Tagged: NRHM

Time to start the work on the new National Health Policy


Image

 Rajendra Pratap Gupta

President & Member

Board of Directors

October 27, 2013

Shri Keshav Desiraju

Secretary to the Government of India

Ministry of Health & Family Welfare

Nirman Bhawan, New Delhi – 110108.

 

Reference: Need for a National Health Policy – NHP

Dear Shri Keshav ji,

I am writing on behalf of the Disease Management Association of India – The Population Health Improvement Alliance. We have been proactively taking up issues with regards to healthcare policy & reforms in India.

On February 01, 2013, when you were appointed as the Health Secretary, people involved with the health sector felt happy that the nation had got its best health secretary!  Expectations are running high!

This communiqué is about the need for setting up a team to draft the National Health Policy. Since the last National Health Policy was drafted more than 10 years ago in 2002, a lot of things have changed, like;

  • NRHM was launched in 2005 as a flagship program focused on rural health
  • RSBY was launched
  • Pandemic outbreaks like H1N1 (Swine Flu) have been a surprise and have shaken the world
  • Rise of MDR – T.B.
  • Increase in the incidence of chronic diseases & the issues related to child health
  • Occupational hazards
  • High IMR/MMR & MDGs deadline approaching in 2015

Besides, a lot of other developments have taken place, like;

  • UID –Aadhaar number for the entire population have been initiated
  • Emergence of mHealth & telemedicine
  • Newer technological interventions for diagnostics and treatment
  • Emergence of Big Data Analytics
  • Also that, India is focusing on transitioning the healthcare system to Universal Coverage
  • Emergence of innovative concepts, like Disease Management, ACOs (Accountable Care Organizations), HMOs (Health Management Organizations)  & Meaningful use.
  • Emergence of the prominent role of civil society organizations in healthcare delivery
  • Role of social media

The 12th five year plan has often been referred to as the plan for health, and I believe, that it is the right time to set up a committee to draft the new National Health Policy by 2015. Even if the committee is set up in early 2014, it will take at least a year to do the survey and complete the policy and so, most likely, the NHP would be tabled by 2015 and would cover a period of next 10 years (2015-2025).

We are sure that you will consider our request seriously and initiate the process for the new National Health Policy

With best wishes and with warm regards

Sd/-

Rajendra Pratap Gupta

CC:

Dr.Manmohan Singh, Prime Minister, Government of India.

Shri. Ghulam Nabi Azad, Union Minister for Health & Family Welfare

Dr.Syeda Hameed, Member, Planning Commission, Government of India

Chairperson, UPA

Presidents of all the National Political Parties

Healthcare policies for a political party


On 5th April, 2013,  was invited to lead the discussions on a healthcare policy meeting of a fast emerging political party

The following discussion points i put forth for the kind consideration of the committee ;

Three key components for reform:

Systems

Service

Staff

Key challenges :

longevity of life

Expenses as budgetary allocation

Timely and quality interventions

Preventive promotive and curative health care

Child health

Chronic diseases

Rural health

Technological interventions

Role of pharmacists and nurses

Private community  partnership-sector

Outcomes with patient satisfaction

Health is not a standalone topic

Four pillars of public health . Hygiene , water , sanitation and nutrition

Protocols & treatment guidelines

Soft skills

Tax on unhealthy products and foods

Challenge is huge country , diverse population , demographics and poor infrastructure .

Why doctors don’t go to rural india ? Poor infrastructure for families and staying locally  coupled with no infrastructure for operations in rural

Several solutions few execution is the problem

Following inputs were given in the format the party needed ( Point wise );

Primary care :

1. Rural healthcare centres be accessible 24 X 7 using technology – Health Helplines

2. Mobile applications on phones connected to ASHA workers etc

3. Clinic on Ambulance model

4. 75 % of the funding of healthcare should go to Primary care

Refer the article on primary care

Child Health 

1. Incorporate health in school curriculum from class IV onwards

2. Pictorial charts and audio-visual films to teach hygiene and health

3. Health parameters be reported in annual and six monthly report cards

4. Junk foods be banned in and around school premises

5. Calorific and nutritional value be written on every packaged food items in relation to RDCA

6. 3 % of the curriculum marks be allocated to health of the student

7. Health & Hygiene be included in school curriculum as an exam based paper from class 4th onwards

Health IT 

1. All programs must be backed by an IT backbone

2. Mobile health record ( PHR ) as an alternative to electronic health record be linked to Aadhaar card

3. Reporting , surveillance and monitoring all programs through live data reporting at the taluka, district and national level

4. Standards and protocols for  all the treatments be issued , so that the AAM AADMI is not fleeced by unscrupulous people in the name of healthcare / treatment

5. All village sub centres be connected via telemedicine and mobile healthcare

6. At least 2 % of the healthcare budgets be spent on Healthcare IT

Chronic diseases 

1. Mass screenings be made available through pharmacies across the nation for diabetes , hypertension & obesity

2. Disease Management Programs be launched for all chronic diseases

3. mobile health be used for chronic disease management

4. Those with habits of smoking and drinking should have a higher co-pay to seek universal healthcare benefits ,  so that the healthy should not subsidise the ‘irresponsible’ sick people

5. Companies spending on wellness should be given incentives

Public health :

1. Focus on healths should be centred on wellness and not just on treatment

2. 75 % of the health budget should be spent on prevention and promotion

3. Corporate and five-star hospitals in urban india / metros should be taxed (levied  5% surcharge )  to subsidise the healthcare delivery in rural India

4. Set up the epidemiological data

We should change the slogan from ‘Health for all’ to ‘All for Health’

India – from Emerging to a Submerging economy


India – from Emerging to a Submerging economy

On 22nd March 2012 , I wrote this on my blog and also sent the same to leading public figures .I had stated dwelling  in detail about how,  ‘ Have we oversold the India story’, and this was much before the bad news starting sinking in !

Link to the blog is  https://commonmansblog.com/2012/03/ .

This blog clearly mentioned that we must be prepared for bad news in April – May – June Quarter , and we know that,  India was downgraded as an economy by the international rating agencies ( S&P & Fitch ) and many Indian banks also faced the brunt , many retailers are gasping for breath ….

This time , I have decided to write about the story of how Indian economy would  enter a dark phase if immediate steps are not taken ,and this note is not against anyone but for everyone who wants to see India doing well !  I have tried my best to put data for every statement ( Besides Almighty , everyone should believe in data !).

So now , it is time to peep in the story of how an emerging economy can become a submerging economy .

Let us look at the following data :

