In an interaction with InnoHEALTH magazine, the Minister asserts that the government would herald a new era of healthcare and the plan announced in the Union Budget would be implemented with full sincerity. It will take a few months to roll out all nitty-gritty’s of implementation. He dismisses apprehensions of those sceptical of the plan in wake of massive funds required for the implementation of the world’s largest healthcare plan. There would be no laxity in the successful implementation of the scheme and it had nothing to do with elections but it is a well-thought-out plan to ensure holistic healthcare to common people. Massive machinery has started churning out plans to bring the scheme to the ground reality. Informatively, a plan to provide health coverage to 50 crore people has been proposed in the current budget 2018-19 and is being viewed as a precursor to the UHC.

WHO’s definition of UHC — one of the goals of sustainable development — includes financial risk protection (against medical expenses), access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

The National Health Policy 2017 approved last year envisages the attainment of the highest possible level of health without anyone having to face financial hardship as a consequence. The Ministry of Health & Family Welfare (MoHFW) has taken concrete steps to reduce the Out of Pocket Expenditure (OOPE).

Mission Indradhanush launched in 2014 which was one of the largest global public health initiatives. In its four phases till date, Mass Immunisation (MI) has successfully reached over 25 million children in over 528 Districts. The focus is also on increasing the basket of vaccines. Since 2014, Rotavirus vaccine, Pneumococcal Conjugate Vaccine (PCV), and the Measles-Rubella (MR) vaccine, and also the JE vaccine for adults have been launched.

Under Pradhan Mantri Dialysis Program (PMDP) 1.43 lakh patients have availed free services from 1,069 Dialysis Units and also under Free Drugs and Diagnostics Program; Affordable Medicine and Reliable Implants for Treatment (AMRIT) outlets nearly 47 lakh patients have benefitted and through the purchase of subsidized medicines from AMRIT Pharmacies.

To provide comprehensive primary care, the Government has announced of transforming 1.5 lakh sub-health centres to Health and Wellness centres i.e. MoHFW is now moving towards the provision of comprehensive primary care through the Health and Wellness Centres.

The MoHFW has initiated universal screening of common Non-Communicable Diseases (NCDs) such as diabetes, hypertension and common cancers at the sub-centre and Primary Health Centre (PHC), which will enable the strengthening of preventive and promotive health, improve patient referral and access to secondary care.

Excerpts

Q. Please share some major highlights of 2017 in promoting health initiatives?

I am proud to say that there have been several achievements. Few on top of my mind are—Release of the new National Health Policy 2017 after a gap of 15 years, the Passing of HIV & AIDS (Prevention & Control) Act, 2017, the Cabinet approves the Mental Healthcare Act 2017, and the most recent National Medical Commission Bill, 2017.

Besides these policy and legislature decisions, the MoHFW launched some major health initiatives. Starting with the most recent National Nutrition Mission 2017 with Ministry of Women and Child Development (WCD), the intensified Mission Indradhanush. After the success of MI, the annual rate of increase of full immunisation coverage has increased from 1% to 6.7 % during the two rounds. We increased the basket of Universal Immunization Programme (UIP) with the introduction of new vaccines i.e. Rotavirus vaccine, MR vaccine and the PCV.

The PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan) has helped detect more than 5 lakh high-risk pregnancies. Similarly, MoHFWs Rashtriya Bal Swasthya Karyakram (RBSK) has screened 11.7 crore children, 43.4 lakh children were referred to secondary tertiary facilities, 27.8 lakh children availed services in secondary tertiary facilities. The MoHFW also launched the Mission Parivar Vikas (MPV) in 146 Districts of 7 states for substantially increasing the access to contraceptives and family planning services in Districts with Total Fertility Rate (TFR) of 3 and above.

