iconhss report 2010

Transcription

iconhss report 2010

INT ERNAT IO NAL CO NFERENC E O N
Health Systems
Strengthening
May 6-10, 2010
Chennai
ICONHSS
REPOR
T
REPORT
International Conference
on
Health Systems Strengthening
ICONHS
S
ICONHSS
May 6 – 10, 2010
Mamallapuram, Chennai
Tamil Nadu, India
Report of the International Conference on Health Systems
Strengthening (ICONHSS) published by the Tamil Nadu Health
Systems Project (TNHSP).
For more details contact:
Tamil Nadu Health Systems Project (TNHSP)
7th Floor, DMS Building
Teynampet, Chennai – 600 006
Tamil Nadu, India
Ph.: +91 44–24345992, 24345996
website: www.tnhsp.org
Disclaimer: This report is a documentation of the proceedings of ICONHSS 2010. While
all attempts have been made to record the inputs of speakers and participants, there
may be some unintended errors which may kindly be overlooked.
English/ 2010
Chennai, Tamil Nadu
22
Financing, Service Delivery,
Human Resource, Governance
P
Preface
T
he International Conference on Health Systems Strengthening
(ICONHSS), hosted by the Government of Tamil Nadu was held from
May 6-10, 2010 at Chennai, India. The conference was a high scale event
in the history of our state government, and brought together a large
number of collaborating partners and participants from across the country
and the world. The participant profile was diverse and rich in experience
as it included students, doctors, researchers, public health academicians
and professionals, government officials, donor representatives, health
service providers, information specialists and media persons, etc. The
presentations and discussions that ensued in the conference were
insightful, informative and provided an opportunity for learning about
several best practices in the area of health systems strengthening.
The support and encouragement received from the highest
echelons of the Governments of India and Tamil Nadu went beyond all
expectations, reflecting not only the political and administrative
commitment towards the issues of health systems strengthening, but also
the need to play a responsive host to a conference of this nature. This
conference was made possible by the collective partnerships of many
stakeholders, including the Government of India, NACO, World Bank,
USAID-INDIA, WHO, TANSACS, ICMR, APAC-VHS, SAATHII, NRHM, the
Tamil Nadu Dr. M.G.R Medical University (TNMMU), PHMI, Chettinad Health
City, ehealth India Megazine, Star Health and allied insurance Co. Chennai
and the Tamil Nadu Health Systems Project (TNHSP).
Chennai’s Mamallapuram area, the venue for this conference was
buzzing with enthusiasm and the logistical display of a one of its kind
international conference in India. The red caps and T-shirts’ wearing
volunteers, the vehicles with the conference logos, the signage on
roadsides and at the conference venue, the visual appeal of the conference
ICONHSS
2010
3
bags and name tags on participants, along with all the hard work of
members of the ICONHSS organizing committee and staff of partnering
organizations added to the interest and energy that this event created.
The inputs of the participants at the conference has enriched the
understanding of health systems strengthening and provided many new
learnings and contacts with experts and practitioners in the field. The
research and experience based sharing on various related issues; the
people to people discourse and some real recommendations for translating
knowledge into action has added to the knowledge base on how to
strengthen health care systems in our state.
The response to the conference has overwhelmed us and we realize
that we have a greater responsibility now due to all the expectations that
ICONHSS has created. We hope to put this commitment into an immediate
follow-up mode so that the content and synergies created by this
conference are not lost.
The journey for overcoming public health challenges in India has
clearly begun in a very meaningful and dynamic way, through this
conference.
This report presents the processes, presentations and discussions
that made ICONHSS a great success, while providing insights for the
future. The report begins with messages from the President & Chairman
of the ICONHSS, followed by an Executive Summary of the report. This
is followed by a background chapter which provides a look at the context
and objectives of this conference. The next is a chapter on the preconference workshop, followed by six other chapters, including the
thematic sessions, the sideline events, the valedictory function, the
recommendations and way forward, conference experiences and selected
press coverage. In the Annexures is included some important additional
information related to the conference.
