Mental Healthcare Act 2010 - Needs Revisions

Registered Speed Post / E-Mail

Dated: March 24th 2011

Shri. Ghulam Nabi Azad

Hon’ble Health Minister

Government of India

Nirman Bhavan,

New Delhi -110108



Reference: Revision of Mental Health Act 1987 & Mental Health Care Act 2010 ( draft )

Dear Shri Azad ji,

This needs your esteem, kind and personal attention.

I am writing this note on behalf of the Disease Management Association of India – ( DMAI)- The Population Health Improvement Alliance . DMAI works with all the stake holders in the entire continuum of care, for improving the population health of the nation . Over the last few years, we have worked with different stake holders to help define the right priorities in healthcare for the policy makers & the care providers .

Through this note , I am drawing your attention to the revision of the mental health act of 1987 and the proposed Mental Health Care act 2010 (Draft). The process of revision of the Mental Health Act 1987 was initiated about a year back, to make it compliant to the United Nations Convention on the ‘Rights of Persons with Disability’. Disability includes persons with long term mental illness. This convention advocates equal rights for all disabled persons.

Dr Saumitra Pathare ( a private psychiatrist) and Dr. Jaya Sagade (a lawyer) of Pune were in charge of conducting the regional consultations on behalf of the Ministry. Over the last one year, there have been 5 regional consultations with various stakeholders. The major stakeholders consulted have been users, care providers, professional bodies in mental health, mental health institutions and state government representatives. However, it is to be noted that, the Medical Council of India, other specialties of modern medicine, and professional organizations of general health field, have not been consulted. This is important, as the changes which are evident in the draft bill have far reaching consequences in terms of the way the modern medicine is taught and practiced currently.

DMAI- The Population Health Improvement Alliance, is surprised with the outcome of the consultations , and that there was hardly any discussion on the final outcome to patients due to the significant changes which are being brought in terms of the 'mental health’ field of practice of medicine by way of promulgating this act. Proposed changes are likely to cost human lives , as persons who have not been trained to be physician (Clinical Psychologist, Psychiatric Social Worker, Psychiatric Nurse), will be entrusted with the role of independent examination, diagnosis and admission of patients in mental health facilities. Currently, this role rests with a Psychiatrist who is a medical doctor (MBBS) trained in Psychological Medicine. In modern system of medicine ,only a physician (M.B.B.S )can diagnose a patient, as only he has received training in all the specialties such as Medicine, Surgery, Eye, ENT, Obstetrics & Gynecology, Pediatrics, Orthopedics, Radiology, Dentistry, Dermatology, Anesthesiology, Pharmacology, Preventive and Social Medicine, Pathology, Microbiology, Physiology, Biochemistry, Anatomy etc. , which essentially means, covering all the systems of the body. Unfortunately, Human body cannot be compartmentalized and however we may wish, but we cannot have an Eye specialist who has studied only ‘Eye’ and not done MBBS ( as a basic general qualification and set of skills covering the entire human body system) to examine each and every system of human body. Similarly, we cannot have a Psychologist who has no training of the subjects studied at MBBS level, to diagnose mental disorders by only doing psychological examination!!!!

Only an MBBS trained doctor with the proper understanding of the entire human body system and its functioning, can do a detailed psychological evaluation and come to a diagnosis of whether the patient has a psychological illness or it is some physical illness, which is presenting itself as a psychological illness. In cases of latter, appropriate referral is required and any delay may even be fatal. S/he can also order various tests and imaging and interpret them for aiding in his diagnosis. After a diagnosis is arrived at, s/he can plan and provide physical treatment (ECT), pharmacological treatment or psychological treatment. The role of psychiatric nurse, clinical psychologist or a psychiatric social worker is to assist him by nursing the patient, helping him in psychological interventions, helping him in psycho-social interventions respectively. But the patient is under the overall care of a psychiatrist who is the leader of the mental health team. All the three categories of personnel work under the supervision of a psychiatrist .

A clinical psychologist, PSW ( Psychiatric Social Worker ) or a psychiatric nurse is not trained to be a physician. They have not studied the human body as an MBBS doctor and cannot do detailed physical or systemic examination, investigations and imaging like a psychiatrist. They are in no position to independently examine, diagnose and advise admission of patient. A PSW and Clinical psychologist have not general training in other subjects of modern medicine. Just by talking to patient, how can a Clinical Psychologist or PSW diagnose a mental disorder? They will be severely restricted by their inability to do general and systemic examination and order and interpret investigations and imaging. A Psychiatry examinee will fail in his examination if he did not touch the patient for examination ; however bright drug treatment he may formulate for the patient ; as without a general and systemic examination, a person cannot make a diagnosis of mental disorder. In many cases special investigations and imaging also has to be ordered and interpreted. As per the diagnostic criteria for mental illness, a mental disorder can only be diagnosed after ruling out that the signs and symptoms are not better accounted for by a medical illness or use/abuse of a substance. In this scenario, without proper validation of the reason for the particular condition , what is the validity of diagnosis of mental disorder by a Clinical Psychologist, PSW or a Nurse ? Even the quacks believe that they can diagnose and treat independently. Each such claim needs to be examined objectively in line of their competence and current practice related to their vocation.

In modern system of medicine, which is regulated by MCI, there is no specialization known as Clinical Psychology, PSW or Psychiatric Nursing. The mandate of ‘Rehabilitation Council’ is limited to rehabilitation of persons with disability and practice of modern medicine under Rehabilitation Council is neither required nor allowed. If at all, new independent specialties such as Clinical Psychology, PSW and Mental Health Nursing without any supervisory role of a Psychiatrist is being planned for modern medicine system, then the whole modern medical system (MCI, Indian Medical Association, Other Medical Specialties) must be consulted .

If we go as per the draft, it means that Clinical Psychology, PSW and Mental Health Nursing personnel are as much a specialist as a psychiatrist and can independently examine , diagnose, admit and treat patients with mental disorders.

It is not understandable why a psychiatrist has to do MBBS (study the whole human body) and then specialize in Psychiatry while for the other persons they need to study only psychology or social work and yet be assumed to be qualified to examine the whole body, diagnose, admit and treat patients (albeit without medicines) . The demand to prescribe medicines by non psychiatrist is also going around (and may be later on this will be also be made possible.) There is no institution in the country where a Clinical Psychologist, PSW, Mental Health Nurse examines patients independently, diagnoses a mental disorders, admits patients and treats them. This amounts to practice of Psychiatry under the modern system of medicine and would invite penal provisions of MCI. The sole aim of drafters is to get the bill through and take credit for drafting the bill rather than have a healthy development of the sector. Nowhere in the country there is a Clinical Psychology ward, PSW ward or Psychiatric Nursing ward. The decision to admit is taken by the leader of the mental health team who is a Psychiatrist and it is the Psychiatrist who is overall responsible for treatment of a patient with mental disorder.

One of the reasons given by the people behind the draft of the Mental Healthcare Act 2010, for giving the role of independent examination, diagnosis and admission in bill, is the shortage of psychiatrist in the country. But if we go by the definition of psychiatrist in the bill which is the same as that in the previous Act, ‘an MBBS qualified person with experience and training in Psychiatry can be designated a psychiatrist’ for the purpose of the Act.

At present , there are about 8 lac medical practitioners in the country and these can potentially be designated as psychiatrist. So where is the shortage for the purpose of the Act ? The only purpose which could be served by giving an independent examination, diagnosis and admission to Clinical Psychologist, PSW, Mental Health Nurse in the bill is to later on claim that if they are capable of doing these jobs, then this means that they can practice their trades independently under the modern system of Medicine. This would mean they will be physicians of mental disorders just like a psychiatrist.

The inclusion of Clinical Psychologist, PSW, Mental Health Nurse for purpose of independent assessment, diagnosis, admission to a mental health facility should be deleted and replaced by ‘psychiatrist’ (an MBBS qualified doctor with some training/experience in psychiatry). After this, there will not be a need for defining mental health professional in the Act. If at all it has to be defined, then Clinical Psychologist and PSW shall be designated as Assistant Mental Health Professional as in the present legislation (Section 22 of State Mental Health Rule 1990) and their role clearly specified as being- to assist a psychiatrist.

Further, the supervision and review of the decision of a psychiatrist by a Clinical Psychologist, PSW, Mental Health Nurse in the mental health review commission is not feasible as review is to be done by practitioner of the same specialty i.e. Psychiatrist. Thus, the provision of Psychiatrist in the review commission should be made mandatory.

In a multidisciplinary team such as a mental health team, each team member has a specific role. If everyone will do the same role, which is to independently examine, diagnose and admit, then there could be no team functioning. Rather the role of each mental health person should be clarified in the Guidelines /Rules clearly, so that there is good team functioning and the public is well informed and is not misguided by manipulative persons. Can we imagine a similar provision for a Nurse specializing in Medical, Surgical, OBG, Cardio-thoracic nursing to independently examine, diagnose and admit patients in Medical, Surgical or OBG, Cardio-Thoracic ward respectively? Then why should we consider similar provision for Clinical Psychologist posted with Neurology department?

