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Trust in public health facilities can be regained only by changing the culture of service: Dr. Alexander Thomas

CHENNAI:02/11/2012: Staff of the Rajiv Gandhi General Hospital pushing a van to start in Chennai,Tamilnadu on Friday. Photo: K_Pichumani | Photo Credit: K_Pichumani

Alexander Thomas, founder-member and president of the Association of Healthcare Providers of India (AHPI), founder-member and president of the Association of National Board Accredited Institutions (ANBAI), founder-member and president of the Consortium of Accredited Healthcare Organisations (CAHO) and consultant to the World Bank, has served the healthcare sector for over 30 years. He played a key role in advancing the progress in India's healthcare landscape, especially in quality and communication. He is also a member of the four-person committee set up by the Union Ministry of Health and Family Welfare to investigate ways to reduce the cost of medical training, Member of the Working Group on Public Private Partnership (PPP) for Non-Communicable Diseases in District Hospitals, NITI Aayog, Government of India; Member-Secretary, Task Force on Karnataka Public Health Policy, Karnataka Jnana Aayoga, Government of Karnataka; Board Member, National Accreditation Board for Hospitals and Healthcare Organisations (NABH).

In this wide-ranging interview to S. Rajendran, Karnataka Representative of The Hindu Centre for Politics and Public Policy, Dr. Thomas speaks at length on the distinct features of the National Health Policy, which, in his view, will benefit the common people and the country.

What constitutes a strong healthcare system? The World Health Organisation (WHO) emphasises five important factors: healthcare services, resources, financing, technologies and governance. Will the new policy help in achieving these goals?

In the context of putting together a strong health care system, the new policy seems to be a step in the right direction. In fact, each of the five areas (i.e. healthcare services, resources, financing, technologies and governance) contain concrete steps to improve these specific components. One of the most significant initiatives is the increased allocation of resources towards health (even though this would take place over a period of time).

The situation analyses done prior to the formulation of this new policy have taken into consideration these parameters and the new policy looks at ways to strengthen the same. Though the policy document is very general, any real impact will result from specific initiatives being implemented under these heads in a time-bound and efficient manner, with appropriate feedback and corrective measures in place.

Maternal and Infant Mortality Rates are important factors in healthcare. Many Indian States have high mortality rates. What needs to be done to achieve low rates—single digit mortality rates?

Maternal and infant mortality rates are indicative of the health status of a community and are affected by social, economic and political factors. Over the years there has been a significant decrease in these rates in India. From a baseline of 556 in 1901, the nation achieved a Maternal Mortality Ratio (MMR) of 167 by 2011-13. Assuming that the Annual Compound Rate of decline observed during 2007-09 and 2011-13 continues, the MMR is likely to reach the MDG-5 target of 139. (Sample Registration System, MMR Bulletin (2011-13),O/o Registrar General & Census Commissioner, GOI). Similarly, from a baseline of 126 in 1990, the nation has reached an Under-5 Mortality rate (U5MR) of 49 in 2013, and if the rate of reduction over the past decade is sustained, the achievement in 2015 will be very close to the target.

However, the rate of decline of still-births and neonatal mortality has been slow. In addition, there are inter- and intra-State variations. For instance, U5MR ranges from 73 in Assam to 12 in Kerala (Social Statistics Division, Ministry of Statistics and Programme Implementation, GoI, Millennium Development Goals India Country Report 2015, New Delhi, Pg.70). Madhya Pradesh has a wide disparity in Infant Mortality Rate, with Indore at 37 and Panna at 85.

To ensure that this progress is sustained, a multi-pronged strategy is needed. The huge shortage of human resources in the health care sector in urban and rural areas should be addressed by introducing nursing practitioners trained in different areas, introducing measures to attract and retain nurses, increasing the MS/MD/DNB seats, especially in the speciality areas of Obstetrics and Gynaecology, Paediatrics, Anaesthesia and Radiology, and use technology in reducing the burden on ASHA workers at the community level. Additionally, we should improve awareness and knowledge on nutritional supplementation and healthy diets in pregnant women and those in the reproductive age group, mandate a minimum of three ultrasounds for each pregnancy, and increase access to high quality and affordable healthcare, especially in the rural areas using technology both for training healthcare workers and for delivery of care at the grassroots.

A higher population (which is still increasing substantially) is a major cause of concern for the country—How is the progress towards replacement-level fertility rate? A lower mortality rate will obviously result in an increase in population.

The new policy will support an integrated approach with screening for the most prevalent NCDs [non-communicable diseases] followed by secondary prevention which should make a significant impact on reduction of morbidity and preventable mortality. This is to be incorporated into the comprehensive primary health care network with linkages to specialist consultations and follow-up at the primary level. Emphasis on medication and access for select chronic illness on a “round the year‟ basis would be ensured, thereby enabling better health outcomes of the interventions proposed. This will lead to a healthier and more productive population.

