Can Machine Learning outdo teaching?

Four years ago, when I was heading the MOOCs division of my University, we had a bunch of young people, running a start-up on graphics and animation based educational courses, give us a presentation. They explained human embryonic development, through graphics in a short film of fifteen minutes. I was amazed by the effectiveness of dissemination of knowledge through graphics. But a disturbing thought was also lingering in my mind, what I had seen was much exciting than the boring biology lessons, I had received in school, and was delivered in a much lesser time too. Would e-content take over class room teaching? The question lingered in my mind and I asked it to our senior Professor. He shrugged, feigning indifference and said, 'For how many years have you had a Guru Shishya parampara?' He meant that nothing could take over the human element in the learning process, and no technology can replace a 'Guru'. Nothing else could be more reassuring to me. I believed him.

Just a few days ago, this thing called 'Machine Learning', managed to occupy my thoughts once again. Machine Learning is a branch of AI, which empowers computers to pick up patterns, that they were not explicitly programmed to perceive, or simply speaking, computers can pick up patterns that human mind will take long to perceive, just by doing some data analytics. Education Initiatives, an Indian company has developed a code called Mindspark,  that is run on 2.5 million answers to a set of 45000 questions, to diagnose common errors that the students tend to commit. Mindspark will infer a thinking pattern that is responsible for a certain error and will suggest remedial exercises. It is basically, getting into the mind of a student, studying his thinking pattern and structure, identifying the possible reasons for it, and suggest a solution.

The students can receive customized solution through this technology. Mathematics and Language can be easily taught to a student in his early years of learning, through this software. Customized exercises can be generated to handle individual problems. Many American companies like Aleks, Knewton and Dreambox Learning, Geekie a South American company, Byju's from India, and 17zuoye from China are providing such solutions. Voice Recognition systems will make the technology much more user friendly. What this technology right now cannot do is that friendly pat on the back that the teacher gives when a student becomes successful with something that he is struggling with, or a 'raise your hands' punishment that one received for uttering something really stupid in the class. From an older generation's point of view, some of the best memories of school life will be eliminated by the technology, but that is an older generation's viewpoint.

Studies have shown that software assisted teaching pedagogues are more successful. Philip Oreopoulos, and Andre Nickow for J-Pal conducted 41 randomised control trials comparing students taught by software assisted methods, to students taught by conventional methods, and found that the software assisted students got better scores. In one such study done by J-Pal in Indian settings by Karthik Mularidharan, Alizendro Ganimian, and Abhijeet singh, it was found that at an Indian after-school, course, students assisted by Mindspark, brought better results in Math and Language, than those who didn't, for a fraction of the cost. Studies have also shown that in softer subjects, Humanities and Liberal Arts, mimicking a teacher is a little difficult.

A teacher cannot provide an individual feedback to a class of students more than 30. That is the reason 30 is an ideal class. The software replaces a teacher in providing individual feedback. But the critical success of software lies in the fact that a student is assisted further in learning at his own pace, without getting bogged down by the performance of others. But sometimes digital displays can create a lot of confusion in the mind of a student. Max Ventilla, a former Googler has done just that, he has created a school called the Altschool in California, where the student is assisted in personalized learning. Teachers save time by not marking or planning lessons and the students learn from each other. However, giving children such attention is not cheap, the cost per student is $27000 per year.

We live in a Googleable world. A child growing up in this world might be tempted not to fill up his mind by information. Would that mean he would be spending more time on thinking? Cognitive scientists argue that human minds are not built to think and thinking hard about things does not come naturally. There is a famous quote by George Barnard Shaw,' I Have Made an International Reputation for Myself by Thinking Once or Twice a Week, because others attempted to think only two or three times a year.' 

Rand report, a report on a study done on school children using high tech personalized learning at 62 schools said that those who used the tech fared better than the children from ordinary schools, particularly those who were at the bottom of the class. Personal Help, argues Mr. Mark Zukerberg in the form of tech solutions is way better. The early adopters prove it. Whether Rand Teachers were highly motivated teachers or not is not proven by the study though.

We live far away from silicon valley, so we are curious about it. Will children of my family be able to perform well in the clog wire of machines, AI and codes in future, I am forced to think. I am uncertain about the answer. But, I was a few days ago telling my brother to get my niece trained in music and art. Information, she will gather with not much difficulty in future. Her academic abilities are explained in far greater detail in her report card these days, anyway.