Psychiatry is a medical discipline as any other discipline. If Clinical Psychologist, PSW and Psychiatric Nurse want to independently examine , diagnose, admit and treat patients without even having the training and skills for the same and government wants to allow the same, then they should be allowed to start their own wards to do so and be responsible for their decisions. If we allow such changes to be brought, this would mean that a Psychiatrist too does not need to do MBBS. Then all the specialties of modern medicine should have direct specialization rather than first spend 5.5 years to be a General doctor. Human body cannot be divided in a compartments. All organs and systems are interrelated. A stroke can present itself as a depression in a mental health facility. What skill a psychologist or a PSW has to diagnose it without doing a full neurological examination or relevant investigations. They will treat for depression while the patient will die. In my view , compartmentalised knowledge is dangerous for the medical profession and defeats the basis of evidence based medicine

We are trying to make Clinical Psychologist, PSW and Mental Health Nurse into Physicians in mental health by giving the role of a Physician to them under the new draft bill on the pretext of shortage of Psychiatrist. However, there are less than a 1000 Clinical Psychologist and PSW both combined in the country. Further, there is no dearth of Psychiatrist under Mental Health Act, as Govt. can very well designate MBBS doctors with some experience in Psychiatry as Psychiatrist (as per the definition and provision in current legislation and the draft Bill). So even the assumptions for the shortage of psychiatrists is not a right justification for this act

The role given to Clinical Psychologist, PSW and Psychiatric Nurse in the draft bill is ; independent examination of patients, diagnosis , admission and then review of decisions taken by a Psychiatrist. Instead of this, in the draft bill, the role of a Clinical Psychologist and PSW- as a rehabilitation professional , and Psychiatric nurse - as a specialized nurse, should have been clarified and focused.

The position of a Psychiatrist as a mental health team leader should be reiterated and the decision of a psychiatrist should only be reviewed by a board having a psychiatrist. These rules could further be clarified In the draft bill psychiatric social worker and clinical psychologist has been mentioned as mental health professional just like a psychiatrist. However, In section 22 of the State Mental Health Rules’1990 (the existing legislation) the PSW and Clinical Psychologist are referred to as Assistant mental health professional. The change in the draft bill under consideration has been done with a view to make their role fit for independent examination, diagnosis, admission to a mental health facility by the drafters, without any regard to the impact of this on the patient care and safety. If they are full-fledged professionals (as they claim) who can diagnose, admit and treat patients, why do they need to be defined as such in the Act. At no place in the draft bill their role has been mentioned separately. At all places they are bunched as mental health professional with no individual roles. At no place it is mentioned that they will function under the supervision of a psychiatrist. If they independently examine, diagnose and admit patients they are then deemed to have an independent role. This will increase the role conflict which is already very high in the mental health team. So much so that at some places there is no team work. In Kerala High Court, there is a case going on, to allow clinical psychologist to independently practice in community to treat patients of mental disorders.

This is a serious issue and needs to be taken up strongly so that untrained people are not given the role of a physician i.e. to practice independently to treat patients.

DMAI insists that the Medical Council of India, Indian Medical Association & patient groups & DMAI needs to be taken in confidence and consulted, as independent examination, diagnosis and admission and also treatment by psychological or psycho-social means is practice of psychiatry under modern medicine and could not be allowed to be done by persons who do not even have a MBBS degree, in view of patient safety and care.

All health personnel shall work within the limits of their competence. In section 43 and 45 of the draft bill related to admission in a mental health facility: a mental health professional (i.e. Clinical Psychologist, PSW, Psychiatric nurse) has a role to examine a person suspected to be mentally ill independently, assess mental illness and its severity and advise admission. This is a role which goes beyond their competence. There are already instances of Clinical Psychologist practicing treatment of mental disorders independently as isolated examples. There is growing demand from clinical psychologist to allow them to practice independently the treatment of mental disorders. This change in the draft bill will allow them to be recognized as persons who can independently examine, diagnose, and admit patients, which will substantiate their claim to practice independently in community rather than under the supervision of a psychiatrist. It’s altogether different matter that they are not trained to examine and diagnose mental disorders as it requires ruling out other physical disorders as well and it requires a person to be a physician to do that. In section 22 of the draft bill : Constitution of district panels of mental health review commission , two members could be mental health professionals (i.e. Clinical Psychologist, PSW, Psychiatric nurse) which may not include a psychiatrist if he is not available, but then how the commission can judge the decision of a psychiatrist if no psychiatrist is in the commission? One needs to have knowledge of psychiatry to assess the correctness of the decision of a psychiatrist in a particular case. Provision of a psychiatrist in the review commission should be mandatory rather than being replaced by non-psychiatrist personnel Mental disorders are medical disorders and should not be treated by non-medicos .

I am quite sure that you will intervene and ensure that the corrective measures are taken to address the lacunae in the bill Also,

DMAI- The Population Health Improvement Alliance has initiated a ‘NCD Policy of India’ initiative, and would be glad to have the views of the ‘Ministry of Health’ involvement on the initiative

I am quite convinced that committed leadership will take cognizance of this note and take measures to implement the suggestions after a debate with all the stake holders in the continuum of care.

Should you need any assistance at my end, do let me know.

With best regards

Rajendra Pratap Gupta

CC. Dr.Manmohan Singh, Sonia Gandhi ,Rahul Gandhi , Dr.Syeda Hameed, Dr.Murli Mahohar Joshi , Montek Singh Ahluwalia ,Shri Dinesh Trivedi , Sitaram Yechury, Members of Parliament , Sam Pitroda , Secy-Health & Family Welfare , GOI, Dr.K.Srinath Reddy, Debasish Panda , Secretary (ME) Governors , MCI DGHS,MOHFW, Dr.Sudhir Gupta , CMO, NCD-MOHFW ,Dr. Suman Sinha, Psychiatrist, IMA , Chief Minister’s of States

Re-structuring Healthcare in India - 12th Five Year plan - NRHM , ICDS & Malnutrition

January 31, 2011.

Dr.Syeda Hameed

Member

Planning Commission

Government of India

Yojna Bhawan,

Sansad Marg, New Delhi- 110001



Reference: Inputs on the 12th Five year plan W.R.T. (1) Eradicating under-nutrition and malnutrition in India through restructuring of ICDS or other means and (2) Suggestions for improvement in the present structure of NRHM.



Dear Dr. Hameed,



I am sure that this finds you doing well. This has reference to the mail from your office on 5th January 2011, requesting me to provide inputs on the 12th five year plan w.r.t.(1) Eradicating under-nutrition and malnutrition in India through restructuring of ICDS or other means and (2) Suggestions for improvement in the present structure of NRHM.



At the outset, let me put my deep appreciation for the NRHM (National Rural Health Mission) and its positive impact on the healthcare of the rural population. I had a chance to visit many rural pockets over the past few years, and my inputs are based on the reality as seen by a commoner, and I do hope it is insightful along with being helpful.



Policy Changes:



To me, there appears to be no single prescription for addressing the diverse healthcare needs of this country, which is as big as a continent, but NRHM has made its presence felt even in the remote parts of the country. Seeing that the NRHM was launched only in April 2005, and would be around till 2012, with a possible extension for another five years , one of the key policy action items that might be worth considering to create a pro-active Rural healthcare system in another six years ( assuming that the NRHM is discontinued in its current form by 2017 ), is to be able to sensitize the population on the adoption of basic standards of personal hygiene , nutrition & lifestyle necessary for fitness ( wellness) that makes our population less dependent on hospital care . This should be one of the key goals of the NRHM for the 12th Five year plan .The current NRHM has put the onus & financial burden on the centre, as the centre and state partnership in terms of the financial outlay is 85: 15 . Second important consideration , this also must get a key policy shift for the 12th five year plan which should have one more stakeholder i.e. center : state : Beneficiary .





Funding for NRHM:



We need to see a financial participation from the beneficiaries of the NRHM, as they would have got used to the services offered via NRHM centers ( ASHA , ANM, Sub Centers , PHC , CHC & District hospitals ) , and the value of offering would have increased through NRHM centers. In addition to this, per capita income will also go up in the next five years if the country continues to grow at the current pace. So we must consider if we can increase the fees for basic services towards the 10th year of NRHM; even a token increase by one rupee can deliver a quantum leap. Besides, we must keep reducing the financial incentives gradually every year to phase it out eventually. Still, the people would enjoy the safe healthcare services which are subsidized or offered at a very low cost. Villagers are getting used to these services , and I am sure that in the 10th year of NRHM , it might be a right time to bring down some of the subsidies and incentives , as the trust would have built up considerably .



NRHM should welcome ‘tax free’ donations from individuals and corporates: This should be publicized and could become a good way to raise funds in a step towards building a financially sustainable healthcare model for rural India



With a gradual reversal in the expense funding between center and the state, the expense part needs a micro planning as, though the hard infrastructure expenses might not be as high as it is now (since we are constructing sub centers & upgrading some existing centers ), but the maintenance of the infrastructure built will become a huge financial burden, and knowing that the divestment & auctions are not routine incomes for the government, this would lead to a huge deficit in the budgets over the next six years if financial planning of NRHM is not planned and managed well.



Also, one of the key considerations for the policy makers is to look at converting NRHM into NHM ( National Health Mission ) , as the conditions remain deplorable for urban poor , and the private facilities are not going beyond tier 1 & 2 towns .