The content is presented in the form of a thematic structuring on
different issues impacting health systems structuring, and includes
information and ideas gathered during the plenary and parallel sessions
and symposium held at the conference, along with comments and
questions from the audience. Brief summaries of the presentations made
across the conference sessions are included in the report, while the
4
detailed presentations can be found on the conference website.
Recommendations emerging from each of the sessions are shared as
highlights within each theme, apart from a final consolidated chapter on
recommendations and ways forward.
The report also provides a glimpse of the poster displays, the
organizational exhibits and stalls, the cultural interactions, the field visits,
and the networking and media outreach that made the conference
complete.
Vignettes of participants’ experiences and learning at the
conference are shared in the report, giving the reader a sense of how
the conference impacted those who attended it. Inserts of some English
language press coverage on ICONHSS is included along with some
photographs from the event. As annexures are included the program
schedule, list of speakers, ICONHSS Organizing Committee members, a
list of partners/ collaborators and the Chennai Declaration.
While bringing this report before you, we invite you to join us in
taking the necessary steps at your different levels for health policy
advocacy and change, creating budgetary allocations, research and
information sharing, enhanced access to health care and service delivery,
human resource management and governance, integration and innovation,
and networking for global-Indian partnerships in this field.
We also invite you to take the Chennai Declaration that has
emerged from this conference as our collective pledge for building on
health systems strengthening in Tamil Nadu and the rest of the country.
Organizing Team, ICONHSS
Chennai, Tamil Nadu
India
ICONHSS
2010
5
A
Acknowledgements
June 2010
T
his conference would not have been possible without the active
participation, encouragement and support of all our local, national and
international partners. It was the efforts of each individual and
organization involved that made it possible for this conference to be
organized successfully.
From planning content and logistics to coordinating participation
of different stakeholders, conducting and recording the proceedings and
keeping the energy of the conference alive through it all – there was a
continuum of support from the partners that made ICONHSS a reality.
We would like to take this opportunity to express our gratitude
towards all key collaborators in the Government of India; Government
of Tamil Nadu; The World Bank; USAID India; Aids Prevention and Control
(APAC) Project – VHS; National AIDS Control Organization (NACO); Indian
Council of Medical Research (ICMR); World Health Organization (WHO) –
Country Office for India; Tamil Nadu State Health Society (NRHM);
Solidarity and Action Against the HIV infection in India (SAATHII); The
Tamil Nadu Dr. MGR Medical University (TNMMU); Public Health Management
Institute (PHMI); Chettinad Health City (CHC); eHealth Magazine;
Directorate of Medical Education (DME); Directorate of Public Health and
Preventive Medicine (DPH and PM); Tamil Nadu State AIDS Control Society
(TANSACS); Tamil Nadu Health Systems Project (TNHSP).
We would also like to thank all the members of the organizing
committees; the logistics providers at each venue and outside; the
representatives of the regional and national media who covered the
conference widely and the student volunteers who worked tirelessly to make
the conference run smoothly.
Finally, we must acknowledge each of the speakers and participants
who travelled from different parts of the world, the country and from
within the state of Tamil Nadu and made ICONHSS an engaging and
interactive experience for all of us.
