INDIA'S HEALTHCARE SYSTEM
==============================
❡ India has made significant strides over the last decade ❡
India ranks poorly in health indicators like maternal & child mortality rates. Communicable disease is significant (48% share & 40% deaths). Sharp variations exist across regions (poor in E & N) and inequities within states.
—✽India’s has come a long way✽—
Yet, key indicators are showing marked improvement over the last decade. Life expectancy has increased by almost four years, from 64.4 years in 2005 to 68.3 years in 2015. Infant mortality has declined from 57 deaths per 1,000 births to 37 currently. Utilization of health infrastructure has accelerated—for example, institutional births rose to 79% from 41% in 2005. Notably, India was declared polio-free in 2014, and tetanus-free in 2015.
—✽Primary healthcare in not functioning as it should✽—
Primary health care is mostly supplied by the unorganized sector. Public funds are insufficient to provide good support beyond its focus on maternal and child health. Formal sector is designed for the urban well-off who may have health insurance— but is otherwise focused on secondary and tertiary care.
Thus, ordinary people are unaware of their health and present with severe forms of the disease. They are completely dependent on doctor or surgeon who sees them for the first time. Large amounts of out-of-pocket monies are spent on dealing with sickness with variable outcomes, rather than looking after the disease at early stages or using simple preventative measures.
—✽Specialist care is grossly inadequate✽—
Public health spending of 1.5% of GDP (or PPP $267 per capita) is clearly insufficient to provide required numbers, which leads to acute shortage of secondary and tertiary hospitals, specialists and specialized equipment and consumables like oxygen and syringes. Referral from preventive health to primary care to secondary and tertiary care is inadequate. Lack of primary health centres in many rural area means that referral chain is broken at the outset.
Regulatory framework is poorly designed leading to restrictive practices (eg inadequate post-graduate seats; restrictions on treating even common diseases and routine procedures). Bribe taking is also common.
—✽Public health system delivers poor outcomes✽—
It can be blamed on low public health spending, poor governance and lack of outcomes orientated approach. Besides correction is needed for low doctor-patient ratio (0.57/1000 vs 1.2/1000 in Asia), scarce yet poorly maintained public infra and equipment, over-reliance on expensive private sector, inadequate insurance cover and low scale of innovation in terms of new tech and operating models.
—✽Actions and proposals✽—
Govt is increasing health footprint (more teaching hospitals), extending primary care, funding essential drugs and paying for many categories of patients. NEET and a new medical commission will address acute shortage of medical professionals. Price control over drugs and equipment has improved affordability. But if taken further (like cardiac stents, or in medical procedures) it will reduce choice and encourage cheats and illegal methods to get around the controls.
Govt has promised to raise public health spending to 2.5% GDP by 2025, which is low compared to China which spent 3.1% in 2014. India spent just 1.4% in 2014, though on a rising trend. However payment structure to support specialist care is missing. A system must be evolved to reimburse out-of-pocket expenses, public funded health scheme for the poor and mandatory insurance for well-off (with some tax-relief). This will meet the needs of informal sector and those who may have to travel to far away locations.
—✽Govt intends to co-opt private sector for health✽—
Govt intends to co-opt private medical facilities to amplify the public sector with quality, access and choice. It is looking for sound long-term proposition that extracts excellent value without hurting the industry. It has the following levers:
1. Lower costs through price control on drugs and devices, and through promotion of local production, R&D, FDI.
2. Govt can leverage treatment by the private sector on acceptable terms in lieu of the preferential treatment given in terms taxes, land, regulations, facilitation of health tourism.
3. Capacity to strike big deals on long-term basis
4. Much higher public spending or tax reliefs, coupled with funds portability, will increase purchasing power of poor & middle class
5. Lower prices generally (due to economy of scales) will lead to much higher revenues for the private health sector (high price-elasticity due to unmet demand of middle class).
