Transcript UHC – What Gujarat Can Do

What Gujarat Can Do to implement
Universal Health Converge
Dr. Dileep Mavalankar
Director
Indian Institute of Public Health,
Gandhinagar
(join imitative of Public Health Foundation
of India and Gujarat Government)
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Structure of PPT
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What is UHC
What is the situation in Gujarat
How UHC can be implemented
Structures and processes needed
Conclusion / summary –
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What is UHC – “all health for all”
• Comprehensive quality health care is
accessible to all and at affordable cost
• Financial risk protection
• Equity and social justice
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High Leven Expert Group (HLEG) Definition of
UHC
“Ensure equitable access for all Indian citizens to health
services that are affordable, appropriate and of
assured quality.”
Health services to include promotive, preventive,
curative, and rehabilitative as well as Public Health
services that address wider determinants of health.
• Government being guarantor and enabler /facilitator
7/17/2015
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HLEG Guiding Principles of UHC
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7/17/2015
Universality
Equity
Non-exclusion and non-discrimination
Comprehensive care that is rational & of good
quality
Financial protection
Protection of patients’ rights that guarantees
appropriateness of care, patient choice, portability &
continuity of care
Consolidated & strengthened public health
provisioning
Accountability & transparency
Community participation
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HLEG Vision of UHC
7/17/2015
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Tentative list of Health Services
Preventive
Services
• Antenatal Care
• Immunization
• Growth
Monitoring
• Screening for
Cancer
• Screening for DM
• Screening HT
• Ambulance
Services
Curative Services
Promotive Services/
social determinants
• Outpatient care
• Emergency
Services
• In-patient Services
• Delivery Services
• CEmOC Services
• ICU Services
• Surgical Services
• Safe Drinking
Water
• Nutrition Services
• IEC service
• Tobacco Control
• Yoga
• Counseling
• Anti Vector
Measures
Situation in Gujarat
• Mixed health care system – following national
norms – Sub-center, PHC, CHC, DH, and MC
• New medical colleges and nursing colleges are
being opened – annual out put increasing
• Rapidly expanding private and corporate sector
• Small and committed NGO sector
• Health indicators – MMR OK, but IMR needs rapid
improvement,
• More use of private sector for curative care and
preventive care by public sector
• Untreated disease leads to avertable death and
disability - Out of pocket costs lead to poverty –
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• Chronic shortage of medical officers in public
system in primary care. Severe shortage of
specialists
• Old teaching hospitals are full with patients – but
CHC – PHC are underutilized
• Big and growing pharma industry
• Good roads and transportation,
• reasonable water, electricity situation
• Rapid economic growth but huge disparities
• Strong leadership & stable government is a big
plus for Gujarat
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UHC can be implemented by three
approaches
1. Incremental approach – starting from current
programs/ schemes and expanding them
2. Massive Strengthening of public system and
reorganization to replace private care for the
poor and middle class
3. De novo – radical approach – developing totally
new UHC and subsuming all the schemes in
them.
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1. incremental approach :
Strengthening existing programs
• Review of existing schemes – to see how coverage can be
increased and solve problems
• Eg: Chiranjeevi and Balsakha – how to expand the coverage to
100% of poor and tribal.
• Next step is to expand to non-BPL but still poor – bottom 50%
to 60% of the population as they also need free services
• MA scheme – expand the procedures covered – and include
all surgeries, and then expand to include medical admissions –
• Upgrading RSBY to include outpatient care and more
population beyond BPL by paying more premium
• Modifying and expanding ESIS – extending to self-employed
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2. Massive Strengthening government
health system and reorganization
• Decongest medical colleges / specialist units – have large
number of GP clinics in CHC, District hospital and Medical
colleges – only referred cases to be seen by specialists
• Offer free medicines and full care with no out-of pocket
costs at government hospitals and clinics
• Link staffing of health center to work load – put 3-4
doctors and 4-5 nurse in each busy PHC, medicine
allocations to be increased by 4-5 times
• Welcoming attitudes – training, roles and incentives
• People will shift from Private to Public if good quality care is
available/ accessible – there is no inherent liking for private
• Make Asha into “village health worker” – with curative and
preventive role – train ANM in to community health nurse
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3. De Novo – UHC scheme
• Start new scheme designed to provide UHC –
– Define what population to cover – only poor, bottom
60% or all
– What services to offer – in-door, out door. Primary,
secondary, tertiary level
– How the services will be delivered – Public – private or
a mix
– How the program will be funded – tax based or social
insurance based or a mix
– How it will be managed – by govt, independent
agency of govt, private agency …..
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Innovative solutions to long standing
problems in health system
• HR – staffing
• Logistics management
• MIS and monitoring
• Financing 14
HR: Set up public health and hospital
management corporation to staff key
positions and manage large hospital
and UHC
• Professionally managed Human resource system
• Corporation to recruit doctors, public health
officers and health managers to staff and manage
the health services – higher wages – low security
of Job – performance linked payments
• Provide better employment conditions in
government / corporation so that doctors do not
want to start private practice
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Logistics and infrastructure
management Agency
• Professional to mange drug and supplies
• Building management to be outsourced
• Adequate funding – smooth systems
• Regular maintenance and up-gradation
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Office of contracting / contract
management
• Lot of services can be purchased from private /
NGO sector – doctors, labs and hospitals –
“contracted-in” services
• These contract will be large and will need technoprofessional management to ensure efficiency
and effectiveness
• Pricing, quality and monitoring outcomes needed
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Office for financial management
• 4-5 times the amount of money will have to be
managed to provide UHC
• How to raise the money and disburse it
• Proper accounting and auditing
• Smooth flow of money
• Fraud checking
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Technical Management office –
What services to provide / buy
• Evidence compilation
• Standard treatment guidelines
• Cost effectiveness analysis
• Costing of service packages – Units…
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Office of preventive, promotive and
educational services
• To cover all non- curative aspects
• Behavior and habit changing in the community
• Health education and promotion – mass media
and inter-personal communication
• Life-style modification and diet
• Tobacco and alcohol control….drug abuse
• Social determinants – water / sanitation.. housing
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What steps & structures
will be needed
• Well documented plan and administrative
commitment in terms of government proposal, notes
and approvals.
• Top level political commitment to allocate resource
and fix problems.
• Fund allocation – 3-4 times current allocations over
next 5-7 years
• High powered office – headed by a senior bureaucrat
of the level of Chief secretary ( may be ex-chief
secretary)
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Consultative processes and data are at
heart of the development process
• Technical unit to work out the packages, contracts and
monitor technical aspects
• Drugs and logistics unit –
• Financial unit to disburse money and do audits
• Planning and monitoring unit
• Communication, community contact and marketing
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Moving Towards by UHC by
2022
Universal Health
Coverage Intermediate situation where SOME services are
provided free of charge to
ALL the population
Current situation most services are paid for by
individual households through
direct out-of-pocket payments
where MOST of the
services are provided
free of charge to ALL
the population.
Success will depend critically on
• Champions with in and outside government
• Real collaboration between public and private
sector
• Astute financial and quality management
• Problem solving and fraud checking
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Gujarat Must take lead in
implementing UHC in India
the cost of not doing UHC is
very high in terms of human
misery and economic impact
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