policies for smokers to dissuade them from smoking
  • Launch a nationwide campaign for creating awareness on avoiding and managing chronic diseases
  • Encourage and implement the use of mHealth for timely access & affordability

 Post my return from UN session , I had discussions with leading pharmaceutical companies as to how to get their support and involvement in this major pan India efforts. All the

Companies  I have talked to are willing to work with the government on the way  to address the issue of chronic diseases . I believe that we must involve the companies in our outreach efforts and form a long term partnership with the pharmaceutical companies

Finally , I must state that success will depend on the development of strategic partnerships, ensuring there are explicit and measurable targets, and governments providing the necessary political leadership. I would be grateful for your consideration of the following in order to ensure a successful Summit in September:

  • Support the strong participation of civil society in the Summit. We request that civil society representatives be included in the official government delegation to the Summit.
  • Invest in the consultation process leading up to the Summit to ensure that the meeting produces an outcomes document with strong recommendations and a concrete plan of international action, as outlined in the NCD Alliance 10 Outcomes Document Priorities. This should include:
  • Language on the NCD Alliance’s 10 Priority Outcomes, based on previously agreed upon language.
  • Acknowledgement of the health, social and economic burden of NCDs in the world, particularly in low- and middle-income countries.
  • An increase in international development funds and technical assistance to NCD prevention and control, including support for international instruments such as the Framework Convention on Tobacco control.
  • Measures that address the availability and affordability of quality medicines and technologies to ensure that people living with NCDs can access life-saving treatments.
  • Agreement to global accountability monitoring, reporting, and follow-up mechanisms.

DMAI – The Population Health Improvement Alliance is a not-for-profit organization formed by global healthcare leaders , and the only civil society organization in India dedicated to the management of chronic disease management in India .  In the past three years , DMAI has worked at both International level and within India to address the issue of chronic diseases with the support of  patient groups , Industry & policy makers , and wishes to put on record the continuous support DMAI has received from policy makers and the industry . We wish to expand this association further to address the issue of NCD’s together in form of a ‘PPPP’ – Profitable Private public partnerships .  I personally believe , that if the first “P” – Profit is missing from PPP We would just be restricted to pilot stage. We should not shy from adding the additional  “P” – Profits , so that the industry is incentivized to align its goals to government, and work together in a sustainable and profitable manner with performance that is measurable and with positive outcomes 

I think without profit , government cannot demand performance ; and without performance, private players should not expect profit . So profit has a pivotal role in the success of PPPP

To show our support for this summit , we have put the sub-theme ‘Management of Chronic Diseases using technology’ at the International Telemedicine Congress ( ) that I am chairing from 11-13 November 2011 at Mumbai, India.

We would very much appreciate the opportunity to share perspectives on the meeting with you or one of your colleagues. At your earliest convenience, please let me know your availability in the coming weeks.

We look forward to your personal participation with a team of civil society organizations at the High-Level UN Summit in September, & I am sure that your thoughts will be really helpful for the summit and will set an example for others to follow . We wish you and the UN a successful summit .

Yours sincerely,

Rajendra Pratap Gupta

President & Member of the Board

Disease Management Association of India

Member – Healthcare , QCI. Government of India

P.N. : Details of the work done by DMAI in managing chronic diseases is available at the website

Encl: Message at the UN delivered on 16th June 2011.


H.E. Ban Ki Moon, Secretary General , United Nations

H.E. Joseph Diess , President of the UN General Assembly

Hon’ble Deputy Secretary General of the UN General Assembly

Ms. Margaret Chan, Director General, WHO

Shri Ghulam Nabi Azad , Hon’ble Ministry of Health & Family Welfare, GOI

Dr.K. Srinath Reddy , President , PHFI

Minister of State for Health & Family Welfare , GOI

Dr.Syeda Hameed, Planning Commission , GOI

Shri K.Chandramouli, Secretary , H&FW , GOI

Board Of Directors , Disease Management Association of India – DMAI , The Population Health Improvement Alliance .

Address of the President of DMAI – The Population Health Improvement Alliance at the UN on 16th June 2011

Venue : UN General Assembly Hall , United Nations , New York.

Chaired by Mr. Joseph Deiss , President of the UN General Assembly .

Dear Friends ,

I am honored to be here , &  have few key points  for the special high level, two-day session that UN will convene in September 2011 for addressing the issue of chronic diseases.

I appreciate the point that UN session talks about local issues across regions . I would further suggest the United Nations that , if we want the governments to act on its recommendations , we must go beyond local i.e. get micro . My experience in public policy makes me believe that governments do appreciate and act on recommendations that are local but also focus on micro issues .

We have mega goals but  our actions have to be micro and we must suggest inputs that are local and at  micro level,  for execution.

Also, let us  accept the fact that for this generation , we are late, and we have already missed the bus . What I would not like is, that our next generation sits in the same UN General Assembly hall after 40 years , and discusses the same issues related to chronic diseases , and says that ‘our earlier generation behaved irresponsibly and did nothing for us ! ’. So the time has come for us to distinguish the ‘Urgent’ & ‘Important’ . Urgent is that we must fix the issues related to the chronic diseases now , but it is more Important  that we plan to build a healthier next generation . So my expectation from the UN is,  that  there will be a dedicated session related to Child health at the UN General Assembly in September .

Also that,  the technology is becoming all-pervasive and we must use this UN session to promote the use of  mHealth to address the issue of chronic diseases . I am expecting that the UN general assembly will dedicate a session to mHealth, and how it can help in the delivery of care for chronic diseases.

Lastly , I would like to run a quick survey on ABCDE of  Chronic Diseases / Healthcare . Where,  A stands for – Asthma/ Arthritis , B stands for Blood Pressure , C stands for CVD / Cancer , D stands for Diabetes & E stands for Epilepsy / Elderly patients ( as 84 % of all the elderly patients are on one or more medications)

If anyone of you or your immediate family members have any of these ABCDE , please raise hands .

The response is unbelievable ! I have made a point . It is not about the 5 or 10 % prevalence rate of chronic diseases. We have just now had the visual proof of the prevalence of chronic diseases , and it is much higher than the figures that we read often .

It’s time to act now .

Thank you.

Rajendra Pratap Gupta

Recording of the speech is available at

Points raised at the Interactive Civil Society Hearing at the United Nations 16th June 2011

Venue : UN General Assembly Hall , United Nations , New York.

Chaired by Mr.Joseph Deiss , President of the UN General Assembly .

 Dear Friends ,

I am honored to be here , &  have few key points  for the special high level, two-day session that UN will convene in September 2011 for addressing the issue of chronic diseases.

I appreciate the point that UN session talks about local issues across regions . I would further suggest the United Nations that , if we want the governments to act on its recommendations , we must go beyond local i.e. get micro . My experience in public policy makes me believe that governments do appreciate and act on recommendations that are local but also focus on micro issues .

We have mega goals but  our actions have to be micro and we must suggest inputs that are local and at  micro level,  for execution.