Mylink:
https://plus.google.com/u/0/100789863972538583352/posts/RG9rbGmB1J5
SUSTAINABLE HEALTH SYSTEM FOR INDIA
========================
—✽Taking encouragement from others✽—
Thailand, Brazil and South Korea are good example of how to transform the status quo. Health system can be designed on own principles and tweaked for differing social, economic and cultural environments. Feedback from providers (risk profiles, costs and outcomes) will sharpen the focus towards well-being— that continuing good health will be seen as a worthwhile endeavour.
—✽Essential components of a new health system✽—
Countries with high performing health systems have 3 essential aspects:
1. Prepayment and pooling
2. Big buyer groups and organized providers
3. Govt is an active participator in shaping the system
Prepayment can be done by high taxation (UK) or mandatory health insurance (Germany, Japan). Very large pools are created to absorb high variability of health expenditure. Pools are managed by large agencies —be it public trusts or big insurance companies—which then buy care from integrated providers. Provider can be a public or private accredited facility which competes for contracts. Contracts may stipulate high quality, innovative treatments, suite of equipment for various procedures, level of coverage be it primary care or outpatients. Payments can be based on mix of capitation, services provided and outcomes. Lastly govt has a role of designing or supervising the system rather than managing health systems and delivering services.
—✽Low cost models✽—
As against a bloated behemoth, tailored approach to health delivery is more efficient. It features widest access, sparing use of resources, low cost operations, preventative measures, good governance, community effort and financial viability:
◘ Preventative care, via regular check-ups, mass outreach
◘ Tele-medicine, simplified medical tasks or operations
◘ Shared capital infra through hub-spoke or mobile vans
◘ Community self-help groups, volunteers, NGOs
◘ Good governance, outcomes monitoring, 3rd party surveys
◘ Use private sector facilities via state insurance scheme
◘ Non-branded generic drugs, consumables & devices
◘ E-procurement via G e-marketplace, digitisation
◘ Global agencies for cheap finance and expertise
◘ Child nutrition, maternity support & fertility control
◘ Good A& E, digital referrals, health & safety at work
◘ Public health measures, via vector control, vaccination, action against adulterated &unhygienic foods, sanitation
Ecosystem model does leapfrogging, sustainable change in one aspect of health. It does root cause analysis and performs a health mission, looking at all aspects incl people participation and effective monitoring. Examples: ODF mission, vaccination, mother + child nutrition
Private sector model propagates innovative or technological solutions which are good quality, low cost and frugal on capital and local expertise. These can be integrated and scaled up. Example: mobile medical vans, simplified medical tasks or operations.
more see v. detailed write-up below
==============================
❡ India has made significant strides over the last decade ❡
India ranks poorly in health indicators like maternal & child mortality rates. Communicable disease is significant (48% share & 40% deaths). Sharp variations exist across regions (poor in E & N) and inequities within states.
—✽India’s has come a long way✽—
Yet, key indicators are showing marked improvement over the last decade. Life expectancy has increased by almost four years, from 64.4 years in 2005 to 68.3 years in 2015. Infant mortality has declined from 57 deaths per 1,000 births to 37 currently. Utilization of health infrastructure has accelerated—for example, institutional births rose to 79% from 41% in 2005. Notably, India was declared polio-free in 2014, and tetanus-free in 2015.
—✽Primary healthcare in not functioning as it should✽—
Primary health care is mostly supplied by the unorganized sector. Public funds are insufficient to provide good support beyond its focus on maternal and child health. Formal sector is designed for the urban well-off who may have health insurance— but is otherwise focused on secondary and tertiary care.
Thus, ordinary people are unaware of their health and present with severe forms of the disease. They are completely dependent on doctor or surgeon who sees them for the first time. Large amounts of out-of-pocket monies are spent on dealing with sickness with variable outcomes, rather than looking after the disease at early stages or using simple preventative measures.
