Tanya Spisbah, Director with Australia India Institute, Delhi is a renowned and influential expert on Australia-India relations, particularly with respect to health and sustainable development. A career diplomat with the Australian Department of Foreign Affairs and Trade for more than a decade, Ms. Spisbah served from 2014-17 at the Australian High Commission in New Delhi, specializing in health and technology diplomacy for inclusive, sustainable growth. She notably led the health agenda resulting in the Australian and Indian Prime Ministers exchanging an MoU for Health and Medicine, paving the way for cooperation on digital health.

Upskilling Existing Medical Practitioners through Online Courses could Strengthen Our Health Systems – A Case Study in Anti-Microbial Resistance

Health innovations are necessary to alleviate the global burden of disease and the suffering and mortality that ensues. We generally think of innovations in health as advances in medtech, digital health and pharmaceutical discoveries. While in many areas, these kinds of technological advances have led to increasing enhancements in health outcomes, in some areas we have slipped backward through overuse of these medical interventions, threatening the gains in health from the Millennium Development Goals and negatively impacting the Sustainable Development Goals. Antimicrobial resistance is one such example. This article explores the notion of short-term online education as an innovative intervention to address unmet needs in the Indian health system as it affects antimicrobials.

Antimicrobial resistance (AMR) refers to the mutating ability of microbes – including bacteria, fungus and viruses – to adapt to pharmaceutical treatments and become resistant, reducing or eradicating the effectiveness of medicines as treatment of bacterial infection or disease. This means perceived advances in healthcare, such as treatment of tuberculosis, have faced setbacks as the bacteria causing tuberculosis becomes multi-drug resistant, leading to increased deaths. It is estimated that AMR will be the cause of 10 million deaths per year by 2050 – causing greater mortalitythan cancer.The issue is a global one and has led to the World Health Assembly adopting a Global Action Plan on AMR, requiring each member country to adopt National Action Plans.

The issue is a global one and has led to the World Health Assembly adopting a Global Action Plan on AMR, requiring each member country to adopt National Action Plans.

India has a complicated health environment – one of the highest burdens of infectious diseases, coupled with one of the lowest public expenditures on healthcare in the world. India is also the highest consumer of antibiotics, with the trend only increasing – in part due to the need to treat bacterial infections and to cover prescription, misuse and availability of antibiotics without prescription.

This health crisis requires a multipronged effort – a multidisciplinary approach by multiple actors in government, industry and educators. India’s National Action Plan identifies that key challenges to AMR include inappropriate prescribing practices and misuse of antibiotics by humans. India is working to set in place stronger health systems and has invested in a stronger primary healthcare system with the implementation of the National Health Policy 2017 and the establishment of the Ayushman Bharat. These national policy responses will go a long way in establishing a framework for primary healthcare strengthening but are not able to provide for a holistic solution to gaps in the health system. While the Indian government is also working to reform the MBBS through amendments to the Medical Council of India legislation and changes to the curriculum, the results of these interventions will take years to work through the system and won’t be able to make material impact today.

Short courses as a medical intervention for AMR Inevitably, interventions are required from a wide range of actors. While national and state governments and industry are often called upon for innovative responses, given that unnecessary prescriptions or misuse by patients is a major identified problem incontributing to AMR, a largely untapped resource is the role that educators can play in the upskilling of existing medical practitioners to respond to immediate weaknesses in the health system to address such global health challenges. While online education interventions may be potentially smaller in scale, it could have far greater direct and local impact in localities across India, particularly in smaller cities.

As an example, the Australian Institute of Medical Administration and Compliance (AIMAC) has developed courses to facilitate good prescribing and dispensing practices. Designed for health professionals, Seema Gupta and Veena Sehgal have created short courses that in just one hour would assist general practitioners in following proper prescribing processes. Courses are written to address an unmet gap that exists between longer term academic courses and the practical issues faced by doctors every day. There is pressure by patients to come away from a doctor’s visit with a prescription, instead of sound advice for medical treatment, which may include simple rest rather than a drug prescription. The courses provide GPs with a quick and easy suite of information and tools about where to obtain further information to increase the quality of their prescription methods and improves collaboration between doctors and pharmacists by having them better understand their respective roles and the instructions being provided to the patient.

Often, it is the social dimension that is underestimated and undervalued when delivering healthcare. While there is a greater focus on patient-centric care and the experience of patients in thehealthcare system, short online courses offer one way of improving awareness of the role each actor undertakes in the prescription process and builds a sense of teamwork between the different members of the healthcare team to provide optimal health outcomes.

Interventions like these may be small in scale, but by empowering our frontline health workers, GPs and pharmacists to better understand the role overprescription and poor use of antibiotics can have on global challenges like AMR, such local interventions can have immediate impact on the lives and health of individual patients, in their respective cities and panchayats, and on the health system as a whole.

Innovations in upskilling to increase the quality of health services to improve, not only patient care, but address gaps in the health system will go a long way to addressing global health challenges such as antimicrobial resistance.

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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