Will tech make the craft of teaching better? We all remember our favorite teachers by not 'what' they taught in class, but 'how' they taught it in class. Unanimously, we would agree that they were favorites because they gave us personal attention.

Do we produce enough Food to feed people in India?

As per the CNNS survey, only 6.4% of kids in India, under two get a 'minimum acceptable diet', the rest 93.6% do not get an adequate diet. This would mean that children less than two years around all of us are not getting adequate diet. This could be my helper's child, driver's child, some child in the neighborhood or worse, some child in my family. Is it because of non-availability of adequate food? Government claims to be net-exporter of food, which means that we export more than we import. India is home to 270 million hungry people, as per Oxfam's report, our position is 103rd in 2018 Global Hunger Index.

Ramesh Chand a member of NITI Aayog predicted a demand of 257.70 million tonnes of food grain in 2015, the country produced 275.11 million tonnes that year, it was an year of average monsoon. During the drought year, the supply could barely match the demand. Per capita food grain availability per annum was 186.2 kg in 1991, it was 177.3 kg between 1903-1908, while in 2017 it was 189.1 kg. In 2015 China's per capita per annum food grain availability was 450 kg, Bangladesh 200 kg and US 1100 kg. In 2012 there was 30% gap in actual and recommended dietary intake in rural India, and 20% in urban India. The per capita income has risen 1400 times between 1991 to 2016, from Rs. 6270 to Rs. 93293, the income distribution, however has been skewed. An average Indian does not have enough purchasing power.

Some experts claim that hunger and malnutrition exist due to distribution problems. Some states have surplus production but poor management, lack of cold storage, and transportation facilities leaves many hungry. In the budget speech FM declared that we have achieved self-sufficiency in pulses production this year. We produce more of food grain, that we require except for drought years, and more fruits and vegetables too.

In India, a large number of farmers have committed suicide, particularly in states like Andhra Pradesh, Maharashtra, Karnataka, Kerala and Madhya Pradesh. When I look at the farmer suicide data and randomly try to co-relate it to under 2 children malnourishment data, I find that the two states where there are maximum farmer suicides, Andhra Pradesh and Maharashtra are having 1.2% and 2.2% children with adequate diet. Close to them are Gujarat Telangana and Karnataka at 3.6%. All these states are developed states, then why do children not have enough food to eat?

Malnutrition exists in India, at the same time, when we have reached the Moon and the Mars. It is a battle that needs to be won, but looking at the basic data, we get an idea that it is a winnable battle. How? We have to figure out. CNNS report is an eye opener. 

A case for Community Health Officer and Nation's Health !

Public Health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988; WHO). Doctors treat individual patients. Public Health takes into account the health concerns of the entire community. Health cannot be ensured without addressing the environmental factors - socio-political-economic-physical-psychological. Thus, community health interacts with many variables in the periphery, and a public health specialist needs to be far more equipped than a doctor is.

The Great Plague of London, from 1665-66, and the Cholera outbreak in 1832, forced officials to realize, that London had to create a new sewer system. The 1848 Public Health Act was passed to help individual cities improve the sanitary conditions of their towns. Vaccination became a requirement for all by the mid-1850s. In the early 1900s  many acts were passed and the England's public health, was being structured.

In India, under the British rule, Bhore committee was formed in 1943, known as the Health Survey and Development Committee, and it submitted its report in 1946. Some of its major recommendations were -

1.Integration of preventive and curative services of all administrative levels.

2. Development of Primary Health Centres in 2 stages :

Short-term measure – One primary health centre as suggested for a population of 40,000. Each PHC was to have 2 doctors, 1 nurse, 4 public health nurses, 4 midwives, 4 trained dais, 2 sanitary inspectors, 2 health assistants, 1 pharmacist and 15 other class IV employees. Secondary health centre was also envisaged to provide support to PHC, and to coordinate and supervise their functioning.

Long-term program (also called the 3 million plan) of setting up primary health units with 75 – bedded hospitals for each 10,000 to 20,000 population and secondary units with 650 – bedded hospital, again regionalised around district hospitals with 2500 beds.

3. Major changes in medical education which includes 3 - month training in preventive and social medicine to prepare “social physicians”.