The MoHFW announced transformation of sub-health centres to Health and Wellness Centres (HWCs) to expand the basket of services of primary care to make it comprehensive. The HWCs are expected to provide preventive, promotive, rehabilitative and curative care for a package of services related to reproductive, maternal, newborn, child, and adolescent health (RMNCH+A), communicable diseases, non- communicable diseases, ophthalmology, ENT, dental, mental, geriatric care, treatment for acute simple medical conditions and emergency and trauma services. In addition, the recently launched population-based Screening of Diabetes, Hypertension and Common Cancers (Oral, Breast & Cervical) represents a massive step in identifying and addressing the risk factors at the community level itself. More than 150 Districts are taking up in 2017-18.

There are global achievements in terms of India being declared Infective Trachoma free. The MoHFW has also signed MoUs with Italy, Morocco and Cuba.

Q. What challenges did you aim to achieve next year?

Provisioning UHC and to restrict the growing burden of Non – Communicable Diseases. We have initiatives in place to manage both.

Q. How to address the fund crunch issue?

There is no fund crunch. In 2017-18 Union Budget, the health allocation was increased by 27.7%. The MoHFW is committed to 2.5% of GDP to healthcare in a phased manner under the National Health Policy 2017. So I don’t foresee any fund crunch.

Q. Your comments on private sector role in healthcare? Is their contribution satisfies you?

Private sector engagement is a part of new National Health Policy 2017 for a reason. They have a very significant and important contribution to the country’s health services landscape. In terms of real-time support, we are satisfied with their contribution to the Pradhan Mantri Swasthya Matritva Abhiyan (PMSMA) and provisioning dialysis services through PPP under the Pradhan Mantri Dialysis Program.

Q. Please throw light on Universal Health Coverage initiatives?
There are several, however, I can list a few:-

• In 2017-18, the MoHFW announced transformation of subhealth Centres to Health and Wellness Centres (HWCs) to expand the basket of services of primary care to make it comprehensive. The HWCs are expected to provide Preventive, Promotive, Rehabilitative and Curative Care for a package of services related to RMNCH+A, Communicable diseases, Non-Communicable Diseases, Ophthalmology, ENT, Dental, Mental, Geriatric Care, treatment for acute simple medical conditions and emergency and trauma services. The indicative package of services envisaged is

a. Care in pregnancy and childbirth
b. Neonatal and infant health care services
c. Childhood and adolescent health care services
d. Family planning, contraceptive services and other Reproductive Healthcare services
e. Management of Communicable diseases: National Health Programmes
f. Management of Common Communicable Diseases and General Out-Patient care for acute simple illnesses and minor ailments
g. Screening and management of Non-Communicable diseases
h. Screening and basic management of mental health ailments
i. Care for common Ophthalmic and ENT problems
j. Provision of basic dental health care
k. Geriatric and palliative health care services
l. Trauma Care and Emergency Medical Services

The Health and Wellness Centre (H&WC) will deliver comprehensive primary healthcare using a team-based approach and would be led by a mid-level service provider with a primary healthcare team including ANMs, ASHAs, and AWWs, of the sub-centre area. Altogether, 4000 sub-centres are targeted to be transformed to HWCs by March 2018 and 1.25 lakh HWCs by March 2022. So far approval has given for 3871 HWCs.

• National Programme for Prevention & Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS)— -In order to prevent and control major NCDs, the MoHFW is implementing the NPCDCS in all states across the country with the focus on strengthening infrastructure, human resource development, health promotion, early diagnosis, management and referral. As on date, the programme is under implementation in total 436 Districts, with setting up of NCD clinics in 435 District Hospitals, and 2145 Community Health Centres. Cardiac Care Units have been set up in total 138 Districts and Day Care Centres for Cancer Chemotherapy have been set up in 84 Districts. Provision has been made under the programme to provide free diagnostic facilities and free drugs for NCD patients attending the clinics at the District and CHC levels.

• Population-based screening for Diabetes, Hypertension and Common Cancer (Oral, Breast & Cervical)—The recently launched Population-based Screening of Diabetes, Hypertension and Common Cancers represents a massive step in identifying and addressing the risk factors at the community level itself.

More than 150 Districts are being taken up during 2017-18. As of September 2017, approvals given for about 170 Districts in 16309 sub-centres and screening has been initiated in about 60 Districts, 12 states, 2 UTs and 20,15,474 people have been screened.

