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AMCHAM 2nd ConferenceHealthcare equity in India: Keychallenges and enablers
Hyderabad, September 20th 2014For discussion purposes only
1
India
S. Korea
Bangladesh
Thailand
SriLanka
Brazil
Bangladesh
SriLanka
Brazil
S. Korea
Thailand
India
1950 Today
The great Indian growth story subdued by the healthcarerealities
1950s
Today
21.0*US$ bn
1,876.8*US$ bn
~ 90 times bigger economy today and among top10 nations in the world by GDP (nominal)
Poorly ranked healthcare systemin the world
Nominal GDP numbers; 2014 GDP from World bank; 1950 estimates from Ministry of Statistics and Programme Implementationhttp://en.wikipedia.org/wiki/Economic_history_of_India#GDP_estimate; healthcare rankings from http://timesofindia.indiatimes.com/india/India-in-healthcare-hall-of-shame-ranked-worst-among-peers-and-neighbours/articleshow/18805659.cms and WHO ratings
2
Beneficiary of healthcare
~31% of population withaccess to
• ~ 70% of care infrastructure
• 4 lakh doctors accross 120 cities1
• multiple formats of care delivery
~ 69% of the population with
• 30% sub centres, 36% PHCs2
functional
• limited available manpower3
only 24% of doctorsonly 47% of nursesonly 12% of specialist doctors
• # PHCs w/o a single doctor : 2,5334
Unaddressed and the underservedAccess to care: 31% of Indianpopulation outweigh the rest
1. http://www.moneycontrol.com/news/cnbc-tv18-comments/ims-survey-reveals-skewed-doctor-density-across-india_929890.html
2. McKinsey report on Indian Healthcare3. Why Are India’s Young Doctors Refusing To Serve in its Villages –
Yahoo News 23 Aug 20134. http://www.tenet.res.in/Publications/Presentations/pdfs/Healthcare_in
_India.pdf
The realities to be addressed sooner…...
3
…. as Indian healthcare is at the cusp of fighting ‘the today’, yetneeding to gear up for ‘tomorrow’
CD* &Vector borne
*Communicable Diseases
Water
Maternal & child
NCD,lifestyle related
DemographicShift
Otheremergencies
4
HealthcarePenetration
Populationreach
Conditionreach
• Socially excluded sections• Economic vulnerable sections• Demographic vulnerable• Physical vulnerability
S
I
R
E
F
Screening
Identification
Referral
Enable
Follow up
• Gender based• Age related• Community based• Endemic• Acute & Chronic
The fight is relevant if and only if there is healthcare equity
5
Healthcare Policy: The steer wheel
Healthcare Financing: The fuel
Healthcare Delivery: The axle
Institutional Reforms Health Service Norms Monitoring and Governance Approvals & guidelines
Community Participation Human Resources for Health Health infrastructure Healthcare ICT Quality of care
Financial adequacy Financial Protection Sustainable financing mechanisms
Enablers to make the 3 dimensional approach a reality
6
Assurance of quality care for all
Uniform accreditation and licensing mechanism
Define governance mechanism to monitor and track care outcome
Facilitating private participation in care policy and delivery
Accessibility
Availability
Affordability
Awareness
Acceptance
Accountable
Theimmediate
TheNext Dos
Policy: The healthcare policy to address certain contingentfactors of healthcare equity and saturation
7
61.6%
38.9%Low
incomecountries
WorldMedian
India
32.5%
46.6%
Government Out of pocket• RSBY
• Rashtriya ArogyaNidhi
• CGHS
• ESIS
• Yeshasvini Co-operativeFarmers Health careScheme, K’taka
• Rajiv Aarogyasri, AP
• Vajapayee Arogyasri ,K’taka
• Apka Swasthya Bima YojnaDelhi
30.5% 60.0%
• ~ 1/3 of Indianpopulation iscovered**
• Prepaid healthinsurancepenetration inIndia @ ~ 4%**
Central Schemes
State Schemes
Financing: Non adequate & scattered Government financing -stretching the out of pocket pay for care in India
Expenditure as a % of total spend on healthcare*
* WHO World stats 2014 report. Data from 2006-2012 average; ** Healthcare financing stats from WHO Worldhealthcare stats 2014
Indicative schemesnot exhaustive
8
5%
23%
54%
14%
44%
217%