Sector – Industry / company Financials ( Loans / NPAs) Source / Remarks
Telecom Sector Rs. 2.00 Lac Crore debt TOI, 26th September , 2012.
Banking Sector NPAs Rs.1.37 Lac crore as of June’12 Mint , 7th September, 2012
Banking Sector According to RBI’s assessment , a fifth of all re-structured loans go   bad . According to RBI, as on March 31, banks had Rs.2.18 Lac worth of   restructured loans on its books Mint, 7th September, 2012
Banking Sector State-run banks  NPA crosses   Rs.1.23 Lac crore Mint , 23/ August/ 2012
Credit card outstanding Rs. 22150.00 Crore As on July/ 21 Ref. ET 14/9/12
Indian Government Total planned borrowing is Rs.5.71 Lac crore for FY 13, of which   Rs.2.0 Lac crore would be in the second half of the fiscal by Dec’12 As per Mint dated September 28, 2012
Banking Sector Report by Credit Suisse group AG points that exposure to 10 large   Industrial groups constitute 13 % of the entire banking system Mint, August 21, 2012.
Banking Sector As of 27th July, Indian banks had loans outstanding of   Rs.36,600.00 Crore to the mining and quarrying sector, and Rs.93,170.00 Crore   to the Telecom sector Mint, 12th September, 2012.
Power Sector As of March, 2011, the accumulated losses of the State power distribution   companies are estimated to be alone Rs.1.90 lac crore which, by now,  would have crossed  Rs.2.0 lac crore IBN Live dated 23rd, September,  2012
Air India ( NACIL) Rs.67520.00 crores in loans & dues NDTV Profit, 8th Feb, 2012
Pantaloons ( Kishore Biyani’s ) Rs.3300.00 crore ET, 14th June 2012 . After selling a portion of its   apparel business to Aditya Birla Group. Before the sell-off , the debt of   Pantaloon was about a billion dollars
Reliance ADA Group Rs.86700.00 crore  FY’12 Business Line August 26th, 2012.
GMR Rs.33600.00 croreFY’12 Business Line August 26th, 2012.
JSW Rs.40,200.00 crore FY’12 Business Line August 26th, 2012.
Jaypee Rs.45,400.00 crore FY’12 Business Line August 26th, 2012.
Lanco Rs.29,300.00 crore FY’12 Business Line August 26th, 2012.
Essar Group Rs.93,800.00 crore FY’12 Business Line August 26th, 2012.
Vedanta Rs.93,500.00 crore FY’12 Business Line August 26th, 2012.
Adani Group Rs.69500.00 crore FY’12 Business Line August 26th, 2012.
Videocon Rs.27,300.00 crore FY’12 Business Line August 26th, 2012.
GVK Rs.21,000.00 crore F’12 Business Line August 26th, 2012.
Fortis Healthcare Rs.6237.00 crore Business Line August 15th, 2012
King Fisher Airlines Rs.7500.00 crore The Hindu, July 2nd , 2012
Losses of top three oil marketing companies Rs.40,500.00 crore in April-May-June’2012 Forbes India , Sept 03, 2012
Airtel Rs.60,018 Till Q1, 2012 Business Line , Aug 3, 2012

The total debt level of  ten companies alone (Adani, Essar, GMR, GVK, JSW, Jaypee Group, Lanco, Reliance ADA, Vedanta and Videocon) has jumped 5 times in the past five years to Rs 5,39,500 crore  ( Indian Express , September 06, 2012 )

Business Line dated August 26, 2012: Credit Suisse said that the aggregate debt of the ten groups accounts for about 13 per cent of total bank loans and a whopping 98 per cent of the entire banking system net worth.

“Therefore, surprisingly now in terms of concentration risk, Indian banks rank higher than most of their Asian and BRIC counterparts,” it added.

The report said a strong loan growth of Indian banking system in past five years is increasingly being driven by a select few corporate groups.

“Given the high leverage, poor profitability and pressure from lenders, most of these debt heavy groups have initiated plans to divest some of their assets. However, given that most domestic infrastructure developers are already over-geared, demand for these assets may be limited,” Credit Suisse said.

Each of these groups alone account for 1-2 per cent of total banking system loans, the report said, while noting that all banks appear to have high exposure to the same few groups.

“With the economic slowdown and a downturn in these sectors, multiple assets of each group appear stressed and financials of these groups are stretched,” the report said.

Bank’s exposure to real estate sector ( ET dated 22nd August , 2012)

Bank Exposure to real estate FY 2011-12 ( Rs. Crore )
State Bank of India 144668.38
ICICI Bank 81421.73
Axis Bank 52730.39
Punjab National Bank 48474.59
IDBI Bank 36784.47
Bank of Baroda 22157.40
StanChart 26027.78
HDFC Bank 25020.26
Total exposure Rs. 437285.00 Crore

Despite an exposure / investment of about Rs.4.37 lac crore from banks  ,still five lac houses remain unsold ( ET, 22/ 08/2012 & TOI dated 18/ 09/ 2012. ) . So land became costly as the builders brought them with loans , houses became expensive due to builder cartels and now that houses are not getting sold , all are a part of the downturn ……..no solution is in sight except for NPA’s and its cascading affect later .

Clearly, Indian economic story lacks ‘depth’ but has been built on ‘debt’ and this is a painful bubble waiting to burst …. So a common man must have enough savings to last a few years if without a job  !

July 26, 2012 in TOI, it was reported that at least eight cases of FDI in some obscure real estate companies – each worth more than USD 100 Million – from Singapore have come under scanner , with Income tax Overseas unit (ITOU) having investigated them for alleged round tripping . Suspicion was raised when authorities detected huge FDI inflows into some little known real estate firms in India in the form of equity participation . A senior finance ministry official said they suspect these real estate firms to be front entities of some corporate houses and their black money has been routed through Singapore to acquire real estate in the country . All these FDIs coming from Singapore pertain to 2011. India received Rs.1.74 Lac crore worth of FDIs in 2011-12, of which Singapore contributed third highest at Rs.24,700.00 , after Mauritius ( Rs. 46,700.00 crore ) and the U.K ( Rs. 45,000.00 Crore).  So , now we can understand why an Indian’s politician’s family have a flat in Singapore and why Indian Government along with a few ‘parties with vested interests’ are pushing  for FDI ! Does it also not answer the question why Government opened the real estate sector to FDI in 2005 ? So that money stashed abroad can be brought back in real estate sector, and further money could be made by investing in and increasing the prices by buying land !  Does Lavasa ring a bell in your ear !

In absolute terms, bank’s bad assets have doubled in three years between 2009 and 2012  – from Rs. 68216 crore to Rs.1.37 Lac crore ( Mint 21st August , 2012).  Bad assets in coal, iron and steel , mining , construction , textiles and aviation sector have been on the rise . Bankers see stress in telecom and power sector, too.  The biggest beneficiaries of loan restructurings are large industrial houses in the manufacturing sector – 8.24 % of loans given to industries have been recast. In the services sector , the comparable figure is 3.99 % , and in agriculture loans , 1.45 %.  It is clear that the small borrowers don’t get relief  from loan servicing but the large industrial houses have gotton one ( Mint , 21, August ,2012. ). According to the same article , public sector banks have 90 % of the restructured assets , and this in my view clearly states one fact – a strong political – bureaucratic and business houses nexus to make loans and buy private jets and show companies in losses to the investors !  What right do the business houses have to question the Government on profligacy and spending when these business houses have huge debts but have their CEO’s / promoters taking home 10’s of crore in salaries plus stakes in companies and still flying private jets on borrowed money ! We know of the large business house where the debts are more than revenue but the flamboyant chairman / promoter flies on private jets ! Such company’s ( any company that has over Rs. 50 crore external debt ), boards must be restructured by the MCA (Ministry of Corporate Affairs)  and independent directors with fixed term and remuneration should be appointed by the Government , so that the loans and shareholders money is not misappropriated by such promoters in the name of expenses and privileges  !