Q. How the Ministry ensures safe pregnancy in rural/remote and tribal areas where access to hospitals is not that easy?
The issue focuses on our entire Reproductive Child Health (RCH) programme and National Health Mission To list a few viz.-
a. Janani Suraksha Yojana (JSY)
b. Janani Shishu Suraksha Karyakram (JSSK)
c. HBNC/HBIC (Home-Based Neonatal Care/Infant Care)
d. National Ambulance Service (108/104)
e. Tribal Birthing/Waiting Homes
f. Pradhan Mantri Swasthya Matritva Abhiyan (PMSMA)

Q. What message do you want to share with the community in their fight against dengue and chikungunya?

I want to focus solely on prevention viz. preventing water logging around the house. And other measures which we keep reiterating through our regular Information, Education, and Communication (IEC) campaigns. This requires community partnership and ownership.

Q.8. What has been the status of constructing of new AIIMS across the country?

The Government has been at the forefront to strengthen the tertiary care. As such six new AIIMS are functioning and six will come up in due course.

Q. Pl throw light on MoU signed with Morocco. What will be the major gains?
The main areas of cooperation include the following:
a. Non-communicable diseases, including child cardiovascular diseases and cancer
b. Drug Regulation and Pharmaceutical quality control
c. Communicable Diseases
d. Maternal, child and neonatal health
e. Hospital twinning for the exchange of good practices
f. Training in administration and management of health services and Hospitals
Q. Generic medicines: How to address availability issue?

The MoHFW recently issued a draft gazette notification making it mandatory for Pharma companies to carry the generic name of drugs on packs that are at least two fonts larger than the brand name. This clause will be a legal provision as a rule under the existing Drugs and Cosmetics Act. And any violation will be punishable under the provisions of the law. The Ministry has sought public comments on the draft, after which it is likely to become part of the drug law.

Also, issued orders to the Medical Council of India (MCI), state governments and all central government hospitals asking them to ensure that doctors write prescriptions with generic names of medicines in legible handwriting.

In last three years, the government has capped prices of around 700 essential medicines. It has also capped prices of stents and is working to make drugs for critical diseases like cancer and heart disorders available through various schemes. It has also launched several programmes to make free drugs and diagnostics available under the National Health Mission.

Also, our AMRIT stores provision generic drugs. 19 states have set 105 pharmacies for providing medicines for Diabetes, CVD, Cancer and other diseases at discounted prices to the patients. A total of more than 5000 drugs and other consumables are selling at up to 50% discounts.

As of 15th November 2017, 44.54 lakh patients benefitted from AMRIT pharmacies. The value of drug dispensed at MRP is Rs 417.73 crore and savings of Rs. 231.34 crore from AMRIT stores thereby reducing theirs out of pocket expenditure.

Q. Doctors’ shortage: What measures should be put in place to address the concern?

• The MoHFW has granted permission for the establishment of 83 new medical colleges in the last 3 years including 31 in the government sector. The country has today 479 medical colleges with more than 67,000 MBBS seats.

• The Ministry has taken various measures to facilitate the setting up of new colleges viz.

a. norms for medical colleges rationalized
b. urban areas have dispensed with the minimum area of land within notified
c. Companies have to allowed to set up medical colleges.

• The MoHFW is implementing a Centrally Sponsored Scheme namely “Establishment of new medical colleges attached with existing district/referral hospitals”

• Under this Scheme, 58 Districts in 20 States/UT has identified to establish new Medical Colleges attached with existing district/referral hospitals. Out of these, 56 have been approved to date.

• Out of 56 approved medical colleges, 8 are functional and 29 have applied for MCI’s permission to start new medical colleges from the academic year 2018-19.

• The increase of PG seats:

• In January 2017 the teacher-student ratio was revised in government medical colleges in clinical subjects and consequently around 3,000 PG seats added as a one-time measure.

• In the normal course of permission under IMC Act added 700 seats. Combined with the increase of DNB seats, the ministry could achieve an increase of nearly 5800 PG seats in 2017.

