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.

Jeffrey D. Sachs is Professor and Director of the Center for Sustainable Development at Columbia University. He is also the Director of UN Sustainable Development Solutions Network and Commissioner of the UN Broadband Commission for Development. He has been advisor to three United Nations Secretary-Generals. He has received many awards including India’s most prestigious award ‘Padma Bhushan’. He has authored numerous bestseller books. Sachs was twice named as Time Magazine’s 100 most influential world leaders and was ranked by The Economist among the top three most influential living economists. Nimisha Singh Verma interviews him on his viewpoint on Sustainable Development Goals and Indian healthcare roadmap to achieve its goal.

Q. Being the architect of Sustainable Development Goals, are you happy with its implementation and impact it has created globally?

I am very pleased and excited by the global acceptance of the SDGs across governments, businesses, and civil society. Yet, actual implementation lags far behind our aspirations and needs. In other words, the big challenge is aligning our plans and actions with the goals. For this we need planning, partnerships, and financial resources in budgets and business investments.

Q. As the world’s most renowned economist, what do you think should be India’s road map to achieve Sustainable Development Goals?

India should pursue the SDGs through six main transformations. First, quality education for all, based on expanded budgets for education at the Union and State levels. Second, quality healthcare for all, similarly based on expanded healthcare budgets at the Union and State levels. Third, decarbonisation of energy, by eliminating the use of coal, oil, and natural gas, and shifting to solar, wind, hydro, and geothermal energy. This will not only contribute to ending global warming but will also clean the air and save millions of lives. Fourth, sustainable land use by restoring degraded lands, protecting endangered species, and ending deforestation. Fifth, investing in sustainable cities, through all-electric vehicles, green spaces, walking areas, and affordable housing. Sixth, being the world leader in using Information and Communications Technologies (the digital revolution) for sustainable development.

Q. Countries have adopted various healthcare financing models as per their needs like Beveridge, Bismarck, and National Health Insurance Model, but every system has its limitations. Do you have any recommendations or hybrid model which India should adopt to serve its healthcare needs for varied segments of its population?

The best healthcare financing is a single-payer approach by government (shared between the Union and State levels). The US model of private health insurance is unjust, costly, and unfair, based on a powerful private – sector lobby that makes exorbitant profits at the expense of society, especially at the expense of the poor. India continues to under-invest in healthcare. It should be spending at least 4 percent of GDP on publicly financed healthcare, with the share rising gradually overtime.Until recently, India has been spending little more than 1 percent of GDP, a shockingly small amount, and perhaps the lowest public-sector outlay on health of any major country. Of course, good health comes not just through a high-quality and equitable health system, but also through healthy life practices. India should avoid the American fast-food industry and the accompanying obesity syndrome, the heavy addiction to cigarettes, and the massive air and water pollution that claim so many lives. Quality education for all, and gender equality will also strengthen health outcomes.

Q. You have vast knowledge of Indian healthcare system, having been associated with various initiatives like National Rural Health Mission. How do you think the Bottom of Pyramid can be served in its healthcare needs?

The surprising point about India is how the government chronically under-invests in healthcare. In this case, India is following the US model, of relying on privately provided healthcare. But that only works for the upper class, not the poor.

Q. How should Indian healthcare policies be structured to integrate the technological innovation to achieve its healthcare goals?

Digital technologies enable low-cost, high-quality, and innovative delivery of healthcare. Smartphones can play a vital role: to connect households with health providers, for remote sensing of patient data, for guiding community health workers (such as ASHAs), for telemedicine and distance diagnostics, for collecting and reporting data, etc. More generally, we are in an era of rapid technological breakthroughs in diagnostics, big data collection and processing, remote monitoring, new medicines, genomics, social medicine (including community-based mental health services), and environmental determinants of health. India should turn to its key institutions such as the Public Health Foundation of India to help set roadmaps for universal health coverage based on innovative technologies. And as with the US National Institutes of Health and the UK’s Wellcome Trust, India should explore an innovation ecosystem built on public financing, private foundations, and private-sector financing for cutting-edge R&D. A single-payer system should reimburse private providers at fixed public rates to give them the incentives to reduce costs and raise the quality through innovations. In other words, a single-payer system can still induce innovation by private providers, but within the context of universal coverage and without the excessive lobbying power of private health providers. European models will be helpful here.

Q. How globalization can help developing countries in improving healthcare? Is it a win-win situation for both developing and developed countries?