Three more developments to be noted to give you a sense of state of affairs in the Indian economy :

Remarks
India S&P rating is BBB (Minus) . Outlook  – NegativeFitch rating is BBB (Minus ). Outlook – Negative  ( TOI, 26th June, 2012 ).
Bharti Airtel Downgraded by Goldman Sachs and other banks. ET .  10th , August , 2012
Retail Sector Fitch has downgraded the ratings to negative

Agriculture / Food crises : The US is facing a severe drought , and India has witnessed a bad spell of monsoon this year with erratic and unpredictably low rainfall . When India imports pulses and oilseeds , & the prices of these commodities is set to rise. Stock piles of the biggest crops will decline for a third year as drought parches fields across three continents , raising the food-import costs already forecast by the United Nations to reach a near record $ 1.24 trillion . Combined inventories of corn, wheat, soya beans and rice will drop 1.8% to a four year low before harvests in 2013, the US department of Agriculture ( USDA) estimates . Crops in the US, the biggest exporter, are in the worst condition since 1988, heat waves are battering European crops . Wheat production in Russia , the fourth largest exporter , will fall 20 % this year , and in Australia , output will decline 19 % and, God forbid, another year of bad spell of rain in India will spell disaster for this country . This situation warrants an emergency action ! On 9th August , 2012 on page 7 of ET, I read an appeal to the GOI by All India Starch Manufacturer’s Association regarding the crises due to non-availability of maize in the domestic market.  Even if starch manufacturers were ready to buy maize at higher prices, it was not available and adding to it was the monsoon failure   !  We are all awaiting a miracle to happen with Wal-Mart et al. But the reality is that these players have not much to contribute. We must not forget that , the supply chain structures in these companies are leaner and they work on shortest inventory, so clearly , these people will not do much for supply chain management . Also, the biggest contribution is stated to be creation of 10 million jobs in India . I wish to ask that these companies have a ROI ( Return on investment ) for each employee and so , clearly , we must see what is the cost that we are going to pay to these MNC chains for them creating 10 million jobs & the Government must come out with a white paper on this ? After all , Wal-Mart is not here in India for charity !  For sure , it would mean we paid will pay them dearly for doing what we could have done 100 times cheaper ! All FDI investments to me appear to be taking the ‘economy in debt’ to ‘sell off’ ( divestment )… We are back to what East India Company did to India but this time , it is not one company, but multiple East India Companies !

Also , a time to look at the sectorial composition of GDP 1950-51 – 2011-12 from CSO data

Agriculture Industry Services
1950-51 53.1 % 16.6 % 30.3 %
2011-12 13.9 % 27 % 59 %

In 1950, India had a population of 350 million and now it is 1210 million. During independence,  the population dependent on agriculture was 72% and now it is  54 %. But except Madhya Pradesh, where agricultural growth has increased to dramatically  , not much is visible in other states .

Infrastructure – Construction firms sector ( Mint , September 11, 2012): for a set of 87 firms with a significant presence in infrastructure , sourced from Capitaline database , these numbers show an increasing difficulty to service debts

For these firms , the interest coverage ratio (ICR), for fiscal 2012, plunged  1.9 times , the lowest in at least five years. In other words , for every Rs. 100 of interest payments, the firms earnings before interest and tax ( EBIT ) stood at Rs.1.90 . The comparable number for 2007 was almost five.

In the fiscal 2012, at least 17 firms did not earn enough to pay the interest ! The list includes some of the bigger and better known firms such as Hindustan Construction Co. Ltd, Gammon Infrastructure Projects Ltd and GMR Infrastructure Ltd. This might give us a sense of where India is headed . First we oversold the India story, and now we are gonna pay heavily for it ….. !

Emerging Economy – really ? Let’s have a look at the following figures ;

  • According to the NSSO survey( July 2011 – June 2012 ), 10 % of India lives on less than Rs.17 a day . As per the survey , half of the population in rural India was living on a per day expenditure of Rs. 34.33 , and this is after two decades of reforms in India !
  • About 8.3 % of the population is unemployed
  • 54 % of Indian families live in houses that don’t have concrete or brick roof ( Census, 2011 )
  • 47 % of the total households live in houses with mud floors ( Census , 2011 )
  • More than 800 Mn don’t have toilets at home
  • Millions of tonnes of grains are stored in the open as we have no place to store !
  • Tata shut production of passenger vehicles for two days to avoid inventory pile up due to bad economic situation
  • 1/3rd of rural Indians and 1/5th of urban Indians forego treatment due to lack of money
  • 47 % of rural Indians and 31% of urban Indians finance treatment by loans or sale of assets
  • One child dies every 16 seconds due to malnutrition , diarrhoea or pneumonia
  • All major currencies have appreciated against dollar but rupee has weakened . Even Singapore dollar is up by about 50 % compared to rupee last year

GDP & Growth without fundamentals & eventual Collapse :  This is the India’s growth story’s fate . Let me give you two glaring examples and rest you can relate for your conclude;

I have travelled to the draught prone areas, and heartland of farmer’s suicides i.e. Vidharbha region of Maharashtra .  Lanco is setting up a power plant in Wardha and has purchased land for as high as Rs. 25 lac per hectare ( as per the farmers statement ). So  , let’s look at this example where Lanco purchased 7 acre land from a farmer for Rs.1.75 crore . A farmer who was drought and debt ridden for years becomes a millionaire overnight, and buys a SUV for himself along with a rifle , gold jewelry for his wife , builds a pucca house with the money he gets , and the money is spent soon as he did not know how to plan and how much to spend and the land is also gone to Lanco ! Also, money brought in a lot of vices ( please check the number of AIDS patients in the region ! ).   This company Lanco, runs a debt of Rs. 29300.00 crore and has gone for CDR ( Corporate debt restructuring ).  The banks that gave the loan should be ready for a NPA ( Non-performing asset )! So , the farmer , the company Lanco and the bank have become a non-performing asset ….. whereas , the farmer buying a SUV, Gold etc, would have boosted the sale of vehicles , gold, wines, apparel companies temporarily , and soared the rates & increased the GDP ! So this is growth in GDP but not a sustainable one or growth without prosperity !

Let me quote another example :  Country auctioned the airwaves (spectrum), a few years ago for which the companies paid tens of thousands of crore for airwaves. The companies took loans , passed on the cost to consumers ( Co’s were not wrong as they had to get an ROI for their investors ) and finally , like Airtel with over 200 million customers, run into a debt of about Rs. 60,018.00 crore ……….So , let me consider an alternative scenario . If companies were given spectrum for a nominal administrative fee of say Rs. 500.00 crore + 50 % revenue sharing . In that case, the companies would have invested more into infrastructure and services would have been better and much cheaper , also , the Government could have made a cool Rs.80,000.00 crore every year taking the current revenue of all telecom operators to be Rs.160,000,00 crore, with probably very little debt on telecom companies and no such scams !  Today, the telecom sector has a debt of Rs. 200,000.00 crore and government barely gets anything of the total revenue of Rs.160,000.00 crore as its revenue sharing is in lower single digits .  All have lost due to myopic policies of the Government . This is what I call GDP without prosperity ,  and this is what our entire Indian economy is passing through . It has no depth but debt ! What I call as lack of strong fundamentals, for which none of the parties have shown a concrete action plan . Companies have stock valuations and we are measuring our strength on the stock market indices which are not at all in relation to our ground realities ,  and only 2 % people in our country dabble in stock markets whereas 98 % suffer the hallucinations of this economic growth and GDP which is backed by loans , subsidies and political doll outs and have become a drain on our economy  & our economy is becoming a bottomless pit ! Here I will not fail to quote  the maiden address of our former finance minister and current President of India on 15th August , 2012  ‘It is indeed a wake-up call to Indian polity that even 65 years after independence and 74 years after Bose’s observation ( Subhash Chandra Bose in 1938 had flagged at the 51st session of Indian National Congress at Haripura that country’s primary challenges were poverty , illiteracy and hunger ) , the number of poor in the country today outstrip the population of the country in 1947’

All the sovereign wealth should be leased on 50-50 % revenue sharing between the Government & the private sector companies , and never be auctioned ! There is no other sustainable model for our meeting the financing needs and auctions only give a one-time income ! This must be made a policy so that every year , Government can make decent money and invest in the infrastructure,  growth and give good governance to all Indians

Indian population a mere statistics  ? Let us take the example of the recently concluded London Olympics . China with a larger population came 2nd with 38 gold , 27 silver and 23 bronze medals and India came on 55th position amongst 79 nations with zero gold , 2 silver and 4 bronze medals ….. this is what our leaders have led us to ! With committed leadership we must have made it the top by now …..