• The country has today around 38,000 PG seats including Diplomate of National Board (DNB).

Q. Please throw light on Mental Healthcare Act, 2016. What steps the did government plan to create awareness on this?

• The Act adopts a rights-based statutory framework for mental health in India and strengthens equality and equity in the provision of mental healthcare services in order to protect the rights of people with the mental health problem to ensure that they are able to receive optimum care and are able to live a life of dignity and respect.

• Mental Healthcare Act strengthens the institutional mechanisms for improving access quality and appropriate mental health care services.

• The Act increases accountability of both government and private sectors in the delivery of mental health care with the representation of persons with the mental health problem and their caregivers in statutory authorities such as Central and State Mental Health Authority.

• The most progressive features of the Act are the provision of advance directive, nominated a representative, special clause for women and children related to admission, treatment, sanitation and personal hygiene; restriction on the use of Electro-Convulsive Therapy and Psychosurgery.

• Decriminalization of suicide is another significant facet of the Act, which will ensure proper management of severe stress as a precursor for suicide attempts.

Finance Minister Arun Jaitley recently has announced two major initiatives in the health sector, as part of Ayushman Bharat programme. This is aimed at making path-breaking interventions to address health holistically in primary, secondary and tertiary care systems, covering both prevention and health promotion.

THE INITIATIVES ARE AS FOLLOWS:-

(i) Health and Wellness Centre:- The National Health Policy, 2017 has envisioned Health and Wellness Centres as the foundation of India’s health system. Under this 1.5 lakh centres will bring healthcare system closer to the homes of people. These centres will provide comprehensive healthcare, including for non-communicable diseases and maternal and child health services.

These centres will also provide free essential drugs and diagnostic services. The Budget has allocated Rs. 1200 crore for this flagship programme. In adopting these centres is also envisages the contribution of the private sector through CSR and philanthropic institutions.

(ii) National Health Protection Scheme:- The second flagship programme under Ayushman Bharat is National Health Protection Scheme, which will cover over 10 crore poor and vulnerable families (approximately 50 crore beneficiaries) providing coverage up to 5 lakh rupees per family per year for secondary and tertiary care hospitalization. This will be the world’s largest government-funded healthcare programme. Adequate funds will be provided for smooth implementation of this programme.

In order to further enhance the accessibility of quality medical education and healthcare, 24 new Government Medical Colleges and Hospitals will be set up, . This would ensure that there is at least 1 Medical College for every 3 Parliamentary Constituencies and at least 1 Government Medical College in each state of the country.

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1. SPEACTRAL INSIGHTS

Pathologists in India don’t lead an easy professional life. And since senior-level pathologists in India are way short in numbers to serve the 120,000+ pathology labs across the country, the work pressure on them is unexceptionally high. There are also several occupational hazards due to the laborious manual process of operating and viewing through the lenses on a microscope for such long time.

Startup firm Spectral Insights aims to come in rescue of pathologists by providing high quality digital copies of slides. The company insists that the technology they are using isn’t new as it’s available in the developed world but unaffordable by labs in India.

So in this light the company has built an affordable automated microscope that makes digital images which are available to pathologists on a computer screen, either locally or over the Cloud. The company also builds various tools to help pathologists make rapid and informed diagnosis, thus increasing their productivity while raising the quality of the outcomes for the patient.

2. CARDIAC DESIGN LABS

It is estimated that India has a ratio of 64 million cardiac patients to 4000 cardiologists. Cardiac Design Labs designs and deploys intelligent devices which help in bringing advanced diagnostics beyond large hospitals. The company has developed a wearable device called MIRC aM (Mobile Intelligent Remote Cardiac Monitor) which is capable of providing real time advanced cardiac diagnosis and monitoring in remote settings. The company believes MIRCaM will bridge the doctor patient gap. Resting ECG which is the prevalent method for diagnostics at small hospitals is only good at detecting patients whose heart problems are acute. However, often many cases with early symptoms go undetected. MIRCaM is designed to solve this problem.

