Universal Health Coverage (UHC)

image The essays on the proposal for Universal Health Coverage (UHC) in India are consolidated in a pdf here. UHC CONSOLIDATED DOCUMENT revised and updated

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Universal Health Coverage Part III: Funding and HLEG Recommendations

                                         

Cooperative action on UHC dissolves on the subject of funding. The objections are easy to comprehend. First, no one wants to accept the burden of another’s rights without the guarantee of responsible utilization (a contributor to spiralling costs) and second, confidence in government’s efficiency with public spending is, at best, reluctant. This is especially so in India where gross income inequality is prevalent, the middle class is already burdened by high taxation and governance is mindless of transparency and/or accountability. In most public funded schemes and corporations, inefficiency, wastage and pilfering are the norm. This institutionalized corruption makes it extraordinarily difficult to ensure the success of well planned and well intentioned schemes, most of which predictably fall by the wayside.

Healthcare costs are affected by a dual set of opposing constraints: affordability and direct payments. The affordability accorded by insurance will spur utilization of the service which then loops into more spending. Contrastingly, a system with a diverse and fragmented purchase model for the same service is hard to regulate, is open to price manipulation and compromises on practice standards. At least, utilization has the benefit of improved outcomes and can also be manipulated to some extent by behavioural modulators. On the other hand, direct, out of pocket, payment has a negative influence on outcomes.  It brings lack of affordability (forcing avoidance of care or worse, denial of care), straight to the heart of health system failure.

Methods of financing:

Countries that have demonstrated successful financing of UHC share these features: 1) pooled public funds as the dominant source of financing and, 2) a universal and mandated health coverage. An optimal financing system incorporates pre-payment, pooled risk and cross-subsidization as critical elements. Commonly used methods of public financing include a combination of taxation, government revenue allocation, innovative financing and donor support. These are highlighted below in Table 1.

Financing methods

 

Comments

1.       Taxation

Is the commonest method by which public health insurance is funded around the world. The best example is NHS in the UK.

Must be accompanied by increasing the efficiency of tax collection. Indonesia has demonstrated great success with tax reform

 

2.       Reprioritising public expenditure

See text for detail

Countries that have demonstrated success with reallocation are Tanzania (now spend 18.4% on health) and Liberia (16%). Figs include donor funds.

Indonesia has been able to finance UHC for all its citizens by reducing its enormous $25 billion fuel subsidies by 1/3

3.       Innovative financing

The Philippines has demonstrated success with financing UHC with sin and sumptuary taxes on tobacco.

WHO’s suggestions for India include:

·         Foreign exchange transactions: A .005% levy on the daily turnover of 34 billion USD will yield 370 million USD

·         Diaspora bonds

·         Solidarity levies (e.g: mobile phone calls)

·         Sin and sumptuary taxes

4.       Donor funds

Need for countries to honour their commitment pledges to ODA (official donor assistance). In this regard, a recent paper on India’s high  contribution to global aid in the face of its own neediness, makes for interesting reading: http://bit.ly/XRiIrZ

 

                                                                                                                                   Table 1: Financing methods

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Expanding on the need to re-prioritize government expenditure: Do we have the money? The first step in planning outlay is to assess the per capita costs. WHO recommends that for UHC to be operational by 2015; LDC’s must raise the per capita spend on health from 32 USD to 60 USD. The recommendation includes infrastructural investment cost. Current per capita public spending is Rs. 675. HLEG recommends raising it to Rs. 1975 by 2017. Both figures are well below the recommendation.

Current health spending:

A comparison of the percentage total public spending in India versus that in neighbouring countries that have recently adopted UHC as an agenda for progress, (Sri Lanka, China and Thailand) throws light on interesting facts. India leads all these countries, in total public spending, by more than 10%. Current figures stand at 34% for India while the other three are in the range of 22-24%. Yet, the allocation, from this, to health is 3-4% in India and 7-14% for these other countries. Health in India is pathetically underfunded and ranks amongst the lowest in the world (Table 2). The numbers confirm, in stark and simple terms, what is common knowledge. That, underfunding is not due to a lack of resources; it is that health has always remained a low priority sector with the government. Public money is routinely allocated to schemes that are considered more populist than health, irrespective of the success of those initiatives. Neighbouring countries, by comparison, appear to be more fiscally conservative. It is important to note that increasing the allocation to health from the pool, only needs a re-prioritisation of extant public spending; away from wasteful schemes and to health.

States contribute close to 65% of total health spending. The rest is supplanted by the Centre; but, central allocation is not proportionate to a state’s resources and is largely equal across the board. This further constrains the capability of poor states. With the exception of Gujarat, UP and Bihar; all other states recorded a reduction in health spending between 2001-2008.

Private spending comprises the bulk (2/3) of total spending on health. 86% of this is from direct payments (out of pocket). More than 70% of private spending is on out-patient care and drugs. Private insurance is still a nascent sector (1.1% in 2006), but, has recorded rapid growth in recent years. Coupled with a slew of public insurance schemes, more than 25 per cent of the population (2010 figures) have access to some form of health insurance (19% public and 6% private). Table 2 is a gross overview of health spending; the figures are from the HLEG report.