While Britain made efforts to develop public health in its own country, as early as early 1800s, it was not done in the colonies. The Indian Medical System was developed for the sole purpose of keeping the army healthy. In 1952, the proposal of the Bhore Committee was accepted by the newly elected government of independent India, but it was only partially implemented. Preventive and Promotive care primarily took a back seat, the 'social physicians' were never recruited. No concious efforts were made to develop a public health cadre in India, until 2017, when for the first time the health policy talked about -

'The policy proposes creation of Public Health Management Cadre in all States based on public health or related disciplines, as an entry criteria. The policy also advocates an appropriate career structure and recruitment policy to attract young and talented multidisciplinary professionals. Medical and health professionals would form a major part of this, but professionals coming in from diverse backgrounds such as sociology, economics, anthropology, nursing, hospital management, communications, etc. who have since undergone public health management training would also be considered. States could decide to locate these public health managers, with medical and non-medical qualifications, into same or different cadre streams belonging to Directorates of Health. Further, the policy recognizes the need to continuously nurture certain specialized skills like entomology, housekeeping, bio-medical waste management, bio medical engineering, communication skills, management of call centers and even ambulance services' (Health Policy 2017)

The Mukherjee Committee in 1966 prescribed a system of targets and incentives and identified ANMs( Auxiliary Nursing Midwifery) and other village-level workers as agents for the populizing  health programs in the community. In the 1950s and 1960s, training of ANMs mainly focused on midwifery and mother and child health.

In 1973, the Kartar Singh Committee of the Government of India combined the functions of the health services and changed the role of ANMs. The committee recommended that there should be 1 ANM available per 10,000-12,000 people.

In 1975, the Srivastava Committee recommended expansion in the role of ANM. Recommended expansion included the role of an ANM as a multipurpose health worker. Along with maternity care, the committee recommended that ANM's work should include child health (immunization) and primary curative care of villagers. The Indian Nursing Council (INC) accepted the recommendations of the committee and included them in the syllabus in 1977. This decision also reduced the training period of the ANM from 24 months to 18 months.

In 1986, the National Education Policy gave the ANM program a status of Vocational Education. However, only a few states of India have made the ANM course a vocational course at the higher secondary level of schooling. According to the latest guidelines by INC, the minimum age for admission to ANM course should be 17 years while the maximum age limit is 35 years.

In 2005, the National Rural Health Mission (NRHM) was launched, which focused on improvising primary health care in villages and further increased the importance of the ANM as a link between health services and the community.

 Before the launch of NRHM in 2005, there was provision of one ANM per sub-centre. Later it was found that one ANM was not adequate to fulfill the health care requirements of a village. In 2005 NRHM made provision of two ANMs (one permanent and one contractual) for each sub-centre. The ANM is usually selected from the local village to increase accountability

The Accredited Social Health Activist (ASHA) is a community health worker. Depending on the area covered by the sub-centre, each ANM is supported by four or five ASHAs. ASHA brings pregnant women to the ANM for check-ups. She also brings married couples to the ANM for counseling on the family planning. ASHA brings children to immunization sessions held by the ANM. ASHA acts as bridge between the ANM and the village.

Ayushman Bharat operational guidelines gave a  key addition to the primary health team at the SHC-HWC, the Mid-level Health Provider (MLHP) who would be a Community Health Officer (CHO). The qualification of CHO, much in line with ANMs, is B.Sc Nursing or GNM. The rationale for introducing this new cadre of health provider is to:

1)Augment the capacity of the Health and Wellness Center to offer expanded range of services closer

to community, thus improving access and coverage with a commensurate reduction in OOPE.

2)Improve clinical management, care coordination and ensure continuity of care through regular

follow up, dispensing of medicines, early identification of complications, and undertaking basic

diagnostic tests.

3) Improve public health activities related to preventive and promotive health and the measurement

of health outcomes for the population served by the HWC (Health and Wellness Center).

In principle, the community health officer would be the nodal workforce to prepare a report on health status of the population served by HWC. This would be made possible by creating a digital health eco -system 'National Health Stack', where digital personal health records captured at the PHC level, will be stored in a national database, under a unique identity number (UIN). National Digital Health Blueprint (NDHB), 'which is more than an architectural document', as it provides an implementation plan of 'National Digital Health Eco-system' has been released on 15th of July, by Ministry of Health and Family Welfare, Government of India.

In future, there would be a wealth of local data, easily retrievable from a national database, to measure and monitor health outcomes. In principle, this looks like a perfect plan, but there is a missing link here, a very important one.

