Chikitsa -Revamping The Health Sector of Maharashtra 2015

A Book By-Dr Shyam Ashtekar (MD-Community Medicine)

CHIKITSACHIKITSA

REVAMPING

THE HEALTH SECTOR OF MAHARASHTRA

AN ENGLISH SUMMARY OF MY MARATHI BOOK

Granthali Publication-Mumbai, May 2015

Outline of this PowerPoint document

A. Introduction

B. Maharashtra Situation & Challenges

C. System Context &

AbbreviationsAYUSH Ayurveda, Yoga, Unani, Siddha and Homeopathy

BEmOC Basic Emergency Obstetric Care

CET Common Interest Test

CME Continuous Medical Education

CSR Corporate Social Responsibility

EmOC Emergency Obstetric Care

ESIC Employees State Insurance Corporation

ESIS Employees State Insurance Scheme

FDA Food and Drug Administration

HR Human Resources

MCI Medical Council of India

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C. System Context & argument for change

D. Suggested10-point plan

E. Summary & Comments

F. Contact, author info.

5/27/2015CHIKITSA-Revamping the Health Sector of Maharashtra-Shyam Ashtekar

MCI Medical Council of India

MMC Maharashtra Medical Council

NHS National Health Scheme

OOPE Out of Pocket Expenditure

OPD Out Patient Department

PCP Public Charitable Partnership

PCPNDT Pre-Conception and Prenatal Diagnostic Techniques (Act)

PG Post Graduate

PHC Primary Health Center

PPT Public Private Partnership

PSU Public Sector Unit

RGJY Rajiv Gandhi Jeevandai Yojana

RSBY Rashtriya Swasthya Bima Yojana

SHI Social Health Insurance

SPV Special Purpose Vehicle

UHC Universal Health Care

Cover page

Blurb

(A) Introduction3

Blurb

What this book offers


The Cover Page-A Rubicube

The rubicube says it all-

we have to manage the health sector with given resources and opportunities,

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and opportunities, recombining various factors and bringing on new equations and partnerships


On the Blurb

The complexity of health medical sector , with its technology, costs and insurance sector implies that free care for all is an impossible proposition that no government can start or manage, like crossing a chasm in half a step..

We should rather develop participatory health care schemes (Social Health Insurance)

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care schemes (Social Health Insurance) towards affordable care of good quality, while improving free care for BPL.

This book gives a graphic plan of how the new state Government can to go about incremental health sector reforms for Maharashtra in the given situation


What This Book Offers

� A situational analysis of the health sector of Maharashtra in 2015- the mix of private public health care sectors, status of each sector, the medical education, ESIS, insurance, Governance,

� Plan for affordable health care for all through participatory schemes (free care for poor retained and improved) rather than the

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insurance, Governance, administration

� A global perspective of health systems within welfare and socialist states, liberal economies, developed vs poor nations, the problems of state run or US like models

improved) rather than the unattainable goal of free care for all through taxes.

� A graphic approach on how to develop health sector of Maharashtra , from 2015 to 5 and 10 years later.


Maharashtra-General

Health-Achievements-

(B) Maharashtra-Situation & Challenges7

Health-Achievements-

Health-Challenges

Situation- Health Mumbai


Maharashtra- General

� Maharashtra is a progressive and somewhat industrialized, urbanized (50%) state in India.

� The state spends Rs 10000 crores per anum on all health sector, and people spend (OOPE) about 3 times this.

Central and state Tax funds for health have remained

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� Central and state Tax funds for health have remained scarce for six decades in India, and states are unable to meet the gap. The state has a debt of 3 lakh crores and 17% revenue shortfall.

� Wide inequality from metros to tribals

� Nearly 50% urbanized

Maharashtra Health 2015-Achievements

� Well spread network of health care, ambulances

� Supply of doctors/hospital beds-(1doc:600 people),

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� More Medical & AYUSH colleges than any state

� Favorable decline in home births, mortality (CDR, CBR, IMR, MMR), Child malnutrition (except some 20 blocks)


Maharashtra Health 2015-Challenges

� High costs of care.