Also, let us  accept the fact that for this generation , we are late, and we have already missed the bus . What I would not like is, that our next generation sits in the same UN General Assembly hall after 40 years , and discusses the same issues related to chronic diseases , and says that ‘our earlier generation behaved irresponsibly and did nothing for us ! ’. So the time has come for us to distinguish the ‘Urgent’ & ‘Important’ . Urgent is that we must fix the issues related to the chronic diseases now , but it is more Important  that we plan to build a healthier next generation . So my expectation from the UN is,  that  there will be a dedicated session related to Child health at the UN General Assembly in September .

Also that,  the technology is becoming all-pervasive and we must use this UN session to promote the use of  mHealth to address the issue of chronic diseases . I am expecting that the UN general assembly will dedicate a session to mHealth, and how it can help in the delivery of care for chronic diseases.

 Lastly , I would like to run a quick survey on ABCDE of  Chronic Diseases / Healthcare . Where,  A stands for – Asthma/ Arthritis , B stands for Blood Pressure , C stands for CVD / Cancer , D stands for Diabetes & E stands for Epilepsy / Elderly patients ( as 84 % of all the elderly patients are on one or more medications)

If anyone of you or your immediate family members have any of these ABCDE , please raise hands .

The response is unbelievable ! I have made a point . It is not about the 5 or 10 % prevalence rate of chronic diseases. We have just now had the visual proof of the prevalence of chronic diseases , and it is much higher than the figures that we read often .

It’s time to act now .

Thank you.

Rajendra Pratap Gupta

The points i talked about as mentioned above ,were highlighted by Sir George Alleyne , UN Special Envoy in his closing remarks.

Mental Healthcare Act 2010 – Needs revisions

The Population Health Improvement Alliance


Rajendra Pratap Gupta


Registered Speed Post / E-Mail

Dated: March 24th 2011

Shri. Ghulam Nabi Azad

Hon’ble Health Minister

Government of India

Nirman Bhavan,

New Delhi -110108

Reference: Revision of Mental Health Act 1987 & Mental Health Care Act 2010 ( draft )

Dear Shri Azad ji,

This needs your esteem, kind and personal attention.

I am writing this note on behalf of the Disease Management Association of India – ( DMAI)- The Population Health Improvement Alliance . DMAI works with all the stake holders in the entire continuum of care, for improving the population health of the nation . Over the last few years, we have worked with different stake holders to help define the right priorities in healthcare for the policy makers & the care providers .

Through this note , I am drawing your attention to the revision of the mental health act of 1987 and the proposed Mental Health Care act 2010 (Draft). The process of revision of the Mental Health Act 1987 was initiated about a year back, to make it compliant to the United Nations Convention on the ‘Rights of Persons with Disability’. Disability includes persons with long term mental illness. This convention advocates equal rights for all disabled persons.

Dr Saumitra Pathare ( a private psychiatrist) and Dr. Jaya Sagade (a lawyer) of Pune were in charge of conducting the regional consultations on behalf of the Ministry. Over the last one year, there have been 5 regional consultations with various stakeholders. The major stakeholders consulted have been users, care providers, professional bodies in mental health, mental health institutions and state government representatives. However, it is to be noted that, the Medical Council of India, other specialties of modern medicine, and professional organizations of general health field, have not been consulted. This is important, as the changes which are evident in the draft bill have far reaching consequences in terms of the way the modern medicine is taught and practiced currently.

DMAI- The Population Health Improvement Alliance, is surprised with the outcome of the consultations , and that there was hardly any discussion on the final outcome to patients due to the significant changes which are being brought in terms of the ‘mental health’ field of practice of medicine by way of promulgating this act. Proposed changes are likely to cost human lives , as persons who have not been trained to be physician (Clinical Psychologist, Psychiatric Social Worker, Psychiatric Nurse), will be entrusted with the role of independent examination, diagnosis and admission of patients in mental health facilities. Currently, this role rests with a Psychiatrist who is a medical doctor (MBBS) trained in Psychological Medicine. In modern system of medicine ,only a physician (M.B.B.S )can diagnose a patient, as only he has received training in all the specialties such as Medicine, Surgery, Eye, ENT, Obstetrics & Gynecology, Pediatrics, Orthopedics, Radiology, Dentistry, Dermatology, Anesthesiology, Pharmacology, Preventive and Social Medicine, Pathology, Microbiology, Physiology, Biochemistry, Anatomy etc. , which essentially means, covering all the systems of the body. Unfortunately, Human body cannot be compartmentalized and however we may wish, but we cannot have an Eye specialist who has studied only ‘Eye’ and not done MBBS ( as a basic general qualification and set of skills covering the entire human body system) to examine each and every system of human body. Similarly, we cannot have a Psychologist who has no training of the subjects studied at MBBS level, to diagnose mental disorders by only doing psychological examination!!!!

Only an MBBS trained doctor with the proper understanding of the entire human body system and its functioning, can do a detailed psychological evaluation and come to a diagnosis of whether the patient has a psychological illness or it is some physical illness, which is presenting itself as a psychological illness. In cases of latter, appropriate referral is required and any delay may even be fatal. S/he can also order various tests and imaging and interpret them for aiding in his diagnosis. After a diagnosis is arrived at, s/he can plan and provide physical treatment (ECT), pharmacological treatment or psychological treatment. The role of psychiatric nurse, clinical psychologist or a psychiatric social worker is to assist him by nursing the patient, helping him in psychological interventions, helping him in psycho-social interventions respectively. But the patient is under the overall care of a psychiatrist who is the leader of the mental health team. All the three categories of personnel work under the supervision of a psychiatrist .

 A clinical psychologist, PSW ( Psychiatric Social Worker ) or a psychiatric nurse is not trained to be a physician. They have not studied the human body as an MBBS doctor and cannot do detailed physical or systemic examination, investigations and imaging like a psychiatrist. They are in no position to independently examine, diagnose and advise admission of patient. A PSW and Clinical psychologist have not general training in other subjects of modern medicine. Just by talking to patient, how can a Clinical Psychologist or PSW diagnose a mental disorder? They will be severely restricted by their inability to do general and systemic examination and order and interpret investigations and imaging. A Psychiatry examinee will fail in his examination if he did not touch the patient for examination ; however bright drug treatment he may formulate for the patient ; as without a general and systemic examination, a person cannot make a diagnosis of mental disorder. In many cases special investigations and imaging also has to be ordered and interpreted. As per the diagnostic criteria for mental illness, a mental disorder can only be diagnosed after ruling out that the signs and symptoms are not better accounted for by a medical illness or use/abuse of a substance. In this scenario, without proper validation of the reason for the particular condition , what is the validity of diagnosis of mental disorder by a Clinical Psychologist, PSW or a Nurse ? Even the quacks believe that they can diagnose and treat independently. Each such claim needs to be examined objectively in line of their competence and current practice related to their vocation.

In modern system of medicine, which is regulated by MCI, there is no specialization known as Clinical Psychology, PSW or Psychiatric Nursing. The mandate of ‘Rehabilitation Council’ is limited to rehabilitation of persons with disability and practice of modern medicine under Rehabilitation Council is neither required nor allowed. If at all, new independent specialties such as Clinical Psychology, PSW and Mental Health Nursing without any supervisory role of a Psychiatrist is being planned for modern medicine system, then the whole modern medical system (MCI, Indian Medical Association, Other Medical Specialties) must be consulted .