Structural changes:



It would be worth considering replacing the hierarchical designations to functional designations to have a clearly defined role and an outcome driven responsibility



Mission Steering Group (at the Centre) could consist of the following :



Director for Planning & Forecasting,

Director for Strategy

Director for Analysis & Research (One who looks into the regular reporting & review)

Director – Innovation & Program improvisation (Program will certainly improvise with regular feedback & inputs)

Director – IT

Director – Procurement

Director – Logistics

Director – Finance & Accounts

Director – Standards - Medical Protocols, GCP (Good Clinical Practices) & Quality Control

Director – IM (Infant Mortality)

Director – MM (Maternal Mortality)

Director – Nutrition

Director – Immunizations

Director – Preventive Care

Director – Mental Health

Director – TB- DOTS

Director - ART

Director – NCD

Director – Anemia & Related Disorders (This needs a special focus, as more than 50 % of women are Anemic)

Director – Oral Care

Director – De-addiction (De-addiction must also be a focus area, as the consumption of alcohol has been on constant rise, and wife beating is prevalent in most of the households)

Director – Ophthalmology

Director – Ambulatory services

Director – Pharmacy

Director – NGO & Alliances

Director – Media & Communication

Director – Human Resources & Training



More people can be added depending upon the focus areas for NRHM. In fact, I would strongly recommend that all the national health programs be merged with the NRHM one by one to ensure that health & wellness issues are addressed holistically in rural India



The reason I am recommending a dedicated resource for each action area like Director – MM, Director IM etc. is that, then we have people with specific deliverable, and outcomes would be better. Currently, at the centre, we have four Joint Secretaries and four directors with multiple responsibilities . These might leave them with delivering outstanding results in some areas, and with serious gaps in some!!



The above mentioned Central Committee (Mission Steering Group ) , should be overseen by the board or committee which has members from Public Health, doctors from modern medicine, Ayush, Nursing, Public representative, patient groups & people from different walks of life, who bring diverse capabilities to the team with proven competence in envisioning and executing projects on mass scale or of making a social impact. 1/3rd of these representatives must change every two years (rotating public participation). 50 % of the members must be from the government and 50 % from the private sector. Also, of the total members, 50 % must be practicing doctors and remaining non-medicos.





Further, a similar structure needs to be set up at the state level. At the District level, the work gets delivered via same field workers.



While the PHC’s & Sub centers are done up very well, some gaps remain, like;



There is a mismatch in the requirement & stocks of medicines. All the PHC’s get similar stocks of medicines irrespective of the load in OPD. So , whereas some PHC have more stocks , some have stock outs – More of Forecasting and logistics issue
Supplies of nutrients is insufficient & inconsistent - Once we have a focused resource ( Director – Nutrition , Director – Forecasting & Director – Logistics ), these problems would reduce drastically
Need is for three doctors instead of the two currently at the PHC, so that the load can be handled well. Currently, at times, the wait period for a patient to be seen could go beyond 4 hours at times in OPD. Also, with this, the PHC can operate 24 X 7 , since doctors can do an 8 hour shift each
It would be good to have the doctor’s residence attached to the PHC
Biomedical waste disposal has to be given priority to avoid infections in villages.


Challenge: Nutrition given during ANC / PNC is consumed by the family and not by the mother.



Solution: If ASHA can monitor this during visits or otherwise, it would be effective or the gender specific nutrition packs could be made to ensure that the females consume what is meant for them. Self Help Groups have emerged as the new power centers in the villages and every village has Self Help groups. ASHA’s must work with SHG’s to address this issue and oversee that the diet meant for the lactating mother is given to her in presence of a SHG member



Challenge: Electricity – Load shedding in villages: This leads to lack of storage conditions in PHC’s & Sub centers



Solution: India has adequate sunshine for 9-10 months in a year, for rest of the months, the load shedding is less, so it is worth considering having solar panels as an integral part at all the PHC’s & Sub Centers for generating electricity needed for storage and other requirements



Challenge: Poor Quality of Medicines: It is observed that the qualities of medicines are poor, and it is procured by the district Health committee. Poor quality of medicine is a serious issue, as the patients are given medicines for treatment, and if the medicines are not effective, it will lead to mistrust in the entire system, and the poor people will have to move towards private practitioners or quacks and suffer more



Solution: Since all the companies in pharmaceuticals have national level operations, it will be good if the national level tie up is done for procurements of medicines at the NRHM rates, and the order, supplies & payments happen locally. With this, we will be able to get the best rates and also give the best quality of medicines to the needy poor patients. Also, generic medicines should only be allowed to be used under NRHM. This will help to save enormous costs to the government. Also, all the PHC’s & sub centers must set up ROP’s (re-order points for all the requirements, factoring in the time lag for supplies based on past trends. This will ensure that there are near zero stock outs).



It was observed that the specialists (Gynecologist ) in one of the model PHC (Wardha district) comes only for two hours and that too, to direct patients to private practice. This must be avoided at all costs, as this will eventually make ASHA’s & ANM’s, agents for private clinics for all the wrong reasons & erode the trust in the NRHM



Challenge: Absenteeism in PHC: It is a common problem to see that doctors are missing or come only for a few hours or few days in a month.



Solution: It is suggested that the entire NRHM attendance moves paperless (biometric attendance be made compulsory). With this, the problem of absenteeism will come to an end



Challenge: Preparing reports and paper work takes most of the productive time of the health workers



Solution: With the advent of low cost tablet PC’s & low price 3 G enabled phones; it might be worth considering giving these devices to health workers like ASHA’s. Also, if these mobiles / tablets have a GPRS connection, it can mean live data updates, thereby, reducing the three month gap between the village data entry and the central review points at Delhi



When I visited the residence of one ASHA worker, she had more registers to maintain records then her daughter would have used in her studies! In all, she had about six registers to maintain records and spent 2-3 hours daily to just fill in her records. I believe that just one register should have been good enough , with name of the beneficiary , under which head ( disease or operation ) , visit for the purpose of , repeat visit , action taken, next steps, and next due visit etc…….The register given by NRHM was in English with words like Vulnerable men / women . I believe that the language used should be bilingual and not just in English …. This needs immediate attention. Digitizing the records through mobile phones would be great, as has been done in Wardha district for IM & MM programs. The data is updated live and the impact is significant with no chances of multiple entry and errors, and also real time actions happens due to SMS based follow up and care.



Ground reality: I visited one centre in a rural area, and I was surprised to see the PHC decked up to welcome the Health & Sanitation committee that was to visit the centre. I was told by the centre staff that they have been waiting since past one week, expecting this committee and they had bouquets etc ready to welcome them. Such visits do not reveal anything and add no value to the working of the village sub centers or the PHC but work only for photo-ops!! Only surprise visits must be under taken with no formal information given in advance, so that the right picture is presented during the visit, and the action oriented steps can be taken to fill the gaps, if any.



Pharmacies are present in every part of India .It is believed that India has about 7.5+ lac pharmacies across the country, and most of the villages have a pharmacy. All the

Pharmacists must work as ASHA support systems due to their knowledge and skills, being the trusted touch point for basic health problems. Focus through pharmacists should be on chronic diseases and paternal care, and through ASHA’s on child and maternal health



Medicine kits given to ASHA should have all the instructions in English, where as all the pharmaceutical companies are expected to carry the same bilingually (English & Hindi). For NRHM supplies, pictorial presentation along with bilingual labeling must be mandated.



Tribals & Upper caste: Despite the best efforts of the government, tribals are still called the ‘Black castes’ and live in a separate area demarcated for them. One of the biggest challenges is that ASHA from a lower caste would still find few takers amongst upper caste households, and vice versa. This is one issue that needs to be addressed. It would be wrong to create two ASHA’s and further the divide , but some really significant work can be given to ASHA , so that it appears to be compelling enough for everyone to seek ASHA’s assistance- Like the entire village birth certificates must have ASHA’s signature etc.



Changes in the delivery of services



New Opportunities:



Community Radio: This is being experimented in Baramati, and must be looked into. Similar services can be started in villages to drive healthy behaviors. I had visited a few villages in north, where a simple awareness campaign (pictorial & through songs in local dialect) have reduced the maternal mortality by 93 %. The expenses in this project were not more than Rs.5000.00 per village. Such models need to be adopted



Toll free based IVR Multilingual helpline: NRHM must initiate this to help reach the right people for the right inputs



m-Health based Jeevandaini scheme : This has been piloted in Wardha district , with good results in institutional deliveries and drastic improvement in MMR. The simple mobile based applications have lead to live data upload and follow up via SMS, leading to good compliance amongst ANM’s & ASHA’s . This health based model needs to be made an essential part of NRHM . Since 3G & WIMAX is now a reality , the rural health information flow and delivery of few basic services must be done adopting m-Health ( mobile health platform ).



Mobile Sub centers: Sub centers are built at a cost of Rs.8.5 – 13.5+ Lacs. It might be worth considering to set-up mobile sub centers( Mobile Vans ) that can go across to the remotest areas and conduct outreach programmes. So the cost of operating the sub center ( rental , electricity etc ) gets consumed in the form of fuel expenses for the mobile health center and also, these sub centers can be used as an ambulance in case of medical emergencies . Thus it would save Rs.300 that is given for transferring patients to the referral centre. The cost of mobile centre is expected to be much lower than the cost of a physical centre. Location of PHC’s & Sub Health Centers is mostly around a few Km’s from the residential areas, and this needs to be corrected or filled up with such mobile health center



Digital Training of Health workers: It might be worth considering creating a TV programme on doordarshan modeled exclusively for training ASHA, ANM & for increasing awareness amongst NRHM beneficiaries. Also the same should be made available through mobile phones as 3G is now a reality. Expecting mothers must be able to see the demo & programme clippings via their handsets or through ASHA’s handsets, which could be upgraded to a 3G enabled mobile handsets for live reporting or for delivering video content for various programmes.