6
C
Contents
Preface
Acknowledgements
Acronyms
9
Messages from the P
resident, Chairman and Co-Chairman,
President,
ICONHS
S
Organizing
Committee
10-13
ICONHSS
Executive Summary
14-24
Chapter 1
Background
25
Chapter 2
Pre-Conference Sharing
29
Chapter 3
Conference P
rocesses and P
resentations
Processes
Presentations
41-121
3.1 Inauguration
41
3.2 Priorities for Health Systems Strengthening
50
3.3 Financing for Universal Access
55
3.4 Health Service Delivery
59
3.5 Human Resource
75
3.6 Health Financing
91
3.7 Governance
98
3.8 Positive Synergies between Health Systems and
Global Health and Development Initiatives
111
3.9 Health Systems Research
118
ICONHSS
2010
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Chapter 4
On the Sidelines
4.1 Poster Display
122
4.2 Display Stalls and Exhibits
124
4.3 Field visits
125
Chapter 5
unction
Function
Valedictory F
132
Chapter 6
R ecommendations and W
ays F
orward
Ways
Forward
135
Chapter 7
ignettes from participants
Vignettes
The Conference Experience – V
144
Chapter 8
In the P
ress
Press
156
Anne
xures
Annexures
A. Program schedule
B. List of Speakers
C. ICONHSS Organizing Committees
D. List of Partners and Collaborators
E. Chennai Declaration
8
122-131
162-180
A
Acronyms
APAC
AIDS Prevention and Control Project
CDC
Centers for Diseases Control and Prevention
HSI
Health Systems Improvement
HRH
Human Resources for Health
HSS
ICMR
Indian Council of Medical Research
ICONHSS
International Conference of Health Systems Strengthening
NACO
National AIDS Control Organization
NIE
National Institute of Epidemiology
NRHM
National Rural Health Mission
PHFI
Public Health Foundation of India
PHMI
Public Health Management Institute
PMTCT
Prevention of Mother-to-Child Transmission of HIV
SAATHII
Solidarity and Action Against The HIV Infection in India
TANSACS
Tamil Nadu State AIDS Control Society
TNHSP
Tamil Nadu Health Systems Project
TNMMU
Tamil Nadu Dr MGR Medical University
USAID
United States Agency for International Development
VHS
Voluntary Health Services
WB
World Bank
WHO
World Health Organization
ICONHSS
2010
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Message from P
resident, ICONHS
S
President,
ICONHSS
Mr
.K. Subburaj, I.A
.S.
Mr.. V
V.K.
I.A.S.
Principal Secretary to the Government Health and
Family Welfare Department (H&FW) Tamil Nadu
I am extremely happy to note that our effort of organizing this first of its
kind international conference in the State of Tamil Nadu has been highly
appreciated by one and all.
During the conference we have learnt a lot from the experiences of all the
participants who came from various parts of the country and the world.
I am aware that this conference is the start of a new chapter for us in Tamil
Nadu. Now we have to perform and make sure that we continue to lead in the
area of health systems strengthening and delivery of quality health care to the
citizens in our state..
We have been seen as leaders in the field, creating examples of best
practices whether in information technology, procurement, service delivery and
financing. It is important that we continue to create successful models that can
be replicated by other states and even be picked up by national and international
agencies to improve the access and delivery of health care.
We hope that this report will serve as a reference of the rich deliberations
at the first International Conference on Health Systems Strengthening, and
looking back we will be able to evaluate how far we have come in achieving the
commitments made at this conference in May 2010.
10
Message from Chairman,
Organizing Committee, ICONHSS
Dr
ijayakumar
.S.
Dr.. S. V
Vijayakumar
ijayakumar,, I.A
I.A.S.
Special Secretary (H&FW) Tamil Nadu & Project
Director, Tamil Nadu Health Systems Project and
Kalaignar Insurance Scheme for Life Saving Treatment
I am happy at the successful completion of the International Conference
on Health Systems Strengthening. Exemplary team work has gone into making
this conference a success. Usually the Government of India or the United
Nations organizations take such initiatives, however here the state government
took the step to organize a conference of this kind.
The participation and response to the conference has been overwhelming.
We had Health Secretaries from 12 states of India, attendance the conference
and representatives from 15 states of India, apart from those who came from
abroad. It was encouraging to see participants listening intently to the
presentations, asking questions and discussing issues in formal and informal
session; also the fact that almost all the invited resource persons accepted our
invitation to make presentation at this conference has been very positive. The
ICONHSS was attended by an overwhelming number of over 600 participants.
I am also happy that we successfully managed to limit the theoretical
discussions and got an opportunity to hear of many case studies and got
learning’s based on real experiences from the ground in the field of health
systems strengthening (HSS). Some of our key learning’s have been that, in
the discourse on public health, we also need to engage institutions and agencies
involved in the area of Water and Sanitation, Hygiene and Social Welfare.
