Essential Health System Design Innovation – A Speech by Dr. Nachiket Mor at the TB Diagnostics Conference in Bangalore, India

By Nachiket Mor, Member, Board of Directors – ICTPH
August 25-26, 2011; St. John’s Research Institute, Bangalore, India

Executive Secretary, Stop TB Partnership, Dr. Lucica Ditiu; Deputy Director, Tuberculosis, Bill & Melinda Gates Foundation, Dr. Peter Small; and distinguished conference participants, it gives me great pleasure to be here. I want to begin by thanking Dr. Madhukar Pai for inviting me to participate in this very important conference and for asking me to share my thoughts about the changes that would be necessary in the overall health systems design if we are to succeed in providing high quality health care to our citizens and benefit fully from the innovations that are going to be discussed here over the next two days, given the extremely limited resources we have at our command as a nation.

At over 3 million square kilometres, stretching 3,000 kilometres from one tip to another, in both directions, with a population crossing 1.2 billion individuals living in over 600,000 habitations, India is one of the largest countries in the world. Some our districts have populations that are comparable to entire countries. For example, Burdwan District of West Bengal at 8 million has a population comparable to that of Bolivia in Latin America. The resources at our disposal are extremely limited however. On average, as a country, we annually spend Rs.2500 or $55 per capita on healthcare with the government spending only about Rs.500 or $11 per capita. This is a miniscule number when compared with a developed-nation average of $5,000 per capita and is smaller even than the amounts being spent by our neighbours China and Thailand who both spend over $150 per capita on health care with, in the case of Thailand, over 75% of that being borne by the government. Unfortunately our problems do not end here. We have a very low supply of physicians that are qualified in allopathic medicine and the few that are qualified are unwilling to serve in remote and challenging locations. Our disease burden continues to have a high proportion of infectious diseases such as tuberculosis but we have, over the past few years, become conscious of a large burden of chronic diseases as well.

Given these debilitating limitations is there any hope at all of us offering even a reasonable quality of healthcare to our citizens or are we, as it were, dead in the water? I am a member of the Government of India’s High Level Expert Committee on Universal Health Care and, while the report of the Committee is not yet final, I believe that we will end up reaching the conclusion that it is indeed possible for India to offer good quality healthcare to all her citizens even within the modest means available to her. However, the Committee will also, in all likelihood conclude that this will happen if and only if a number of radical changes are made in the manner in which healthcare is financed and provided. I do not speak for the Committee today and nor am I at liberty to discuss the recommendations that they will make. However, I am keen to share with you some of my own thoughts on how this might be achieved. I have the good fortune of being associated as an independent Board Member, with the IKP Centre for Technologies in Public Health, led by Dr. Zeena Johar, who is in the audience today and will be sharing her thoughts with you at the 2:00 pm session tomorrow. Most of what I have to say today has been drawn from their research work in health systems design.

It is important to realise, as many countries have done earlier, that the foundation of a sound healthcare system is the Primary healthcare system. And that high quality Primary healthcare must be available very close to where people live. In addition, higher levels of care, while very easily available and accessible to citizens, must be closely integrated with Primary care and focussed on the whole individual and that financing, risk sharing and referral mechanisms must all act in concert to ensure that this happens. Spain in the developed world and Thailand in the developing world are health systems models where this vision of healthcare has been most fully realised and it is not surprising that on many indicators their health systems have been rated as the best in the world. The research work being carried out at ICTPH is dedicated to developing viable models for making this vision a reality in the Indian context.

In ICTPH it is our view that while viable solutions do exist they need to be found with multiple components of design working closely together. It is also our belief that while India has done a relatively good job of addressing challenges at the secondary and tertiary care level, as evidenced for example by the growing medical tourism industry, on the twin dimensions of provision of Primary care and integration of care across higher levels, we have a long journey ahead. The focus of ICTPH’s work is therefore on these two dimensions. In our view, clever human resources strategies, advanced point of care diagnostics, health management information systems, and expert architectural designs, by themselves will not be able to address these challenges but, when combined together in interesting ways, they have the potential to dramatically transform the provision of Primary healthcare and the integration of care across levels. Our research work examines health systems along four complementary dimensions:

  1. Human Resources
  2. Infrastructure
  3. Interventions
  4. Financing

On the human resources dimension we believe that the vast pool of Ayurvedic, Unani, and Siddha practitioners, who, the Supreme Court has confirmed, are legally permitted to practice allopathic medicine, can provide the field force that is necessary to provide comprehensive primary care, including vision, dental and mental healthcare. They are available in a reasonable number; their supply can be increased relatively quickly; their compensation expectations are modest; and most importantly, they are willing to serve, if compensated adequately, in the remotest of rural locations. However, mere recruitment and placement of these physicians will not in and of itself deliver on the vision of high quality healthcare. Several other components would need to fall in place, including comprehensive field and classroom based training and re-certification of these physicians in allopathic medicinal practice; strong technology-facilitated centralised audit and control by senior physicians who are formally trained in allopathic medicine; recruitment and intensive training of locally resident health extension workers who have the capacity to assist the physician; and a full development of the other three components of the ICTPH Health Systems Design.