The missing link is the availability of qualified and skilled public health workforce at all levels of care, primary, secondary and tertiary, to work for preventing disease, prolonging life and promoting health through the organized efforts of society. As of now, ANM, ASHA and proposed CHOs, are the only public health cadres we have in India. They are not qualified or trained, they will join the work force, learn on job, and make a delivery. Their role will be further extended as and when required, and accordingly, they will be provided training for the job. The way we developed ANMs, we will develop CHOs. There is just one difference, the CHOs will be computer literate and will be trained to capture personal health data, digitally.

There is a long list of capabilities that a public health workforce should have in order to function effectively, but I will address that in a separate post.

Public health has had several success stories in India, smallpox, polio, TB, and HIV being some of them. Yet, season after season, we have instances of dengue and swine flu outbreaks, physical inactivity is increasing, stress levels are getting higher, pollution is becoming dangerous, malnutrition is rampant and tobacco abuse is increasing. Can a public health workforce possibly help that ? The answer is YES, for the simple reason that when a patient comes to a hospital with a problem, a doctor can diagnose a disease, but cannot scan his socio-economic-political-psychological environment, where usually the cause is.

Community Health Officer at HWC, should be made responsible to study such causes for a population of about 3000-5000, covered by one HWC, contribute in planning public health interventions and execute them. Community Health Officer will be the pivotal unit, in primary care, tilting the axis towards preventive and promoting care. Its historic. Many state governments have announced several positions for community health officers, which is a welcome move, but getting in a workforce whose roles and responsibilities are not very well defined, for such an important function is inapt and uneconomical.

Investing in public health brings better economic value, its just about time to do intense brainstorming about, what value should public health officials at various levels, can add to nation's healthcare.

The citizens deserve it. 

The idea of health !

I was attending a conference, a couple of years back. The speaker, who is a very well-known CEO of a state of the art hospital in India, and an eminent doctor, responded to a question asked by me, whether in India we could have cycling tracks; he snapped back at me with an imperious gesture, that you are asking for cycling tracks in the cities, where half the India doesn't have roads. I wondered, cycling tracks were for road safety in the cities and to prevent environmental hazard, how would that be a counter argument for constructing rural roads. But, I was too intimidated to speak, I had a very senior doctor admonishing me. 

A research study done by Dr. David Bishai, from JHU, reiterates that there is a zero sum game between preventive and curative care. It says,"too often, only a single, limited government health budget is available for investments in both non-personal preventive and curative personal health services. the growth of curative care services can crowd both fiscal and policy space for the practice of population level prevention work, requiring dramatic interventions to overcome these trends." In India we have seen that primary health care always receives lesser funds than the secondary and tertiary health care. Under Ayushman Bharat, there was an announcement made to transform 150000 sub-centers into Health and Wellness centers in the country by 2022. The budgetary allocation for these centers has been Rs.249.96 crores in urban areas and Rs.1349.97 crores in rural areas, for the year. This means about Rs.107000 to each center. Even if you have the same allocation for the next three years, it will be just Rs. 3,00,000 per center. It will be very difficult to fulfill the infrastructural requirement alone, with this much of money. At each HWC, we need to have a community health officer, supply of drugs, diagnostic facilities, paramedics and yoga instructors, it is clear that this much is not enough. Should we generate CSR funding for HWCs? I will write more on that in a separate blog. 

Health is a human right. The earliest health system was created to respond to this basic right of a human being. For years, it continued to function like that and health care providers offered their services with an altruistic ardour. Modern healthcare system positioned health in a market system. The demand and the supply determined the price. Preventive care took a beating under the argument that the more the people fall sick, the more there would be a demand for healthcare. The lesser the supply the bigger price it could fetch. Market economy argument is based on allocational efficiency, but health and education are such sectors, where allocational efficiency is not determined by market forces as there are huge externalities generated by these services. 

I was talking to Dr. D.K.Mangal, my senior colleague and a veteran public health exponent, about Dr. Bishai's proposition. He said that with the advent of allopathy, health care providers turned into providers of curative care and the entire system is centred around that. Resultantly, primary health always takes a back seat. He said, one solution to the problem could be to change the construct of curative care and bring it totally under the public good/service domain by banning private practice entirely, and connect it to primary health. The other solution to the problem is to delink the healthcare from curative centred infrastructure and  create a parallel primary health infrastructure based on preventive and promotive health models to create a balance. 