If we go as per the draft, it means that Clinical Psychology, PSW and Mental Health Nursing personnel are as much a specialist as a psychiatrist and can independently examine , diagnose, admit and treat patients with mental disorders.

It is not understandable why a psychiatrist has to do MBBS (study the whole human body) and then specialize in Psychiatry while for the other persons they need to study only psychology or social work and yet be assumed to be qualified to examine the whole body, diagnose, admit and treat patients (albeit without medicines) . The demand to prescribe medicines by non psychiatrist is also going around (and may be later on this will be also be made possible.) There is no institution in the country where a Clinical Psychologist, PSW, Mental Health Nurse examines patients independently, diagnoses a mental disorders, admits patients and treats them. This amounts to practice of Psychiatry under the modern system of medicine and would invite penal provisions of MCI. The sole aim of drafters is to get the bill through and take credit for drafting the bill rather than have a healthy development of the sector. Nowhere in the country there is a Clinical Psychology ward, PSW ward or Psychiatric Nursing ward. The decision to admit is taken by the leader of the mental health team who is a Psychiatrist and it is the Psychiatrist who is overall responsible for treatment of a patient with mental disorder.

One of the reasons given by the people behind the draft of the Mental Healthcare Act 2010, for giving the role of independent examination, diagnosis and admission in bill, is the shortage of psychiatrist in the country. But if we go by the definition of psychiatrist in the bill which is the same as that in the previous Act, ‘an MBBS qualified person with experience and training in Psychiatry can be designated a psychiatrist’ for the purpose of the Act.

At present , there are about 8 lac medical practitioners in the country and these can potentially be designated as psychiatrist. So where is the shortage for the purpose of the Act ? The only purpose which could be served by giving an independent examination, diagnosis and admission to Clinical Psychologist, PSW, Mental Health Nurse in the bill is to later on claim that if they are capable of doing these jobs, then this means that they can practice their trades independently under the modern system of Medicine. This would mean they will be physicians of mental disorders just like a psychiatrist.

The inclusion of Clinical Psychologist, PSW, Mental Health Nurse for purpose of independent assessment, diagnosis, admission to a mental health facility should be deleted and replaced by ‘psychiatrist’ (an MBBS qualified doctor with some training/experience in psychiatry). After this, there will not be a need for defining mental health professional in the Act. If at all it has to be defined, then Clinical Psychologist and PSW shall be designated as Assistant Mental Health Professional as in the present legislation (Section 22 of State Mental Health Rule 1990) and their role clearly specified as being- to assist a psychiatrist.

Further, the supervision and review of the decision of a psychiatrist by a Clinical Psychologist, PSW, Mental Health Nurse in the mental health review commission is not feasible as review is to be done by practitioner of the same specialty i.e. Psychiatrist. Thus, the provision of Psychiatrist in the review commission should be made mandatory.

In a multidisciplinary team such as a mental health team, each team member has a specific role. If everyone will do the same role, which is to independently examine, diagnose and admit, then there could be no team functioning. Rather the role of each mental health person should be clarified in the Guidelines /Rules clearly, so that there is good team functioning and the public is well informed and is not misguided by manipulative persons. Can we imagine a similar provision for a Nurse specializing in Medical, Surgical, OBG, Cardio-thoracic nursing to independently examine, diagnose and admit patients in Medical, Surgical or OBG, Cardio-Thoracic ward respectively? Then why should we consider similar provision for Clinical Psychologist posted with Neurology department?

Psychiatry is a medical discipline as any other discipline. If Clinical Psychologist, PSW and Psychiatric Nurse want to independently examine , diagnose, admit and treat patients without even having the training and skills for the same and government wants to allow the same, then they should be allowed to start their own wards to do so and be responsible for their decisions. If we allow such changes to be brought, this would mean that a Psychiatrist too does not need to do MBBS. Then all the specialties of modern medicine should have direct specialization rather than first spend 5.5 years to be a General doctor. Human body cannot be divided in a compartments. All organs and systems are interrelated. A stroke can present itself as a depression in a mental health facility. What skill a psychologist or a PSW has to diagnose it without doing a full neurological examination or relevant investigations. They will treat for depression while the patient will die. In my view , compartmentalised knowledge is dangerous for the medical profession and defeats the basis of evidence based medicine

We are trying to make Clinical Psychologist, PSW and Mental Health Nurse into Physicians in mental health by giving the role of a Physician to them under the new draft bill on the pretext of shortage of Psychiatrist. However, there are less than a 1000 Clinical Psychologist and PSW both combined in the country. Further, there is no dearth of Psychiatrist under Mental Health Act, as Govt. can very well designate MBBS doctors with some experience in Psychiatry as Psychiatrist (as per the definition and provision in current legislation and the draft Bill). So even the assumptions for the shortage of psychiatrists is not a right justification for this act

The role given to Clinical Psychologist, PSW and Psychiatric Nurse in the draft bill is ; independent examination of patients, diagnosis , admission and then review of decisions taken by a Psychiatrist. Instead of this, in the draft bill, the role of a Clinical Psychologist and PSW- as a rehabilitation professional , and Psychiatric nurse – as a specialized nurse, should have been clarified and focused.

The position of a Psychiatrist as a mental health team leader should be reiterated and the decision of a psychiatrist should only be reviewed by a board having a psychiatrist. These rules could further be clarified In the draft bill psychiatric social worker and clinical psychologist has been mentioned as mental health professional just like a psychiatrist. However, In section 22 of the State Mental Health Rules’1990 (the existing legislation) the PSW and Clinical Psychologist are referred to as Assistant mental health professional. The change in the draft bill under consideration has been done with a view to make their role fit for independent examination, diagnosis, admission to a mental health facility by the drafters, without any regard to the impact of this on the patient care and safety. If they are full-fledged professionals (as they claim) who can diagnose, admit and treat patients, why do they need to be defined as such in the Act. At no place in the draft bill their role has been mentioned separately. At all places they are bunched as mental health professional with no individual roles. At no place it is mentioned that they will function under the supervision of a psychiatrist. If they independently examine, diagnose and admit patients they are then deemed to have an independent role. This will increase the role conflict which is already very high in the mental health team. So much so that at some places there is no team work. In Kerala High Court, there is a case going on, to allow clinical psychologist to independently practice in community to treat patients of mental disorders.

This is a serious issue and needs to be taken up strongly so that untrained people are not given the role of a physician i.e. to practice independently to treat patients.

DMAI insists that the Medical Council of India, Indian Medical Association & patient groups & DMAI needs to be taken in confidence and consulted, as independent examination, diagnosis and admission and also treatment by psychological or psycho-social means is practice of psychiatry under modern medicine and could not be allowed to be done by persons who do not even have a MBBS degree, in view of patient safety and care.