Technology must be leveraged in NRHM for accountability, transparency and telehealth. 12th five year plan must consider opportunities to digitize NRHM in all spheres of its implementation



Minor surgeries in PHC: Now that that PHC’s have facilities for delivery, minor surgeries must be allowed in the PHC. So far, minor surgeries are not allowed in PHC. This is one important decision that can help save a lot for hassles for villagers and bring revenue for the government. The PHC’s can enroll patients for minor surgeries, and then get a surgeon on call for a day from a nearby town and complete the minor surgeries at the PHC to function as day care centers .



Reporting of NRHM across states should be on the same format as of KPI’s (key performance indicators) so that it leads to apples to apples comparison and this could be on these indicators



Structural : Setting up and maintenance of the facilities
Functional : Human resource management and flow of instructions and funds
Fund utilization: special focus must be paid as to why the funds could not be used, as the money is meant to be spent with an outcome allocated to every rupee spent.
Outcomes : Measurable outcomes in improvement in the village / Taluka health must be done every quarter


Reporting and review must be



Weekly for Talukas
Fortnightly for Districts
Monthly for states
Quarterly at the centre


This timely reporting will itself bring out better outcomes. It was sad to learn that during the mid-term review of the 11th five year plan in July 2009, the ministry of health & family welfare was not even aware of any targets. The reality is that, the files from the planning commission were not even looked into by the ministry of health & family welfare until the mid-term review of the plan started. One of the senior official of the MOHFW had revealed to me that rarely MOHFW looked into the files from the planning commission , and they were not even aware of any targets set by the planning commission , and that if the MOHFW did not respond to the plan targets set by the Planning Commission , the planning commission assumed the targets as accepted by the Ministry of Health & family welfare .This is a structural and procedural lacunae and needs to be addressed from the planning stage for the 12th five year plan , so that the ministry does not question in the meeting who set the targets for them ??



Administrative changes:



Financial planning and flow of funds: The fund flow on time is the biggest problem. I have met people working at the lowest level in PHC & Sub centers, where the salary has not been paid for months, and the funds for 2010 were received in mid – Jan 2011. This clearly will encourage corruption. People drawing a monthly salary of Rs.5000-8000 cannot sustain their family without salary for months. Either they will resort to bribing; selling the government supplies or starts absconding and working for employers in parallel. The fund meant for a sub Center or PHC must be transferred in advance for the quarter if not half yearly. This is one single biggest action item to make a sub center or PHC Staff working 6 days a week



Referral centre: It has been found that the referral centre in Panvel (district Raigad) does not even accept patients & turns them away from the door itself ( this is a reality ), and the patients are routed to the Alibag referral centre. Such centers must be a common occurrence across India. Government is paying for them, but they are operational only on paper. Such center must be tracked down, and either made fully operational or closed down. As not only they cause a loss of money to the exchequer, but also diminish the trust of the common man in government’s flagship schemes like NRHM



Why programmes succeed or why they fail- Lessons to learn: Let’s take a look at the successful programmes like NACO for Aids, National TB control programme & the Pulse Polio programmes. All these programmes have worked well because of the fact that they have proper structure and resources allocated. In the ministry of health & family welfare, the programmes are fantastic announcements, but the human resources required are not properly allocated in the ministry to handle such programmes; only the funds are transferred in the bank for the programme. So the department handling the programme is under resource crunch , they do not even have people to handle the communication , and most of their time goes in reporting ; Result – the funds remain un-utilized and are returned back in case of calamity announcement from the PM’s fund or for other reasons and thus programmes fail to leave an impact . Planners must study the success of National TB control programme & NACO and implement the learning’s in all the programmes for Health & family welfare



Incentive to health workers ASHA’s ANM’s & other Sub center & PHC staff: It is expected that since ASHA’s and ANM’s are incentivized for institutional deliveries, referral etc. The incentive might also make them turn to private practitioners over a period of time, as the lure of money will drive them to recommend private gynecologists & give less focus to home visits and counseling, and this might be happening even today as well. It is suggested that the ASHA’s & ANM’s must be incentivized for counseling, home visits, immunization & preventive checks as a routine part of their job and the incentive must be paid for each home visit ( even Rs. 2 to Rs.3 per visit is good enough ) . This will lead to a fixed remuneration to ASHA’S & ANM’s. Certain Evaluation parameters for the success of an ASHA must be established like how many households are aware of sanitation, hygiene, preventive health and healthy lifestyle. Since the NRHM has a huge outlay of funds for the national healthcare, a ‘dip–stick’ audit using random sampling must be done with the households, and this must be done every quarter across the states where NRHM is currently operational.



ASHA is not paid a salary but is paid incentive for institutional deliveries (Rs.100), DOT treatment (Rs.250), meetings for once a month (Rs.150, out of which Rs. 100 is for travel and Rs.50 for refreshments). A supervisor is above ASHA’s and she handles about 30 ASHA’s. She is paid Rs. 3000.00 per month. She is supposed to be meeting two ASHA’s a day. Since both the ASHA’s and Supervisor have to travel long distances by road , and keep in constant touch with each other , I would recommend free local roadways pass to NRHM workers , and a mobile connection with CUG ( Closed user group , that allows free calls between users ) for NRHM staff. The cost of which could be less than Rs.75 per month



NRHM Handbook : Since the NRHM programme is the biggest healthcare programme so far, it is imperative that a detailed multi lingual NRHM Handbook, manual or ready reckoner be brought out for all those involved in the programme , covering basic protocols, bio medical waste disposal , do’s & don’ts dealt with FAQ’s . Also, the digital version must be available on mobiles and internet.



1-3 months rural posting of nurses, pharmacist and doctors must be made mandatory for the courses to fill the resource crunch, and the professionals must be remunerated for these postings along with free accommodation on site at the sub center and PHC.



Awareness & sensitization: Since NRHM is addressing the key areas when it comes to health and hygiene, it is imperative that a chapter on NRHM is added in secondary education (class 6th onwards). This will lead to awareness and sensitization amongst children to adapt to healthy habits



Role model & Case studies approach: People believe in facts, and the case studies & success stories of ASHA & ANM’s must be shared nationally to make the acceptance more impactful for behavioral change. I must share with you something interesting that I witnessed in north India. I was visiting rural belt in north India, and came across an ancient custom called ‘Shourey pratha’. Under this , when the lady delivers a child , she is confined to a room for 40 days , and cow dung is plastered on the walls ,and baked cow dung cakes are burnt non-stop to fumigate the room, automatically the mother and child suffocate to death . Now we can well imagine why the IM &MM (Infant Mortality & Maternal Mortality) was very high in the rural belt in north India. With simple explanations and scientific explanations with the help of the Self Help Groups (SHG’s), this tradition is on its way out. SHG’s is the most powerful change agent in rural India and the NRHM must use this channel to drive a behavioral change in rural India.






Eradicating under-nutrition and malnutrition



The issue of under-nutrition and malnutrition is not just an issue associated with poverty . If I were to say that malnutrition is also prevalent due to the lack of sanitation facilities, people would not believe it, leave alone talking about linking the two.



Here is an interesting linkage : Females in the village have to defecate in the open , and for that , they either go out in early mornings or late evening when it gets dark . To avoid going in between , the women not only eat little , but also feed children just good enough so they do not go out and defecate too often , and this has been a cause of malnutrition and under-nutrition . There is a common habit amongst girls studying in schools with no proper toilets that , they seldom drink water during school hours to avoid going to toilet !! Strange but true . Similarly , mal-nutrition and under-nutrition has become a sanitation issue . This calls for the involvement of the ministry of rural development to address the sanitation issue in rural India to completely address the issue of malnutrition & undernutrition . Also, the ministry of food processing to work with the players for producing locally fortified foods to reduce the cost of ready-to-use therapeutic foods (RUTF).



Nutrition is often overshadowed by other medical conditions, like malaria or diarrhea, despite the fact that malnutrition, combined with these conditions, can more often be fatal." A "severe acute malnourished child" is more than nine times more likely to die than a well-nourished one, & malnutrition from any means retards normal growth .



Besides sanitation , societal traditions that female child is a burden still plagues the nation ,and there is a bias towards the male child who is treated as an inheritor and an insurance in the old age for parents . Government needs to step its machinery on all fronts . It is a known fact that, a weak female will never bear a healthy male child , and this should form the basis of the Healthy India campaign as the discrimination against the female child is rampant in every part of the nation . The issue needs to be attacked multi-fold ;when the mother is expectant , post child birth , adolescent years, post puberty age in girls . Special focus has to be given to the female child , who bears a male child in future .



One of the key pillars of NRHM must be eradication of anemia amongst women with the focus on the girl child. Special fortified biscuits or snacks with calcium, iron and zinc need to be made available for the girl child ( developed specially for females, so that male child is not given those products ! ) and separate packing for boys to be given as mid day meal or as packaged snacks made especially for children fortified with nutrients ; ready-to-use therapeutic foods (RUTF). For boys, the nutritional support must continue till the age of 6 years but for females , this support must continue till 16 years in age



The deficiencies varies with the region , like Vidharbha region has a severe issue of sickle cell anemia , and this is becoming a serious genetic health issue . Similarly, deficiencies in every region needs to be addressed region-wise.