A few months ago, I was having a discussion with Dr. David Bishai, and he said that a 'community health officer', preparing a quarterly report on the health data, collected by him for the people registered at his HWC, bringing to light, the 'winnable battles', for his area, would illicit very quick action from the providers. Public health interventions could be planned based on these reports provided by the CHO, so that the healthcare reaches 'the last mile'.

'If we don't take active steps to address the problem, perhaps the technology will force us to do it, science will', was how Dr. Mangal concluded his discussion with me. I too agree with him. Technology is a great leveller. Dr. Narayan Murthy, talking about technology said, "It has improved transparency, conquered distance and class barriers. It has the potential to create a fair society and enhance the accountability of the rich, the powerful and the elite to the poor and disenfranchised in every society."

The word 'Arogya' in sanskrit means 'overall well being'. Conventional Indian thinking around the idea of health was prevention of disease rather than treatment of disease. If we focus our entire attention towards developing a model of healthcare, which is clinic driven, the system will merely diagnose the disease and treat it. The system will never focus on the environment from where the patient is coming from, the possible psychological, environmental and physical causes of disease, and to address those causes. Allocation of human, physical and monetary resources, in that case will also be on 'cure', and it will result in a very inefficient allocation. Research in the right direction of 'arogya' will not happen. It will require a complete revamping of the health system. To achieve a preventive or 'arogya' focus, the redefining of the roles and responsibilities of all major stakeholders,  be it doctors, pharmacies, diagnostics, patients and policy makers. A more judicious and efficient allocation of resources will be possible only if pursue 'arogya'. 

Digital Health, Data Analytics, Tele-medicine, Internet of things, Artificial Intelligence, and Genetic Engineering will help in developing a fair health system. Would it create a balance between primary and tertiary, preventive and curative health care systems in future? Will science develop to an extent that the gene would be modified and be made into a 'designer gene', so that the disease and old age will be eliminated? But, for that too we will have to allocate the resources in the right direction. 

We all think alike, across geographies, nations, sectors and age-groups. We are a minority though, but waves of change could be felt. 

Health and wellness, and the first showers !

Ayushman Bharat brought us the concept of 'Health and Wellness' centers, 1.5 lakh of them to be established in the country. As per the operational guideline of Ayushman Bharat, primary health centers  and sub-centers would be converted to HWCs. The principle of HWCs would be a seamless continuum of care that ensures the principles of equity, quality, universality and no financial hardship. It looked like a great concept on papers, so I was always inquisitive to know, how it would be operational.

I was taking the poster presentation of the students for summer internship when one student told me that his project was to help convert a PHC into a HWC. I was curious. How did you go about it, I asked him?

For the next hour and a half, what he explained to me, I am tempted to share it with everyone. As per the guideline, the HWCs would be providing an expanded range of services, which would include screening, prevention and management of non-communicable diseases, Ophthalmic, ENT, Oral care, emergency services, elderly care and mental health care. These services would be executed through, Mobile Medical Units, Tele-medicine, Partnership with NGOs and Corporate, electronic recording of data and reports, and emphasizing health promotion.

I saw a lot of opportunities there. Physician or general practitioner at HWC, could act as a  gatekeeper. We could have a family doctor for a population of 2500. This family doctor would be equipped to do basic diagnostic, through simple, cost effective diagnostic methods, available at PHC itself. For complex diagnostic procedures, sample could be taken and be sent to a nearest empaneled diagnostic lab. A network of diagnostic services could be created.

A referral could be generated through these centers and nearby private and public hospitals could connect through internet and a specialist through, internet technology could look at a patient's reports and could generate a referral for him.

CSR expenditure could be directly sourced by HWC, as a potential source of funding for establishing infrastructure.

HWCs could be directly linked with schools, private and public for health promotion initiatives. We could have an elderly care home and a child care home attached to HWC. 

HWC would be the first point to generate health data, for every patient with a unique identification number, same data could be accessed any where in the health system. The data thus generated would help researchers and innovators.

Database would help in generating accurate demand and supply predictions for the drugs.

Alternative medicine, Yoga and other wellness techniques could be made instrumental through 'Wellness Rooms'. Nutritional solutions through PPPs could also be planned and delivered as per the requirement of the population.