On the infrastructure dimension, in our view, there is a need to begin with the very architecture of the health facility which is low cost, easy to clean, warm and welcoming, and wellness focussed, which is co-located with public buildings such as local schools and becomes a part of the daily life of the community, not just when people fall seriously ill. In addition, there is need for very advanced technological infrastructure to be available at the health facility including a strong health management information system; computers, mobile phones, and Tablets which are used to geo-tag and risk-profile each member of every household in the community, even before the healthcare facility becomes operational; and very importantly, advanced point-of-care diagnostics. The Health Management Information System will allow physicians to keep track of their patients; identify those patients that are at high risk of disease and follow them closely; facilitate real-time audit by a centralised team; and once referral happens to a higher level of care then make available the full-history of the patient to the secondary and tertiary healthcare provider; and conversely keep a close track of the care being provided for necessary follow-up and monitoring once the patient is discharged. On the issue of diagnostics, since the room is full of experts and innovators, I want to take this opportunity to leave a specific thought with all of you. Given an annual budget of say $33 per capita for the total provision of healthcare, the amounts available for primary care will at most be $15 to $17, with more than half of that to be reserved for medicines and most of the rest for salaries. With these low amounts, even diagnostic tests that cost $1 are far too expensive. Diagnostic procedures are needed whose costs, at the population level, can go as low as $0.10 to $0.20. It is our belief that this can only be done if diagnostic solutions are built which may require more money to be spent on fixed capital costs but have negligible variable costs. Since India has a large population base the fixed cost will amortise very quickly and allow us to offer diagnostic procedures even free of cost if necessary. However, unfortunately, most times we are shown solutions, which have been designed keeping a strong capital constraint in mind and therefore have very high variable costs which, even with very high volumes, do not fall significantly, making the solution unaffordable.

On the interventions dimension, in our view, given reduced familiarity of the front-line physicians with allopathic systems of medicine and the very wide range of services that are sought to be delivered, development and implementation of very clearly laid down protocols for all treatments is absolutely essential at the primary care level. This provides clarity to the physician and makes it possible for formal audit and control procedures to exercise a very high level of discipline. In our experience, without this clarity which is combined with tight control, even very experienced physicians start to make mistakes or become in attentive to all the necessary details. In the ICTPH Health Systems Design the process of enrolling a household; carrying out a rapid-risk profile of each member and giving each one a unique identity card; and offering them promotive guidance and preventive or curative treatment, are all sought to be clearly protocolised so that there is no scope for error and an Atul Gawande style “Checklist” environment is created. We have thus far rolled out curative protocols for all the major illnesses we encounter in the field as well as preventive protocols for Cardio Vascular Disease, Diabetes, and Women’s Health, which includes a detailed protocol for Cervical Cancer.

The work on financing seeks to address two principal questions: (a) how to augment the financial resources available for healthcare in the face of government reluctance to spend beyond $11 per capita in a manner that leads to optimum consumption of healthcare by every member of the community and (b) how to ensure that payments for higher levels of care are effected in such a manner that the focus of attention remains the wellness and wellbeing of the patient. In our work we hope to experiment with a number of models including fixed price healthcare, zero consultation fee for all patients, and zero total cost for all high risk patients. Challenges of identification of low income households as well as the presence of high levels of “in-home” poverty are the ones we hope to find solutions for through this work.

ICTPH at the moment works closely with one field based partner in Thanjavur to field-test many of its ideas. Over time we hope to expand the number of engagement partners. On the research and training front we have thus far partnered with the University of Pennsylvania School Of Nursing, University of Washington’s Brown School of Social Work and Public Health, the Adyar Cancer Institute in Chennai, and the L. V. Prasad Eye Institute in Hyderabad. It is our firm belief that our work and that of several other pioneers in this field, such as Dr.Abhay Bang in Home Based Neonatal Care and Dr.Vikram Patel in the provision of mental healthcare in primary care settings, will gradually allow us to move closer to a vision of universal and high quality healthcare for all the citizens of India within the financial and human resources available to her.

Thank you once again for inviting me to speak to you today. My colleagues and I will very much be here for the next two days and hope to catch up with you and get your feedback and support for our work.

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