2009 figures

 

India

China

Total Health expenditure as % of GDP

4.5%

4.6%

Total Public Health expenditure as % of GDP

1.2%

2.3%

Total Private Health expenditure as % of GDP

3.3%

2.3%

 

 

 

 

Total public spending

33.6%

22-24%

% Total Spending on Health

 

 

% of total public spending on health

Only 9 countries (out of 191) spend less than GOI on health

4.1%

10.3%

 % of total private spending on health

67%

 

 

 

 

 

Per capita spending

 

 

Total per capita public spending (in Rs.) on health

Center (1/3) : 220

State (2/3): 475

675

 

Total per capita private spending on health

1825

 

 

 

 

 

Private spending on Health:

 

 

% out of pocket payment

86%

 

% of total population covered by private insurance (‘10 data)

6%

 

                                                                Table 2: Health spending overview

 

HLEG recommendations:

Successful financing of a behemoth like UHC will require providing for adequate revenue resources and projected planning for increased utilization necessitating higher spending in coming years. The HLEG report suggests the way forward with a series of recommendations. These are summarized in Table 3. Note: Comments are with specific reference to these recommendations. An alternate model for UHC is discussed in a follow up article.

Recommendations

 

Expanded notes

Comments

Recommendation 1:
Increase public spending from 1.2% to 2.5% by 2017 and 3% by 2022
(Figs are as percentage of GDP)

 

 

Only nice countries (out of 191) spend less on health than India

1. Secure funding sources by compulsory pre-payment and, pooling of resources and risk

2. Private (out of pocket) spending is currently 3 times higher than public spending. With the proposed increased allocation, this ratio will reverse even if the total health spending stays at current levels of 4.5%

3. For UHC to be a successful initiative it has to be both compulsory (to eliminate the sinkhole of adverse selection) and subsidized.

As seen in Table 2 total public spending is already high at 34%. UHC needs a committed reprioritization  of resource allocation to health

The timeline needs to be advanced. For UHC to take root the planned outlay should be disbursed over the next three years

Recommendation 2:

Ensure availability of drugs by increasing spending on drug procurement

1. Increase public spending on generic drugs for government hospitals from 0.1% to 0.5%

2. Pooled public procurement system

UHC should cover all IP and OP drugs; government should strictly negotiate prices to package rates, provide free access to drugs and services and include a prescription plan reimbursable at any pharmacy.

Private pharmacies, for a fee, can own and operate their franchises within the public health system.

Recommendation 3:

Use general taxation as the principal source of revenue generation

1. Tax-GDP ratio in India is very low @ 15% . Lower than most other countries with per capita income less than 1000 USD

2. General taxation in order to include the unorganized sector

3. Improve tax productivity

4. Enhance revenue productivity of tax with other sources – DTC and GST and payroll tax

Mere taxation without improving the efficiency of collection is an anachronism. The system for improved and effective collection must be structured with full and free transparency and accountability.

Recommendation 4:

Do not levy sector specific financing

Reasons for the recommendation:  it is not going to significantly alter financing and that earmarking from one sector might be offset by reductions in others

Disagree.  The WHO dubs this, ‘Innovative Financing’.

1.Other countries have shown success with this model. Examples include:  Annual charge on bank balance sheets in UK, VAT in Ghana, Mineral rental tax in Australia, taxes on petroleum products, and sin and sumptuary taxes on tobacco and alcohol in the Philippines

2. A 0.005% levy on foreign exchange transactions in India (daily turnover is 34 billion USD) would generate 370 million USD

3. The World Bank and the WHO recommends an increase of tobacco tax to 65% of the retail tax. India’s tobacco tax is at 38%; far lower than most other countries.

4. WHO studies in 22 LDCs shows a 50% increase in tobacco excise tax would yield revenues close to 1.42 billion in sin and sumptuary taxes

5. Other financing avenues: telecom, tourism and carbon taxes

Recommendation 5:

To not levy user fees of any kind under UHC

User fees (out of pocket, point-of-care fees) are responsible for non-utilization of health services and add an extra burden of administrative costs with questionable revenue benefit

Agree

Recommendation 6:

Equalization of cash transfer by the Centre to low per capita income states in order that the entitlement is equitable

Low capita income states have poor health indicators that need high health expenditure but typically have low health spending

The resource allocation from the Centre is not meant to substitute but to supplant pre-determined health spending in the state budget as additional funding

Agree; but should be performance and outcome based. An initial three year kick-start period should be followed after, as outcome driven incentivization. These states must be subject to additional audit of central funds

Recommendation 7:

The Centre should adopt a flexible and differential financing system for states

 

Agree

Recommendation 8:

Earmark at least 70% for Primary Health Care

Focus on prevention of disease and promotion of good health. Focus on maternal and child health, infectious disease, malnutrition disorders, chronic illness and geriatric rehabilitation

The overall emphasis of universal coverage can be on Primary Health Care as is the case with Cuba; but that will also entail a complete revamp of practice methods at this level in both urban and rural areas. The other para-determinant of health at the level of primary care is access to water. In order that primary care is effective there must be a parallel investment in the provision of clean water and sanitary facilities. This infrastructure must be developed in parallel with, if not ahead of, health reform.

Recommendation 9:

Who purchases the service? Recommendation is for the Department of Health and Family Welfare to take on the responsibility and not allow insurance companies or independent agents to purchase on behalf of the government

 

Strongly agree.

 

Recommendation 10:

Continuation of the above. Purchase of services must be undertaken directly by the Centre and the State governments directly or through quasi-government autonomous bodies set up to work on their behalf

 

Strongly agree that government must be the direct purchaser of services

Recommendation 11:

All government sponsored insurance plans to  be merged under UHC with public distribution of a ‘Health Insurance Entitlement Card’

 

Strongly agree. Although the card can surely have a more interesting name!