Looking at the future of health systems development, we should not focus
on various blocks of HSS in isolation, but develop a comprehensive understanding
of all the building blocks and their interactions. Moving forward from this
conference, we aim to convert the recommendations and suggestions that have
emerged in doable items. We are also working towards setting up a national
level task force under the leadership of Ms. Sujatha Rao, Secretary, Union
ICONHSS
2010
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Ministry of Health and Family Welfare. This task force would focus on research
and inputs for policy formation in this field.
The Chennai Declaration is a very significant outcome of this conference;
and we are going to take it up at the national level as an agenda for advocacy.
We have a great responsibility to fulfill the expectations raised at the
ICONHSS. We owe it to the people of our state and our country that this
is done in the near future.
I believe that one of the key reasons for our motivation in organizing this
conference has been the patronship of very senior people, including Prof Thiru
K. Anbazhagan, Hon’ble Minister of Finance, Government; Thiru M.R.K.
Paneerselvam, Hon’ble Minister for Health and Family Welfare, Government
of Tamil Nadu; Ms Syeda S. Hameed, Member, Planning Commission; Ms.
Sujatha Rao, I.A.S., Secretary, Union Ministry of Health and Family Welfare
Government of India, Thiru. K. Chandramouli. I.A.S., Secretary and Director
General, NACCO, Dr. Vishva Mohan Katoch, Secretary DHR and Director
General, ICMR and many other partners.
12
E
Executive Summary
T
he Government of Tamil Nadu organized the first International
Conference on Health Systems Strengthening (ICONHSS) in Chennai
between May 6 - 10, 2010. The conference was inaugurated in the
presence of Hon’ble Minister of Finance, Government of Tamil Nadu, Prof.
Thiru K. Anbazhagan; Hon’ble Minister for Health, Government of Tamil
Nadu, Thiru M.R.K. Paneerselvam; Ms Syeda S. Hameed, Member, Planning
Commission; Ms. Sujatha Rao, I.A.S., Secretary, Union Ministry of Health
and Family Welfare Government of India; Thiru V.K. Subburaj, I.A.S,
Principal Secretary to the Government of Tamil Nadu (Health and Family
Welfare); Dr. Mukesh Chawla, Sector Manager, Human Development
Network, The World Bank; Ms. Erin Soto, Minister - Counselor for
International Development, USAID-India; Prof. Giridhar J. Gyani and Dr
S. Vijayakumar, Special Secretary to Government Health and Family
Welfare Department, Tamil Nadu and Project Director, Tamil Nadu Health
Systems PROJECT (TNHSP).
The objectives of this conference were as follows:
S
To discuss implementation issues in enhancing health systems
with respect to service delivery, financing, human resources, and
governance.
S
To share international experiences for promoting cross-learning of
good practices in health systems strengthening.
S
To guide national and state policies for improving health systems,
governance.
ICONHSS
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The following themes framed the content of the conference:
m
Health Service Delivery: The service delivery component is
concerned with how inputs and services are organized and
managed – to ensure access, quality, safety and continuity of care,
in a variety of health conditions, across different locations and time
frames.
m
Health Finance: Methods adopted to finance health care have an
impact on equity, and on the risks and impoverishments that clients
could face in accessing health care.
m
Health Workforce: Health systems are human resource intensive.
However, there is a severe shortage of human resources in the
health system, and this has had a direct bearing on health
outcomes in several communities.
m
Governance: There is a strong causal relationship between good
governance and better development outcomes. Governance is a
multi-dimensional concept that is anchored in all the other issues
of health sys-tems.
Around 600 participants from various parts of the country and the world
attended the conference, making it a huge event in terms of response
and logistics. The participants at the conference included senior
government officials from health departments of over ten states of the
country, planners, policy makers, academicians, donor representatives,
technical experts, doctors and other medical personnel, NGO workers and
students, media persons, etc. from across the country and the world.
The conference was organized
over a five day period, with
the first day as a preconference sharing of
experiences under the TNHSP
and selected national projects
on HSS in India. During the
three main conference days,
over 30 speakers made
presentations across ten
14
sessions, including plenaries, panel discussions and symposiums on
different dimensions of health systems strengthening.