3. FORUS HEALTH

Forus Health is a medical technology startup founded by a group of engineers with the goal to eradicate avoidable blindness. According to data provided by the company, 80% of blindness in the world could be saved if screened and treated early. For this, Forus Health has built an imaging platform called 3nethra, a portable device for screening common eye problems.

Here, IoT helps in conducting remote diagnosis. The images are screened in remote locations and doctors in towns and cities grade them and the patient gets the report back in their respective locations wherein all this happens over the Cloud.

So far 3nethra has helped in more than 300,000 remote reading and reporting and has been able to touch around 150 locations. They aim to cover 3000 locations in coming years.

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Read all the issues of InnoHEALTH magazine:
InnoHEALTH Volume 1 Issue 1 (July to September 2016) – https://goo.gl/iWAwN2 
InnoHEALTH Volume 1 Issue 2 (October to December 2016) – https://goo.gl/4GGMJz 
InnoHEALTH Volume 2 Issue 1 (January to March 2017) – https://goo.gl/DEyKnw 
InnoHEALTH Volume 2 Issue 2 (April to June 2017) – https://goo.gl/Nv3eev
InnoHEALTH Volume 2 Issue 3 (July to September 2017) – https://goo.gl/MCVjd6

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Any detailed analysis of the current state of Indian healthcare can be confusing. The decades of under-investment and lack of systematic planning has resulted in widespread chaos, degeneration of values, skewed distribution of resources, and a sense of helplessness on the part of both the state and the population. It is sadly true that doctors have systematically attempted to benefit from the failure of the policy and the regulation rather than seeking to correct it and their leaders have been busy protecting their own positions and interests rather than that of the patients they are meant to serve. Though the situation seems impossible, there is still hope. A series of determined initiatives can fix the problem.

Indian society is going through a catharsis. In an increasingly interactive but ever more disintegrated world, Indians are finally finding both the confidence and the desire to transform their own society. A country of 1.3 billion people is no longer prepared to accept being an “also ran”. In this process of churning, undeniably, there will be much pain but from this one hopes, will emerge an India – confident, strong, and sure.

There is a lot wrong with contemporary Indian society – it’s thinking, it’s structure, it’s systems but we still have a chance. Each one of us alive today will not be here in say just less than 100 years time. Almost every single house in the country will become inhabitable in not too distant a future, and our cities will almost completely have to be rebuilt. We just need to ensure that the “new” that replaces the “old” is robust and before you know India would be transformed. I sincerely believe that with appropriate corrective action, we can resurrect almost every aspect of the Indian society – yes it’s thinking, the structures, and even the systems.

This corrective action, however, will only become possible if we come out of our current situation where failure has led to arrogance rather than introspection. We will have to start by admitting freely and openly what is wrong with our society and then engage in a collective discourse to fix it. We need to raise both the level and the intellectual quality of our public discussion and move forward slowly – a step at a time – but decisively.

Any detailed analysis of the current state of Indian healthcare can be confusing. The decades of under-investment and lack of systematic planning has resulted in widespread chaos, degeneration of values, skewed distribution of resources, and a sense of helplessness on the part of both the state and the population. The task at hand is enormous.

Human Resources

Healthcare industry is heavily dependent upon human resources. You can’t look after patient without doctors, nurses, technicians, etc. and yet little thinking has gone into ensuring an adequate work-force for the future that we can retain to work in the country. The current situation is that we are creating doctors and nurses but without the adequate hospitals and clinics for them to work in. The government keeps saying doctors and nurses don’t want to work in rural India but without understanding that doctors and nurses need adequate facilities, diagnostics, and other supporting services to deliver healthcare. Doctors and nurses need decent houses, schools for their children and facilities for a productive and entertaining social life. Given the fact that this is unlikely to change anytime soon in rural India, we will need to provide incentives for people to work in the villages – the same sort of thing that can force a doctor or a nurse to go and work in a small town in Saudi Arabia can also take them to a village in their own country. Our planners simply need to wake up to this reality. If a doctor or a nurse sees that he’ll save for four years by working for a year in a village, he is likely to drag himself there and also ensure he works hard to keep his patients and employers happy. The current situation where nobody wants the job in the first place does not leave the government with any levers when those in it don’t perform or simply don’t turn up! Adequate salary and tax incentives can go a long way in helping retain our homegrown talent and will ultimately pay back for itself by ensuring a healthier society. Health, after all it used to be said, is wealth.