Nithin Shanbhogue, my student, informed me that he was a part of a team at a leading development agency which helped the Jharkhand Government in establishing Health and wellness centres, in Jharkhand. He was a part of a team which conducted supportive supervision on nine functional criterions - 1)Infrastructure and Branding, 2)Human Resource and Training, 3)Expanded services, 4)Drugs, 5)IT system - teleconsultation, 6)Health Promotion wellness activity - Yoga, 7)Population Enumeration and NCD screening, 8)Community outreach activity - school health programs, VHSNCs etc, 9)IEC material 

He found out the infrastructural gaps, whether the existing building was owned or rented by the state, whether it had enough space to house, IPD, OPD, Yoga room, supply of drugs, electricity, water, mobile network, tablets, computers and other facilities. Where-ever the gaps were found he had brought it to the notice of State Nodal Officer, who took necessary measures to fulfil the gaps, the budget allocation for which had already been made. Apollo group of Hospitals is already running tele-medicine outlets at PHCs in Jharkhand. 

He assisted in doing the population enumeration at the HWC. NCD screening was done after the population enumeration was cmpleted. ANMs selected the high risk patients and they will be sent to Community Health Centres. Training of ANMs has been completed for gathering the health data of the community on a tablet in digital form, and the training of ASHAs is in progress. 'Community Based Assessment Checklist'(CBAC) forms were available on tablets. Patient data thus collected, will be stored in a national database, which would be bifurcated at state and district level. A unique ID will be generated for every patient and his test results and diagnostic details will be saved by that ID. Referrals will be generated based on that. A monthly report will be prepared by frontline health workers and Community Health Officer posted at HWC, will send it to the state. District Program Officer, State Nodal Officer and doctors will have an access to data and reports. CBAC forms, duly filled up will be saved in a family folder. A micro-plan for fixing a day for NCD screening has been executed at select HWCs. The OPD data will be collected real time and will be stored in the database. 

An NCD tool kit has been supplied to the HWC, which contains Glucometer, Tongue Depressors, BP instrument, and anti-diabetic, anti-hypertension and anti-epileptic drugs. A community health officer will be posted at each subcentre. A bridge course on community health of six months has been designed by IGNOU to train CHOs in their jobs. For the purpose the program study centres have been established. 

AYUSH will take care of the Yoga centres. A fixed schedule would be generated to conduct Yoga sessions. 

HWCs will have several backward forward linkages. India's foray into digital health through HWCs, will provide huge opportunities in future. AI will be developed, Innovation will be done, supply chains will become more effective and the cost of care will be reduced. It will provide the necessary data for research. We will leapfrog to the advanced health systems. 'Winnable battles' would be fought and won, because of reporting of real time data. 

I have always believed that my country does not have the resources(given the huge population) to provide universal health care, through curative care models that exist in US and other developed countries. The very thought is pinching, that some people will have to go without care, because of resource constraint. 

WE CAN find new models based on preventive health care, technology enabled new methods, digital health and more sustainable resources. Networks will help us build sustainable models, and the new challenges put forward by climate change and microbial resistance will be better handled. I tried to picture the backward-forward linkages of HWCs in my mind and I have tried to put it on paper. 

As a result of technological interface, hospital space will shrink. A lot of convention services provided by the hospital can be outsourced. Many startups will contribute to shrinking of the hospital space by entering into the space of laundry services, food supplies, infection management, financial services, TPA management, patient tracking, tele-medicine, homecare, diagnostics, advocacy and research. Big data will enable leapfrogging to advance health systems, that would enable targeted interventions in the area of nutrition, lifestyle change, behavior change, environmental awareness and zero inventory or waiting time scenarios. It will enable, large scale diagnostic labs to be established, unique breakthroughs in genetic engineering, disease management and development of drugs. A diverse and IT enabled country like India can become a hub for healthcare innovation in future. Artificial intelligence and seamless flow of data through block chains will bring about unique research opportunities, both on the preventive as well as curative side. Many dimensions to continuum of care will open up. 

After many Sunny Days, this came as a respite of the first shower of the rain. Fresh smell of the dampened earth outside, is filling up my room, as I write this piece. 

Hope, manifests in many ways, and fills up the heart surreptitiously ! Hail!

Healthiest Nations in the world - and Cuba!

Bloomberg Healthiest Country Index results of 2019 edition have been announced, day before yesterday. The index grades nations based on variables including life expectancy while imposing penalties on risks such as tobacco use and obesity. It also takes into consideration environmental factors including access to clean water and sanitation. The index puts Spain as the healthiest nation, and the US at 35th position. Cuba is placed five spots higher than US at 30th position, making it the only nation not classified as 'high income', to be ranked that high on the index.