—✽Specialist care is grossly inadequate✽—
Public health spending of 1.5% of GDP (or PPP $267 per capita) is clearly insufficient to provide required numbers, which leads to acute shortage of secondary and tertiary hospitals, specialists and specialized equipment and consumables like oxygen and syringes. Referral from preventive health to primary care to secondary and tertiary care is inadequate. Lack of primary health centres in many rural area means that referral chain is broken at the outset.
Regulatory framework is poorly designed leading to restrictive practices (eg inadequate post-graduate seats; restrictions on treating even common diseases and routine procedures). Bribe taking is also common.
—✽Public health system delivers poor outcomes✽—
It can be blamed on low public health spending, poor governance and lack of outcomes orientated approach. Besides correction is needed for low doctor-patient ratio (0.57/1000 vs 1.2/1000 in Asia), scarce yet poorly maintained public infra and equipment, over-reliance on expensive private sector, inadequate insurance cover and low scale of innovation in terms of new tech and operating models.
—✽Actions and proposals✽—
Govt is increasing health footprint (more teaching hospitals), extending primary care, funding essential drugs and paying for many categories of patients. NEET and a new medical commission will address acute shortage of medical professionals. Price control over drugs and equipment has improved affordability. But if taken further (like cardiac stents, or in medical procedures) it will reduce choice and encourage cheats and illegal methods to get around the controls.
Govt has promised to raise public health spending to 2.5% GDP by 2025, which is low compared to China which spent 3.1% in 2014. India spent just 1.4% in 2014, though on a rising trend. However payment structure to support specialist care is missing. A system must be evolved to reimburse out-of-pocket expenses, public funded health scheme for the poor and mandatory insurance for well-off (with some tax-relief). This will meet the needs of informal sector and those who may have to travel to far away locations.
—✽Govt intends to co-opt private sector for health✽—
Govt intends to co-opt private medical facilities to amplify the public sector with quality, access and choice. It is looking for sound long-term proposition that extracts excellent value without hurting the industry. It has the following levers:
1. Lower costs through price control on drugs and devices, and through promotion of local production, R&D, FDI.
2. Govt can leverage treatment by the private sector on acceptable terms in lieu of the preferential treatment given in terms taxes, land, regulations, facilitation of health tourism.
3. Capacity to strike big deals on long-term basis
4. Much higher public spending or tax reliefs, coupled with funds portability, will increase purchasing power of poor & middle class
5. Lower prices generally (due to economy of scales) will lead to much higher revenues for the private health sector (high price-elasticity due to unmet demand of middle class).
Mylink:
https://plus.google.com/u/0/100789863972538583352/posts/RG9rbGmB1J5
SUSTAINABLE HEALTH SYSTEM FOR INDIA
========================
—✽Taking encouragement from others✽—
Thailand, Brazil and South Korea are good example of how to transform the status quo. Health system can be designed on own principles and tweaked for differing social, economic and cultural environments. Feedback from providers (risk profiles, costs and outcomes) will sharpen the focus towards well-being— that continuing good health will be seen as a worthwhile endeavour.
—✽Essential components of a new health system✽—
Countries with high performing health systems have 3 essential aspects:
1. Prepayment and pooling
2. Big buyer groups and organized providers
3. Govt is an active participator in shaping the system
Prepayment can be done by high taxation (UK) or mandatory health insurance (Germany, Japan). Very large pools are created to absorb high variability of health expenditure. Pools are managed by large agencies —be it public trusts or big insurance companies—which then buy care from integrated providers. Provider can be a public or private accredited facility which competes for contracts. Contracts may stipulate high quality, innovative treatments, suite of equipment for various procedures, level of coverage be it primary care or outpatients. Payments can be based on mix of capitation, services provided and outcomes. Lastly govt has a role of designing or supervising the system rather than managing health systems and delivering services.