Diet charts are as important as immunization charts and needs to be given together during child birth based on the physique of the newly born



RDDA’s ( Recommended Daily Dietary Allowance ) should be worked out specific to each child . The role of the nutritionist gains significance in NRHM and is central to the issue . The diet plan must be made for each new born and followed under the directions of ASHA locally . So far, I have not seen a prominent role of a dietician in either the sub center or the PHC



I would recommend national health planners to tie up with WFP ( World Food Programme ) to provide daily nutrition for as low as Rs.5 per day . Even companies like Unilever are working on creating BOP Healthcare ( Bottom of Pyramid Healthcare ) models focusing on healthcare basics for the rural masses. It might be worth exploring PPP ( Public Private Partnerships ) to address this issue & come out with ready-to-use therapeutic foods (RUTF)

Indian Pediatrics has brought out a Special Issue (August 2010) on Severe Acute Malnutrition, which deliberates in detail on the global and national evidence relating to pertinent issues on this subject.

Severe acute malnutrition (SAM) in children is recognized as a major underlying cause of death amongst under-five children. These deaths are preventable provided timely and appropriate actions are taken.

According to National Family Health Survey-III, conducted during 2005-2006 in India, 6.4% of children below 60 months of age were suffering from this malady . With the current estimated total population of India as 1100 million, it is expected that there would be about 132 million under-five children and amongst these about 6.4% or 8.1 million are likely to be suffering from SAM.

With the emergence of home based management approach for SAM children, which includes the use of Therapeutic Nutrition (TN) as part of Medical Nutrition Therapy (MNT), it is possible to address this issue in a cost-effective manner. More than 85 % of total SAM cases are without medical complications and can be identified through active case finding in community to be successfully managed at the home level. Global evidence suggests that with integrated management of SAM children, case fatality rates can be reduced to less than 5 percent. Short-term therapeutic nutrition for 6-8 weeks is an integral component of home-based management of SAM. There is an urgent need to develop an indigenous preparation of therapeutic nutrition in the country and operationalize the community management of SAM. Exploring a tie up with WFP / Unilever might be a good start. Also NRHM can start a mission GYM ( Grow Your Medicines) at the PHC , Sub centers and in every households ,as most of the green vegetables and fruits can be grown locally , and can be used for fighting mal nutrition and under nutrition . On one side , fortified snacks could be given , and also the NRHM can distribute seeds for growing vegetables and fruits that can mean much cheaper source of right nutrition .

Height weight charts must be distributed in all households to keep them aware of age- weight –height ratio and the relation to malnutrition . Automated SMS based service could help in ensuring compliance as seen in the case of Wardha pilot for MM /IM.

Awareness and sensitization must happen through short films and pictorial comics about the deficiency of Iron & Calcium in females

ICDS : Policy makers must consider merging ICDS with the NRHM , as it might be worthwhile to double the number of ASHA’s and allocating more high priority job to ASHA’s.

Health Fairs must be organized locally to create awareness on the issue of malnutrition . Those parents who have the healthiest girl child must be made ‘Role Model’s’ for others to follow . A ‘healthy girl child award’ must be instituted in each village ( Say Rani Laxmi Bai Award ,Sarojini Naidu or Indira Gandhi award etc) , and the government must recognize the mother and father ( Good Parenting ) for healthy upbringing of the female child ,along with a cash award of say Rs.1000.00 , or other incentives like 2 KG extra ration at the PDS shops, free bus travel for parents for one year in ST ( state transport ) bus , 50 % fee reduction in graduation of the child ,if studying in government college etc, could also be considered depending upon the consensus of the relevant stake holders. This can be a good competition to start with, which will drive home the message that bringing up a healthy girl child is beneficial in the short run and in the long run & the responsibility of the parents , with the Government acting as an enabler for this . To start with, if each of the 6 lac + villages gives this award to one girl ( parents ) , and each encourages 10 people to take care of their girl child , we would have got 6 crore healthy females in the next 10 years !! If we want faster results , we can fix the criteria for a healthy girl child for the age group 1- 16 years , all those who qualify can get incentives for the healthy upbringing of the girl child like free travel on ST bus etc . Ministry of women and child development might like to take this up in the 12th five year plan.

NRHM must insist with the ministry of education to include in the curriculum few chapters on micro nutrients and their role in healthy living , and this should start from class eight onwards.

I do hope that these inputs are of some help .I remain at your disposal should you need more inputs on other aspects of healthcare & rural economy

With best regards

Rajendra Pratap Gupta

Office@rajendragupta.in

Budget Expectations- Preventive Care

January 25th , 2011.

Shri Pranab Mukherjee

Minister for Finance

Government of India

North Block,

New Delhi -110001



Subject : One action item in the budget for 2011-12 that can raise the GDP by 1-3 %



Dear Pranab Da ,



I am sure that your team is working hard to find a balance between maintaining the growth, reducing inflation , keeping the debt within reasonable limits , and still maintain India as one of the most appealing investment destination for foreign investors !! I know that it is quite a challenge, but we are sure that your team will achieve it under your leadership



I am making this request on behalf of The Disease Management Association of India ; DMAI- The Population Health Improvement Alliance . At DMAI, we work with various stake holders to bring about a lasting improvement in our healthcare system Healthcare in India is a big economic issue and is fast turning out to be a social & a political issue .



Let me walk you through one reality – Healthcare is not an individual issue , it is a family issue . Take the case of a person suffering from just one of the chronic diseases like Arthritis, Diabetes , Cardiac disease or Cancer (It is a known fact, that by the time an Indian reaches the age of forty , he is either at the risk of or suffering from a chronic disease) . If a person in family suffers from a chronic disease , not only does that person lose his efficiency ( productivity ) , but loses many work days every year due to treatment and restrictions imposed during the course of treatment . In addition to the person having a direct loss in his productivity , his entire family has to make some adjustments & sacrifices , thereby having a cascading effect on the productivity of the entire family !! Ultimately, this affects the entire family , organizations where these people are working , and finally pulls down the productivity of the entire nation directly , which is what I understand as the GDP of our nation !



Pranab Da, just consider one step in your budget , and you would be the first Finance minister in the world to have given top priority to health to boost the productivity of a nation !



I am hopeful that you will allow expenses in meditation , Yoga , Swimming pool , fitness centers, Gyms & preventive health check-ups to be included in the rebate for income tax -Just like we have health insurance premiums which qualify for tax rebate . Health insurance is nothing but transferring the risk and payment to a pool, but what we need desperately in India is “Health Assurance” – avoiding diseases , and that means, we need to encourage healthy habits & provide appealing benefits to people to take to activities that promote fitness and take away sickness !!



I am sure that you will consider to levy a 4 % service tax on all the providers of services like meditation training , Yoga classes , Swimming pools , fitness centers, Gyms & preventive health check-ups , but also give rebate to the citizens who enroll in such activities . Further , I would request you to give equal rebate to Health insurance & Health Assurance in this budget in terms of the total amount qualifying for the rebate in income tax.



I am very sure that, the ministry of Finance and the entire nation would gain from the healthy population in terms of enhanced productivity and lesser loss of man days , in addition to a healthy collection of taxes from the service providers in the fitness segment that will add up the numbers drastically. I personally believe that this one step that has the potential to raise the GDP of the nation by a minimum of 1 % and can go as high as 3 % additional increase in GDP , which means that by 2012, India can grow at 10-12 % in terms of GDP by just taking one step in this budget !



In addition to the growth in GDP , our future generations would always feel indebted to your selves ,for taking this most important decision for bettering the healthcare of individuals & raising the productivity of the nation



I am sure that this very important recommendation would be considered positively and acted upon!



We will always remain thankful to you for the kind consideration



Yours in good health

Rajendra Pratap Gupta



CC.

Sonia Gandhi Rahul Gandhi Dr.Manmohan Singh Dr.Murli Mahohar Joshi Shri Ghulam Nabi Azad Montek Singh Ahluwalia Dr.Syeda Hameed. Shri L.K.Advani Smt. Sushma Swaraj Shri Dinesh Trivedi Sitaram Yechury Members of Parliament Sam Pitroda Secy , Health & Family Welfare , GOI Dr.K.Srinath Reddy Chief Minister’s of States Dr.Salim Hebayeb, WHO Gerard M La Forgia , World Bank

Media

Give us a Prime Minister - Manmohan Singh is a good professor but certainly not a PM material

Dear Mrs.Sonia Gandhi,

Since you are the President of Congress party , please look into this email

Over the last few years , we have tried to accept Dr.Manmohan Singh as our Prime Minister , but his performance as a congressman might be good , but he has failed completely as a Prime Minister . Congress has been blinded by Gandhi dynasty to such an extent that it has become poor in chosing the right people for the right job. May be that your and Rahul’s intellect is not upto the mark where you can choose competent people .

Over the years , congress government under your Presidency has become a government of faulty planning , false promises , blaming coalition for your failures and blame free investigations in most of the scams

This government has too many highly educated people, economists & NRI experts & advisors , but still the wisdom to understand the problems and give exact solutions is missing .

Every time your Congressmen give a new date about controlling inflation , and every time they miss it . When the inflation is perpetually high , you blame coalition politics for it. So why do Indian’s pay a price for your forming the government ?Dissolve the government and go for fresh elections .

You are not able to judge the talent and most of your ministers are highly inefficient and corrupt , and we were hoping that Sharad Pawar would be removed so that he could focus on the ICC world cup in 2011( Which he will do anyways !!), but he seems to have hypnotized you !! He is still around !

Your party believes that , by revealing the names of those who stole the government money and deposited them in Swiss Banks , would pose a security risk ! So you are trying to tell India that, majority of your office bearers are Swiss account holders !! And that their getting caught would mean that the government would collapse !! Anyways , Julian Assange is on the way for dropping a few names , and I do hope that they are not from India & Congress !!