                                                                                                Table 3: HLEG Recommendations for financing

The translation of a national health program like UHC into a working model with secure funding and monitored quality standards, is a gargantuan exercise. Although funding occupies the centre and corners of all discussion on the subject; the problems with health reform extend far wider than this. In countries like India the struggle is all the more compounded by the entrenched fault lines of a complex system that has had a haphazard evolution. There are dual functioning health systems (government and private), abysmal health infrastructure, poor to none regulation of quality or standards, ill equipped health infrastructure, enormous human resource needs, lagging medical education reform and most critically maybe – an appalling lack of access to the para-structure of water and sanitation.

Despite some truly good initiatives and investments; in the overall analysis, government has failed in delivery of services and the public system is in a shambles. This juncture, where reform is being considered seriously, is a good place to rethink the real potential for partnering with the private sector towards the achievement of the national aspiration that is UHC.

(The next article in the series proposes a direction for change)

Universal Health Coverage Part II: Evolution and Criteria

                                                               

[This article is published as the first part of a series in the January 2013 issue of Infomed (pgs:12-15)]

Evolution

The 20th century: 1948-2000

International accreditation of the right to health was first achieved in the Universal Human Rights charter in 1948. This position was ratified again in 1966 by the International Covenant on economic and socio-cultural rights. These then were followed by the Alma Ata Conference in 1978 that defined health, for the first time in a positive context, as, ‘a state of wellbeing and not merely the absence of infirmity’. Alma Ata also captured the public health goal for nations in a Declaration: “Health for All”. It brought Comprehensive Primary Health Care (CPHC) to the centre of health reform and stressed a holistic approach that integrated social development with health.

Hardly was the agenda set at Alma Ata, when a movement that shifted focus from CPHC to Selective Primary Health (SPH) took shape; first in a conference in Bellagio in 1970 and later endorsed by both the UNICEF and the World Bank. SPH rejected the holistic approach of CPHC and launched instead the GOBI program that focused on four vertical and distinct child interventions: Growth monitoring, Oral Rehydration, Breastfeeding and Immunization. A few years later, in 1982, it was expanded into the GOBI-FFF to include food supplementation, family planning and female literacy.

Many nations followed the lead established by the international organizations and accordingly, shifted priorities from CPHC to SPH. Two decades on, the consequences were visible. While there was definite improvement in these predetermined areas of interest; overall public health metrics had deteriorated and the move towards ensuring the universal right to health for populations was severely derailed. SPH had translational difficulties too. The standardized implementation models of SPH ignored local sociocultural determinants of health, critical determinants of health policy success and therefore, its goals struggled to translate into positive outcomes.

The 21st century:

By 2000, many lessons had been learnt  The UN once again included the universal right to health and CPHC in its millennium development goals. From thereon, the WHO has taken the lead in setting the public health agenda of nations by issuing two major statements. In 2005, it passed the UHC resolution, defining UHC as the international standard for progressive reform and development in health and in 2008, the WHO annual health report brought CPHC back to the core of its global health program. Despite these laudatory efforts, international organizations like the WHO and the UN have normative functions of setting agendas and directing efforts. The ground reality is that both UHC and CPHC are political processes and require political and governmental will for success.

The road travelled by nations:

Apart from and alongside these institutional efforts, individual nations have charted their own course towards fulfilling their responsibilities to the health of their peoples. The country experience with UHC is long and varied. National aspirations for UHC preceded the international impetus. Nationwide health insurance was set in motion by Germany in the late nineteenth century. The UK followed this example by instituting NHS in 1911. Today, both these robustly far thinking systems continue to thrive and sustain their populations. Further, all the OECD (save the USA) nations have followed suit and provide near total health insurance coverage (of some sort) for their populations. At the present time, 58 countries around the world have achieved and delivered on UHC and 23 more have it legally mandated.

Criteria of coverage: What comprises the criteria of coverage? How is a country determined to have achieved UHC?

Since coverage cannot include 100% of the people for 100% of services, UHC is accepted as achieved when: 1) more than 90% of the population has insurance coverage and, 2) more than 90% of the population has access to maternal skilled health workers.

UHC broadly encompasses two themes: population coverage with access to an affordable package of healthcare services and, the infrastructure for delivery with an adherence to a minimum quality standard. Simple coverage of a population does not mean much unless it comes with the guarantee of quality and services. It is easier to define what constitutes population coverage than to agree on the package of services that insurance will cover and the quality of delivery. At this level, the decisions become intensely political and local and no one blanket model or system can be laid down across cultures and continents. The most that international organizations can do is lay down the norms for practice and work with national ministries to develop a health system that best suits their needs and sets them firmly on the UHC road.

Can governments of poor countries afford UHC? The general consensus and the empirical evidence says, yes. Poverty, per se, is not seen as a deterrent. Contrariwise, inaccessibility to health is one of the factors contributing to poverty. A more-true deterrent to the implementation of UHC is the lack of functioning systems and/or the infrastructure that will ensure delivery and guarantee outcomes. Much of the success of UHC is therefore in the domain of the political will and muscle of the government to implement true reform. In this regard, Mexico, Thailand and Chile are shining examples of success.