One reason for Cuba's health is attributed to an emphasis on preventive care. The focus in more developed economies like US is on diagnosing and treating illness, rather than preventing illness. Prioritizing primary health care, which is provided by public providers, specialized family doctors and staff nurses, by getting preventive services to children, women and elderly patients.There is a concept of socialized health care, adopted by Cuba, and some other countries in the world. 'Socialized Healthcare' is the universal health care system, provided free, largely by the government, on a no-profit basis, prioritizing primary care and prevention as well as addressing social determinants of health. It is about making 'health' available to all, irrespective of social or economic status. It is about developing a health system, which serves all, which brings equality, through healthcare.

Cuba spent 10.57% on health, as per 2014 statistic, which is higher than many countries in the world. Cuba’s “army of white coats”, as it was termed by Fidel Castro,was formed in 1960. Today, around 50,000 Cuban medical workers are present in 67 countries. The healthcare industry is also one of the country’s main sources of income.Doctors are arguably Cuba’s most profitable resource and the country’s medical missions have proved to be a lucrative diplomatic tool.  In 2014, Cuban authorities estimated overseas healthcare services would bring in $8.2 billion, putting it ahead of tourism.

Cuban medical schools, which are government-run and tuition-free, incorporate primary care, public health, and social determinants in their curricula. Cuban medical education system, comprises of a student entering into a six-year training directly from high school, and first educated as primary care practitioner. Later, those who wish to specialize go for a post-graduate degree. 

The set-up and structure of Cuba's health is a geographic-based health care system. The Cuban 'consultorio' comprises a doctor and nurse team who provides basic primary care services for 600–900 patients in both the clinic and patients' homes. Mornings are devoted to OPD, and afternoons for a household visit to address prevention needs, and counselling about environmental factors affecting health. Physicians are expected to understand a patient's family and social backgrounds and reach out to those who typically avoid interaction. Cuban health care system stresses the physicians' role to promote public health and their moral obligation to address health care disparities and inequalities. For more complex services, physicians refer patients to local polyclinics, each serving a single geographic area of approximately 25,000–35,000 people.

Why is it essential for a doctor to understand social determinants of health such as education, housing, environmental elements (e.g. sanitation and clean air), food and nutrition, and employment? The simple answer is that many diseases can be prevented when these aspects are addressed. Lack of education, adequate nutrition, unclean environment, lack of clean drinking water, housing conditions, poverty, unemployment, and the resultant stress in life is the cause of diseases. Treatment does not address the cause, social, behavioral and public health interventions do. 

Considerable amount of data that is collected on a regular basis, through household visits is used to drive innovations for unique and local health problems. Data also helps in getting to the crux of the problems. Health interventions incorporating social and behavioral change are planned based on data. 

Cuban health system is still far from perfect. There are chronic medicine shortages. Facilities often lack basic supplies or equipment, and physicians receive poor compensation. There are clinics which cater to medical tourists and VIPs and they have better facilities.Yet each dollar spent on healthcare brings about better results than some of the developed countries, including US.

The key is in realizing that ensuring health to all the citizens as a basic human right, and making efforts to bring 'health' out of the demand supply based pricing system. Preventive care methods establish health as a condition, and not as a service. Being healthy is a right of a human being and socio-political structures must respond to that. 

If India wants to develop a healthcare system like that of Cuba, structural changes, in infrastructure and law would be required. One can argue that a strong political will and public opinion will be required. As a matter of fact, there is no way out. India doesn't have resources to follow the curative care path like US. Preventive care is much less costlier than curative care and thus it brings more value per dollar spent. 

We consume tobacco, have developed junk food eating habits, pollute air and water, do less exercise, and create stressful lifestyles. Inequality creates more stressful societies - be it economic or social. 

Can't we have the national consciousness to utilize health to bring in a more equal society? Can't we have the political and social will to bring in structural changes?

Moving to Value Based Health Care from Volume Based health Care...

Today, I was teaching the last class of Hospital Management. I was trying to bring home the concept of value based health care to them, using Michael Porter's work on the topic, and telling them that they will be the future healthcare managers and providers; so they need to understand the concept. In between a discussion on Porter's concept of value, bundled pricing and IT enabled Integrated Practise Units(IPUs), one student commented that value based health care seemed like a utopian concept to her, much like an idealistic world, that we will never be able to attain. She had her own long list of arguments to support her precept. I was not able to answer her question adequately in class. 

Long after the class was over, I kept thinking that if ever we are given a power to build up the most ideal healthcare system, what would it be like?

