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. 

I am TIM Jr., Taimur Ali khan's grandson ! Please listen to my story !

Tim has had a good day's sleep and he has just woken up. Its 7.30 PM. He gets out of his bedroom, which is at under ground level and climbs up the stairs, to reach the second level, where he will have some water to take a bath, and a vacuumed water less toilet to relieve himself. His famous grandfather Taimur Ali Khan had opened his eyes in the same building, they lived in a beautiful apartment some floors above. There was a garden where he used to play and a balcony, where he had a swing. When Tim Jr., as he is called, was born, they had shifted in an under ground apartment, because carbon-dioxide in the atmosphere was so much that it was impossible to live in a house above the ground. During his great grand father Saif Ali Khan's days, this phenomenon was called global warming. The apartment that he lives in, is two small rooms, and is oxygen conditioned. It is impossible to live without Oxygen Conditioners these days, which is fixed on underground apartment vents, takes in the carbon-dioxide from the air, in, converts it into the oxygen, and throws it into the room. His great grand father used to park his car, where his apartment is located today. In those days, parking was underground and people lived in the floors above. 

Due to global warming, the temperatures started rising, during his great grand father's time. The extent of ultra-violet rays is so much, that it is impossible to come out during the day. That is the reason all the activities required for life, happen during the night. After his dinner, which is the first meal of the day, Tim will go to his office. He is the head of a production house that his great grand father had established. He will be shooting for the whole night. His movie is based on the real story of a poor woman, who had a sick daughter, suffering from flu, needed to be taken to a doctor, had got out of the home, without an anti-ultraviolet attire, and as a result, suffered from skin cancer. Due to microbial resistance, flues are sometimes fatal in nature for the kids, there are no effective medicines. Tim Jr, creates socially responsible cinema.  

Tim walks out of his house, to get to his studio. People use solar battery driven cars, which are very small in number. Cars or bicycles are used to commute in Mumbai. There was a time when there was heavy traffic in the city. But due to a major water crisis, that happened during his father's time, many people moved out of Mumbai City. As a result of a drought, there was no water to drink in Mumbai. Now-a-days, people do rain water harvesting, and use the upper floors in the buildings for water storage. Rains are scanty, and everyone has to carry his own drinking water everywhere. There have been major fights among the workers because of water.

During Tim's grand father's time farmers used chemical fertilizers. As a result the ocean waters in many places like Mumbai, have become toxic, because of high level of phosphorus and nitrogen flowing into the oceans. Fishes and other animals have died. There are no fishes in Mumbai now, which used to be a staple diet at one point of time. The bottom of the sea is also full of plastic and polythene. Fruits, vegetables and grains are also in short supply. Although, plants can handle UV better, but agriculture has come down. As Tim walks, he wonders... Why did the generation of my grand father cut so many trees, when they could not plant as many? Why did they not think of me and my generation? If trees were there, my life would have been much more easier. He takes a sigh, and enters his office.

The heroine of TIM's film is five feet and three inches tall, who is his great grand uncle Ranbir Kapoor's grand daughter. It has been very difficult to find a hero for her, who matches her height. She is very very tall. The average height of males is about five feet and those of the women is about 4.7 feet. Many young people came for an audition and finally they could cast a hero, who was about five feet and two inches. Whenever, Tim has looked at the family photographs, he marvels at the fact that everyone in her family had been so good-looking. People in those days used to be tall and handsome. His great grand uncle Ranbir Kapoor had been about six feet tall. The population of the world is just one third of what it was hundred years ago

TIM's great grand father was wise enough to buy his grand father an apartment in Switzerland, in the woods. There are very few areas in the world, left, where there is fresh air and water. How much TIM dreams of that tiny, little house, that he had gone to when he was a kid. It was a long journey through the sea, after many days of travel they had reached there. People no more travel by air these days. The oil reserves of the world have almost died down. Whatever has been remaining has been conserved by most countries for defense purposes. The mode of transportation is solar operated ships. 

This is 2118. Tim is a twenty year old young boy. Hundred years ago, people used to say, Save the earth - when they should have said, save your grand children. Tim sometimes wonders, why the generation of his great grand father could not have been a little less selfish, a little less stupid. Why?

Disclaimer - The thoughts expressed in this post are that of the author, and all references of those dead and alive are purely incidental. These dismal thoughts came after reading this article - 

https://www.theguardian.com/environment/2015/jan/15/rate-of-environmental-degradation-puts-life-on-earth-at-risk-say-scientists

What should be done to make Ayushman Bharat Successful?