� Overindulgence, unfair practices?

� Tertiary care in corporate sector.

� Decline/stagnation of quality of med-education and care

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� Deterioration of public institutions

� Decline of ESIS

� Oversupply & urban clustering of consultants.

� Shortfall of nurses and paramedics

� Rising load of non-communicable diseases, ageing and costs of care


Situation -Mumbai (Based on Praja Foundation Report)

� Stable level/decline, of malaria, TB, diabetes, high BP

� About 11-44% medical/other posts vacant in public health institutions, HR discontent!

� Only major public hospitals

� About 7-8% of family income spent on health, across income groups

� Medical insurance cover 12% (poor families) to

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� Only major public hospitals for tertiary care, second rung hospitals only deals with general and mother-child

� Huge presence of Pvt care in all three levels

12% (poor families) to 32% (rich families)-average 20% families

� Satisfaction score for Pvt care is 84%, and 68% for Public health facilities


�Guiding principles

�Reality check-welfare state-global map

( C) Systems Context & Argument for Change

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�Reality check-welfare state-global map

�Health spend of OECD and India

�Overview of health systems-NHS, SHI, US, India

�Limitations of private insurance model

�Argument for Change


Guiding Principles for Health Care

1. Emphasis on primary and preventive care more than hospitals

2. Scientific (evidence based) and rational.

3. Ethically sound (see MCI code)

4. Humane, sympathetic

5. Affordable-for Govt and Citizens

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Affordable-for Govt and Citizens

6. Protection for poor/needy families (good quality free care)

7. Preserve and restore AYUSH in health care.

8. Health is Right with Responsibility and participation (legal right to health care is problematic)

9. Use existing public facilities neatly before launching new big projects.

10. Review needs, costs, practices, outcomes, options etc


Reality check of Welfare state (>20% of GDP) limited mainly WESTERN economies

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The Health spend in OECD countries (6-15%) and

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15%) and India (4%) with 3:1 Pvt-public share


Overview of Health Systems (1)NHS (UK) 9% of GDP-

Yet Serious delays in care

SHI (Germany) 9% GDP-

No serious crisis

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Even in UK NHS-delay and costs (at 9% of GDP) are threatening-

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Overview of health systems (2)

USA ->17% of GDP on Health Care,

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Care,

More with Obamacare

Overview of health systems (3)

India’s Mixed care (4% of GDP)-30%

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GDP)-30% Public,

70% Pvt Care

SHI systems are more participatory, stable

and rooted in the society-From R Saltman

An insider’s perspective..The attraction of the SHI approach for both citizens and policy-makers appears, on initial viewing, to be based on 3 structuralcharacteristics.•SHI..seemingly private in both the funding and delivery ofhealth services.

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health services.•SHI systems ..self-regulating, managed by the participantsthemselves (e.g. sickness funds, physicians and, to a lesserdegree, patients).•SHI ..perceived as stable in organizational and esp. financialterms.This stability often appears to be the most highly prized of allthe outcomes associated with SHI systems.


Limitations of Private Insurance Model

� No involvement of Govt

� Only 3-32% people are med-insurance covered in India (Mumbai average 20%)

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average 20%)

� 80% business with Indian PSUs

� Premiums rise annually

� 20% overheads

� Overbilling, conflicts


The Argument for change

� WE can plan and manage to get good quality care in primary-secondary-tertiary structure harnessing the Public-Private spend, improving the functioning of public institutes, and reorienting institutional arrangements mainly

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reorienting institutional arrangements mainly with not for profit sector.

� And we need do all this within a public health framework of health sector management in a changing India.

� Need to make our public institutes efficient and responsive.

