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 12^th 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 12^th 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

12^th 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/ 24^th 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 12^th 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