All health personnel shall work within the limits of their competence. In section 43 and 45 of the draft bill related to admission in a mental health facility: a mental health professional (i.e. Clinical Psychologist, PSW, Psychiatric nurse) has a role to examine a person suspected to be mentally ill independently, assess mental illness and its severity and advise admission. This is a role which goes beyond their competence. There are already instances of Clinical Psychologist practicing treatment of mental disorders independently as isolated examples. There is growing demand from clinical psychologist to allow them to practice independently the treatment of mental disorders. This change in the draft bill will allow them to be recognized as persons who can independently examine, diagnose, and admit patients, which will substantiate their claim to practice independently in community rather than under the supervision of a psychiatrist. It’s altogether different matter that they are not trained to examine and diagnose mental disorders as it requires ruling out other physical disorders as well and it requires a person to be a physician to do that. In section 22 of the draft bill : Constitution of district panels of mental health review commission , two members could be mental health professionals (i.e. Clinical Psychologist, PSW, Psychiatric nurse) which may not include a psychiatrist if he is not available, but then how the commission can judge the decision of a psychiatrist if no psychiatrist is in the commission? One needs to have knowledge of psychiatry to assess the correctness of the decision of a psychiatrist in a particular case. Provision of a psychiatrist in the review commission should be mandatory rather than being replaced by non-psychiatrist personnel Mental disorders are medical disorders and should not be treated by non-medicos .

I am quite sure that you will intervene and ensure that the corrective measures are taken to address the lacunae in the bill Also,

DMAI- The Population Health Improvement Alliance has initiated a ‘NCD Policy of India’ initiative, and would be glad to have the views of the ‘Ministry of Health’ involvement on the initiative

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, do let me know.

With best regards

Rajendra Pratap Gupta

CC. Dr.Manmohan Singh, Sonia Gandhi ,Rahul Gandhi , Dr.Syeda Hameed, Dr.Murli Mahohar Joshi , Montek Singh Ahluwalia ,Shri Dinesh Trivedi , Sitaram Yechury,  Members of Parliament , Sam Pitroda , Secy-Health & Family Welfare , GOI,  Dr.K.Srinath Reddy, Debasish Panda , Secretary (ME) Governors , MCI DGHS,MOHFW, Dr.Sudhir Gupta , CMO, NCD-MOHFW ,Dr. Suman Sinha, Psychiatrist,  IMA , Chief Minister’s of States

Include Homeopathy in National Health Schemes

DMAI wants the govt to give due weightage to homoeopathy in NRHM

Suja Nair Shirodkar, Mumbai Wednesday, March 30, 2011, 08:00 Hrs [IST]

The Disease Management Association of India (DMAI) has recommended the Public Accounts Committee (PAC) of the central government to increase the role of homoeopathy in the National Rural Health Mission (NRHM), especially for acute illness.

At present homoeopathy is not being leveraged properly under NRHM in spite of it being the cheapest way of treatment in the country. Rajendra Pratap Gupta, president and director DMAI pointed out that the homoeopathic medicines are cheaper and much more accessible to patients thus it is only natural that its potential should be utilised properly under NRHM.

Though the treatment used in homoeopathy is superficially similar to the medicines prescribed by a conventional doctor it differs in their source, preparation and dosage. He observed that in spite of having enough qualified homoeopathic physicians in the country the government is not giving them enough chance to play any role in the national health program. “Today there are  hospitals and colleges that cater to homoeopathy and encourage its use then why isn’t the government utilising these resources to increase the demand for homoeopathic medicines among the rural population.

The government should take step to ensure that the people in the rural India can also benefit from this system,” he pointed out. He said that the demand for homoeopathy has increased over the years as more and more people are adopting homoeopathic treatment due to its effectiveness compared to other available methods. Thus it should be put to use more effectively. He added, “Homoeopathic medicines are very cheap, in almost two rupees a patient can get a weeks worth of medicines which will be a great support to the rural population, it would provide them with cheapest alternative that assures best treatment.”

Homoeopathy is a system for the treatment of illness that is based both on the recognition of patterns within the symptoms of the illness and a wider consideration of how the individual is as a person. Although conventional medical assessment also takes these issues in to account, the homoeopathic approach integrates personality type, previous experiences, emotional state, the influence of the environment and other social factors to a greater degree than is usual with standard medical practice.

Rajendra Pratap Gupta

DMAI wants the government to extend the NRHM till 2017 with radical operational changes

The Population Health Improvement Alliance                                                                                                                                                                                                                  

The Disease Management Association of India (DMAI), a non-profit organisation propagating disease management concept and tools in the country, has urged the Public Accounts Committee (PAC) of the central government to reconsider its recommendations for scrapping of National Rural Health Mission (NRHM) as the NRHM has made an impact on the lives of the rural population in the country.

The DMAI suggestion in this regard was put forth by the DMAI president and director Rajendra Pratap Gupta in a letter addressed to PAC chairman Dr Murli Manohar Joshi recently.

The NRHM was launched in the country on April 12, 2005 for a period of seven years i.e. from 2005 to 2012 for providing integrated comprehensive primary health care services, specially to the poor and vulnerable sections of the society. It means that NRHM will get expired by 2012. However, seeing its impact on the rural population, the government is thinking of a possible extension for another five years. In this regard the government had asked PAC to review the NRHM. However, in its reports the PAC has recommended on scrapping the NRHM scheme.

However Gupta suggested, “NRHM is a very useful programme and has been successful in having its presence felt even in the remote parts of the country. However, there are many radical administrative and operational changes needed to be made in the present format of NRHM.”

He suggested that with proper administrative and operational tactic, this programme certainly will have the power to create desired impact in the rural health scene. In his recommendations to the planning commission on the changes needed in NRHM for the 12th five year plan, Gupta suggested that technology must be leveraged in NRHM for accountability, transparency and telehealth and that 12th five year plan must consider opportunities to digitise NRHM in all spheres of its implementation.

He said, “There are many important changes that needs to be undertaken in the NRHM, but of all changes the first and foremost change should be to improve the quality of medicines that is being supplied at the NRHM centres. Secondly, minor surgeries are not allowed in Primary Health Centres (PHCs) as of now. This should be changed and the government must allow minor surgeries in the PHCs as it would help reduce a lot for hassles for the villagers and bring revenue for the government as well.”

Other issue that he had highlighted in the letter was on the inadequate fund flow on time which could lead to corruption among the people working at the lowest level in PHC and sub centres.

“I have met people who were not paid salary for months, and also discovered the fact that the funds that were supposed to be sent for 2010 were received by the centres in mid January 2011. Such delays must be stopped with immediate effect as this clearly will encourage and lead to corruption as people drawing a monthly salary of Rs.5000-8000 won’t be able to sustain their family without salary for months. Either they will resort to bribing, selling the government supplies or starts absconding and working for employers in parallel. Thus I suggest that the fund meant for a sub centre or PHC must be transferred in advance for the quarter if not half yearly,” Gupta points out.

He put special stress on telehealth adoption goals for NRHM and other healthcare projects, as setting up and manning the physical infrastructure with qualified professionals at remote places is nonviable. To stress the importance of telehealth adoption in the country the Telemedicine Society of India (TSI) is organising a three-day conference Telemedicon’ 11 in Mumbai from November 11 to 13. TSI is completely dedicated to the promotion of telehealth in India and is being organised at a time when there is a big push from the government and private players in the field of telehealth in India.

Rajendra Pratap Gupta

Re-structuring Healthcare in India – 12th Five Year plan – NRHM , ICDS & Malnutrition



January 31, 2011.