Industrial growth has been reduced to 2.7 % , lowest in the past 18 months . Would like to answer it why ? Rather , I must ask you if your people know at all why it happened ?

People are very bullish about rural India, and every major FMCG , White good & vehicle manufacturing company is over- joyed with the growth coming from rural India in terms of the purchases being made . Let me take you through a very dangerous & disturbing development in rural India – I call it Rubble ( rural bubble ). I have been visiting rural India and talking with villagers . Here is what I want to tell you. Let’s take the example of Chavane village in Raigad. The village has changed dramatically in the past 3 years. It is great to see concrete (Pucca )houses with two wheelers parked in front of the houses. As you dig deeper , the facts reveal that people sold their land to MHADA for Rs.30,000.00 per acre for SEZ, and with sudden flow of funds, the thatched roof houses got converted into Concrete (Pucca ) houses, and two wheelers were also purchased along with some jewellery . Villagers had for the first time seen so much money, so instant money that came by selling land was used to make aspirational purchases , and it is over now , lands are gone as well !! What will the farmer do ? What will the farm labourers do ? How will they earn their living ? Let’s take another village 80 Kms from Nagpur , where Lanco plant is being built . Villagers have sold land for the rates as high as Rs. 25 lac per hectare . In India , average size of the land holding would be around 5-7 acres. Selling the entire land would fetch Indian farmers between Rs. 1.25 lac to 1.75 crore depending upon the size of the holding and the rate paid by the acquirer. On these lands , manufacturing plants would come up. We would never see greenery again. And farmers and their children who do not have jobs and land to do farming will be the next anti social elements or naxalites !! With land not available for agriculture , inflation would be higher than what it is today . Today farming is seen as a disdainful activity , and people want to do a job of Rs. 4000 but do not want to work in farming . Your congress government has kicked the ass of 100’s of millions of farmers over the past 60 years , and we are on a temporaray rural growth that I call as a rural bubble – Rubble !! India is headed for a major crises , & all because of the faulty policies of successive congress governments focused just on building billionaires , industries and encouraging FDI !! Get retail FDI in India , and see how the 12 million kirana stores and their families will starve to death . I have had discussions with the Parliamentary Committee of Commerce , Chairman in 2009 , Dr.Murli Manohar Joshi , and have given him in detail the reasons why we need to avoid FDI for the next 5 years at least !!

For price rise , last year ,Manmohan ji said that it was due to poor rains , in 2010 we had good rains and good crop , so why the price rise ? Kindly explain

I was in Nagpur on 17th / 18th , and I read in one of the news papers about the fact stated by none other than Mr.Subramanian Swamy that, your bank balance was about Rs.10 crore some twenty years back , and now it is Rs.80,000.00 crore !! I think that this shows that inflation is very high at 10, Janpath . Please clarify if you actually made 60 % money in the 2G scam or this money came from abroad ? You are answerable

Ironically , in the current times , we have a strong opposition but a weak ruling party . How can this government run ? If BJP comes down on its demand for JPC in budget session, Indian public will assume that it ‘settled’ the matter with congress and will never let them win again the seats that they are looking for, and if they keep their agitation on like the winter session , your government will have to go , and India will see a sign of relief !!

Madam, congress might be your personal fiefdom , but not this country . You have created multiple power centers more powerful than the PM , like Rahul , NAC etc….You are the worst Congress President in the history of this country . But usual , we have a saying ‘Andhon main Kane Raja’ So you are the right person for the congress, which does not have any talent left !!

We have an outdated finance minister , unfit Agriculture minister , Hyper environment minister and an ineffective Person on the seat of the PM. All along, I have heard that we need 100 good people or 1000 good bureaucrats etc. But the fact is that , we just need one right person : at the seat of Prime Minister . One right person will change the future of this nation , and Manmohan certainly is a disaster at the cost of people . At this time , we cannot afford to have a lame duck as a Prime Minister of this youthful nation . Please give us a Prime Minister , we do not need a professor !!

A suggestion for controlling food inflation : Please ask the government to start a daily free ( even if you charge the farmers for this service, it is fine ) truck service from the remote villages to cities , where only farmers can come directly to the market and sell their products, rather than selling through agents , mandis or APMC . This will ensure that the person who adds maximum value and takes maximum risk for growing the produce ( farmer ) should also get the maximum profit . The profit at every point of sale post the harvestor ( farmer) should not cross 15 % , and this will bring down the prices to reasonable levels permanently . I read Subbarao stating that the government is desperate to control inflation and will raise the base rate , I heard Chidambram that government is clueless about the tools to control inflation , Sharad said that he cannot control what the farmers want to grow and so he cannot control food inflation . All these stupid statements come because you have bookish professors and so-called highly placed intellectuals and NRI & outdated advisors , who have no connection to ground reality . I do not understand how will raising the rates decrease inflation ? You have been doing this for the last two years and the result has been same – inflation has only increased . Do we need such economists who do not have answers to the common man’s problem ?

Do you never apply your brains about this fact that, the prices of the grains and vegetables are sky-high , still the farmers are committing suicides ? Does this not help you understand the problem and get an answer ? You all must be high level fools then !!

In addition to high prices of food stuffs, by increasing the price of petrol again you have signaled the common man that ‘do not eat , do not go to work’

Nitin Gadkari ji , please take up these matters with utmost seriousness , as congress is forcing the poor people to take to suicides by failing to control prices . If BJP does not take the matter seriously , the people of India will feel betrayed. Congress is fast becoming a failed party under you Sonia Gandhi ! Please either give us a PM or you and PM can go now ….. do not let this great country go to dogs !! This email is marked to Sharad, your dear son , FM , HM etc. to do some soul-searching and step down

Rajendra Pratap Gupta

www.rajendragupta.wordpress.com

Healthy foods- A must have

Rajendra Pratap Gupta
President
Disease Management Association of India (DMAI)

Dated: October 22nd, 2010.

Shri Ghulam Nabi Azad
Hon'ble Minister for Health & Family Welfare
Government of India
Nirman Bhawan, New Delhi -110108.

CEO’s of the industry
Subject: An important appeal


Dear Shri Azad ji & CEO’s ,

This appeal needs your esteem, kind and personal attention.

Disease Management Association of India (DMAI ) – The Population Health Improvement Alliance is thankful to the Ministry of Health & Family welfare for taking action on its recommendations for health reforms appeal sent last year ( dated November 23rd 2009 ). Members, associated organizations and the Board of Directors of DMAI – The Population Health Improvement Alliance, are highly appreciative of the steps that the current government is taking to tackle the healthcare issues concerning our nation.

One area where DMAI feels that the Ministry & the industry have to draw its focus and attend urgently is:

Issue guidelines & standards ( and enforce them ) with regards to the food served in airlines , railways , other public transports, government canteens, private dining establishments, School canteens & packed foods ( all forms )

All such foods / foods items must carry the calorific intake for each serving

The customer must be given a choice of low calorie, low glycemic index, and zero cholesterol options rather than forcing them to eat unhealthy foods that adds to the disease burden of this nation.
Above all, all packaged food companies must carry tips for good health on the individual packs – at least a one liner if not more!!

It is proven that Indians are genetically susceptible to circulatory disorders , and that we can only fight it by inculcating healthy eating habits by educating the public on healthy foods, promoting healthy foods ,and at last , giving them an option to eat what is good for their health .

I have personally experienced that all the airlines, Indian railways, public transport and eateries are serving foods that have a high glycemic index, high in fat content and are loaded with calories that remain in the body as excess fats. Such foods are a slow poison for consumers!! This is the main cause of India becoming a diseased nation, and the alarming rise in the obesity amongst children in addition to diabetes and hypertension. DMAI had conducted a random Health Risk Assessment with 2000 people in association with IIHMR, Delhi. The revelations have been shocking!! We have an abnormally high incidence of diabetes, hypertension and obesity. It’s a call to action.

We have to aim at keeping the BMI of Indians below 23, and today, it is shocking that about 50 % of Urban Indians are either at the risk of obesity, diabetes, hypertension or joint pains or suffering from it.

By the time Indians reach forty years of age, they become patient of one form of illness or another. It is high time that we all get together and put efforts to make India a healthier nation. We cannot just blame the government for the healthcare issues and leave it to handle this issue alone!

Through this appeal, we expect all the airlines, public transport and eateries to ensure that they serve healthy food and carry the total calorific intake for each serving.

It is also expected that that all the concerned will take the health of Indians as a top priority in all the offerings when it comes to foods intake , and give options like brown bread , sugar substitutes , low calorie and low fat meals as an option and not force the passengers & customers to eat high calorie meals.

DMAI is committed to working with all the major stake holders in the entire continuum of care to bring about a population health improvement through actionable steps

We expect the government to formulate definite guidelines on this issue, and the industry to take a proactive approach. Work place wellness must be focused on by the HR captains and CEO’s of all the ‘responsible’ corporations.