—✽Low cost models✽—
As against a bloated behemoth, tailored approach to health delivery is more efficient. It features widest access, sparing use of resources, low cost operations, preventative measures, good governance, community effort and financial viability:
◘ Preventative care, via regular check-ups, mass outreach
◘ Tele-medicine, simplified medical tasks or operations
◘ Shared capital infra through hub-spoke or mobile vans
◘ Community self-help groups, volunteers, NGOs
◘ Good governance, outcomes monitoring, 3rd party surveys
◘ Use private sector facilities via state insurance scheme
◘ Non-branded generic drugs, consumables & devices
◘ E-procurement via G e-marketplace, digitisation
◘ Global agencies for cheap finance and expertise
◘ Child nutrition, maternity support & fertility control
◘ Good A& E, digital referrals, health & safety at work
◘ Public health measures, via vector control, vaccination, action against adulterated &unhygienic foods, sanitation
Ecosystem model does leapfrogging, sustainable change in one aspect of health. It does root cause analysis and performs a health mission, looking at all aspects incl people participation and effective monitoring. Examples: ODF mission, vaccination, mother + child nutrition
Private sector model propagates innovative or technological solutions which are good quality, low cost and frugal on capital and local expertise. These can be integrated and scaled up. Example: mobile medical vans, simplified medical tasks or operations.
more see v. detailed write-up below
3
1
- India's health system suffers from all the ills, namely quantity, quality, footprint, access and affordability.
REPLY Oct 2, 2017 - "There is a political drive to this initiative too. Providing healthcare assurance to all and reducing out-of-pocket spending was one of the main points in the ruling party’s election manifesto in 2014. It will need something to show as action taken in 2019. That the government intends to co-opt the private sector for healthcare services is very clear".
REPLY Oct 4, 2017 - New ways of delivering affordable healthcare
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A tailored approach is needed to transform India’s healthcare system, and key stakeholders must work in tandem towards realizing a common goal. This will ensure the most effective use of India’s scarce resources to the benefit of its people.
▬ Private sector will deliver healthcare. They devise solutions that are tailored, low cost and incorporate innovations. Parties incl hospitals, pharmaceutical and medical tech firms, and NGOs
▬ Govt provides platforms to enable scaling up, leapfrogging. If not govt, global agencies can provide financing and access to expertise on their networks
Key criteria-----------------
○ Access to all - community visits
○ Tailored low cost solutions
○ Fully exploit existing infra
○ Frugal with new infra and capital costs
○ Access expertise and finance at lowest cost
○ Sustainable healthcare via preventative care
Ecosystem model
It needs related reforms and good governance. People have to be flexible and amenable to change. Change agents have to coordinate a large and diverse community of stakeholders around a shared goal.
Eg. Swachh Bharat Abhiyan is a govt scheme with a finite timescale. Govt ensures no corruption, co-ordination, finance and monitoring outcomes. Self-help groups help to transition people towards change of behaviour.
Eg. State sponsored insurance scheme to increase access to variety of provisions.
Eg. Govt can promote preventative care through outreach (media and volunteer), mobile checkups and low cost medication
Eg. Female community health volunteers (ASHAs - ie. accredited) fulfil govt scheme to support mothers in rural areas.
Private sector model
Propagate innovate solutions which usually come from private sector or NGOs. These should be cheap, good quality, bring forth efficiency and have low capital costs.
Eg. HealthCare Global Enterprises Ltd has a hub-and-spoke model where expensive equipment is shared in the hubs.
Eg. Complex operations (or medical tasks) are broken down to well defined protocols than can be done relatively error free, at low cost. Use affordable medical devices.
Detailed
India needs a different, innovative system-------------------------------------------------------
A behemoth of developed countries is probably too expensive for India. Bite size changes will be faster and better designed for low cost, sustainability and accountability. Public sector has financial and political constraints and so needs to combine with private sector. But traditional public-private co-opt fails due to high recurring costs and lack of innovation.
Aims of new innovative system:
▬ Avoid expensive infra, equipment ("white elephants")
▬ Avoid high fixed costs (upkeep of surplus buildings)
▬ Incorporate new technology, efficient operations to reduce operating costs
▬ Avoid short-term financial payback. Use innovative finance
▬ Strong accountability, monitoring and course correction mechanisms.