Dr.Syeda Hameed


Planning Commission

Government of India

Yojna Bhawan,

Sansad Marg, New Delhi- 110001

Reference: Inputs on the 12th Five year plan W.R.T. (1) Eradicating under-nutrition and malnutrition in India through restructuring of ICDS or other means and (2) Suggestions for improvement in the present structure of NRHM. 


Dear Dr. Hameed,

I am sure that this finds you doing well.  This has reference to the mail from your office on 5th January 2011, requesting me to provide inputs on the 12th five year plan w.r.t.(1) Eradicating under-nutrition and malnutrition in India through restructuring of ICDS or other means and (2) Suggestions for improvement in the present structure of NRHM. 

At the outset, let me put my deep appreciation for the NRHM (National Rural Health Mission) and its positive impact on the healthcare of the rural population. I had a chance to visit many rural pockets over the past few years, and my inputs are based on the reality as seen by a commoner, and I do hope it is insightful along with being helpful.

Policy Changes:

To me, there appears to be no single prescription for addressing the diverse healthcare needs of this country, which is as big as a continent, but NRHM has made its presence felt even in the remote parts of the country.  Seeing that the NRHM was launched only in April 2005, and would be around till 2012, with a possible extension for another five years , one of the key policy action items that might be worth considering to create a pro-active Rural healthcare system in another six years ( assuming that the NRHM is discontinued in its current form by 2017 ), is to be able to sensitize the population on the adoption of basic standards of personal hygiene , nutrition & lifestyle necessary for fitness  ( wellness) that makes our population less dependent on hospital care . This should be one of the key goals of the NRHM for the 12th Five year plan .The current NRHM has put the onus & financial burden on the centre, as the centre and state partnership in terms of the financial outlay is 85: 15 . Second important consideration , this also must get a key policy shift for the 12th five year plan which should have one more stakeholder i.e.  center : state : Beneficiary .

Funding for NRHM:


We need to see a financial participation from the beneficiaries of the NRHM, as they would have got used to the services offered via NRHM centers ( ASHA , ANM, Sub Centers , PHC , CHC & District hospitals ) , and the value of offering would have increased through NRHM centers. In addition to this, per capita income will also go up in the next five years if the country continues to grow at the current pace. So we must consider if we can increase the fees for basic services towards the 10th year of NRHM; even a token increase by one rupee can deliver a quantum leap. Besides, we must keep reducing the financial incentives gradually every year to phase it out eventually. Still, the people would enjoy the safe healthcare services which are subsidized or offered at a very low cost. Villagers are getting used to these services , and I am sure that in the 10th year of NRHM , it might be a right time to bring down some of the subsidies and incentives , as the trust would have built up considerably .

NRHM should welcome ‘tax free’ donations from individuals and corporates: This should be publicized and could become a good way to raise funds in a step towards building a financially sustainable healthcare model for rural India

With a gradual reversal in the expense funding between center and the state, the expense part needs a micro planning as, though the hard infrastructure expenses might not be as high as it is now (since we are constructing sub centers & upgrading some existing centers ), but the maintenance of the infrastructure built will become a huge financial burden, and  knowing that the divestment & auctions are not routine incomes for the government, this would lead to a huge deficit in the budgets over the next six years if financial planning of NRHM is not planned and managed well.

Also, one of the key considerations for the policy makers is to look at  converting NRHM into NHM ( National Health Mission ) , as the conditions remain deplorable for urban poor , and the private facilities are not going beyond tier 1 &  2 towns .


Structural changes:

It would be worth considering replacing the hierarchical designations to functional designations to have a clearly defined role and an outcome driven responsibility

Mission Steering Group (at the Centre) could consist of the following :

Director for Planning & Forecasting,

Director for Strategy 

Director for Analysis & Research (One who looks into the regular reporting & review)

Director – Innovation & Program improvisation (Program will certainly improvise with regular feedback & inputs)

Director – IT

Director – Procurement

Director – Logistics

Director – Finance & Accounts

Director – Standards – Medical Protocols, GCP (Good Clinical Practices) & Quality Control

Director – IM (Infant Mortality)

Director – MM (Maternal Mortality)

Director – Nutrition 

Director – Immunizations

Director – Preventive Care

Director – Mental Health

Director – TB- DOTS

Director – ART

Director – NCD

Director – Anemia & Related Disorders (This needs a special focus, as more than 50 % of women are Anemic)

Director – Oral Care

Director – De-addiction (De-addiction must also be a focus area, as the consumption of alcohol has been on constant rise, and wife beating is prevalent in most of the households)

Director – Ophthalmology

Director – Ambulatory services

Director – Pharmacy

Director – NGO & Alliances

Director – Media & Communication

Director – Human Resources & Training

More people can be added depending upon the focus areas for NRHM. In fact, I would strongly recommend that all the national health programs be merged with the NRHM one by one  to ensure that health & wellness issues are addressed holistically in rural India

The reason I am recommending a dedicated resource for each action area like Director – MM, Director IM etc. is that, then we have people with specific deliverable, and outcomes would be better. Currently, at the centre, we have four Joint Secretaries and four directors with multiple responsibilities . These might leave them with delivering outstanding results in some areas, and with serious gaps in some!!

The above mentioned Central Committee (Mission Steering Group ) , should be overseen by the board or committee which has members from Public Health, doctors from modern medicine, Ayush, Nursing, Public representative, patient groups & people from different walks of life, who bring diverse capabilities to the team with proven competence in envisioning and executing projects on mass scale or of making a social impact. 1/3rd of these representatives must change every two years (rotating public participation). 50 % of the members must be from the government and 50 % from the private sector. Also, of the total members, 50 % must be practicing doctors and remaining non-medicos.

Further, a similar structure needs to be set up at the state level.  At the District level, the work gets delivered via same field workers.

While the PHC’s & Sub centers are done up very well, some gaps remain, like;

  • There is a mismatch in the requirement & stocks of medicines. All the PHC’s get similar stocks of medicines irrespective of the load in OPD. So , whereas  some PHC have more stocks ,  some have stock outs – More of Forecasting and logistics issue
  • Supplies of nutrients is insufficient & inconsistent –  Once we have a focused resource ( Director – Nutrition , Director – Forecasting & Director – Logistics ), these problems would reduce drastically
  • Need is for three doctors instead of the two currently at the PHC, so that the load can be handled well. Currently, at times, the wait period for a patient to be seen could go beyond 4 hours at times in OPD. Also, with this, the PHC can operate           24 X 7 , since doctors can do an 8 hour shift each
  • It would be good to have the doctor’s residence attached to the PHC
  • Biomedical waste disposal has to be given priority to avoid infections in villages.


Challenge: Nutrition given during ANC / PNC is consumed by the family and not by the mother.