An ideal healthcare system, first of all would be equitable and non-discriminatory. It will not discriminate between rich and poor, powerful and vulnerable, or caste, creed, race or religion. This would mean that anyone who fell ill would be provided the same service by the provider. To create this kind of system, state will take the initiate and health care would be entirely in public domain. The state and the society would be so evolved that people will consider healthcare as a human right and would be willing to make all efforts to let every individual exercise his right to access health. The rich would be willing to pay for the poor. Society and the state will take the responsibility of taking care of an individual's health at different stages of his life.

The first step towards achieving such a healthcare would be to get lessons pertaining to healthy lifestyle getting included in the course books, healthcare being offered as a compulsory course during all the school years. From childhood to adulthood, children would get to learn important lessons on human body, healthy life and lifestyle through books and experiential learning. Sports, Yoga, Meditation and Healthy diet would be an essential part of school curriculum. No child would be able to pass high school, until he has attended the necessary 'health', part of his courses and practical's.

Of course to make this a reality, education will have to be equitable too. Everyone will go to a similar school and study the same curriculum.

Everyone will be covered under a state insurance for a lifetime, immediately after the birth. The premiums for this insurance would be paid by all citizens, every year, in the form of tax. All the hospitals, healthcare units and wellness centres would be financed by the National Trust, created out of healthcare tax collection. Health would be entirely in the public sector, no private practise would be prevalent in the country. The payer will have to just pay his taxes to get an access to healthcare.

Every child will get a unique health identity number(HIN), as soon as he is born. All the health records, right from the time of his birth will be recorded and saved digitally. All the hospitals in the country will be on the same network, will be connected by IT infrastructure and will be sending and receiving information at a fast pace. There will be huge national databases which will store all the health information of all the citizens of the country. There will be a real-time updation of database.

All the hospitals and health and wellness units will be connected in the country. Vaccination and Screening programs will be conducted for the entire population and the data thus generated will be available to physicians, healthcare providers, researchers and people. Rigorous research on diseases and socio-economic-environmental aspects of health will be done in national laboratories.

All the transactions, for each individual at the hospital would be cashless. When a patient entered in a hospital he will be registered with his HIN, and all his past records will be made available to the doctor at the click of a mouse. Any new diagnostic tests, or imaging done for him will be updated in the database by his HIN. He need not pay anything at different levels of care. His bill will be raised as per the cost at each level, will be accumulated at the time of his discharge and will be sent to the insurer. Healthcare will be provided on a no-profit basis. Bundling of costs will be done and bills will be raised accordingly. There will be no such thing as healthcare pricing. Healthcare costing, and costs will be determined based on the actual cost of the service provided at each level. Healthcare provider will have no incentive in increasing the cost of care. He will be naturally creating value by reducing the unnecessary cost, as it will only increase his or his colleague's work.

It would be considered honourable to work for the healthcare system. Healthcare providers would be highly respected in the society. The exact demand for the healthcare workforce, be it doctors, nurses or paramedics would be projected accurately, based on Health Data Analytics. The workforce would be educated and trained accordingly. High level of personal ethic would be considered as a pre-requisite for an admission in educational institutions providing health education. There would be a standard remuneration structure for the health providers and workers, based on specialisations. The workforce would be self-motivated, dedicated and efficient.

 This model of healthcare would be naturally value based. Value created at different levels of healthcare system will determine the final health outcome. Value generation, rather than volume generation would be the practise, simply because bigger volumes will not be incentivised or rewarded. This way, the healthcare service will naturally move towards wellness rather than cure, towards preventive care rather than curative care. The resources in the economy will be optimally utilized. Infrastructural needs will be taken care of by the government. Health Infrastructure will be created by the government, technological development in healthcare will not be allowed to bag a market price, and most of the technological development will come through government funding.  Disruptive innovation will be rewarded on an individual basis, but market forces will not be allowed to fix the price for innovative technology.

It will be a Utopian world, so it will be a clean environment, be tobacco free and everyone will be adequately nourished. People will lead stress free lives because they would be evolved, and they would have the intelligence to make a sustainable and justifiable use of natural resources.
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Utopia - has a merit. Human being's imagination of Utopia, makes it possible to evaluate the deviations from the Utopia, in the real world.

If the real world, remains real, we can still rate ourselves and our systems, on the scale of deviations from the Ideal System. The lesser the deviations, the better the system is. 

I hope, this answers your question - My dear Students.