Health has thus moved into the purview of universal fundamental rights. The dramatic progress in treatment options (drugs, devices and procedures) has increased the potential for cure, extended lifespans and enhanced quality of life despite disability. Every individual has the right to expect to avail of the benefits of these advances in science. Health is a need, not an entitlement. Not an avoidable item in a consumer’s budget. It is fundamental to living and ranks high amongst people’s priorities for a good life and for a measure of happiness.

(This is the second article in a series. The next will focus on the India experience)

References:

1. The long road to Universal Health Coverage, The Rockefeller Foundation: http://www.rockefellerfoundation.org/uploads/files/23e4426f-cc44-4d98-ae81-ffa71c38e073-jesse.pdf

2. HLEG report on UHC for India: http://uhc-india.org/

3. Universal Declaration of Human Rights: http://www.un.org/en/documents/udhr/

4. The world health report 2010 on Health Systems Financing. http://www.who.int/whr/2010/en/index.html

 

Universal Health Care Part 1: Making the Case

                                                        

[This article is published as the first part of a series in the January 2013 issue of Infomed (pgs:12-15)]

In health policy circles the acronym with the buzz is, UHC. It is used interchangeably for both Universal Health Coverage and Universal Health Care, although the accepted expansion is Universal Health Coverage.

Universal Healthcare, as the term suggests, is defined as the universal guarantee of healthcare to all citizens. It implicitly affirms healthcare as a right. The colossal scope of UHC necessitates government involvement to ensure its success. Governments do this either through legislation, mandate, or regulation. Achieving Universal Health Care is dependent on balancing two critical factors – coverage and cost. The details of delivery and access are addressed under the broad umbrella of coverage while health economics wrestles with the tough problem of the cost and funding of the details. For the present, coverage has precedence. Globally, healthcare delivery systems are somewhat in place even if, in many cases, rudimentary.  Yet many millions around the world go without access because they can’t afford it. UHC models were developed internationally, to plug the gap that kept people out of the healthcare system and to satisfy the moral, ethical and economic need of progressive societies. No one model fits all groups. Member countries are working in close collaboration with the WHO to develop indigenous versions that include the local culture and involve the local community.

Definitions: 

UHC is a globally recognized public health concept, goal and aspiration that varies in its details according to the population it aims to serve. Therefore, the term does not seek to define standards but expresses within it the components and characteristics of an affordable health system accessible by all. These include: people, services and needs; where people should get free and affordable medical services according to their needs1.
A concise yet comprehensive definition has been articulated by the HLEG (High Level Expert Group) report2, commissioned by the Indian Government to develop a blue print for health reform. Here, UHC is defined as: “Ensuring equitable access for all Indian citizens regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality as well as public health services addressing the wider determinants of health, with the government being the guarantor and enabler, although not necessarily the only provider of health and related services.”

At the level of the consumer, UHC aims to provide the 4As (affordable, accessible, assured quality and appropriate health); whilst simultaneously guaranteeing the 3Es at the delivery platform (efficiency, effectiveness and equitable health with accountability)

Making the case for UHC:                                                         

The argument for UHC can be neatly summed under three headings: 1. Moral/ethical, 2. Economic and 3. Financial hardship

The moral/ethical question: The political and economic dialogue has spilled over into health with the oft touted question; is health a responsibility or a right; a duty or an entitlement? For those that work in the health sector and for the people who have had a personal experience with illness, this question is moot. Their experience attests to the common knowledge that while responsible health behavior leads to better outcomes; that alone, in and of itself, cannot guarantee freedom from debilitating disease. Linking ‘freedom from disease’ to responsible behavior is mistaking the correlative for the causative. Our bodies are biological machines. Despite the adoption of the best possible practices; there are times (the simple process of aging is itself an example) when the balance tilts to infirmity and/or disease. At that point, can a society dissociate itself from the obligation to provide the benefit of available treatment and knowhow to a large swath of its people simply because of financial considerations? Health is a right to be enjoyed by all; not a privilege to be enjoyed by a few. This is also asserted as such, by Article 25 of the UN’s Universal Declaration of Human Rights3.

Economic inequity: We live in a large heterogeneous structure called society, within which actions are enmeshed and interrelated with outcomes. Health is a complex system within this framework. A healthy population is a determinant of economic and social development. Contrarily, a society wherein large numbers of people are ill or do not have access to treatment, languishes from a marked waste of human potential, man-hours and productivity. The chasm in health metrics is an ever widening one, between rich and poor nations; between the haves and the have-nots. A recent WHO report4 describes the socio-economic disparity in stark numbers: A citizen of a wealthy nation can live up to 40 years longer than someone in a poor country. Of the 136 million women who give birth annually, about 58 million (43 %) receive no medical assistance during childbirth or the postpartum period. Per capita health care spending statistics reveals more of the same, ranging from around 6000 USD in wealthy nations to 20 USD in the poorest. Traditionally, countries that have large gaps in economic equality have more difficulty transitioning from private systems to a public funded UHC. Health and economic inequity make the civic structure lopsided and promote unstable growth with the ultimate consequence of social unrest, chaos and collapse.

Financial Hardship: In the context of health, the WHO4 defines financial catastrophe as, spending that exceeds 40% of household income on health after basic costs have been met. Even for those that can afford health to some moderate extent; the potent combination of rising costs and inadequate coverage can lead to financial catastrophe in a health crisis. This is true across the spectrum of nations from the very rich to the very poor. Medical expenses are the commonest cause of bankruptcy in the US (almost 60 % of personal bankruptcy). At the other end of the scale, more than 100 million people around the world are pushed below the poverty line, annually, because of medical bills and another 150 million suffer financial hardship.