Solution: If ASHA can monitor this during visits or otherwise, it would be effective or the gender specific nutrition packs could be made to ensure that the females consume what is meant for them. Self Help Groups have emerged as the new power centers in the villages and every village has Self Help groups. ASHA’s must work with SHG’s to address this issue and oversee that the diet meant for the lactating mother is given to her in presence of a SHG member

Challenge: Electricity – Load shedding in villages: This leads to lack of storage conditions in PHC’s & Sub centers

Solution: India has adequate sunshine for 9-10 months in a year, for rest of the months, the load shedding is less, so it is worth considering having solar panels as an integral part at all the PHC’s & Sub Centers for generating electricity needed for storage and other requirements

 Challenge: Poor Quality of Medicines: It is observed that the qualities of medicines are poor, and it is procured by the district Health committee. Poor quality of medicine is a serious issue, as the patients are given medicines for treatment, and if the medicines are not effective, it will lead to mistrust in the entire system, and the poor people will have to move towards private practitioners or quacks and suffer more


Solution: Since all the companies in pharmaceuticals have national level operations, it will be good  if the national level tie up is done for procurements of medicines at the NRHM rates, and the order, supplies & payments happen locally. With this, we will be able to get the best rates and also give the best quality of medicines to the needy poor patients. Also, generic medicines should only be allowed to be used under NRHM. This will help to save enormous costs to the government. Also, all the PHC’s & sub centers must set up ROP’s (re-order points for all the requirements, factoring in the time lag for supplies based on past trends. This will ensure that there are near zero stock outs).

It was observed that the specialists (Gynecologist ) in one of the model PHC (Wardha district) comes only for two hours and that too, to direct patients to private practice. This must be avoided at all costs, as this will eventually make ASHA’s & ANM’s, agents for private clinics for all the wrong reasons & erode the trust in the NRHM

Challenge: Absenteeism in PHC: It is a common problem to see that doctors are missing or come only for a few hours or few days in a month.

Solution: It is suggested that the entire NRHM attendance moves paperless (biometric attendance be made compulsory). With this, the problem of absenteeism will come to an end

Challenge: Preparing reports and paper work takes most of the productive time of the health workers

Solution: With the advent of low cost tablet PC’s & low price 3 G enabled phones; it might be worth considering giving these devices to health workers like ASHA’s. Also, if these mobiles / tablets have a GPRS connection, it can mean live data updates, thereby, reducing the three month gap between the village data entry and the central review points at Delhi

When I visited the residence of one ASHA worker, she had more registers to maintain records then her daughter would have used in her studies! In all, she had about six registers to maintain records and spent 2-3 hours daily to just fill in her records. I believe that just one register should have been good enough ,  with name of the beneficiary , under which head ( disease or operation ) ,  visit for the purpose of , repeat visit , action taken, next steps, and next due visit etc…….The register given by NRHM was in English with words like Vulnerable men / women . I believe that the language used should be bilingual and not just in English …. This needs immediate attention. Digitizing the records through mobile phones would be great, as has been done in Wardha district for IM & MM programs. The data is updated live and the impact is significant with no chances of multiple entry and errors, and also real time actions happens due to SMS based follow up and care.

Ground reality: I visited one centre in a rural area, and I was surprised to see the PHC decked up to welcome the Health & Sanitation committee that was to visit the centre. I was told by the centre staff that they have been waiting since past one week, expecting this committee and they had bouquets etc ready to welcome them. Such visits do not reveal anything and add no value to the working of the village sub centers or the PHC but work only for photo-ops!! Only surprise visits must be under taken with no formal information given in advance, so that the right picture is presented during the visit, and the action oriented steps can be taken to fill the gaps, if any.

Pharmacies are present in every part of India .It is believed that India has about 7.5+ lac pharmacies across the country, and most of the villages have a pharmacy. All the

Pharmacists must work as ASHA support systems due to their knowledge and skills, being the trusted touch point for basic health problems. Focus through pharmacists should be on chronic diseases and paternal care, and through ASHA’s on child and maternal health

Medicine kits given to ASHA should have all the instructions in English, where as all the pharmaceutical companies are expected to carry the same bilingually (English & Hindi).  For NRHM supplies, pictorial presentation along with bilingual labeling must be mandated.

Tribals & Upper caste: Despite the best efforts of the government, tribals are still called the ‘Black castes’ and live in a separate area demarcated for them. One of the biggest challenges is that ASHA from a lower caste would still find few takers amongst upper caste households, and vice versa. This is one issue that needs to be addressed. It would be wrong to create two ASHA’s and further the divide , but some really significant  work can be given to ASHA , so that it appears to be compelling enough for everyone to seek ASHA’s assistance- Like the entire village birth certificates must have ASHA’s signature etc.

Changes in the delivery of services


New Opportunities: 

Community Radio: This is being experimented in Baramati, and must be looked into. Similar services can be started in villages to drive healthy behaviors. I had visited a few villages in north, where a simple awareness campaign (pictorial & through songs in local dialect) have reduced the maternal mortality by 93 %. The expenses in this project were not more than Rs.5000.00 per village. Such models need to be adopted

Toll free based IVR Multilingual helpline:  NRHM must initiate this to help reach the right people for the right inputs

m-Health based Jeevandaini scheme : This has been piloted in Wardha district , with good results in institutional deliveries and drastic improvement in MMR.  The simple mobile based applications have lead to live data upload and follow up via SMS, leading to good compliance amongst ANM’s & ASHA’s . This health based model needs to be made an essential part of NRHM . Since 3G & WIMAX is now a reality , the rural health information flow and delivery of few basic services must be done adopting m-Health ( mobile health platform ).

Mobile Sub centers: Sub centers are built at a cost of Rs.8.5 – 13.5+ Lacs. It might be worth considering to set-up mobile sub centers( Mobile Vans ) that can go across to the remotest areas and conduct outreach programmes. So the cost of operating the sub center ( rental , electricity etc ) gets consumed in the form of fuel expenses for the mobile health center and also, these sub centers can be used as an ambulance in case of medical emergencies . Thus it would save Rs.300 that is given for transferring patients to the referral centre. The cost of  mobile centre is expected to be much lower than the cost of a physical centre. Location of PHC’s & Sub Health Centers is mostly around a few Km’s from the residential areas, and this needs to be corrected or filled up with such mobile health center

Digital Training of Health workers: It might be worth considering creating a TV programme on doordarshan modeled exclusively for training ASHA, ANM & for increasing awareness amongst NRHM beneficiaries. Also the same should be made available through mobile phones as 3G is now a reality. Expecting mothers must be able to see the demo & programme clippings via their handsets or through ASHA’s handsets, which could be upgraded to a 3G enabled mobile handsets for live reporting or for delivering video content for various programmes.

Technology must be leveraged in NRHM for accountability, transparency and telehealth. 12th five year plan must consider opportunities to digitize NRHM in all spheres of its implementation

Minor surgeries in PHC: Now that that PHC’s have facilities for delivery, minor surgeries must be allowed in the PHC. So far, minor surgeries are not allowed in PHC. This is one important decision that can help save a lot for hassles for villagers and bring revenue for the government. The PHC’s can enroll patients for minor surgeries, and then get a surgeon on call for a day from a nearby town and complete the minor surgeries at the PHC to function as day care centers .