DMAI appreciates the proactive approach of the government to ensure healthcare for all. Should the government agencies need any assistance in drafting guidelines or in the implementation plan, DMAI would be more than happy to volunteer for the same

In hope of the needful

Sincerely

CC:

Dr.Manmohan Singh, Prime Minister

Ms.Sujatha Rao, Secretary, Health & Family Welfare, GOI

Shri Dinesh Trivedi, MOS, HFW

Dr.K.Srinath Reddy, President, PHFI

Health Minister of States

CEO, Jet Airways, King Fisher Airlines, Goair, Indigo, Air India, Spicejet

Minister for Railways

Ministry of HRD / Ministry of Labour / Ministry of Civil Aviation

Koutenya Sinha, Editor Health, Economic Times

Sonal Shukla, Hindustan Times

Priyanka, DNA news

Rajdeep Sardesai

Barkha Dutt

CII, ASSOCHAM, FICCI & CIAT to circulate this to all its members

Impact of Healthcare Globalization on our Economy

Address as the Session Chairman for Panel Discussion on the topic “Impact of Healthcare Globalization on Economy” at the 3rd International Healthcare Quality Conclave, 31st July, 2010



Good evening friends. I have an Interesting topic for discussion amongst my esteemed & learned panel of experts.


Let me introduce you the expert panel. I have with me, Mr. Rajiv Sharma, CEO, Sterling Hospitals, Dr Anupam Sibal, Group Medical Director, Apollo Hospitals, Mr. Sudhir Bahl, COO, IVEN Medicare India Ltd, Dr. Dharmendra Nagar, Managing Director, and Paras Hospitals

Coming to the topic, I have had a chance to be involved with a few healthcare systems across the world: The largest, over-funded and under-performing healthcare system – US Healthcare system, the government supported UAE healthcare system & the one that is under-funded and under-performing healthcare system – India

What will be the impact of healthcare globalization on the Economy? Firstly, why will the healthcare globalize? And when this happens, what impact will it have on our economy?

My understanding is that the healthcare in the US / Europe has already embraced the ‘Moment of truth’ - that both these systems are not sustainable in the current form. I believe that the solutions for the healthcare problems of the developed world lie in the developing world, and so, healthcare globalization is the only way forward! With private Indian healthcare organizations setting up world class facilities in India, a good number of Indian faculties are headed back home with better environments to work in their very own home country. This will lead to reverse migration.

Also, developed world is facing the problem of high cost and a long waiting period for major interventions. Certainly, Indian healthcare system offers solutions to fill in this need gap with an assurance of world class care. Adding to this is the healthcare insurance products being launched by some insurance companies in the US that will encourage the patients to travel overseas for treatment

Today, US healthcare system is a big talk everywhere as it is 17 % of its GDP. In India, a 1.2 Trillion USD economy, healthcare is 2.91 % of the GDP. This number of 2.91 % of the GDP is too low to impact the economy unless it becomes 2-3 times of its present number. One of the impacts of healthcare globalization will be that it will increase the healthcare’s share of GDP in India

Recently, we saw a major healthcare group in India bidding for a regional healthcare group. I can safely bet that the Wal-mart of healthcare will be from India

With Healthcare globalization, the healthcare will improve and impact the healthcare of the common man, and ultimately the productivity of our country’s work force will go up; thereby leading to a more vibrant economy

Overall, the impact of Healthcare globalization in our economy will be felt across sectors as Healthcare is a complex industry with the highest employment potential . Healthcare globalization will positively impact employment across sectors like manufacturing , R & D, tourism , textiles, hospitality , education , IT, Insurance , BPO , Telecom etc , and so one can easily understand the multiplier effect on the economy in India due to healthcare globalization

We have started the journey for globalization. India has the potential to set India class standards for the world rather than aping the world class standards for India. We have some great leaders in Healthcare like Dr.Syeda Hameed, and we are sure to reap the benefits that healthcare globalization brings to our economy

So if I were to sum up the impact of the healthcare globalization on our economy, it would:

a) Reverse brain drain in healthcare

b) Increase the share of healthcare as a percent of GDP

c) Create the Wal-mart of healthcare from India

d) Enhance the productivity of the workforce and make our economy more vibrant

e) Have a multiplier effect on many sectors of our economy

Thanks for patiently hearing me out. Now let me open the session to our expert’s panel

National Council for Human Resources in Health - NCHRH

Date : June 30th , 2010.

Mr. Debasish Panda
Joint Secretary
Ministry of Health & Family Welfare
Government of India
Nirman Bhawan , New Delhi 110108

Ref: D.O. V.11025/10/2009-ME(P-1) dated 8th June 2010

Dear Mr.Panda,

Thanks for the invite for the regional consultation on NCHRH . Unfortunately, I could not attend the meeting at Mumbai on 18th June due to a prior commitment at Bangalore for the India Innovation Summit on the same date.

I had sent you an email on the NCHRH with two recommendations. Since then, I have dwelled on the issue at length and wish to submit some recommendations for your kind consideration

Before I start on the specific recommendations, let us consider a few important points that need to be kept in mind for the National Council for Human Resources for Health - NCHRH

• India has 1.2 Billion population out of which about 1/3rd is illiterate population
• In the next 10 years, India will add 120 million people in the working age category
• Currently, India has about 2/3rd of the population below 35 years in age
• Currently , 2/3rd of India lives in rural India and probably, in that category, healthcare does not figure in the list of priorities
• 2/3rd of India does not have adequate access to healthcare
• Awareness and sensitization about healthcare is missing . People will go and splurge money on dining outside , but will not spend a fraction in wellness .
• India believes more on religion , spirituality and charity than wellness
• Healthcare professionals available are not willing to work in the so called rural India . At max, they are willing to work in semi urban India
• The incidence of diseases is not vastly different in rural India from that of urban India for most of the ailments
• Status of urban poor is deplorable when it comes to healthcare
• PPP’s in healthcare are not going to work in rural India
• Those who study for healthcare in urban areas, majority of them are not willing to adjust to the rural lifestyle for professional or family reasons . Gives us a reason to think to start medical colleges in rural settings !!
• The entire healthcare system is focused on medicine , doctors, clinics and hospitals etc. This has created a fear & suspicion amongst the healthcare users that healthcare means pills, surgery and hospitalization
• New models of care are evolving for addressing the changing disease patterns and Indian healthcare system is ill prepared to handle the same
• Time has come to take health ( not medical ! ) education from medical school to primary school. Basic healthcare education should be made compulsory at the school level.
• 3G has now become a reality , so mHealth will not just re-define the healthcare delivery but also healthcare education

In short , I would say that , the world over , no healthcare system has answers for our problems, as all the systems are already failed or heading towards a collapse . This provides a unique challenge and an

opportunity to build a robust healthcare system for India that is low cost, agile , protocol driven, and evidence based and not eminence based system; one that avoids errors , trails and wastage . Then only we can have an outcome driven health system that cares !

Here is what I submit for your kind consideration :

NCHRH ( National Council for Human Resources for Health ) has been set up with the goals to overcome the acute shortage and uneven distribution of human resources in public health delivery system & aims at overhauling the current regulatory framework. Toward this end, it is proposed to set up a National Council
for Human Resources for Health as an overarching regulatory body to achieve the objective of enhancing the supply of skilled personnel in the health sector

What I can understand from the above stated purpose for NCHRH is that NCHRH will ;

• Regulate the current set up
• Identify the current need gap
• Project the future requirement for the next 10, 20 & 30 years
• Asses the population mix and the disease patterns and address the issues in a proactive manner
• Create a resource pool & knowledge pool ( not just impart knowledge but create it as well )
• Human resources for disaster management in healthcare is missing from the draft that I have gone through . It needs to be incorporated

Health in India has to be looked regionally and planned at the district level: It would be wrong to just limit it to five members headed by a chairman. I would suggest that you must create an “Indian Health & Wellness Service (IHWS )” for the entire nation on the lines of IAS . Today , if I have to complain against deficiency of healthcare services or standards or care at a hospital, there is no grievance redressal mechanism !! Because the system is ambiguous and there is no demarcation for people to look at health and wellness services. For erring police , I can go to SP City , DIG –Range or IGP or the DGP; for an erring postman , I can go to the Post master general etc., and the same for most of the services ; but if there is a deficiency in a hospital service provider where does a common man go ? Another hospital, I suppose !!

So when you are planning for NCHRH , You must consider having an all India service to tackle the multi headed monster called healthcare.

Have separate members in NCHRH, each having a clear role and responsibility for capacity building for the following :

1. Urban Health
2. Rural Health
3. Tribal Health
4. Health in hilly areas
5. Health in Armed forces
6. Health for retired government employees
7. Health for private sector
8. Work Place wellness
9. Healthcare amongst Minorities
10. Expatriates working in India
11. Geriatric care in urban & rural health should be handled separately by different members
12. Split ‘Mother and Child care’ under separate heads, each under a separate member . It is glaring to note that According to International Institute of Population Sciences , Mumbai , 56 % of the Indian women in the age group of 15-49 suffer from anemia
13. Diabetes
14. Hypertension
15. Arthritis
16. Cancer
17. Epilepsy
18. Mental Health
19. Telehealth should be a strong focus area for Urban & rural health. It should also be a part of the Medical curriculum and a 3 month internship should be made mandatory for telehealth
20. Medical Education
21. Home health & care technicians
22. Healthcare counselors and Physiotherapists
23. Health administrators for clinics , hospitals other wellness providers
24. Gyms & Wellness centers
25. Diet and Nutrition
26. Acute care
27. Immunization
28. Awareness & Education about wellness
29. Awareness & Education about diseases
30. NGO’s capacity building
31. Disaster management in healthcare including outbreaks & epidemics
32. Epidemiology & research on regional requirements . One example I will quote here. In north eastern part of India , in tea gardens , people take black ( known as red tea in NE ) with salt and so there is a very high incidence of Hypertension and stroke . Same applies to other belts in India which have very specific requirements that cannot be tackled with centralized planning and execution
33. Technical up-gradation & training of the workforce on latest developments in equipments and technology
34. CME for each level of workforce
35. Nurses should be renamed as Physician’s Assistant (PA’s ) or Health & Wellness Officer (HWO’s ) . There should be a plan to create enough specialized resources under this head for rural health, geriatric care , telehealth , chronic diseases etc. We need not make our healthcare system doctor & hospital centric . The number of PA’s / HWO’s should at least be double of that of the doctors in the next 10 years
36. For medical education ( all streams ), behavioral psychology should be added in the curriculum . This is one of the most important change that we need in the medical curriculum . Doctors have just been reduced to diagnosis & prescription machines . Whilst we might be imparting the best of medical knowledge, but patient care and handling is missing totally from the curriculum . Writing prescriptions does not deliver care . Patient friendly care is a must . Because of the lack of understanding of the behavioral psychology amongst doctors , the patients fear and suspect the doctors . Even the doctors do not go beyond prescriptions !! This needs an immediate change to ensure compliance and outcome from the treatment , most importantly, regain ‘Trust’ in the system by the users
37. Put a separate head for innovation in healthcare education
38. Separate head for guidelines, standards , treatment protocols , assessment & accreditation for each aspect of medical & health education and research