Total spend by the poor per episode as a % ofaverage House hold expenditure*
Spending by poorfor healthcare
Acute care
Chronic care
OPD treatment
IPD treatment
Acute care
Chronic care
IPD treatment
OPD treatment
Gov
t.Fa
cilit
ies
Priv
ate
Faci
litie
s
Financing: Lack of apt financing can be taxing for the poorand it’s time India develops a formal care financing model
* Understanding the health care access in India- IMS health consulting report 2013
9
Financing: Surprising examples present a key learning forIndia: Transition to a centralized integrated insurance model
Social insurance modelin Thailand*
a. Integrated and centralized insurance model
b. Covers 48mn beneficiaries i.e.~80% of thepopulation
c. Comprehensive package that covers preventiveservices, promotive, ambulatory and inpatient care
a. ~ 88,000 households were prevented from fallingbelow the poverty line (4-5 years since inception)
b. Well-controlled diabetic patients increased from12.2 to 30.6 per cent (4-5 years since inception)
c. Well controlled hypertensive patients increasedfrom 8.6 to 20.9 per cent (4-5 years since inception)
Universal health coverage"Mutuelles de Santé** - Rwanda
a. Integrated and centralized insurance model
b. Preventive and curative packages
c. Maternal and child, HIV care given moreemphasis
a. Only country in Sub-Saharan Africa on aprogressing to meet MDG by 2015
b. Life expectance rose from 28 to 56 years
c. HIV prevalence maintained at only 3percent for the last 7 years
* VOLUME 18: Successful social protection floor experiences by Thaworn Sakunphanit Worawet Suwanrada; ** http://www.csmonitor.com/World/Africa/2013/0327/In-tiny-Rwanda-staggering-health-gains-set-new-standard-in-Africa
10
Financing: While best practices can be explored, Indiacan potentially look at a tiered approach
Fina
ncia
l sec
urity
& In
com
e
High
Low
Stat
e H
ealth
Sch
eme
High
Low
Informal sectorPoor and Low incomeclass
Middle and workingclass
The RichFringe benefits from
state
Social insurancethrough contributory
approach
Apportion tax moneyapproach
Economicclass
Potential insuranceapproach
Recreated and contextualized representation; original from Social Security guidelines by JICA
11
5+ KMs
5+ KMs
OPD
IPD
62.5%
34.0%
Staff absent on atypical day**
40 to 44.5percent
Percentage of ruralPopulation*
DoctorsOthermedicalstaff
Accessdenial
Accessdenial
Availabilitydenial
Availabilitydenial
Delivery: The poor, especially in the rural areas face myriadchallenges of care availability and accessibility……
* Understanding the health care access in India- IMS health consulting report 2013** http://m.aljazeera.com/story/20147308234358102
12
INDIA
HospitalBeds Doctors
WorldMedian
9.0
Nurses
WHOThreshold
7.0 17.1
23.0 23.0
28.428.0-30.0 12.8
ShortagePer WHOthreshold(As on date)
~ 1.2mn ~ 7,00,000
… and it’s an enormous task for the Government alone toaddress the challenges
Per 10,000Population(2013-2014)
19.0
Sufficient
http://www.who.int/hrh/fig_density.pdf?ua=1; 2014 WHO Healthcare statshttp://archive.indianexpress.com/news/india-has-1-govt-hospital-bed-for-879-people/1159306/
13
Delivery: ICT platforms can play a pivotal role in bridgingthe gaps in care availability and accessibility
Re-
imag
ine
Re-
engi
neer
Incremental
Purposive disruption
Care Transparency+
Care Traceability=
Care Accountability
Efficiency
Effectiveness
Expansion of care availability
Reduction of care costs
Business model innovation
Benefit Change
The dual benefits of ICT platforms in healthcare
14
Health InformationHelpline
Re-imagine thepurpose ofcommunication
Healthcare informationaccess 24 hours,365 days
Covered 416mnpopulation
Care advices providedfor 26mn incomingcalls
Mobile HealthUnits
TelehealthModels
Re- engineerthe services
GPS tracking andunique beneficiarytracking ensuredefficient care outreach
Covered 45mnpopulation
Addressed 13.5mncare seekers
Re-imagine the teleconference platforms
Specialist care and
second opinion access