SDG 3 sets a shared global set of health objectives – “healthy lives for all at all ages”. In other words, the SDGs can build a shared global perspective and strategy. Of course, the gains are win-win. If all countries coordinate on decarbonizing the energy system, all will gain in improved health (fewer extreme heatwaves and climate-related disasters, reduced air pollution). If they cooperate on improved delivery of primary healthcare, there will be fewer uncontrolled epidemics of emerging diseases. If they cooperate on regulations on antibiotic use, there will be much less onset of antibiotic resistance. If all countries cooperate on sustainable farm practices, there will be healthier diets and less irresponsible use of antibiotics for farm animals. In other words, there are huge gains to global cooperation. Moreover, the poor countries depend on financial support from the rich countries like – to finance the control of epidemic diseases, the shift to clean energy, and the implementation of universal health coverage. Crucial institutions like the Global Fund to Fight AIDS, TB, and Malaria, need much more global financing. The world’s billionaires should be doing much more than most of them are doing now to put their vast wealth at the service of humanity. No country should say, “America first,” or “India first,” or “China first.” All countries should say “The World First,” and we will all come out ahead.

Q. What are the updates for 2019 regarding Indo-Danish relationship in Healthcare?

The relationship between India and Denmark is becoming better each day. In December 2018, the Foreign Ministers of both the countries met in New Delhi and relaunched the Indo-Danish Joint Commission, which provides the framework for all strategic sectors’ cooperation including healthcare. This breakthrough paved the way for the Danish Prime Minister’s visit to India in January this year. Among other things, he participated in Vibrant Gujarat spearheading a Danish business delegation, where he also met with Prime Minister Modi. The purpose of these visits was to strengthen political and economic ties between India and Denmark because both countries will benefit tremendously from increased interaction and business collaboration. In this regard, healthcare is a key focus area for 2019. This decision is based on the success of two large projects in 2018; one is focused on non-communicable diseases and the other on attaining the SDGs within healthcare. We were able to develop concrete grounds for working in a focused manner in this field and assist Danish companies looking to gain a footing in India. Several Danish companies are already established in the Indian market including Novo Nordisk, Widex, Coloplast, Fertin, Falck and many more are expressing their interest.

Q. The Danish Health System is incorporating changes for good in recent past with new hospitals and other delivery mechanisms, can you share your viewpoint on the relevance of them to India?

The Danish health system is a publicly funded scheme, which covers all Danish citizens. There is a lot Denmark can contribute to India in terms of know-how and sharing of best practices. Areas where Denmark can assist India to include:

• Digitalization of some solutions to address the challenges that exist in the current healthcare system. Denmark is a leader when it comes to digital workflows and working with electronic health records. Like in India, there are multiple stakeholders within the healthcare system (doctors, patients, nurses, local and state authorities, pharmacies, etc.) that are bound to work together but at the same time operate as individual entities as well. Denmark managed to achieve a high level of efficiency by digitalizing processes and thus, improve efficiency.

• Digitalization has helped Denmark save both time and money. These learnings can be adopted in India to bring down costs in public as well as private set-ups.

• Empowered its patients allowing them to access all relevant information about their health and well-being. I believe that the Indian government’s launch of Ayushman Bharat Scheme is also a move in a similar direction and with the similar intent of providing better healthcare access to all. Therefore, I see a great scope of collaboration and partnership between the two countries.

• Other areas where Denmark has done exceptionally well is the use of Telemedicine for connecting patients in remote locations and reduce time at the hospitals.

• The Danish hospital system is undergoing unprecedented expansion and restructuring. Denmark has spent years of research and gathered experts from all over the world to develop 5 new national super hospitals and renovating 11 existing hospitals. India can leverage this knowledge while it is at a stage where there are still new hospitals getting on.

Q. What can India offer to Denmark, your opinion?

One of the common areas of work between Denmark and India is dealing with NCDs. It is a global challenge. Denmark is currently investing a lot in developing solutions to address this global multifaceted issue. Our research environments, universities, and companies are trying to create products that could be suitable not only for Denmark but across the globe. One of the very specific things Denmark could explore is:

• India has a lot of data available and Denmark could collaborate with India to develop solutions and therapies.

India is a bigger country with a much bigger amount of data; this can be utilized to further make the Danish healthcare sector more effective.

Furthermore, private players dominate the Indian healthcare sector, which has created different incentives and quicker implementation time. Both learnings from private players and data from India can be beneficial to the Danish healthcare sector.

Q. Any message for the readers of InnoHEALTH Magazine that you want to share?

Healthcare is a global challenge, and we need global solutions to attain the Sustainable Development Goals. Having in mind that 17 percent of the world population lives in India, it is safe to say that if India fails, the world will not succeed. Therefore, the strategic sector cooperation between Denmark and India is very important.