Let us do a rough sum of Indian economy which has a GDP of approximately Rs. 100 lac crore and we still borrow about Rs. 5.2 lac crore every year, and we already have  debts of about Rs. 45 lac crore . India’s  42 % of the net annual tax revenues of Rs.7.71 lac crore goes in servicing its debt ( Rs.3.20 lac crore ). Another 25 % goes in subsidies ( Rs.1.90 lac crore ) – an annual amount that would actually be Rs.78000.00 crore higher if off-balance sheet fuel subsidies to oil marketing companies were included.  The fiscal deficit of Rs.5.19 lac crore – 5.9 % of nominal GDP – is 67 % of the net central tax revenue . This was detailed in TOI dated 19th August 2012. I had read somewhere that , 54 % of Indian’s income goes in interest payments on debts taken for decades , 30 % is the cost of running the inefficient Government & bureaucracy and 16 % for subsidies ……so I keep wondering , does India have any money at all to invest in infrastructure or for future !!!! ( Hope I am wrong in remembering these numbers and India does better ). If not , time to take action !

According to Apparel Promotion Export Council ( APEC) , an estimated 4.5 million jobs have been lost over the past 3.5 years . Do our policy makers know how an ordinary Indian would survive without a salary for even a week and what pains his family and relatives pass through him being a jobless !

If all of you witnessed the discount sales season, it was advanced and even extended to make up for the shortfall , and this must show the desperation from the companies to meet the numbers . Unfortunately , If corrective steps are not taken immediately , we will have more companies getting into CDR or closure and millions of jobs might be lost till 2015……worst is yet to come !

Let me quote a facts about why India gained political independence and what was the average age of leadership . Maulana Azad became the President of INC at the age of 35 , Bose became the President of INC at the age of 41 and Nehru became the  President of INC at the age of 40… So now we know  why we got political freedom and why we have not been able to get economic freedom ??? For a nation with more than 65 % of the population below 35 years , it is important to take care of the representation of youth to lead this country with fresh innovative ideas for a double digit growth and that too  grounds up. Though our policy makers tell us that we cannot grow at about 8 % , but the fact is that, in 2011 calendar year , 12 countries clocked more than 8 % growth and some of them like Ghana , Iraq , China , Argentina and Turkey are not exactly small . We have been capped by the ‘old school of policy makers’ and their thinking , who believe that they know all and what they do is right ! This has to go now ! We need leaders with a nose on the ground , good governance and a strong political will and rest will fall in place . Government must earn from the rich and middle class, and help upgrade the lower income class to middle class on a ‘mission mode’ basis by empowering them by providing them training , education, healthcare  and technology  .

Our country’s finance ministers have taken to ‘Populonomics’ ( Economics of populism ) , and not ‘economics’, and this has clearly shown the results to the common man . India is heading towards an economic disaster and short cuts like FDI are short lived solutions !

I can bet you that if a party rises above caste , religion ,reservation, dynasty ,  and parochial regional politics, it is sure to win the youth and come to power without taking to populism !

It is the time for the finance minister to move from being an ‘efficient tax collector’ to ‘passionate creator of wealth through innovation & entrepreneurship ’. India is the only country in the world at this time that  has ample opportunities for each problem to be solved and is a fertile basin for innovation ! If you were born as a human- being , you must be lucky, but if you are born as a human -being and that too, in India , you must be the luckiest on earth, and this describes our India today and what it can offer to the world !

All ministries must have wealth creation strategies  ! Just imagine that for the year 2012-13, India will have gross tax receipts of 1,077612 crores and expenditure of Rs.1490925 crore…. Even if we do the sell-offs , we still cannot pay off the Rs.45 lac crores of debts that India has ! Which assets will be left to sell for our next generation ( oh boy that’s too far , I must say in the next 10 years ) ,to sustain our economy ? I think then , our Government will call upon the US President and ask his farmers & companies to come and invest in Indian land and make it more productive , and that will be the final sell off of this once a great nation i.e India

I am not an economist, though , I have studied economics during my graduation ( but I must confess that I do not remember anything I studied during graduation J , and I am glad that I don’t remember anything J) All that I have written here is a common man’s perspective from the data and facts available in the public domain.  I have researched the state of economy well over five months to help our dear policy makers to do a better job and making the life of a common man better and not bitter !

I am leaving to US for two weeks on 14th October evening , and on my return, I will launch www.indiawewant.org ,and would welcome your suggestions and participation

With best wishes

Rajendra Pratap Gupta

Economy I Healthcare I Retail I Innovation         

http://commonmansblog.com

 

National Digital Health Plan – NDHP


 Rajendra Pratap Gupta

 President & Member

Board of Directors

September 22, 2012.

Dr.Manmohan Singh

Prime Minister,

Government of India

7, Race Course road, New Delhi -110001.

  Email/ speed-post

Reference: National Digital Health Plan (NDHP)

Dear Dr. Singh,

I am sending this note on behalf of 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

Let me start by quoting Kathleen Sebelius, Health Secretary of the United States, “Mobile Healthcare is the biggest technology break-through of our time to address our greatest national challenge”. Ms. Sebelius said this last year at the mHealth summit in Washington DC. This statement is more relevant to our country as, though for the developed world, mHealth is another option for healthcare delivery but for a developing country like India, mHealth is the only option!

We urge upon your good selves to initiate the National Digital Health plan – NDHP (Digital Health means Telemedicine, mHealth & technology backed healthcare delivery) for India, and may be, consider to form an inter-ministerial group to give this a definite shape. According to WHO review in 2010, only a quarter of countries worldwide had drawn up a national telemedicine policy or strategy. Let us take the lead in setting up the National Digital Health Plan (NDHP).

With 6 billion mobile phones globally at the end of 2011 and about 960 million cell phones in India, mobile phones provide a matchless platform for delivering change at the grass roots and are a tool

To deliver programs aimed at economic & social inclusion & more importantly, inclusive healthcare.

We must think seriously & act now about incorporating Telemedicine & mHealth (mobile healthcare) in our healthcare system and building a road map of Digital Health for India. With over 800 million people living in rural India and about 640,000 villages as per the latest data of planning commission’s approach paper for the 12th five year plan, it is imperative that we build a national roadmap for telemedicine in India to address the issue of accessibility & affordability with sustainability on one side, and on the other side, for leveraging a global business opportunity for Indian entrepreneurs, like what IT (Information Technology) did to India’s growth story. It is time to replicate the IT success story this time using mHealth and help the industry build a few multi-billion dollar global corporations

Telemedicine is needed for delivering ‘Inclusive healthcare’ to India & also to serve across various sectors like in defence, help in job creation, veterans’ health and disaster management.

Defence services: We need Telemedicine through dedicated satellites for armed forces posted on Naval Ships and remote areas at the border and at Siachen. Also, the ECHS for ex-servicemen could have a healthcare facility through Telemedicine at various polyclinics .This must be initiated and the ECHS clinics must be connected with Army referral centers. US Veterans administration, for e.g., found that overall the practice of telemedicine / mHealth cuts hospitalization by 30 % & admissions for heart failure by 40 %

Disaster Management: During national disasters, Telemedicine & mHealth can be the only healthcare delivery channel for the affected areas and this calls for a Telemedicine road map under National Disaster Management Authority (NDMA), at the Prime Minister’s office. During Tsunami in Japan, Continua Health Alliance members came together and gave a solution in a record time. It would have been a double catastrophe, if such a Tsunami ever destroyed paper medical records and the patients had to be moved to a remote place for treatment. Nothing could have been worked without medical devices which were interoperable and an EMR hosted over a cloud. This calls for immediate planning to avoid healthcare disaster along with a natural disaster!