The Role of the Government

In modern societies, we have left it to the governments to set the appropriate structures upon which we can all build our individual lives. If the structure is robust, our lives can indeed be very fulfilling but if it is not, the whole system can degenerate into chaos. The policy has failed Indian healthcare at every step and exploited by the very people entrusted to protect and develop it. Doctors continue to be educated and trained in a system that rarely keeps pace with the changing needs of the patients and the scientific developments. Underfunded medical colleges continue to treat the impoverished in shabbiest of the conditions and produce little in the name of research and scientific

output. They struggle to recruit world-class faculty while those who take up these jobs find they can neither deliver world-class care nor engage in academics or research because of the lack of funding and bureaucratic controls. Our corporates happily donate millions of dollars to foreign institutes as they have well-established mechanisms for publicity that our institutions have failed to establish. And while our educational institutions and hospitals are crumbling due to lack of resources, our temples are one of the wealthiest in the world. There is much for us all to reflect over in the contemporary Indian society.

The Profession

At the same time, it cannot be denied that healthcare is fundamentally the doctors’ responsibility in any society. If any of the other stakeholders’ are falling short, it is up to us to make noise and ensure we can deliver quality healthcare to the people. However, Indian healthcare is remarkably short in this area too. A large number of doctors, let down by the system, have become so cynical that greed and self-aggrandisement have taken over empathy and ethics. The profession has got infested with one corrupt practice after the other and the doctors have simply chosen to look the other way. Yet, they complained bitterly when medical services were brought under the purview of the consumer courts. I agree that involving courts was not the right thing to do but what options did the doctors leave for the patients when the regulator, the Medical Council of India (comprising entirely of doctors), does not have an effective patient complaint cell or even a register of all qualified doctors. It is true that the desire of the medical profession in India to protect each other is much stronger than their will to protect patients. And while the rot was setting in, the so-called leaders of the profession were building their own hospitals and nursing home. Isn’t it amazing that not a single leader from the profession has spoken against the widespread lack of healthcare provision in the country for the poor or the ethical abyss that the profession has sunk into? It is sadly true that doctors have systematically attempted to benefit from the failure of the policy and the regulation rather than seeking to correct it and their leaders have been busy protecting their own positions and interests rather than that of the patients they are meant to serve. If you don’t believe me, just think how many of hundreds of medical societies in the country come out with anything useful for the people. Where is the desire to develop the local evidence base to guide local care? Where are the local guidelines for common clinical conditions that can be used by doctors and nurses working in remote towns and villages? Despite this, hundreds of conferences are organised annually at considerable expense and much fanfare where the emphasis is on reciprocating lectures and chairmanship rather than any real scientific data sharing. There will no doubt be islands of excellence in this vast sea of greed and corruption but I hope I have been able to give you a general idea of the state of the affairs. Many of these problems are not simply confined to India either.

The Private Sector

The private sector rose to fill in the vacuum left by the state and it is a fact that without private healthcare, large sections of our communities will have nowhere to go. But once again, the private sector has been allowed to mushroom without any attempt to match demand to supply. This has led to a situation where they are killing and pulling each other down into a moral quagmire with over competition in urban areas while vast sections of rural parts of the country are left un-served. Private nursing homes, diagnostic facilities, and hospitals are functioning without a regulatory overseeing mechanism and poor patients have no alternative, as the state hospitals are not fit for human treatment.

Though the situation seems impossible, there is still hope. A series of determined initiatives can fix the problem. We need reform across the board. We need to reform our state primary health care provisions, our medical colleges and how we fund them, medical education and postgraduate training, continued medical education, regulation of the profession and the hospitals, mechanisms for patients to voice complaints, planning to distribute provisions evenly, and systems for accountability from all. And even if we did all this, there will be yet more left to do.

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