A cursory look at the graph of health care costs worldwide shows movement in only one direction – upward. Countries that have a more homogeneous, less fragmented system of paying for health are able to better contain costs. At the same time, they also provide an equitable standard of services. More than 3 billion people around the world rely on direct payment (out of pocket) to pay for medical care. High out of pocket costs invariably result in people choosing to not take treatment at all and often, women and children are the first to fall through the money gap. Health economics research has consistently proven that wherever direct payment is the dominant reimbursement method; fewer people can afford to purchase health, people with precarious financial situations teeter into poverty and/or medical bankruptcy and those that can afford to pay at the time of need, face rising costs and unaffordability at a later time. The solution to keep costs down is to increase coverage, pool funds, pool financial risk, standardize reimbursement, make it accountable and reduce direct payment to lower than 15% of total cost.

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(This is the first article in a series. The next will focus on the Evolution of UHC)

References:

1. The long road to Universal Health Coverage, The Rockefeller Foundation: http://www.rockefellerfoundation.org/uploads/files/23e4426f-cc44-4d98-ae81-ffa71c38e073-jesse.pdf

2. HLEG report on UHC for India: http://uhc-india.org/

3. Universal Declaration of Human Rights: http://www.un.org/en/documents/udhr/

4. The world health report 2010 on Health Systems Financing. http://www.who.int/whr/2010/en/index.html

The Electronic Health Record (EHR). A good augury for the doctor-patient relationship?

[This article is published in the October 2012 issue of Infomed; pgs: 58-59]

There is change happening in Health Care. In hospitals, and in neighbourhood clinics. The traditional method by which doctors and nurses recorded a patient’s visit in the outpatient or documented a patient’s progress in a hospital admission; using pen and paper, on sheets filed under the patient’s name and hospital number, and stored in the Records Department, is giving way to a new digitized method of record keeping called, Electronic Health Record or Electronic Medical Record (EHR/EMR). The terms are used interchangeably.

For decades now, computer technology has been slowly and successively integrating into traditional medicine at every stage of the patient-doctor-hospital system interaction – in the labs, radiology investigations, pharmacy and/ or nursing.  The change in documentation style happened early with labs and radiology because of the technological advances in diagnosis (lab reports, hospital summaries, and radiology studies are ‘printed out’ as hard copy or packed in CDs as soft copy). However, the actual physical interaction with a doctor, a physician assistant or a nurse continued to follow the traditional hand-written style and was stored as a paper file in storage rooms called ‘Department of Records’. With the introduction of interactive applications into computers within a hospital network; this last bastion has crumbled and pens and pencils on a doctor’s desk have been replaced by a mouse and a keyboard.

What are the advantages of this shift? Will all players and participants in the healthcare system benefit?

The US government recently invested 27 billion to incentivize and accelerate the transition from paper medical records to EHRs. The size and scale of this investment is a good indicator of the value addition of this technology. For healthcare providers, the immediately obvious advantage of the EHR is improved productivity and efficiency in workflow. Data entry is easy and there is greater confidence with data integrity and reproducibility. Medical records have now become potable and that makes them accessible from any location with an internet connection. Finally, the cumbersome storage methods of paper files have been dramatically condensed and transformed. However, the larger and more significant long term impact is in Data Analytics. The automatic accumulation of large volumes of data, that happens when records are digitized, can now be studied in depth across a host of areas that range from clinical research to behavioural pattern recognition and operational errors in the workflow of a hospital system. The transformational potential of Data Analytics is huge and will bring about a much needed streamlining of Healthcare delivery and costs.

Such potential for positive disruption is often accompanied by worries and medicine is no exception. Here too, the magnitude of the collected data volume has raised concerns about data security, mining and misuse. To address these concerns, it is now mandated by Law that all certified systems have inbuilt safety controls that include encryption and regular audit tracks (this is a list of who has accessed records and when). Further, patients too can access their records over the web and the access also includes both audit and encryption. Increasing transparency and inclusiveness in medicine is of direct benefit to both doctors and patients. Last week, the Annals of Internal Medicine1 published very heartening results of the success of the OpenNotes2 Project undertaken by three medical centres in the US. 70% to 80% of participating Primary Care Physicians and 92% to 97% of participating patients thought, patient access to a doctor’s notes to be a good idea and a welcome step forward.

These are well documented contributions of the EHR to the betterment of the clinical workspace. But how does a patient or as a user of healthcare services benefit?

1. Improved Care: By having all your medical records in one place, your primary care doctors and specialists, as well as nurses and paramedical staff can coordinate treatment and care better. By putting all information about a patient in one place, a cooperative interaction between doctors and treatments is automatically effected and repetition of tests and prescription errors erased

2. Access: By having access to records and doctors’ notes; a patient is transformed into an active participant in his/her own health

3. Inclusion and Control: EHRs foster the doctor-patient relationship by promoting patient participation and inclusion. Patients also feel a greater sense of control by being able to access their own data. A few hospitals in the US have launched OpenNotes – an interactive format that allows patients to contribute and access a doctor’s notes in an outpatient setting. These simple measures are a first step to rebuilding trust between provider and patient. By having access to information, patients also are motivated to assume more responsibility over their own health

4. System change: Fewer prescription errors, reduced time of information sharing and reporting, and better follow up

5. Patient tools for self-monitoring: Often, variations and swings in symptoms and metrics like blood glucose levels, heart rate and blood pressure happen at home. A doctor is not witness to these fluctuations. Smart Phone applications for monitoring health metrics (currently in use for: blood sugar, blood pressure, ECGs) are making a rapid entry into home-health. This form of healthcare that uses smart phone and medical app technologies to facilitate home monitoring by patients is called mHealth (short for mobile health). mHealth allows self tracking by a patient and can alert both patient and doctor to early signs of change in a medical condition. In addition an easy and simple form of record keeping (by and for patients), of all this tracked data is being introduced and is called the Patient’s Health Record (PHR).