Reporting of NRHM across states should be on the same format as of KPI’s (key performance indicators) so that it leads to apples to apples comparison and this could be on these indicators

  • Structural : Setting up and maintenance of the facilities
  • Functional : Human resource management and flow of instructions and funds
  • Fund utilization: special focus must be paid as to why the funds could not be used, as the money is meant to be spent with an outcome allocated to every rupee spent.
  • Outcomes :  Measurable outcomes in improvement in the village / Taluka health must be done every quarter


Reporting and review must be

  • Weekly for Talukas
  • Fortnightly for Districts
  • Monthly for states
  • Quarterly at the centre


This timely reporting will itself bring out better outcomes. It was sad to learn that during the mid-term review of the 11th five year plan in July 2009, the ministry of health & family welfare was not even aware of  any targets. The reality is that, the files from the planning commission were not even looked into by the ministry of health & family welfare until the mid-term review of the plan started. One of the senior official of the MOHFW had revealed to me that rarely MOHFW looked into the files from the planning commission , and they were not even aware of any targets set by the planning commission , and that if the MOHFW did not respond to the plan targets set by the Planning Commission , the planning commission assumed the targets as accepted by the Ministry of Health & family welfare .This is a structural and procedural lacunae and needs to be addressed from the planning stage for the 12th five year plan , so that the ministry does not question in the meeting who set the targets for them ??

Administrative changes:


Financial planning and flow of funds:  The fund flow on time is the biggest problem. I have met people working at the lowest level in PHC & Sub centers, where the salary has not been paid for months, and the funds for 2010 were received in mid – Jan 2011. This clearly will encourage corruption. People drawing a monthly salary of Rs.5000-8000 cannot sustain their family without salary for months. Either they will resort to bribing; selling the government supplies or starts absconding and working for employers in parallel. The fund meant for a sub Center or PHC must be transferred in advance for the quarter if not half yearly. This is one single biggest action item to make a sub center or PHC Staff working 6 days a week

Referral centre: It has been found that the referral centre in Panvel (district Raigad) does not even accept patients & turns them away from the door itself ( this is a reality ), and the patients are routed to the Alibag referral centre. Such centers must be a common occurrence across India. Government is paying for them, but they are operational only on paper. Such center must be tracked down, and either made fully operational or closed down. As not only they cause a loss of money to the exchequer, but also diminish the trust of the common man in government’s flagship schemes like NRHM

Why programmes succeed or why they fail- Lessons to learn:  Let’s take a look at the successful programmes like NACO for Aids, National TB control programme & the Pulse Polio programmes. All these programmes have worked well because of  the fact that they have proper structure and resources allocated.  In the ministry of health & family welfare, the programmes are fantastic announcements, but the human resources required are not properly allocated in the ministry to handle such programmes; only the funds are transferred in the bank for the programme. So the department handling the programme is under resource crunch , they do not even have people to handle the communication , and most of their time goes in reporting ; Result – the funds remain un-utilized and are returned back in case of calamity announcement from the PM’s fund or for other reasons and thus programmes fail to leave an impact . Planners must study the success of National TB control programme & NACO and implement the learning’s in all the programmes for Health & family welfare

Incentive to health workers ASHA’s ANM’s & other Sub center & PHC staff: It is expected that since ASHA’s and ANM’s are incentivized for institutional deliveries, referral etc. The incentive might also make them turn to private practitioners over a period of time, as the lure of money will drive them to recommend private gynecologists & give less focus to home visits and counseling, and this might be happening even today as well. It is suggested that the ASHA’s & ANM’s must be incentivized for counseling, home visits, immunization  & preventive checks as a routine part of their job and the incentive must be paid for each home visit ( even Rs. 2 to Rs.3 per visit is good enough ) .  This will lead to a fixed remuneration to ASHA’S & ANM’s. Certain Evaluation parameters for the success of an ASHA must be established like how many households are aware of sanitation, hygiene, preventive health and healthy lifestyle.  Since the NRHM has a huge outlay of funds for the national healthcare, a ‘dip–stick’ audit using random sampling must be done with the households, and this must be done every quarter across the states where NRHM is currently operational.

ASHA is not paid a salary but is paid incentive for institutional deliveries (Rs.100), DOT treatment (Rs.250), meetings for once a month (Rs.150, out of which Rs. 100 is for travel and Rs.50 for refreshments). A supervisor is above ASHA’s and she handles about 30 ASHA’s. She is paid Rs. 3000.00 per month. She is supposed to be meeting two ASHA’s a day. Since both the ASHA’s and Supervisor have to travel long distances by road , and keep in constant touch with each other , I would recommend free local roadways pass to NRHM workers , and a mobile connection with CUG ( Closed user group , that allows free calls between users ) for NRHM staff.  The cost of which could be less than Rs.75 per month

NRHM Handbook : Since the NRHM programme is the biggest healthcare programme so far,   it is imperative that a detailed multi lingual NRHM Handbook, manual or ready reckoner be brought out for all those involved in the programme  , covering  basic protocols,  bio medical waste disposal , do’s & don’ts  dealt with FAQ’s . Also, the digital version must be available on mobiles and internet.

1-3 months rural posting of nurses, pharmacist and doctors must be made mandatory for the courses to fill the resource crunch, and the professionals must be remunerated for these postings along with free accommodation on site at the sub center and PHC.

Awareness & sensitization: Since NRHM is addressing the key areas when it comes to health and hygiene, it is imperative that a chapter on NRHM is added in secondary education (class 6th onwards). This will lead to awareness and sensitization amongst children to adapt to healthy habits

Role model & Case studies approach: People believe in facts, and the case studies & success stories of ASHA & ANM’s must be shared nationally to make the acceptance more impactful for behavioral change. I must share with you something interesting that I witnessed in north India. I was visiting rural belt in north India, and came across an ancient custom called ‘Shourey pratha’. Under this , when the lady delivers a child , she is confined to a room for 40 days , and cow dung is plastered on the walls ,and baked cow dung cakes are burnt non-stop to fumigate the room, automatically the mother and child suffocate to death . Now we can well imagine why the IM &MM (Infant Mortality & Maternal Mortality) was very high in the rural belt in north India. With simple explanations and scientific explanations with the help of  the Self Help Groups (SHG’s), this tradition is on its way out. SHG’s is the most powerful change agent in rural India and the NRHM must use this channel to drive a behavioral change in rural India.



Eradicating under-nutrition and malnutrition


The issue of under-nutrition and malnutrition is not just an issue associated with poverty . If I were to say that malnutrition is also prevalent due to the lack of sanitation facilities, people would not believe it, leave alone talking about linking the two.

Here is an interesting linkage : Females in the village have to defecate in the open , and for that , they either go out in early mornings or late evening when it gets dark . To avoid going in between , the women not only eat little , but also feed children just good enough so they do not go out and defecate too often , and this has been a cause of malnutrition and under-nutrition . There is a common habit amongst girls studying in schools with no proper toilets that , they seldom drink water during school hours to avoid going to toilet !! Strange but true . Similarly , mal-nutrition and under-nutrition has become a sanitation issue . This calls for the involvement of the ministry of rural development to address the sanitation issue in rural India to completely address the issue of malnutrition & undernutrition . Also, the ministry of food processing to work with the players for producing locally fortified foods to reduce the cost of  ready-to-use therapeutic foods (RUTF).

Nutrition is often overshadowed by other medical conditions, like malaria or diarrhea, despite the fact that malnutrition, combined with these conditions, can more often be fatal.” A “severe acute malnourished child” is more than nine times more likely to die than a well-nourished one, & malnutrition from any means retards normal growth .