India has shown a consistent improvement in population stabilisation, with a decrease in decadal growth rates, both as a percentage and in absolute numbers. Eleven of the twenty large States for which recent Total Fertility Rates (TFR) are available, have achieved a TFR of at or below the replacement rate of 2.1 and three are likely to reach this level soon. (Statistical Report 2013, Registrar General of India). The challenge is now in the remaining six States: Bihar, Uttar Pradesh, Rajasthan, Madhya Pradesh, Jharkhand and Chhattisgarh. These States account for 42 per cent of India’s population and 56 per cent of the annual population increase. The National Population Policy (2000) lays out the strategic directions for population stabilisation and has been showing progress in the right direction.

Another concern in India is that of geriatric care, particularly against the backdrop of the joint family system giving way to nuclear families and with senior citizens left to fend for themselves. Can you suggest the ways and means of providing good geriatric care as available in the advanced countries?

The geriatric population in India has shown a steady increase from 7.4 per cent of the country’s population in 2001 to 8.2 per cent in 2011. This is projected to touch almost 20 per cent by 2050. This translates to huge numbers that requires mammoth plans and resources. Advances in science and medicine have added years to life, but a major portion of those years for senior citizens unfortunately seem to be weighed down by financial dependency, ill-health, disability, social exclusion and even abuse.

The needs of India’s older adults are unique and complex owing to our society’s diverse cultural and socio-economic composition. This warrants adopting a holistic approach that includes strengthening health care, facilitating economic empowerment and promoting social integration. In addition, we should pay more attention to vulnerable groups among the elderly – rural women, the widowed, the disabled, the Scheduled Castes and Scheduled Tribes (SC/ST) sections of the populace, tribals, migrants, refugees and the homeless.

In the area of healthcare the following interventions will go a long way:

(i) Strengthening political will and increasing allocation of government resources for geriatric care.

(ii) Enhancing knowledge and competencies in the area of geriatrics from grassroots to tertiary levels for healthcare providers.

(iii) Creating awareness.

(iv) Re-orienting healthcare delivery systems to provide affordable, accessible and elder-sensitive services.

(v) Fostering a public-private partnership (PPP) approach to deliver a portfolio of essential and affordable geriatric services.

(vi) Establishing sustainable financial mechanisms to address the essential medical needs of the elderly.

(vii) Developing IT innovations to operationalise elder-friendly mechanisms.

Social concerns related to senior citizens can be addressed through the following:

(i) Promoting accessibility through age-friendly systems and barrier-free environments.

(ii) Building elder-sensitive communities by fostering multi-generational social bonding.

(iii) Building systems and services for the dependent elderly.

(iv) Engaging various stakeholders for Elder Care and building synergy.

(v) Making existing social security schemes elder-friendly

Financial aspects of elderly living can be addressed through:

(i) Budgeting of financial resources for Elder Care.

(ii) Improving tax benefits and promoting affordable services for the elderly.

(iii) Enhancing pension and strengthening social security.

(iv) Restructuring health insurance to be elder-friendly.

(v) Enhancing utilisation of reverse mortgage schemes.

(vi) Raising the income and employability of the elderly.

(vii) Fostering financial preparedness of the elderly for retirement through non-formal financial education.

Ensuring that the rights of senior citizens are protected in the phase of their lives where they feel most vulnerable can be done by:

(i) Formulating elder-specific laws to safeguard the rights of the elderly.

(ii) Improving awareness and access to legal entitlements of the elderly.

(iii) Mediating in dispute resolution for the elderly.

(iv) Addressing legal considerations for elderly women.

The most effective approach would be to foster collaboration among seemingly diverse stakeholders so that the needed momentum for the care of the elderly is reached, their rights are preserved and a dignified and fulfilling life becomes theirs to claim.

It is common knowledge that in the Government healthcare sector, be it in the services provided at hospitals or dispensaries, corruption is rampant, ranging from, for instance, providing a wheelchair to conducting a surgery. What are your views on how to eradicate corruption in this vital sector.

Though the government has many well thought out rules and regulations to deal with corruption in the healthcare sector, these are not implemented in letter and spirit to address corruption. Additionally, good governance is a cornerstone to overcoming issues related to corruption in the health sector. Some of the tools that will enhance good governance are the creation of a culture of accountability and transparency, leveraging the availability of new technologies to monitor and strengthen current systems, easy access for patients to air their concerns through the establishment of local grievance cells, community-based monitoring of critical aspects of health care delivery, promoting cashless transactions and sensitisation of patients to their rights and the services they are eligible for. It is heartening to note that some government institutions have managed to deal with the problem of corruption to a large extent by utilising some/ all of the tools mentioned above thereby ensuring that affordable health care is made accessible in a timely and efficient manner.