The Industrial Revolution in the 19th CE and the Information Technology Revolution of the 20th CE leapfrogged civilization in a matter of a few hundred years to extraordinary heights of achievement and excellence. The last three decades have seen great strides in the technology of medicine in diverse areas such as, diagnostic methods, robotics in surgery and stem cells and tissue engineering, to name a few. While dramatically expanding treatment options and cure, the takeover of machine was seen as dehumanizing. Patients and their care-givers dropped into the wide-split chasm between technical wizardry they got and the human connect they sought. They bore the brunt of the struggle to comprehend the technology and its impact on their health outcomes. Patients have felt systematically excluded from the health system, as a whole, despite the fact that, ‘they’ were the consumers and in effect therefore, the drivers of the change. Happily, the more recent advances in computer applications like EHRs and mHealth are set to reverse this trend by promoting the very welcome change of greater inclusion and participation of patients with and in the system. That both doctors and patients are embracing the change is heartening and holds out hope for an industry that has been at the receiving end of much criticism in recent times.

Links to refs:

1. http://annals.org/article.aspx?articleid=1033220

2. http://www.rwjf.org/en/research-publications/find-rwjf-research/2010/07/open-notes.html

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This article was published in the October issue of Infomed. Link:
http://www.infomed.com.my/magazine/1685501518/index.html   (Pgs 58-59)

Do doctors not want to be doctors, anymore?

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Dr. Parthasarathy was a household name in Bangalore. A graduate of medicine from the pre-Independence days; he was what was then called an LMP – an early 20th CE version of the MBBS, expanded as a Licensed Medical Practitioner. He was a big man a little more than six feet tall; portly, had a ruddy complexion, dressed in tweeds and suspenders and always wore a tie. Oh, and a beret. Bangalore was an English cantonment town; its culture, lifestyle and entertainment was very Western (cosmopolitan they called it) and this sort of attire was quite commonplace for the time.

His office was on a tree lined but busy commercial avenue named for the trees whose sky framing canopy exists to this very day – the beautiful Sampige mara, or the Eastern Magnolia (Magnolia champaca). It was a tiny place with dark wood paneling the walls; a feature which, despite making everything feel boxed in, had an incongruous but comforting Harley Street ambience. There were wood partition screens with big blocks of carved wood for legs that divided the place into small cubby hole practice rooms. Some had eye-level ground glass panels with cut-glass green inserts and with inbuilt in-out slats. A totally unnecessary addition; considering that once he settled into his chair (he had no formal desk), his shoes would always poke out from underneath the partition. It was a wonder he managed to squeeze his frame into the small cubicle that had just enough space for making a quick half turn. I was small then and, to my miniature eyes, his office seemed like the inside of wooden chest. I can only imagine what the adults felt. Apart from this room, there was an examination room and in the back a compounder’s room with a small procedure table mounted against the wall. The entry had a waiting area with narrow benches along the wall that seated a quarter of the bum and on which you had to necessarily sit erect because if you stretched your legs you’d lock ankles with your equally ill and not a little irate neighbor. Shelves on the wall had an assortment of dusty magazines and comics that were never touched. Even if kids asked to look; scowling adults would ignore them.

The partitions between these rooms were themselves relics of another era. The interiors were always dark and a naked bulb or two would be left on even during the daytime . Their dim incandescence filtered through the gritty ground glass panels like fog, with a mysterious effect of clairvoyance. The partitions didn’t ride all the way up to the ceiling and so, every conversation behind them was well heard by all. No one made eye contact with the patient emerging from his very public, but separated, meeting with the doctor. All screams and groans were equally communal. Our anxiety and their noise rose in harmonious concord. Children invariably started crying and harassed parents would run out into the welcome distractions of the street. Across from a side door there was a tiny alleyway that led to a pharmacy – ‘Famous Drug House’. And on the other side was a bakery that had wonderful smelling bread. We never got to taste it, since the only reason we were there was if one of us was ill and any attempt to opportune the elders for ‘bakery’ goods at such a time would be rebuffed. We were left to indulge our longing stares and smell the air. The clinic’s interiors and the bakery aroma gave fever induced deliriums a welcome respite. There was no reception, no pesky counters, no fussy data recorders and no fancy gadgets. Just a big jolly doctor with a big heart and what looked like a giant stethoscope. There were also some painful glass syringes in the back with the compounder but that’s a side story.