Change Impact on Care delivery Outcomes (Inception – till date)
Delivery: Case in point - Piramal HMRI leveraged ICT enabledcare delivery platforms through PnPP models
Screening / diagnosisof at least 5 chronicconditions
Care in neighbourhood to2Lac rural population
15
Piramal HMRI Experience: A snapshot of ‘on the ground’care delivery
A Mobile Health Unit passing through difficult terrains toaccess beneficiaries in Assam
A pregnant woman receiving medical advice via teleMedicine in Adilabad, Telangana
Pregnant women board ‘Mobile Unit to reachtelemedicine centre for consultation in Andhra Pradesh
Trained executives attend to basic healthcare queries in ahot line centre in Hubli, Karnataka
16
What facilitating role should policyaim and in what direction
What integrated framework is requiredto manage the overall ecosystem
What new integrationapproaches need to be developed
Where is the unused potentialand how to unbundle
Which components need support
How will the human resourceshandle ICT platforms
What areas of skills/training need tobe developed
GovernanceMonitoring & evaluationLegal, technical frameworks
Mobile networkInternet connectivityData compatibility
Device manufacturersTech. playersTelecomNetworkersImplementersFinancersProviders
DoctorsNurses, ANMParamedicsHealthcare workers
Critical factors for success of ICT enabled healthcare delivery:Our observations
What hybrid and innovativemodels need to be developed/deployed
How to speed up projects/players fromsuccessful pilot to scale
What optimum mix and scale need to bedeveloped for reducing costs
17
1. Telemedicine Act
2. National standards & State guidelines• Electronic records
• Standardization of devices (POC/rapid diagnosis)
• Clinical data mgmt., data compliance & integrity
3. ICT infrastructure• Rural focus
• Unbundling and optimal use of existing infrastructure
4. Healthcare delivery model (esp Primary healthcare)• Focus on PnPP models for primary care delivery
• Single window clearance for healthcare PnPP projects
• Level playing/preferential access for pioneers during RFQ/Bidding
5. Fostering innovation• National level fora/platforms to contextualize new ICT platforms for care delivery
• Pioneers/inventors/industry to get a representation in planning and execution of new models
• National seed funding for ICT enabled healthcare pilot programmes
6. Capacity building of Health human resources (esp. last mile health workers)• State level platforms (with industry participation) to train manpower
• ICT enabled care delivery leveraging e-learning, voice based learning, podcasts etc.
Key areas of ICT enabled care needing attention
18
Tomorrow transformed: Enabling model for equitable care inIndia
Government
Public healthFacilities PnPP/ PPP
Facilitators
Augment
Compliment
Last milereach
Private
Androiddevices
Helpline
Out reach throughICT Disruption
MobileAccess to careintervention
Access to careintervention
Direct to home
Chartdependencies
• Policy 80% contemporary, 20% futuristic• Role as a provider, insurer, enabler, governor Accommodating Private
in care policy
Createaffordability
19
Piramal Swasthya is a registered non-profit organization based in Hyderabad, Telangana State. Piramal Swasthya is supported by PiramalFoundation and works towards making healthcare accessible, affordable and available to all segments of the population, especially those mostvulnerable. In order to achieve this goal, Swasthya leverages cutting edge information and communication technologies to cut costs withoutcompromising quality as well as public-private partnerships to scale its solutions throughout India and beyond.
Swasthya envisions a future in which all vulnerable groups have the necessary information to make informed decisions regarding their healthand affordable, available and accessible high quality health infrastructure to support the realization of those decisions.
© Piramal Swasthya All Rights Reserved