At the macro level, the whole system surrounding the ‘making’ of doctors including the capitation fees paid by students to get admission into medical colleges, bribes paid by healthcare personnel to get deputed into specific locations or positions, the culture of commissions associated with diagnostic tests and patient referrals, to name a few, are large systemic issues, which need intervention at a higher policy-making and sectoral level. Introduction of the NEET examination is a step in the right direction.

To achieve tangible improvement it is imperative for the Government to allocate at least three percent of the Gross Domestic Product for the health sector but in reality only around one percent of the GSDP [Gross State Domestic Product] is the allocation in most States. Added to this, a sizeable part of this budgetary allocation is siphoned away in the form of various leakages. May we have your views on the same?

It would be ideal to allocate 3 per cent of the GDP to the health sector given its importance and the direct and indirect effects it has on the economy of the country. The new health policy envisages taking steps towards this direction over a period of time. However, it is more important that the funds be allocated in an optimal manner based on actual data. Key areas in the health sector need to be identified that are in line with the government health policy and the health needs of the population. Resources have to then be allocated accordingly followed by strict monitoring of the fund utilisation.

Steps should also be taken to ensure that current facilities are utilised to the maximum and efficiencies related to location, access and scale are leveraged appropriately. Good governance and tools to help enhance it as mentioned earlier would ensure that resources allocated to health are used in the manner intended and have significant impact on the ground.

The manufacture and sale and distribution of drugs is another important component of healthcare. Pharmacies in Government hospitals, both in the urban and in the rural areas, largely do not provide medicines to even the poor patients and there have also been instances of adulterated medicines distributed to patients. Can this sector be streamlined?

Most of the pharmacies in Government hospitals, both in urban and rural areas, do a good job of providing quality drugs on a regular basis to patients. While there are instances of pharmacies having adulterated drugs, frequent stock outs and exploitation of prevalent systems to serve vested interests, a lot can be done to streamline this sector. Firstly, it is important that standard operating procedures that are in place for pharmacies are implemented across the board strictly. Regular pharmaco-vigilance followed by strict action, if rules are not followed, will send an important message to all personnel working in this sector.

Current advances in science enable the use of technology for acquisition, distribution and monitoring of drugs being supplied to hospitals. If these technologies are used within a good governance model, it will greatly enable the provision of high quality services and drugs. Additionally, it is important that policy decisions taken at higher levels do not discourage the use and availability of latest technologies in the country by putting in place pricing mechanisms that make it impractical and financially unfeasible for manufacturers to recover their costs.

Implementation of new medical technologies and installation of state-of-the-art equipment is largely in the corporate sector hospitals and rarely in the Government health sector. Can there be better rapport between the Government and the corporate sector wherein the latter are mandated to provide care for the poor.

There is no doubt that the government alone cannot meet the huge demand for healthcare services of such a large country like India. In fact, even now 70-80 per cent of healthcare in India is provided by the private sector. It is hence absolutely essential that there is close collaboration between the government and corporate sector at all levels in the health care delivery system.

There have been many instances of PPP models that have worked well and are currently being implemented in many States. Lessons learnt from these models show that any model proposed has to be based on mutual respect for both parties and ensure that there is a win-win situation for all stakeholders. Studies done recently have shown that being part of government schemes presently results in a loss for most hospitals because the payments for services usually tend to be lower than the costs incurred by hospitals to provide the services, and delays in release of payments result in cash flow problems for many hospitals. Hence it is imperative that collaborations between the government and corporate sector take these factors into account to ensure that future PPP models are sustainable.

The Union Government has come out with a national health policy though health is a State subject. Given the manner in which the earlier national health policies were implemented (the one brought forth in 1984 followed by the one in 2002) will the latest policy bring about any salutary change. Implementation of a policy of the kind that has been envisaged requires a comprehensive team effort of the State and the Union Governments apart from a framework and inbuilt deadlines.

There is no doubt also that the previous health policies have had a significant positive impact on some of the key health parameters and indicators in our country. While there have been many achievements, some of the key successes which stand out are the eradication of polio, the success of the TB programme, the progress made in the fight against HIV and AIDS and significant strengthening of the health systems; all these have been possible because the centre and the States worked together to address the specific issues. In this context, the new health policy is a continuation of the same process as it builds on the foundation that has been laid by the earlier policies.

It is hoped that, given the intent expressed in this new health policy, and with better cooperation between the States and the centre, the healthcare needs of the population would be addressed more effectively. Regular national level consultations between State and the Union governments along with specific time- and deliverable-based workplans, backed by adequate resources will definitely ensure that the policy is implemented in a more effective manner.

What have the past national health policies achieved, and how do you evaluate the latest policy in terms of its ability to bring in a significant difference?