Sitting in his office it felt like 1840; you could almost hear the horse carriages rattling over cobble-stoned paths and the horses harrumphing outside. That he could create this ambiance in a busy thoroughfare in the heart of a bustling neighborhood is testament to the man himself. I often wondered if it was our overactive imagination fed on English children’s books that made us think so; but, no. I am quite certain that most others’ reminiscences would be along these lines. Maybe it was another figment of my imagination but, every person who emerged from that cubicle would have a look of lighthearted relief. The good doctor would’ve dissipated their anxiety and all that was left was the minor matter of the physical ailment for which he’d have armed them with bolstering words of courage, a prescript for some medicine and a recommendation to sample the bread with very hot milk and a generous sprinkling of sugar. After which, he would boom over the partition – ‘next’ – and we would make way for the next sufferer in line, impatiently waiting our turn for his magic.

He practiced there, in that same place, for sixty five years. Maybe, more. Every day he would open shop at the same time. On time, every time until his very last day. Retire home for a siesta and return with renewed vigor in the evening. For a staggering number of years, well into the nineties; he unfailingly followed this same routine. William James would’ve been proud. Do I hear you say, fees? I remember a board outside that said two Rupees per consult. There was a box by the side of the door in which the fees were to be dropped. Many would plead inability to pay that and he would never protest. I remember him locking up one late evening when my father and I hurried to catch him; and I remember too, the jolly gusto with which he unlocked the big padlock and took us in. He silenced our fervent apologies by ordering hot almond milk from the bakery; astutely remarking that I was without the mindful escort of my mother. A liberty he would never have accorded himself in her presence. A secret delight, he knew I could only sample this way.

This was the doctor figure of our growing years. The one we modeled our ambitions around.  The one we wanted to be when we grew up. The one we tried to emulate. And yet, here we are today with a measure of the heart perhaps but with not a spot of the persona; that even the most generous would fail in making a favorable comparison.

So, what changed and why? Of course the practice method itself is vastly different. Complex technologies have come to dominate our science. Today, a doctor wouldn’t be able to stay financially viable with a practice like that. The business of medicine and health has become so huge; it has come to occupy a permanent fixture in our lives. No more do people go to see the doctor for the occasional times when they are ill. It is now commonplace routine to go when well in order to be told that all is well. This change has been talked and discussed ad nauseum with so many different points of view. What is less talked about; is how the humans, in medicine and running it, have changed.

A doctor was seen as a member, a necessary and vital part, of a community. Neither the community nor the doctor saw themselves as separate entities, distinct from each other. Medicine was a social profession. As such, most doctors were sociable and social beings. They ‘liked’ interacting with the community. They thrived on it; they actively sought it. A good portion of their knowledge was also empirical. It came equally from listening, observing, communicating; none of which was possible without spending time with people. Less time was spent maintaining records; more in conversation with the patient. By doing so, they consigned to memory their patients’ stories which, for them, was the best record of all. For doctors like Dr Parthasarathy, it was about the people. He and his tribe saw themselves first as pillars of the community and as healers only after.

Today’s doctors are vastly different. Though the patient load is frequently blamed for the change; it was more the explosive invasion of technology that fueled it. The much talked of thoughtful lateral shift, that incorporated the old ways into the new, did not happen. Almost overnight, these grand viziers of health were cast overboard and the new, technology and drug driven medicine, moved into its place. The change happened right under our noses; but sadly, the regulatory bodies did not have the muscle or the will to stem the tide and give it direction. As each machine made more exquisite diagnosis and after books became tomes of data, doctors had little choice but to submit to the constraints of time bound learning of both text and technology. Slowly they receded into the great buildings with sharp white lights and chemical odors of sanitation, behind reception desks and complicated registration procedures, behind payments and reimbursements and behind monitors and data screens. The simple human interaction of eye contact, a smile, a warm handshake, a comforting word or two, a shared experience, – qualities that are so ordinary they ought not to be an expectation – these same qualities slowly ceded space to the mechanized takeover of electronic systems and the creation of a health industry. Where medicine was once about community and its people; it now became a single minded pursuit in the excellence of the self. More degrees, more accreditations, more gizmos, more procedures, more papers and more zonal dress codes. A series of layers, each taking the doctor farther away from his primary interest – the community and the patient. Patients thus morphed into bodies, into data, diseases, symptoms, signs and a diagnosis. The tortured anxiety of a patient’s eyes became unrecognizable to the tortured anxiety of the doctor’s pressure to stay in the game. For both, the interaction has become a discontented trek to nowhere.

We could retrace our steps in time to some extent by empowering Primary Care Physicians and Family Medicine Specialists. It would require easing of the controls over these fields and making them competitive by increasing reimbursement to these practitioners. By making Primary Care a profession of choice we give ourselves a second chance at rebuilding health delivery to a standard of care that only a synergy of both the art and science of medicine can bring. However, policy change is so slow in comparison with the speed of technological advancement that by the time this decision is implemented, it will probably take a form very different from the one that is currently envisaged.

The flipside of all this is that it might only be a couple of generations that feel this angst. Doctors and medicine have only changed in lockstep with a rapidly evolving societal dynamic. A new generation is turning the corner; those brought up on technology, whose daily life is ruled by it and who therefore don’t expect much different from their doctors. To this group; the contradiction of doctors morphing into hi-tech health industry technicians might not matter as much. At that point in the future; will we still want empathy and the personal touch from our doctors, or will we settle for technical prowess and peer ratings. With doctors on track to becoming service providers, and in the absence of investment in primary care, the gaps of the heart will probably be plugged by resources like social networks and patient communities. The last especially holds great promise as a bridge between a physician’s sterile prescription and the actual life tools for sustaining cure and for balancing illness with a quality of life.