1. Governance

2. Human Resources

Health Expenditure and constraints/comments

(D) The plan, suggestions23

3. Health Expenditure and constraints/comments

4. A proposed SHI model

5. Primary care

6. Free and affordable hospitals

7. Drugs, AYUSH and technology

8. Preventive programs

9. Care of special groups

10. Small family and demography

11. Review of medical Acts/laws


The Reform program- 10 sector radar

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3

4

5

6

7

8

9

10

Governance/admin

Affordable Hospitals

Participatory Health Schemes

Small family

Review medical acts

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0

1

2Schemes

Primary Care

HR

Drugs/techno/AYUSH

Prevention and Nutrition

Care for Special group

2015

2020

2025


1. Governance and administration

� Integrate Medical education and Public Health depts (Also FDA)under one minister, Pr secretary

� Remove disadvantages of Public Health Dept HR vis a vis Med Ed & Research, establish mutual exchange of doctors/staff

Involve village panchayats to own and manage

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� Involve village panchayats to own and manage subcenters

� Convert subcenters into Ayurvedic Dispensaries

� Encourage Municipalities to start, own and manage financially sustainable hospitals/health centers

� (Need to merge National Health Mission into Health Dept)


2. Human Resources

� Serious quality gaps in Medical education, CETs

� PG Entrance Exam playing havoc with graduate learning, skills, attitudes both in Govt/Pvt institutes

� Can we legally scrap CET & PG Entrance Exam, restore importance of board & grad exams?

� Review of syllabus

Better administration of

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learning, skills, attitudes both in Govt/Pvt institutes

� Overproduction of doctors & AYUSH grads but undersupply of nurses, paramedics

� Serious distortion of ratio basic doctor : Post Grad

� Better administration of colleges- and training

� Expand Nursing education

� Paramedic Council and institutions

� RESEARCH??


2.Health Services Doctors get a rough deal

Compared to doctors in Medical Education dept, Health Services Doctors get a rough deal,

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� Stay rural, 40% less pay

� Stagnate-fewer promotions & opportunities

� 30% on annual contract-for years


2. HR-General Issues

� Long pending demands of resident doctors and rural medical officers-with or without financial implications need to be attended.

� Vacant positions despite

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� Vacant positions despite oversupply of doctors

� A good HR management and leadership is necessary for improving compliance and quality of care in PHCs, hospitals and colleges


3. Public Health Exp (crores) Maharashtra (2013-14)

Budget Est -Public Health Exp in Mah 2013-14 (cr Rs)

Secretarial services 105

Public Health dept 3395

National health Mission 101

Jeevandayi Yojna* 695

ESIS 220

Mah AIDS control scy 418

Secretarial services1%

Public Health dept34%

admin and others0%

BMC and other municipal bodies25%

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Mah AIDS control scy 418

FW 684

Med Ed and Research 1624

Ayurveda etc 223

FDA 66

admin and others 22

BMC and other municipal bodies 2500

Total 10053

National health Mission1%

Jeevandayi Yojna*7%

ESIS2%Mah AIDS

control scy4%

FW7%

Med Ed and Research16%

Ayurveda etc2%

FDA1%

0%


Health Care Finance

� Maharashtra spends about 10000 cr on all public health care-of which is about 25% is from Municipal bodies

� About 30000 cr possibly comes from Private expenses (OOPE)

� Free Care for All is a daunting challenge due to constraints on state (& central) budgets (need 20-30000 cr more for this)

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state (& central) budgets (need 20-30000 cr more for this)

� ..Even then we cant guarantee delivery of good care.

� Tax based health care models have other problems that the UK NHS is facing for the last decade(s)—delays, queues, rising costs, inefficiency etc– All this at 9% of GDP)

� No Indian Govt can start and manage such a Free -UHC, and there can be no retreat if any Govt starts a Free-UHC


Towards a Social Health Insurance model

� Affordable care is feasible, free care for all is NOT feasible

� It will be better to step up public health care with innovative participatory models, low cost hospitals run by Medical colleges, local bodies, non-profit

Choose the right model and approaches31

colleges, local bodies, non-profit bodies, ESIS and CSR for rural hospitals etc- The supply side!