Chronic Diseases:  In the USA, FDA (Food & Drugs Administration) has started approving mHealth applications and two of the insurance companies recently agreed to pay for mHealth applications for diabetic patients. mHealth holds the promise to address the biggest challenge facing our nation i.e. chronic diseases & the implementation of secondary prevention program

With approximately 960+ million cell phone users; healthcare in India will converge to mHealth, and ultimately, this is where all practitioners, payers and users will converge too! It is time to look at mHealth as a tool for ‘Inclusive Healthcare’. With mHealth, ‘Universal Healthcare’ will move faster from a dream to reality!

Earlier, it was said that, ‘An apple a day keeps a doctor away’, and now it is being said rightly that, ‘An app ( mobile application ) a day keeps a doctor away’.

According to the PWC & Economist Intelligence Unit (EIU) recent study – 2012, conducted in 10 countries including India, Patients believe that convenience, cost and quality of health in the next three years will change due to mhealth

According to this study;

59 % of the doctors and payers believe that the wide spread adoption of mhealth in their countries is inevitable

In the next 3 years,

57 % of the patients in emerging markets believe that mHealth apps / services will make healthcare more convenient

54 % of the patients in emerging markets believe that mHealth apps / services will improve the quality of care

53 % of the patients believe that mHealth apps / services will substantially reduce the overall cost of care

59 % of the emerging-market patients use at least one mHealth application or service.

The Department of Health, U.K. had set up a WSD (Whole System Denominator) program to help provide an evidence base for setting further policy in this field. This was claimed to be the largest randomized control trial of Telehealth & telecare in the world. The program was launched in May 2008 involving around 6200 patients and 238 GP practices. Early indications from WSD show that, if used correctly, Telehealth can deliver a 15 % reduction in accident & emergency visits, a 20 % reduction in emergency admissions, a 14 % reduction in elective admissions, a 14 % reduction in bed days and an 8 % reduction in tariff costs. They also demonstrate a 45 % reduction in mortality rates

According to Lord Nigel Crisp, Former CEO of NHS, U.K. (National Health Service) and Member, House of Lords, ‘In UK, NHS direct started free health advice service over phone. It has over 6 million subscribers, over 10% of the country’s population’.

For chronic disease patients, Home care based ‘Nuvola It Home Doctor system’ was developed by Telecom Italia in the Piedmont region. As a part of the policy to bring health services closer to the community, patients suffering from chronic diseases monitor certain biological parameters using traditional electro-medical devices and send them to the Telecom Italia data center, using a dedicated mobile phone provided by the hospital. Home-based care is estimated to cost 180 euros compared to 700-1000 euros in hospital. mHealth based home care can provide tremendous relief to geriatric patients in India, in addition to psychiatric patients with the existing ratio of psychiatrists: population nearing 1: 10, 00000

OPD workload in Government district hospitals: In India, the biggest problem in district hospitals is the patient overload in OPD (Outdoor patients department).

By using mHealth / telemedicine, we can provide right timely interventions at the point of care and cut this OPD overload anywhere by 30-60 %.

mHealth as a tool for diplomacy: A few years ago, ISRO had taken up some key initiatives along with the Ministry of External affairs for setting up the ‘PAN network’. It is time to revive that actively, and provide remote consultations, not just in India but in developing countries of Asia & Africa. Telemedicine can be a good tool for diplomacy. I had made a keynote presentation at Lahore, Pakistan under Aman-ki-Asha in May 2012, and telemedicine and mhealth was a key point of discussion to increase collaboration between the two countries. Healthcare is the most impactful tool for political diplomacy with our neighbours who have similar challenges when it comes to healthcare.

Rural Health: With over 640,000 villages where doctors are not willing to work, technology seems to be the best solution and mHealth appears to be the best technology

In Turkey, Acibadem Mobile runs a mHealth nutrition service with 450,000 members. Also, in less than two years, an emergency healthcare service offered in conjunction with Turkish Telecom has grown to 100,000 members. . In Mexico, Medicall Home has five million subscribers who pay US $5 a month on their phone bills in order to access medical advice

Across the border, in Bangladesh, Grameenphone has set up Healthlink to allow its customers to talk to the doctors 24 X 7. This service has fielded 3.5 million calls in the last six years

Strengthening India’s healthcare system: Also, India is presently building on its healthcare system, and the 12th Five Year Plan has been referred to as the ‘Plan for Health’! Now is the right time for the policy makers to ensure that technology is embedded in all programs that the Government is planning to rollout for healthcare delivery. In specific, mHealth has tremendous potential to reduce costs, improve the reach and access to Health Care, make the healthcare system more outcomes driven, and more importantly, help in establishing an ‘empowered patient’.

According to the EIU PWC report 2012, USA has been at the forefront of mobile health deployments in the world. Almost 40 % of the solutions deployed work towards strengthening the healthcare systems. mHealth is not just promising but truly transformative to healthcare. From pill reminder, training of health workers, reducing IM / MMR, T.B. – DOTS, HIV treatment compliance to quitting smoking to managing diabetes, obesity & emergency surgeries, mHealth is becoming an integral part of healthcare delivery. It is time for the best brains to work on mHealth with all stake holders in healthcare delivery

In my view, mHealth is the only option in India, where people pay 2/3rd of the healthcare costs and only 1/3rd get healthcare in the real sense.

Seeing the potential of telemedicine, & mHealth in particular, India needs a roadmap for mHealth / Telemedicine encompassing areas of rural health, tribal health, chronic disease management, disaster management, defense services, coastal healthcare services etc.

Following might be helpful in building the digital health road map for India

Focus areas that need to be considered in the NDHP                                           Ministry / Deptt / Org. involved

 

  1. Incorporating Digital Health in Medical education / training                       MCI, NIFW, MOHFW
  2. ESIC clinics connected via Telemedicine & home care

facilities provided through mHealth for ex-servicemen                                                MOD / ISRO

  1. Sub-centers in rural areas to be replaced gradually

with mobile health Units (MHU’s & this could                                 Consider under MNAREGA,

also double as medical ambulances at the time                               NRHM – MOHFW

  • of emergency in rural areas)
  1. mHealth national grid                                                                           MOHFW/ML&E/ MOD/MIT
  2. National / Regional IVR Health helplines on the lines of 108        MOHFW / State Govts
  3. mHealth for Chronic disease management                                      MOHFW
  4. Skills Development for Digital Health                                               NSDC / MHRD
  5. Telemedicine / mHealth under Disaster Management – NDMA    PMO
  1. Regulation of tariffs ( special tariffs for mHealth services)              TRAI
  2. Mental health Telemedicine Network                                               MOHFW
  3. Checking counterfeit & Spurious medicines using mHealth           Deptt. of Pharmaceuticals
  4. Healthcare facilities in Jails                                                                Min. of Home Affairs
  5. National IT policy 2011 & health as a mission mode project           Min. of Comm. & IT
  6. National Institute of telemedicine & mHealth                                  MOHFW
  7. DST- TDB could set up ‘mHealth innovation village’

like the Startup village in Kochi                                                         DST, TDB / CHA