Prime Minister Narendra Modi on September 23 launched the Pradhan Mantri Jan Arogya Yojana (PMJAY)-Ayushman Bharat and termed it a "game-changer initiative to serve the poor". The scheme aims to provide a coverage of Rs. 5 lakhs per family, annually and will benefit 10 crore families. Five states have already opted out of the scheme - Delhi, Kerala, Odisha, Punjab and Telangana. The financing of the scheme is by 1% cess, which is expected to collect an amount of Rs.11000 crore to the exchequer. If even 10% of the sum insured is claimed it will produce a bill of Rs. 50000 crore to the government. The government will have to resort to a reliable source of finance to make PMJAY successful.

It is not clear so far, which insurance company will be an insurance provider for PMJAY. Health insurance should be kept in public domain and a new company for health insurance (by merging the health insurance division of the three insurance providers in the public sector) should be created, in public domain. This company can create various insurance products, for different kinds of payers. Scale economies will generate low cost products, which would enable people to bear the cost of insurance largely. Poor and marginalized population in that case can also pay a part of the premium.  

In July, 2018, Niti Aayog issued a document called 'National Health Stack' as a first step towards 'Ayushman Bharat'. 'The National Health Stack (NHS) is a visionary digital framework usable by centre and state across public and private sectors. Through this platform, digital health records for all citizens by the year 2022 will be stored in a database'. Through this platform, national health electronic registries, a coverage and claims platform, a federated personal health records framework, and a national health analytics platform will be made possible. A strong and resilient digital backbone to the health system will bring transparency, and will enable the process of shifting from illness-focused to wellness-oriented approach and to ensure cost-effective healthcare. With the help of this kind of data, specific customized solutions can be developed for the people at local level. Technological innovations like telemedicine, gene mapping, large scale diagnostic labs etc. will enable health systems in the country to leapfrog to a more vibrant and sustainable health care delivery system. A large population is to be served, but it also gives opportunity in terms of scale economies, as per person cost of technology is bare minimum.

Effectiveness of primary healthcare centers is the key to the success of Ayushman Bharat. Gate-Keeping in  healthcare system is a mechanism of care referral where a general practitioner is the first point of contact in the patient's care path and thus controls the patient's entry into the health care system. In case of our country the gatekeepers will be physicians or nurses in the PHCs and CHCs. Referrals from these centers to an empanelled PMJAY hospital, will be the starting point of the chain in this scheme. Ability of tertiary care hospitals in public and private sector, to take the patients who have PMJAY card, and providing them a cashless treatment would complete the process. Studies have shown that patients get referred to the private sector hospital, as government hospitals are over crowded and there is lack of trust at user's level.

There are significant infrastructural gaps in India, as far as health care delivery is concerned. There is a normative gap of 3469 community health centers for a population of .1 million, 5887 primary health centers for every 30000 people and 27430 subcenters for every 5000 people.  Even if these facilities exist they are not fully equipped. There is a gap in the number of doctors, nurses, paramedics, and frontline health workers required to run this system as well. Because of this gap at the lower levels, a referral system cannot be created and thus the burden is shifted to tertiary level hospitals and medical colleges in the district. 

Private hospitals are not comfortable with the cost of care estimated under PMJAY. A delegation of private players had given a representation at Niti-Aayog in this regard. They find the rate too low. However, there are reportedly 9000 private hospitals empanelled with PMJAY. Putting too much of money in insurance, considering wide gaps in government infrastructure will transfer committed funds to private sector every year. Capital Expenditure on health will get a boost in the private sector, but it will also give rise to cost of care, drugs, and diagnostics. Very strict regulations and constant negotiations with the private sector to bring down the cost, will make this public private machinery work, otherwise it will give rise to various un-ethical practices. Privatization of a basic service like healthcare, brings up unique inequities, like it is in US, those who can pay have a better access to health. Forcing private sector to prioritize the poor is a sound maxim, but government will have to generate economies with which it would work. 

The last initiative would be improving the management of hospitals. Government Hospitals are very poorly managed, and the reason often cited is the over crowdedness of the hospitals. Military hospitals in India are equally loaded, a doctor sitting in OPD, in a military hospital usually entertains, the same number of patients, OTs, wards and other services are also equally demanded for. The difference is in the management. Military hospitals are managed efficiently, SOPs are followed, and monitoring and regulation is very strict. The same can be done for government hospitals too.