� Expand RSBY, ESIS and RGJY (Jeevendayi) by allowing entry of middle class families with attractive premiums and services- The demand side.

� Strengthen primary care, pre and post hospital care


A Suggested financial Model Participatory Health Care

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4. Primary Care

� Train professional paramedics for urban and rural settings, home care etc

� Select health subcenters can be handed over to panchayats willing to run part-time Ayurvedic or

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panchayats willing to run part-time Ayurvedic or other dispensaries with 50-50 shared support and small user fees

� Evening OPDs in all public health facilities

� Primary care info sources in Marathi

� CME for General Practitioners


Expand Primary Care- Using the health Subcenter

� Hand over select health subcenters to panchayats for part-time dispensaries with 50-50 shared support and small user fees

� We can appoint part-time Ayurvedic doctors to

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� We can appoint part-time Ayurvedic doctors to health subcenters

� We have 10000 subcenters, and a shared scheme will cost only 500 crores per anum to the state, rest borne by users/panchayats/CSR


Primary Care-ArogyaBanks (AB) or Health Kiosks

� In places where we don’t have even health subcenters, we need some quick-fix solution

� Arogyabanks can serve this purpose http://bharatswasthya.net/download

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http://bharatswasthya.net/download

� Trained paramedics (ASHA+ to ANM) can take over Abs

� AB will have 20 medicines for 50 common illnesses and some basic tasks


5. Free and affordable Hospitals

� Manage the Rural Hospital for BMOC, and for EMOC with mobile teams to give EMOC

� Encourage genuine PCP (Public CharitablePartnership) with start up assistance/CSR and RSBY+RJGY schemes

Public

PCPs

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RSBY+RJGY schemes

� Improve public hospitals with CSR, open paid/insurance wards for middle classes, incentives to in-service doctors/staff

� Develop/Improve Govt/Pvt medical college hospitals for tertiary care

� Open up RSBY & RJGY for middle class participation with affordable premiums.

Open and Expand RGJY for middle classes

Public Hospitals


6. Drugs, Technology & AYUSH

� Set up an advisory committee to review drugs/technology choices, costs and issue guidelines

� Explore alternative technology options-old and new-for important health problems

� Promote Standard Treatment Guidelines, make these available online,

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� Promote Standard Treatment Guidelines, make these available online,

� Periodic audit/studies/monitoring use of drugs/technology in public and private sectors.

� Use telemedicine (and mobile phones) for improving patient care and education.

� Promote AYUSH esp. at subcenter level, AYUSH research


7. Preventive Programs

� Open up preventive programs on obesity, diabetes, hypertension, accidents, tobacco use, alcohol addiction etc

� Effective programs on mosquito- borne diseases, greater citizen participation and responsibility.

� Awareness and action program for preventing malnutrition

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� Awareness and action program for preventing malnutrition from childhood to adolescents.

� Commission studies on growth in child-adolescent age groups using both secondary and primary data.

� Water pollution, esp. hardness/chemical pollutants are an important emerging problem.

� Open defecation rampart in many districts, while programs are not matching needs


8. Care of Special groups

� People with old age, sex workers, risky occupational workers, vimukta jatis, nomadic tribes need special attention as regards health protection and enhanced services may be with specially trained paramedics

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paramedics

� Endangered tribes (like Kolam) need special care programs

� We need to understand malnutrition of various tribes, specific causes if any and interventions


9. Small Family, Demography

� The family size in both urban and rural population (including general tribal population) has reduced in Maharashtra, below the replacement level

� However sex ratio at birth (894) declined, implying continued son-selection. Need to go beyond PNDT

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continued son-selection. Need to go beyond PNDT

� Family size is still large in some tribal societies (like Bhils and pavara) and minorities. This hurts the health of women and children. Meet the unmet need!

� Early age of marriage/child-bearing is a problem in Marathwada districts--needs attention.

� Also a general need of spacing of births.