  1. Electronic Health Record – RSBY                                                      MOL & E / HIMSS / CHA
  2. ECHS / Naval Telemedicine / Siachen / borders                            MOD / MHA / ISRO
  3. mHealth for Tribal health & North Eastern states                          MDONER / MTA
  4. Civil Aviation / airports                                                                      MOCA / ISRO
  5. Social media strategy for health                                                        Min. of Comm & IT / HIMSS
  6. Medical Devices standards & Interoperability                                 Min. of Comm. & IT /CHA
  7. Electronic Health records for all new born’s                                   MOCWD / CHA /HIMSS
  8. Treatment protocols for various diseases                                       ICMR / PHFI / AIIMS
  9. Enactment National Telemedicine / Digital Health Act               MOHFW/Min. of Legal Affairs
  10. Applications Venture fund for telemedicine                                    TDB / DST
  11. Digital adoption lifecycle benchmarking of different states        Planning Commission /HIMSS
  12. National Cloud computing policy for healthcare                             MIT / MOHFW / HIMSS
  13. Privacy / data security issues of patients                                         MOHFW / BIS / CHA
  14. e-Prescription policy ( Electronic / digital prescription)                MOHFW / MIT /HIMSS

On the acceptability & adoption front for telemedicine & mHealth, let me quote examples;  a rural telemedicine service provider in Indi has done about 200,000 consultations with 30-40 % repeat visits, across states of U.P. , Bihar, Karnataka & Maharashtra . A leading eye care hospital does over 2.5 lac telemedicine consultations every year and another eye care hospital does over 1.5 lac telemedicine consultations in a year in India.

EMRI – 108 services in Andhra Pradesh is on a PPP model, and this service receives 58000+ calls per day with 4800+ emergencies a day and has saved 20165 lives. A true example of successful mHealth / telemedicine in our own country!

HMRI -104 (Health Management Research Institute, A.P.), is about providing information on health, counseling and healthcare services via health helpline. Till May, 2008, it received 51000 calls per day. Medical advice given to 40860, counseling attended- 7493, information of health facilities provided- 6331 & complaint calls received on healthcare facilities- 253. Top 10 ailments attended were recurrent abdominal pain, back pain, knee pain, cough, hair loss, chest pain, and eye pain or problems with eyelids, rash, pain in ankles or feet, belching, growing stomach or gas.

I had a chance to visit these facilities personally and observe the calls from patients / public, and I must say that this is something every Indian must have access to, rich or poor ! With an average cost per call of Rs.9, this is definitely a successful telemedicine & mhealth model for implementation in India. http://nrhm-mis.nic.in/UI/MEActivities/goa_web/PDFs/02-05-08_pdf/Pre%20Lunch/Goa%20presentation_AP.pdf

Also, I have visited remote places in Wardha district of Maharashtra, where mHealth has been used by rural health workers and has helped reduce maternal mortality from 91 per lac to 51 per lac in a period of about 1 ½ years with an approximate investment of Rs.4000 per village . There was a 43.95 % reduction in MMR using simple phones, through text messaging and covering high risk expectant mothers with the existing network of anganwadi workers

According to the GSMA deployment tracker, currently there are around 300 commercial deployments globally. (http://apps.wirelessintelligence.com/tracker/, extracted in Dec 2011).

So clearly, mHealth & telemedicine is fast pervading and showing its impact on the healthcare system in India

Digital Health & Medical tourism: India is fast losing to other South East Asian nations as a centre of excellence for medical tourism due to lack of IT usage in its hospitals and dismal usage of mhealth / telemedicine. International patients follow the international electronic data / medical records standards , and also would like to connect with their care givers using telemedicine , and if we do not promote EMR & telemedicine through hospitals , India is likely to lose billions of dollars in revenue which otherwise could accrue through foreign patients seeking treatment in Indian facilities

Healthcare program reporting, review & timely interventions: Currently, the healthcare data is reaching after months and in some cases well over two years. This could become live and actionable for timely interventions by using GPS enabled devices & e-reporting. Solutions are already available and are scalable. It is the right time to adopt the same in NRHM, and create a national household medical record (NHMR) for the families in rural / urban India. This will help us study the epidemiology & family health risk assessment. May be, we must make it compulsory to ensure that all the 18 million new born’s must have the electronic health record and then move upwards to put an electronic health record for all Indians, post the national screening program. At least, the next generation must be having a digital health record right from birth so we do not have to change the system backwards for them in future.

So, for sure, mHealth & Telemedicine is a proven model for care delivery, and we need to support it in a more structured and institutional manner for the next 5 years .

It is beyond doubt that , mhealth will add efficiency to affordability , acceptability ,  accessibility & efficiency on one hand , and create about 2 million jobs and also add  about 0 .5 % of growth in the GDP at a minimum in the next 5 years .

Inclusive innovation & inclusive growth have now added a new dimension, i.e. ‘inclusive healthcare’, with digital health being the starting point. mHealth is the fastest solution to the oldest problem of reaching the unreachable! We must seriously consider deploying at least 3 % of our total healthcare budget on ICT, and this will certainly make the data live and lead to timely interventions and thus saving lives, establishing accountability of the service provider through periodic reviews and bring transparency in functioning of the various programs

US FDA has approved mobile health applications for diabetes management besides others, and two insurance companies have agreed to reimburse mobile health applications for treatment of diabetes. This development indicates that the big multi-billion untapped market of the developed world is waiting to be tapped and the government needs to step in, like it did to develop multi-billion dollar corporations in the field of Information Technology. According to the Economist Intelligence Unit (EIU) & Pricewaterhouse Coopers (PwC )report 2012, mHealth market is likely to be USD 23 Billion by 2017, and Asia Pacific market will be 30 % at USD 6.8 Billion .If we work towards setting the right enabling policies for mHealth, Indian companies would grab a major portion of this market, like we did for IT industry a few decades ago. Besides, given the technical & competent manpower in India, mHealth & telemedicine can do for country what IT revolution has done for India!  This calls for a dedicated action group on Digital Health (mHealth & telemedicine) .

mHealth & Telemedicine is becoming the focus area for all the major healthcare systems across the world, and given India’s expertise in this area, India can become a global provider of products and services in the field of Telemedicine & mHealth. We believe mHealth can add at least 0.5 % to country’s GDP in the next 3 – 5 years, create at least 5 billion dollar companies in mHealth, and lead to creation of over 20,00,000 (2 million) jobs directly by becoming a Global leader in this space. If two persons are deployed in every village for Telemedicine, and considering that India has over    6,40,000 villages, we will create over 1.2 million jobs directly just in rural India and this could be a worthwhile project to be considered for funding under MNAREGA scheme that will not only create jobs, but also lead to better health for rural India and lead to tremendous savings under NRHM expense head!

The good point is that, we have a least complex healthcare system in India, and we are building it up. Also, we have quite receptive and friendly policy makers who are willing to try initiatives.

Hopefully, we will lead and show the world an outcome driven & a self-sustainable healthcare delivery model built on strong foundations.

Over the past few years, I had a good experience working with policy makers across geographies and it has been a wonderful experience, especially in India, working with different stake holders to discuss new ideas and policies aimed at better healthcare options for the common man.

This is not a complete or a reference document but just to initiate a few discussion points. Should your office or any concerned organization, department or ministry need more inputs or support, my colleagues at the World Economic Forum, The Telemedicine Society of India, HIMSS & Continua Health Alliance, would be more than glad to volunteer and assist. I am sure that this submission will also be considered positively by the various stake holders in the Government and acted upon, so that we can see large scale deployment of mHealth & telemedicine projects in all major departments and programs of the Government making healthcare accessible and affordable to provide timely advice & right interventions for the common man 24 X 7.

Yours in good health

Rajendra Pratap Gupta

Member, World Economic Forum’s Global Agenda Council – Digital Health
Board Member, Care Continuum Alliance, Washington DC. USA
Executive Council member, Telemedicine Society of India
President & Member of the Board, Disease Management Association of India (DMAI).

http://www.dmai.org.in

CC:

Mrs.Sonia Gandhi, Chairperson , NAC.