Besides sanitation , societal traditions that female child is a burden still plagues the nation ,and there is a bias towards the male child who is treated as an inheritor and an insurance in the old age for parents .  Government needs to step its machinery on all fronts . It is a known fact that,  a weak female will never bear a healthy male child , and this should form the basis of the Healthy India campaign as the discrimination against the  female child is rampant in every part of the nation . The issue needs to be attacked multi-fold ;when the mother is expectant , post child birth , adolescent years, post puberty age in girls . Special focus has to be given to the female child , who bears a male child in future .

One of the key pillars of NRHM must be eradication of anemia amongst women with the focus on the girl child. Special fortified biscuits or snacks with calcium, iron and zinc need to be made  available for the girl child ( developed specially for females, so that male child is not given those products ! ) and separate packing for boys to be given as mid day meal or as packaged snacks made especially for children fortified with nutrients ; ready-to-use therapeutic foods (RUTF). For boys, the nutritional support must continue till the age of 6 years but for females , this support must continue till 16 years in age

The deficiencies varies with the region , like Vidharbha region has a severe issue of sickle cell anemia , and this is becoming a serious genetic health issue . Similarly, deficiencies in every region needs to be addressed region-wise.

Diet charts are as important as immunization charts and needs to be given together during child birth based on the physique of the newly born

RDDA’s ( Recommended Daily Dietary Allowance ) should be worked out specific to each child . The role of the nutritionist gains significance in NRHM and is  central to the issue .  The diet plan must be made for each new born and followed under the directions of ASHA locally . So far, I have not seen a prominent role of a dietician in either the sub center or the PHC

I would recommend national health planners to tie up with WFP ( World Food Programme ) to provide daily nutrition for as low as Rs.5 per day . Even companies like Unilever are working on creating BOP Healthcare ( Bottom of Pyramid Healthcare ) models focusing on healthcare basics for the rural masses. It might be worth exploring PPP ( Public Private Partnerships ) to address this issue & come out with ready-to-use therapeutic foods (RUTF)

Indian Pediatrics has brought out a Special Issue (August 2010) on Severe Acute Malnutrition, which deliberates in detail on the global and national evidence relating to pertinent issues on this subject.

Severe acute malnutrition (SAM) in children is recognized as a major underlying cause of death amongst under-five children. These deaths are preventable provided timely and appropriate actions are taken.

According to National Family Health Survey-III, conducted during 2005-2006 in India, 6.4% of children below 60 months of age were suffering from this malady . With the current estimated total population of India as 1100 million, it is expected that there would be about 132 million under-five children and amongst these about 6.4% or 8.1 million are likely to be suffering from SAM.

With the emergence of home based management approach for SAM children, which includes the use of Therapeutic Nutrition (TN) as part of Medical Nutrition Therapy (MNT), it is possible to address this issue in a cost-effective manner. More than 85 % of total SAM cases are without medical complications and can be identified through active case finding in community to be successfully managed at the home level. Global evidence suggests that with integrated management of SAM children, case fatality rates can be reduced to less than 5 percent. Short-term therapeutic nutrition for 6-8 weeks is an integral component of home-based management of SAM. There is an urgent need to develop an indigenous preparation of therapeutic nutrition in the country and operationalize the community management of SAM. Exploring a tie up with WFP / Unilever might be a good start. Also NRHM can start a mission GYM ( Grow Your Medicines) at the PHC , Sub centers and in every households ,as most of the green vegetables and fruits can be grown locally , and can be used for fighting mal nutrition and under nutrition .  On one side ,  fortified snacks could be given , and also the NRHM can distribute seeds for growing vegetables and fruits that can mean  much cheaper source of right nutrition .

Height weight charts must be distributed in all households to keep them aware of age- weight –height ratio and the relation to malnutrition . Automated SMS based service could help in ensuring compliance as seen in the case of Wardha pilot for MM /IM.

Awareness and sensitization must happen through short films and pictorial comics about the deficiency of Iron & Calcium in females

ICDS : Policy makers must consider merging ICDS with the NRHM , as it might be worthwhile to double the number of ASHA’s and allocating more high priority job to  ASHA’s.

Health Fairs must be organized locally to create awareness on the issue of malnutrition . Those parents who have the healthiest girl child must be made ‘Role Model’s’ for others to follow . A ‘healthy girl child award’ must be instituted in each village ( Say Rani Laxmi Bai Award ,Sarojini Naidu or Indira Gandhi award  etc) , and the government must recognize the mother and father ( Good Parenting ) for healthy upbringing of the female child ,along with a cash award of say Rs.1000.00 , or other incentives like 2 KG extra ration at the PDS shops, free bus travel for parents for one year in ST ( state transport ) bus , 50 % fee reduction in graduation of the child ,if studying in government college  etc, could also be considered depending upon the consensus of  the relevant stake holders.  This can be a good competition to start with, which will drive home the message that bringing up a healthy girl child is beneficial in the short run and in the long run & the responsibility of the parents , with the Government acting as an enabler for this . To start with, if each of the 6 lac + villages gives this award to one girl ( parents ) , and each encourages 10 people to take care of their girl child , we would have got 6 crore healthy females in the next 10 years !!  If we want faster results , we can fix the criteria for a healthy girl child for the age group 1- 16 years , all those who qualify can get incentives for the healthy upbringing of the girl child like free travel on ST bus etc . Ministry of women and child development might like to take this up in the 12th five year plan.

NRHM must insist with the ministry of education to include in the curriculum few chapters  on micro nutrients and their role in healthy living , and this should start from class eight onwards.

I do hope that these inputs are of some help .I remain at your disposal should you need more inputs on other aspects of healthcare & rural economy

With best regards

 Rajendra Pratap Gupta

National Council for Human Resources in Health -NCHRH

Date : June 30th , 2010.

Mr. Debasish Panda

Joint Secretary

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

Dear Mr.Panda,

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 :

  1. Urban Health
  2. Rural Health
  3. Tribal Health
  4. Health in hilly areas
  5. Health in Armed forces
  6. Health for retired government employees
  7. Health for private sector
  8. Work Place wellness
  9. Healthcare amongst Minorities
  10. Expatriates working in India
  11. Geriatric care in urban & rural health should be handled separately by different members
  12. 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
  13. Diabetes
  14. Hypertension
  15. Arthritis
  16. Cancer
  17. Epilepsy
  18. Mental Health
  19. 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
  20. Medical Education
  21. Home health & care technicians
  22. Healthcare counselors and Physiotherapists
  23. Health administrators for clinics , hospitals other wellness providers
  24. Gyms & Wellness centers
  25. Diet and Nutrition
  26. Acute care
  27. Immunization
  28. Awareness & Education about wellness
  29. Awareness & Education about diseases
  30. NGO’s capacity building
  31. Disaster management in healthcare including outbreaks & epidemics
  32. 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
  33. Technical up-gradation & training of the workforce on latest developments in equipments and technology
  34. CME for each level of workforce
  35. 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
  36. 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
  37. Put a separate head for innovation in healthcare education
  38. 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 ICEInsitute 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 :


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.

Rahul Gandhi

Dr.Sharat Chauhan, /

Dr.Gautam Sen

Dr.Devi Shetty

Encl: note on healthcare reforms sent on 23rd November 2009.