Further , each member should be responsible for research , planning & execution for his department. It is clear that if we do not plan for human resources , it will not just lead to deficiency in healthcare services but also increase the cost of healthcare . Limited number of healthcare professionals would be available for jobs and that will definitely lead to unrealistic inflation of salaries amongst health professionals

Since this note is about the healthcare in the country , I would also like to add that, we must look at setting up a TAB ( Technology Adoption Board ). India must not import technologies simply because GE / Siemens have



produced it and it is the latest. Technology is one of the major cost drivers for healthcare . TAB must ensure that the technologies that have demonstrated positive impact on the treatment compared to its cost and accuracy of diagnosis should only be allowed in practice . In 2007 , a 64 slice CT Scan was the most advanced , now it is 914 slide CT scan . The question is what is the difference in cost and accuracy of diagnosis compared to the earlier versions ?

Also, MOHFW should set up ICE – Insitute of Clinical Excellence to formulate and work on clinical pathways & protocol based treatment for all major illnesses , so that the doctors do not resort to expensive and arbitrary line of treatment at the cost & care of patient . A protocol based treatment would let all the stake holders in the continuum of care to work in close coordination

Also, the time has come to move to a greener healthcare system. I hope that we will learn from the MEA ( Ministry of External Affairs ). When you apply for a passport , the passport office gives you two or three receipts , one for the passport application fees, second for jumbo passport ( if you opt for ) and a third one for tatkal category ( if you fall under that category) . I fail to understand that, would it not be better to have one receipt with multiple options for ticking !! It wastes paper , ink and generates three times the heat and noise printing three receipts . MOHFW needs to ensure that we move to a Mobile Health Record system (MHR ) that does not depend on paper . Mobile phones could carry all the records, and more so , when most of the people are likely to carry mobiles. Providers could sync all the medical records with SIM cards. But the success of this depends on the will of the policy makers, honesty and efficiency of implementers ( bureaucrats ) and literacy amongst users

Lastly, it is high time to check migration of our best brains & highly skilled manpower. We can build six AIIMS like buildings, but building institutions will be an onerous task in the current scheme of things, and this could well be the first test for NCHRH.

With some good leaders at the helm of affairs in healthcare , I am quite confident of the changes in healthcare for the benefit of the common man

I do hope that the recommendations are of some help. Incase, you need some clarifications or assistance , I remain at your disposal .

With best wishes

Rajendra Pratap Gupta
Email : office@rajendragupta.in

C.C.-
Shri Ghulam Nabi Azad, Union Minister for Health Family Welfare, Govt. of India
Dr.Syeda Hameed, Member , Planning Commission , Government of India
Shri Dinesh Trivedi, Minister of State for Health , Government of India
Sam Pitroda, Advisor , Prime Minister of India & Chairman, National Knowledge Commission .
Ms.K.Sujatha Rao, Health Secretary, MOHFW, Govt. of India
Dr.K.Srinath Reddy, President , PHFI, Government of India
Dr.Murli Manohar Joshi, MP.
Mrs.Sonia Gandhi , Chairperson ,NAC , UPA.
Rahul Gandhi
Dr.Sharat Chauhan, csharat@ias.nic.in / rshankar50@hotmail.com
Dr.Gautam Sen
Dr.Devi Shetty
Encl: note on healthcare reforms sent on 23rd November 2009.

eHealth & Adoption incentives

Adoption of e-Health



Today i was attending the Joint Round Table on Communication Policy – eHealth in India

I made a few comments and they were accepted by the Round Table, and will be presented to the Hon’ble Union Minister for Health , Dr Dinesh Trivedi & the Planning commission on Monday , 8th March 2010

My view was that if the government tied up with private players like TCS, Infosys , Cognizant ( or anyone ) and worked out a nationwide uniform solution for eHealth for the practising doctors and nurses , it could transform the healthcare system in many ways

The government can bear the cost of the software ( Entire solution- i am not a techie so cannot spell the exact terminology !! ) and give it free to doctors who wish to get on this platform within the next three years . This will help a faster adoption of the EMR or the eHealth platform . After three years , the doctors will be charged for the program on the market cost . Here the disincentive will work as the incentive
The government can negotiate the rate with the hardware vendors for doctors who wish to install the hardware. This way , the doctors will get a better deal
This eHealth can start with 40 metros and finally drive down to smaller towns and finally to every doctors
This will check fake doctors . As only registered / qualified doctors will be given login id / password . The patient can even identify the fake doctors
This will get the government the actual number of doctors working in India in each geography. This will help government map the ‘gap’ areas and post government doctors in those areas or initiate PPP in those select areas on priority
With the doctors details resting on the central database , i can simply SMS to a number and get the details of the nearest doctor to my pin code . Pin code mapping will get government and patient the correct picture of the practitioners in the area
Patient database can be used for patient education and immunization of children in an effective manner . Since patient’s medical and allergy history will be available , the medication errors will minimize to a large extent and the treatment will become more outcome and compliance driven .
Spurious drugs can also be tackled to some extent
Medical history / patient record can be made mobile / universally accessible
This will empower the patient for referral / changing his doctor . The patient might not be required to repeat the same tests if he changes the doctor in a short time , as all the tests might be available online for a similar treatment
My view is doctors are not adopting to EMR – eHealth, as most of the dealings are in cash and there is no record of how many patient the doctor sees per day. With this one uniform system , the government’s tax collection will zoom . Thereby making the entire policy change a zero sum game for the government . The government will make money by selling the software to doctors who come on this system after three years , and also by increased tax collection for recording each patient on the central database .

Worth adopting this !!

Rajendra Pratap Gupta

Email : office@rajendragupta.org

2010- The start of the India Decade

Happy New Year

I wish all my friends a very happy new year and a great decade ahead.

I truly wish that this decade becomes the ‘India Decade’ for the World, and we emerge as a great nation by 2020.

Best regards

Rajendra Pratap Gupta
India Decade Foundation
Email: office@rajendragupta.org
Mobile : +91 9223344542

Plenary address at the India Health Summit - Rajendra Pratap Gupta

Plenary address at the India Health Summit 2009, Rajendra Pratap Gupta, President, DMAI & Director, DMAA- The Care Continuum Alliance, USA

Dear Friends,

This is an interesting audience which includes policy makers and those who can influence policy makers. I have a short message for you all. I feel so great about our nation. The developed world has failed in healthcare, and fortunately, in India, we are starting to build our healthcare system. This is the time when we can have the strong fundamentals ingrained in our population health improvement model

According to Kaiser Family Foundation the healthiest 50 % of Americans account for just 3 % of the annual spending; the sickest 15 % represents nearly 75 %. Half of the spending goes to those 55 and over, a third to those over 65 and over. In Europe, the chronic care accounts for 70 % of the healthcare expenses.

Today, we are the youngest nation with an average age of approximately 26.5 years, 30 years from now; we will be the oldest nation. Also, that we will become older before we become wealthier.

At present, we are not able to provide healthcare to more than 65 % of our population, and we are growing in numbers and age both. If we don’t pay attention to preventive healthcare, our health systems will soon become over burdened, under-funded and outdated as well.

This sums up clearly that we need primary preventive care as the starting point for healthcare and secondary preventive care in the continuum of care. We have the best of tertiary care in India but preventive care is missing!!

I believe that the biggest threat to our healthcare system is our generation. Our ‘lifestyle’ will lead to ‘disorders’ that will become the ‘Chronic diseases’ for us, and ‘Genetic disorders’ for our very own next generation. It is a call to action.

I must reach out to you all the come and participate in the three Global campaigns that I am starting at the Disease Management association of India

1. Red Flag campaign - If you have BMI above 23. Work Hard. Did you all ever think that having a BMI at 25 is being at borderline and being predisposed to chronic risks!! Let’s try and get it at 23. A healthier India should be our goal
2. Blue Building Campaign – We have green buildings to conserve energy. What about conserving health and becoming more employee health friendly. let’s have blue buildings, where the employers are proactive about employees health
3. Eat more, Burn more campaign. Have the RDA for each lifestyle. Live happy, live healthy. If you eat more, don’t feel guilty and regret, just you need to work out a little more and burn the extra calories. Isn’t that simple.

Thank you.