Dr.M.M.Joshi, Chairman, Parliamentary Accounts Committee .

Dr.Sam Pitroda, Chairman, National Innovation Council, GOI.

Shri A.K. Antony, Hon’ble Minister of Defence , GOI.

Shri Ghulam Nabi Azad, Hon’ble Minister for Health & Family Welfare, GOI

Shri Kapil Sibal, Union Minister for HRD/ Comm & IT, GOI

Shri Jairam Ramesh, Union Minister for Rural Development, GOI.

Shri Ajit Singh, Union Minister for Civil Aviation, GOI

Shri Salman Khurshid, Union Minister for Law, GOI

Smt. Krishna Tirath, Union Minister of state (I/C) for Women & Child Development, GOI

Shri Jitendra Singh, Union Minister of state for home affairs, GOI.

Shri Sachin Pilot, Union Minister of State for Comm. & IT, GOI

Dr.Syeda Hameed, Member, Planning Commission, GOI

Dr.K.Srinath Reddy, President, PHFI.

Shri. P.K.Pradhan, Secretary – HFW, GOI

Shri. Keshav Desiraju, Addl Secy – HFW, GOI

Shri. Anil Swarup, Joint – Secretary, Ministry of Labour & Employment, GOI

Mrs. Anu Garg, Joint Secretary – HFW, GOI

Shri Harkesh Mittal, Secretary, Technology Development Board, GOI

Shri Rajeev Aggarwal, Secretary, TRAI, GOI

Shri Shankar Aggarwal, Addl Secy, MOD, GOI

Dr.Jagdish Prasad, DGHS, GOI

Dr.V.M.Katoch, Secretary DHR & DG, ICMR. GOI

Director, NIFW, MOHFW, GOI

Governors, MCI.

Chairman, ISRO.

Dilip Chenoy, Managing Director, NSCDCL,

Board of HIMSS Asia Pacific India chapter

President, Continua Health Alliance

Board, Telemedicine Society of India

Board members, Disease Management Association of India.

Abbreviations used:

NDHP: National Digital Health Plan

MOHFW: Ministry of Health & Family Welfare

MHA: Ministry of Home Affairs

PHFI: Public Health Foundation of India

HFW: Health & Family Welfare

DGHS: Director General of Health Services

MCI: Medical council of India

TDB: Technology Development Board

DST: Department of Science & Technology

NIFW: National Institute of Family Welfare

TRAI: Telecom Regulatory Authority of India

MOD: Ministry of defence

MNAREGA: Mahatma Gandhi National Rural Employment Guarantee Act

NRHM: National Rural Health mission

MOL & E: Ministry of Labour & Employment

MCWD: Ministry of Child & Women Development

MIT: Ministry of Information Technology

MHRD: Ministry of Human Resource Development

MDONER: Ministry of Development for North East Region

MTA: Minister of Tribal Affairs

PMO: Prime Minister’s office

MOCA: Ministry of Civil Aviation

ICMR: Indian Council of Medical Research

BIS: Bureau of Indian Standards

CHA: Continua Health Alliance

HIMSS: Healthcare Information Management & Systems Society

NSDC: National Skills Development Corporation

Min: Ministry

Deptt: Department

Org: Organization

EMR: Electronic Medical Records

ISRO: Indian Space Research Organization

 

Reports referred in this note:

Touching lives through mobile health by PWC

A Better insight to mHealth adoption

Telehealth Report 2011 by Telemedicine Society of India ( www.telemedicinecongress.com )

Emerging mHealth: paths for growth by PWC

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 http://www.dmai.org.in

12th Five Year Plan – DMAI


Image

Rajendra Pratap Gupta

President & Member

Board of Directors

March 09, 2012

Via e-mail / Speed-Post

Dr. Manmohan Singh,

Prime Minister

Government of India

Shri Ghulam Nabi Azad,

Union Minister for Health & Family Welfare

Government of India.

Subject: Strategic Considerations for Healthcare in the 12th five year plan

 

Dear Dr. Singh & Shri Ghulam Nabi Azad ji,

I am writing this note on behalf of DMAI – Disease Management Association of India.

Disease Management Association of India (DMAI – The Population Health Improvement Alliance) is formed by leaders from the Global Healthcare fraternity, to bring all the stake- holders of healthcare on one platform (Both the public & the Private sector). DMAI has been successful in establishing an intellectual pool of top healthcare leaders 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 resource – 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.

Earlier in 2009, I have authored the comprehensive healthcare reforms agenda for India, and this has been appreciated by political and policy-making leadership at the highest level. Further, the healthcare reforms agenda  (detailed agenda is available at the DMAI website http://www.dmai.org.in/Healthcare_Reforms_Agenda.pdf) has been incorporated in the healthcare planning in the state of Chhattisgarh.

Further, DMAI has given inputs to various government bodies, as sought from time to time on:

Re-structuring of ICDS

NCD Policy

Re-structuring the 12th Five year plan for healthcare

Formation of NCHRH

Inputs in the high level UN summit for NCD’s (DMAI was an official invitee to the UN)

DMAI has raised important issues w.r.t. The Mental Health Act 2010, banning of Junk food in schools, reservations in airlines and railways for critically ill and in times of medical emergencies, radical changes in Jan Aushadhi scheme, healthcare reforms in J & K, Protocols and treatment guidelines for all major acute and chronic illnesses; besides other issues. Details available on www.dmai.org.in

12th five year plan is being talked of as the ‘Plan for Health’, and through this note, DMAI wishes to bring a few important issues before the policy makers for debate and appropriate action:

Quality of Healthcare: Last year, I was nominated to the five member Healthcare committee of the Quality Council of India. Since then, I have been discussing with all the stakeholders in healthcare, including the patient groups, about how to improve the quality of healthcare in India.

Action:  It must be made mandatory for all healthcare providers (Care Givers), to submit the Patient / treatment outcomes data e.g. for hospitals (including admissions, no. Of night stays, re-admissions, infection rates, deaths, referrals, etc.) to the government every year without fail. Also, getting similar data for doctors, clinicians etc. should also be looked at. This data could be maintained under the Quality Council of India (QCI) or an entity under QCI, funded jointly by the government and private players or, as an independent organization. This organization must analyze the data and post it on the website, so as to enable the patients to make an informed choice when it comes to choosing the doctors / hospitals or the caregivers. This will be the first step in bringing transparency in healthcare and a major boost to improving quality in healthcare. A hospital stay costs an average of $236 per day in India, $655 per day in France and an average of $3,949 per day in the US, according to a report — 2011 Comparative Price Report Medical and Hospital Fees by Country – released by the International Federation of Health Plans.  After paying USD 236 (Approximately Rs. 11328.00 / day (USD 1= INR 48), what does the patient get in return?  . We believe that by implementing this reporting by caregivers, the caregivers would work harder to improve their performance in terms of outcomes for treatment and, in a way, it will lead to ‘Pay for Performance’.  Patient would be able to make choices based on whosoever provides the best care!

Also, all the hospitals / care givers must ensure appropriate patient follow-up and feed back mechanism, and the government must devise an institutional mechanism to collect the data on success rate of treatments and examine the reasons for failure so that the quality of healthcare delivered can be improved.

This must be done by setting up the National Institute for Research in Healthcare Quality Improvement.

This institute must focus on coming out with annual reports on improving the quality of healthcare in all the states, as the healthcare issues vary from state to state. We have seen that recently, West Bengal has been home to dozens of child deaths in major government hospitals.