Maybe, by then, a doctor will cease to embody our nostalgia for empathetic care. Perhaps, a name change will come about and we will call ourselves something more in keeping with the time. And roses will no longer be roses and their smells no longer as sweet.

Does India have the highest Child Mortality Rate or did the Media get it totally wrong?

A little less than a week back; Indians woke to yet another screaming headline and ‘breaking news’ story from the media. Every major news outlet (as can be seen in the link) carried the story in bold print. This one was truly alarming – that the latest Unicef report had cited India as having the highest Child Mortality Rate in the world. After the initial horror and dejection waned, and ceded ground to the next horrible thing to hit us, the story continued to gnaw at common understanding of ground realities. Despite the fact that India does have some truly bad public health data; there are still countries doing far worse than us and to have surpassed them all, implied a splendid surge of negative performance that even we, would have struggled to achieve.

Reading the report reveals a complete misreading of the data by the media with the expected misinterpretations. The Unicef report contains no such data, as publicized, and neither has any international publication mirrored the domestic media reports. This then was the over-eager Indian media skewering our reputation in its enthusiasm to be the Ur-harbinger of bad news. Attempts to get them to correct the narrative have fallen on deaf ears (emails and tweets) and this post is written with the hope of correcting the glaring discrepancies in the reportage.

[Pic courtesy: www.indiacsr.in]

No, India does not have the highest child mortality rate. We have the highest number of children that die under the age of five; that number is reflective of the size of our population. A distinction must be made between the total number of children that die under the age of five and the child mortality rate. Since these are two totally different things; it is important to lay bare the difference. While doing so, no attempt is being made to diminish, minimize or molly coddle the appalling figures. For a country with high ambitions of economic superpower-dom and that is called an ’emerging market economy’; these figures are, plain and simple, unacceptable.

To get at the ‘hows and whys’ behind these dismal figures; we must first separate Infant Mortality Rate (IMR) from the Under-five Mortality Rate (U5MR). Causation is different in these two categories. Mortality Rate (MR) refers to the number of children that die per 1000 births. IMR refers to the number of children that die under the age of one. U5MR refers to ALL children who die under the age of five and therefore incorporates IMR figures within it.

U5MR declines globally at a higher rate than IMR. It is far more difficult to grapple with IMR. These are the figures: globally, IMR has low rates of decline: 32% in the past two decades and an annual decline of 1.8%. Compare this with U5MR that, for the same period, records 41% and an annual decline of 2.5%. For South Asia and India, IMR contributes more than 50% to the U5MR figures. And India, independently, contributes 30% to the global IMR. It would be more appropriate therefore to address U5MR as the sum of its two individual components – IMR (birth – 1 year) and CMR (Child Mortality Rate of children between 1 and 5 years). These two categories are very different beasts. The determinants, causation variables and policy outcomes are different and varied in both.

1. CMR operates at a macro-level, is relatively homogeneous and is more easily subject to criteria like access and affordability. These factors make it amenable to standard policy measure that are easy to implement across different strata of experience. Effective and determined deployment of vaccination and access to: safe drinking water, sanitation and basic health facilities significantly alter CMR figures. That we haven’t been able to tackle this component of U5MR is indeed a matter of poor governance. The appalling figures clearly reflect the deficiencies in the drafting and implementation of policy.

2. IMR, on the other hand, is in an entirely different category. IMR is not as readily subject to simple health economics and is strongly affected by culture and gender; two variables that are difficult to regulate by policy alone. It is heterogeneous and operates at the micro-conditional situation of family, individual and communities. The ‘pre-term and post-term causes’ listed in the report, are variables that impact IMR. IMR reflects on both mother and child and is affected by a culture-spread that extends from the treatment of women in a society, to prenatal attention, to delivery/obstetric practices and finally to the postnatal period. Gender discrimination and cultural handling of birth (breast feeding, cord management, etc.,) factor directly into IMR. Health information dissemination and reform of cultural norms have to be critical compositional elements of any policy that targets IMR. To deliver on outcomes through the maze of socio-cultural barriers is not easy and when the deeply diverse nature of our myriad cultures is factored in, it seems a nigh impossible task. Yet, if we invest our collective energies and efforts on effectively tackling IMR, the rewards will accrue on multiple levels, since this one factor encompasses mother, child and all in between.

U5MR data analysis: (figures are from the report)

1. Sierra Leone has the highest U5MR in the world. 185 children die per 1000 live births. Twenty nations have UFMR higher than 100. Of these, nineteen are in Sub-Saharan Africa and one outside Africa, in Asia – Afghanistan. Afghanistan has a U5MR of 101

2. Comparison of Sub-Saharan Africa and South Asia:

a. Sub-Saharan Africa has a higher U5MR than South Asia (1 in 9 as compared with 1 in 15 for the latter. To understand how appallingly bad these figures actually are – in industrialized nations, the ratio is 1 in 167)

b. But, the rate of decline is faster in Sub-Saharan Africa than in South Asia; an encouraging trend for them

c. As of current figures however; a child born in Sub-Saharan Africa still has a 1.8 times greater probability of dying than a child born in South Asia

3. 50% of the ‘total number’ of child deaths (not a rate; but a number) occurred in five countries – India, Nigeria, DRC, Pakistan and China. In *this category, India clocked 24% and was highest

4. A quick comparison U5MR in countries: Sierra Leone 185/ Afghanistan 101. India – 61, Nigeria – 124, DRC – 168, Pakistan – 72, China – 15