10 Review of Medical Acts

� Several medical acts are either ineffective or counterproductive.

� Need to review PCPNDT, Clinical Est Act, MMC (even MCI at central

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Act, MMC (even MCI at central level), consumer protection, legislation regarding cross practice. Some laws are hardly used-for instance act against violence against doctors.


(E) Summary42


Summary & Comments

� Health sector improvement calls for joint efforts from State Govt, professional associations and users

� A somewhat deconstruct plan of reforms based on the 10-sector radar-diagram (though many sectors are variously interconnected).

Incremental effort on these lines can achieve free care

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� Incremental effort on these lines can achieve free care for poor and affordable health care for all with a participatory approach.

� Free care for all is not feasible technically, legally or financially. It may be a counterproductive, costly model which no Govt with current and foreseeable constraints can undertake or manage or even exit from.


Comments from an economist (1)

� Govts (in India) are working under severe financial constraints, hence raising allocations see to be difficult. But..

� Under the revised guidelines of the RBI on the priority sector lending of banks, health care has been included for raising loans at about 9% interest.

� The total CSR obligation is placed at Rs.20, 000 crore worth

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� The total CSR obligation is placed at Rs.20, 000 crore worth of funds. For Maharashtra a notional 10% of this is 2000 crores (theoretically the spend can be anywhere in India) annually.

� The state needs to raise a SPV to harness these funds & credit facility, For instance, there can be an SPV for 400 rural hospitals, or all municipal hospitals or any social sector task.


Comments from an economist (2)

� The Govt of Maharashtra can formulate a model design of the scheme with support of concerned experts to create an institutional framework to take advantage of both these provisions. Govt- corporate sector-banks-public [community] participation.

Govt. of Maharashtra must do a mapping or inventory

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� Govt. of Maharashtra must do a mapping or inventory of all the public hospitals/ dispensaries/ health care centers [govt. or municipal] and assess their land, real estates and other similar physical assets. Unutilized land or infrastructure capacity of such facilities can be leveraged under the four P model for expanding the health services.


�How to get this Marathi book

Contact details of author

Contact details, author info46

�Contact details of author

�Author information


How to get this Marathi book

� Book-CHIKITSA Arogyasevanchi (By Dr Shyam Ashtekar)

� ISBN-978-93-84475-38-3

� Available at all Granthali Prakashan outlets. Granthali PAN No -AAATG2479B,

� You can purchase online at Cost per book Rs180/ (includes posting/courier)

� Bank Name - IDBI Bank Branch- Dadar (East) Mumbai 400 014 IFSC Code -IBKL0000454 Account Name – Granthali

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Bank Name - IDBI Bank Branch- Dadar (East) Mumbai 400 014 IFSC Code -IBKL0000454 Account Name – Granthali

� Current Account No- 0454651000000356

1 Please transfer the amount in the Granthali Account by RTGS/NEFT

2..DO NOT forget to email to [email protected] about sending the said book, copies and address with phone number

3. Granthali will send the book after the confirmation of amount in about one week by courier or post

4 For help you can call Ph022 24216050/24306624 between 11.30 to 5 pm all days except Sunday/holiday. Contact person shri Mahesh or Smt Dhanashree on this number.


Author Information

� MBBS (1978), MD, Community Health (1985)

� Worked in rural health center, Municipal health dept, medical college, NGOs, Community Health networks, and as Founder Director of School of Health Sciences at YCM Open University

� Study of health systems of China, UK, Germany, USA in 1997-2000 with MacArthur Pop fellowship

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1997-2000 with MacArthur Pop fellowship

� Learning material / Marathi and English books for health workers, paramedics, National ASHA program

� Review of health systems, Nutrition programs, training programs etc

� Open info sites for primary care in Hindi bharatswasthya.net , Marathi arogyavidya.net

� Contact: 9422271544

� [email protected],

� 21 Cherry hills society, Anandwalli Nashik 422013


Chikitsa -Revamping The Health Sector of Maharashtra 2015

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