But as of now, there is no investigating body for healthcare to look into these issues, and the crime investigating agencies (Police) lack the necessary qualifications & skills to carry out any meaningful investigation and suggest remedial steps for such incidents. It is the time to correct this by setting a dedicated national body for such incidents.

USA has moved towards ACO’s (Accountable Care Organizations); and it is high time that India sets up the guidelines for all healthcare delivery organizations to become self-regulated ACO’s

Recently, DMAI was actively involved in doing the biggest Healthcare camp in Ajmer (the constituency of Shri Sachin Pilot), and examined over 50,000 (according to some media estimates, approximately 71,000 people). The people were given free diagnostic tests & medicines only due to active participation & support from the private sector. It is high time that the government acknowledges that the private sector has a pivotal role to play if the ‘Healthcare for all- Universal Healthcare’, has to move beyond ‘mike & paper’! Private sector has always shown commitment by providing resources for ‘pilots’ and ‘Free camps’, but we must not forget that, ‘Charity is as deep as the pocket’! It would be a win-win, if the government starts with launching the mass screening program with the private sector, re-launching the ‘Jan Aushadhi’ scheme with the private sector & implementing mass scale telemedicine / mHealth projects with the private sector

I was an invitee to the meeting called by the Hon’ble Health Minister /WHO on 23/ 24th August 2011 at Delhi, and was also involved in the writing of the document called ‘Delhi call to action’.  I recall, that the Hon’ble Minister made an announcement to screen 200 million people for diabetes and hypertension by March 2012. I have learned through reliable sources that this mass screening plan, that was to start with 100 districts was reduced to 10 districts and finally to slums of two districts, and the results were not encouraging! In a way, even 10 % of the target of 200 million (2 crores) has not been achieved. This reminds me of the Sir Joseph Bhore Committee report in 1946, which talked about Universal Healthcare.

Also of the National Health Policy (NHP) 1983, which talked about ‘Health for All’ by 2000 AD’.

Both these committees failed to deliver Universal Healthcare. So, essentially, even after 65 years, ‘Healthcare for all’ has just remained a ‘concept’ & a mere ‘talking point’.

In the current plan – 2012, we are again talking about the same thing ‘Healthcare for all’. This time, we have a high level committee and the wordings have changed to ‘Universal Healthcare’. Doubling of budgets for healthcare will not be able to address the healthcare problems facing the nation, till we ‘double our understanding’ of the real issues and the solutions and give up the parochial approach to remedy the ills in our system!

It is clear that the government lacks an execution plan, and also that; ‘execution’ has never been the forte of the government. It is high time that government puts “PPPr”- Private Public Performance based rewards partnership in place like the NHAI and then only releases the budget for the 12th five-year plan.

It is time to learn from what you did in UID! A person from the private sector has already issued 30 million Aadhaar cards, and this has already become the biggest biometric program in the world. Can we not learn from UID and implement in MOHFW ?

We need a ‘Professional’ CIIO (Chief Innovation & Information Officer) in the Ministry of Health, who will bring the necessary capabilities in the ministry to make a difference in the ‘Health for All’.

Free insurance & Free medicines: This scheme is a ‘Killer Combination’.  ‘Social healthcare’ has failed miserably in the western world, and we seem to have not picked up the lessons but are hell bent on ‘Importing failures’ of the west into the Indian healthcare system. As I mentioned in the 2009- ‘Healthcare reforms agenda’, I will re-iterate that we need a ‘Co-pay’ model for healthcare delivery.  Except the BPL families, all others must have’Co-Pay’ component in the healthcare services even if it is a token of 5-10 % of the total healthcare cost borne by the government. Co-Pay must go up with the income slabs!

Rajiv Aarogyashree scheme (highly publicized scheme of Andhra Pradesh), is now widely talked of as a ‘failure’, and the government is not in a position to pay the empanelled facilities for the ‘free treatment’ that has been a part of the popular scheme

It is time to re-look at ‘Free universal healthcare schemes’. If the government examines the free healthcare schemes currently offered all over the world, it would think twice about free healthcare!.

Free medicines scheme: During my visits to Rajasthan (medicines are given free in Rajasthan government hospitals), I was made to re-think about this scheme

This scheme has created a peculiar situation for doctors.  Doctors are told that the family member is suffering from cold, cough or backache, and s/he is asked to give the medicine!

When the doctors request to examine the patient as to check if it is dry cough, TB induced cough etc., the response that the family members give is, ‘ When the medicines are provided free by the government, then why do you ask so many questions?

If the doctor refuses to give medicines, political pressure is applied and the doctors are harassed! Doctors have been reduced to ‘compounders’, and are just dispensing medicines rather than treating patients, because of the ‘free medicine scheme’!  Even in the USA, we have seen scams where ‘dummy patients’ were created under Medicaid, and reimbursements taken from the government in the name of ‘diabetic patients’. India will witness large-scale organized frauds if such a scheme is rolled out without adequate checks and controls.

When it comes to medicines, I must request the government to monitor the pharma industry closely, as the customer is not getting the benefit of ‘low prices’ (read as- schemes that are offered by the industry to the distributors).  Just for the sake of information, I am quoting two examples:

Panegra is available at an MRP of Rs. 124.00 and the scheme offered by the manufacturing company is- seven strips free on purchase of one strip! Still the end consumer buys the medicine on MRP!  The manufacturer distributor – retailer nexus swallows the entire margin.

Another example is that of Cifran, priced at Rs.58.80 and the scheme offered by the manufacturing company is – one strip free on buying two strips. But, such benefits are never passed on to the ignorant end customer- patient. Similarly, 1000’s of products are available with such ‘deals’ but the patient does not get the benefit.

Government must take decisive action against such pharma companies. The two companies quoted here are just for reference and most of the companies are indulging in these practices

Also, the government must give a big push for mobile healthcare (mHealth & Telemedicine). CDAC Mohali (a government body) has developed a great application for telemedicine, and DMAI used that service during the mega healthcare camp at Ajmer, in collaboration with PGI, Chandigarh. It is time to promote such institutes and organizations.

May be, it would be worth having a joint working group between the ‘Ministry of Communications & IT’ and ‘Ministry of Health & Family Welfare’, to explore the commercially deployable models of telemedicine & mHealth

It is the right time to train all our nurses & pharmacists in healthcare counseling through online training modules and create a special cadre of healthcare counselors for chronic diseases.

It is the right time to set the Patient Charter for Healthcare, which includes the patient’s rights and responsibilities. DMAI is driving an initiative to come out with a ‘Patient Charter’ under the leadership of Dr.Aniruddha Malpani.

These changes are required if we wish to make an impact on the healthcare delivery system.

Currently, there is a big gap between ground realities, policy formulation & execution framework. We need radical changes in our thinking to create an ‘Inclusive Healthcare Ecosystem’. It is better that immediate steps are taken to correct the loopholes so that Healthcare for all can become a reality without compromising on the quality of care.

DMAI would be willing to volunteer with its knowledge pool and resources should the policy makers need the same

Yours in good health

 Rajendra Pratap Gupta

CC:

Mrs.Sonia Gandhi

Shri Nitin Gadkari

Dr.Manmohan Singh,

Dr.Murli Manohar Joshi, Chairman, Parliamentary Accounts Committee

Minister for Communication & IT, GOI

Montek Singh Ahluwalia

Dr.Syeda Hameed.

Shri L.K.Advani

Smt. Sushma Swaraj

Shri Sudip Bandyopadhyay

Sam Pitroda

Rahul Gandhi

Sitaram Yechury

Secy, Health & Family Welfare, GOI

DGHS, MOHFW,GOI.

Dr. K. Srinath Reddy

Dr.Girdhar Gyani, QCI.

Dr.V.K. Singh, QCI

Board of Directors – DMAI