The past health policies played a significant role in strengthening various key areas that determine good healthcare delivery—healthcare services, resources, financing, technologies and governance. Though a lot still needs to be done to further improve these areas, a lot of the achievements and progress seen in various national health programmes, Millennium Development Goals and health system strengthening has happened due to the past health policies that have been in place. The latest National Family Health Survey 2015-16 (NFHS-4), is indicative of some of the progress made in the nation as a result of the past health policies and if this has to be extrapolated to when the first health policy was released it would show a huge difference in almost all parameters related to health in the country.

The new health policy proposed does seem to be a step in the right direction in continuing the work that has been happening over the last many years. It is hoped that with the allocation of more money, accountability, use of technology, preventive and promotive health emphasis, increased skilling in the health sector, governance with oversight from the Prime Minister’s Office, it could result in better implementation of proposed programmes. Since the major challenge in India has always been not the lack of a good policy document but the effective and timely implementation of health programmes at the ground level, an evaluation of the latest policy in terms of its ability to bring in a significant difference would be possible only after seeing how these policies are rolled out at the ground level.

As States are the main spenders on health, how do you see the allocations from the Central revenues for States in this sector?

Over the years every financial cycle has seen more clarity and a more systematic approach to the allocation of revenues from the centre to states for health programs. It is envisaged that while this basic model will continue, the centre would seek a more bottom-up approach where the state makes projections based on realistic needs and the Union government holds States to greater levels of accountability in terms of resources utilised and deliverables achieved vis-a-vis specific timelines. The last few years have seen resource allocation vary significantly depending on the health status of States, the strengths of the current health system, and, to a certain extent, the political relationship between the governments at the centre and state level.

Universal Health Coverage is an ideal that has been placed in the Policy. Simultaneously, there is a move to provide insurance-based health coverage. Do you think that the insurance-model will suit India?

Universal Health Coverage is an ideal which is hard to achieve. In fact only two countries, Thailand and Brazil, have achieved some form of Universal Health Coverage and they have achieved it through strategic purchasing from the private sector coupled with a larger allocation of resources to the health sector.

The insurance-model could be one of the models that could help improve the provision of healthcare in India. Given the huge variations in the health-seeking behaviour of our nation, issues related to geographical and financial access, availability of resources, for instance, it is clear that one single model that ‘fits all’ will not work in the Indian scenario. What seems more appropriate, at the moment, is that the government continues to take the lead in building a more practical health care model of its own that would have a State level and central level insurance component while at the same time leveraging the strengths of the private sector (including the not-for-profit, for profit and corporate hospitals). This will vary further depending on the type of disease treated and the level of health care provided.

How feasible would it be to implement a tax-revenue supported healthcare delivery system by the state? What are the impediments?

Since provision of better health care delivery systems naturally requires higher allocation of funds, a tax-revenue supported healthcare delivery system seems to be an attractive option on paper. Past experience with such sector targeted tax schemes of the government eg. Swacch Bharat cess have shown that it is highly unlikely that the resources generated through such a system actually end up being utilised for the specific purpose for which the taxes have been collected.

Furthermore, the current standard of health care provided in most States does not inspire any confidence in the public that the additional taxes paid would enhance the quality of health care services provided in public health facilities. Unless critical and basic challenges related to the health delivery system like good governance, addressing issues like corruption, basic strengthening of systems etc. are corrected, imposing additional taxes in the name of better healthcare delivery would not be well-received by the public.

Based on Indian and international experience, what do you think should be the role of the state in the provision of health care services to its people?

Based on both national and international experience in the health care sector, it is not advisable for the state to disassociate itself completely from the provision of an important service like healthcare. The role of the state can evolve whether it be of a provider of accessible, affordable, quality care through public hospitals wherever possible in areas that are less cost-intensive and technology-driven while continuing to play the role of regulator across the board. Strategic partnerships with insurance companies and corporate hospitals at different levels for super-speciality care could enable access to different levels of treatment for the citizens of the country at an affordable price.

The 2017 Policy talks about “reinforcing trust in the public health care system”. What are the challenges, and can this aim be achieved?

The basic reason why trust has to be reinforced in the public is because of non-delivery or delivery of low quality services to patients who have approached the public health care system. This can be due to various reasons including lack of good governance, ethics, limited resources available with the Union Government.

Trust can be regained only by changing the culture of service provided at public health facilities through good governance so that every patient visiting the facility feels welcome and is sure that they will receive high quality care with total transparency on a consistent basis. This, in turn, implies making major changes to the entire system through which health care is being provided and in a sense also calls for a significant reworking of the systems currently in place with optimal leveraging of resources and technology. It is when patients are provided ethical service with the availability of all consumables, including drugs and laboratory tests, that the perception of the general public will change and their trust will be regained.

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