What Gujarat Can Do to implement Universal Health Converge

1. What Gujarat Can Do to implement Universal Health Converge Dr. DileepMavalankar Director Indian Institute of Public Health, Gandhinagar (join imitative of Public Health Foundation of India and Gujarat Government)

2. Structure of PPT • What is UHC • What is the situation in Gujarat • How UHC can be implemented • Structures and processes needed • Conclusion / summary –

3. 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

4. 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

5. HLEG Guiding Principles of UHC • 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

6. HLEG Vision of UHC

7. Tentative list of Health Services Preventive Services Curative Services PromotiveServices/ social determinants • Antenatal Care • Immunization • Growth Monitoring • Screening for Cancer • Screening for DM • Screening HT • Ambulance Services • 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

8. 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 –

9. 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

10. UHC can be implemented by three approaches • Incremental approach – starting from current programs/ schemes and expanding them • Massive Strengthening of public system and reorganization to replace private care for the poor and middle class • De novo – radical approach – developing totally new UHC and subsuming all the schemes in them.

11. 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

12. 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

13. 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 …..

14. Innovative solutions to long standing problems in health system • HR – staffing • Logistics management • MIS and monitoring • Financing -

15. 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

16. 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

17. 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 techno-professional management to ensure efficiency and effectiveness • Pricing, quality and monitoring outcomes needed

18. 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

19. Technical Management office – What services to provide / buy • Evidence compilation • Standard treatment guidelines • Cost effectiveness analysis • Costing of service packages – Units…

20. 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

21. 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)

22. 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

23. Moving Towards by UHC by 2022

24. 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

25. 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