Ecosystem model--------------------------
A measurable target is chosen and multiple stakeholders brainstorm and find a sustainable and viable way to meet it.
It helps that a root cause analysis is done (data based), is holistic (multi-disciplinary teams), sustainable (low cost tech solutions) and viable (innovative finance).
Example
○ Mission -- global vaccination
○ Strategies -- multiple aspects considered (eg. supply chain, technology, workforce, finance, data management and transport)
○ Action plan -- who, how and costs (eg. strategy aspects linked to partners be it public, private, trade, foreign)
○ Finance -- identify beneficiaries, income streams, innovative sources
○ Monitoring -- data based tracking, adjudicating on outcomes and course correction.
Innovation themes---------------------------
It's called leapfrogging because new tech, operating models or changing behaviour work in ways not imagined earlier. Leapfrogging can be applied to all 7 dimensions of health systems as specified by WHO.
○ Technology : new health related activity or product
○ Operating model : new organisational setup or delivery method
○ Behavioural change : altering set patterns of thinking
Leapfrogging and scaling---------------------------------------
Though Indian system has many leapfrogging initiatives, scaling is missing. Scaling can be considered a separate initiative— as it is the most difficult step due to govt/ finance/ staff/ patient opposition.
6 key lessons from other's leapfrogging:
◘ 1. Anchor innovation in fundamental human behaviour: A leapfrog’s defining characteristic should appeal to a universal human trait. This makes any required behavioural change, and the leapfrog adoption, easier. For example, social experiments by the Abdul Latif Jameel Poverty Action Lab aim to change behaviours related to immunization in Haryana considering a fundamental human trait—a mother’s desire to act in favour of her child. A bouquet of initiatives is facilitating change, including non-financial incentives for completing immunizations, tailored reminders on immunization schedules and getting village networks to spread the word.
◘ 2. Adapt to survive, diversify to thrive: Tailor operating models to local communities. Customize products and services as needed to increase adoption. Arvind Eye Care diversified into manufacturing intraocular lenses with a view to supplying global markets through its Aurolabs subsidiary, capturing 8% of the global market share of intraocular lenses.
◘ 3. Empower communities to shape and own the model: Encourage community ownership of the model, instead of adopting a “top-down” approach. This will result in a much higher impact, due to greater involvement of emotionally connected community participants. VisionSpring trains “Vision Entrepreneurs” from the communities that it serves to operate a micro franchise, travelling from village to village and conducting vision camps, checking eyesight and selling glasses.
◘ 4. Build partnerships: Actively seek partnerships, even outside the healthcare industry and leverage relevant innovations. For example, MicroEnsure (a micro insurance provider) and Bharti Airtel Ltd have partnered in nearly eight African countries to launch a health incentive plan. Airtel subscribers are entitled to health insurance coverage, provided they spend a minimum amount of airtime. Insurance coverage is directly correlated to the amount a consumer spends on airtime. Airtel pays for insurance premiums offset by the increased utilization of its services. For around 86% of Airtel/MicroEnsure consumers, this scheme was the first time they had insurance of any kind.
◘ 5. Ensure “design-to-scale”: Actively engage with the government to design solutions that target the gap in public healthcare and can scale up effectively within the constraints of the public healthcare system. Operation ASHA utilizes the community to bridge the gap between the disadvantaged and government infrastructure in six Indian states and Cambodia. The organization partners with India’s government-run National Tuberculosis Control Programme that provides free treatment and diagnostics, and leverages technology and community health workers to ensure compliance with the TB treatment regimen.
◘ 6. Objectively evaluate progress, and course-correct: Set the foundation for rigorous data collection and evaluation during the development stage itself. Robust tracking of key metrics will help engage the concerned stakeholders, and influence changes to care delivery.
REPLY Jan 24, 2018
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