The key highlights of the pre-conference day were, sharing of learnings
among the partners of the Tamil Nadu Health System Project (TNHSP)
to help set the tone for the conference. It also laid the basis for enhancing
cross-sectoral and indepth understanding around health systems
strengthening from other states and internationally during the main
conference. The last day of the conference was spent in field visits to
selected sites under the TNHSP, showcasing best practices around HSS
in the state of Tamil Nadu.
Clearly, the successes of Tamil Nadu in the health sector were significant
enough for it to have taken the initiative for organizing such a conference.
The main conference was extremely rich in content and gained from the
diversity of participation. Across the main themes and their sub-themes,
several presentations were made, from which emerged several issues.
Issues of Discussion
Health Service Delivery: The key issues that emerged from the various
presentations under this theme helped provide a holistic picture of the
state of health service delivery globally, nationally and locally:
l
l
Health service delivery challenges need to be looked at in the
“context” of the increasing global burden on health care. For
instance, Malaria alone infects more than 300 million people
worldwide and kills more than 900,000 people annually. 90% of
these fatalities are children below 5 years. Similarly, more than 9.2
million people get infected with Tuberculosis (TB) every year, and
more than 1.7 million people across the globe die from TB. On the
other hand, non-communicable diseases are increasing at an
alarming proportion across the world. There is thus a need to
provide for the increasing health care needs of our population along
with improving the environment in which people are falling ill.
The “quality” of service provided is an issue of great concern as
it is accepted that the poor are also entitled to and expect a certain
level of quality in terms of cleanliness, hygiene, comfort, respect
ICONHSS
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and access to competent health
professionals and medication.
Providing for this basic level of
quality is a matter of immediate
attention within health care delivery
systems - to be able to make the
systems perform effectively.
l
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16
The “double burden of disease”
is a challenge that needs to be
faced upfront. With the onset of
non-communicable diseases, the
entire system has come under
due to increased workload on the
one hand, and, on the other
hand, it is also driving up the cost
of health care. Infact the cost of
health care is going up because of
the excessive use of high
technology in diagnostics and also
due to a larger number of Chronic
Diseases like Hypertension, Diabetes, etc. The challenge that remains
is to keep health care affordable for the poor and marginalized people
in the country.
Effective service delivery is related to the issue of “Financing”, which
is in turn connected to the nature and extent of disease and disease
control. In India, the prevalence of both communicable and noncommunicable diseases (NCDs) is so significant, that it puts a huge
strain not only on those who have to spend but also those who
have to invest in making health care qualitative. With the increase
in NCDs, particularly cardiovascular diseases which are asserting the
Indian population in its productive years, and leading to the loss of
earning capacity, there is an increased burden of paying for medical
expenses. In fact, this trend is pushing people into “neo-poverty”
and there is an urgent need to address this issue through systematic
financial investments. One of the possibilities here is the use of
‘Insurance’, as a way of ensuring effective Health Service Delivery
especially in the areas of secondary and tertiary prevention of NCDs
and there are several examples of such insurance schemes working
on the ground.
Health Workforce: The key issues that emerged from the various
presentations under this theme provided a comprehensive idea of the
nature of human resource management issues in the health sector,
including recommendations for making the necessary inputs at the state
and national level.
l
l
l
l
The nature of workforce: One of the key discussions related to
the competencies that India needs in providing quality health care
to its large population. This question is directly linked with the
strategy of providing health care. Should the country adopt the
Clinical approach to health care or the Public health care approach?
While the clinical approach to health is focused on curative health
and hence dependent on qualified doctors and nurses, the Public
health approach is focused on preventive health and hence
demands more “feet on the street” kind of health professionals who
focus on Primary Health Care and fulfilling basic health care needs
at the community level.
Strategies for attracting and retaining: What are the necessary
factors for attracting trained staff and retaining them? How should
one motivate health care professionals to provide services in
remote rural areas? These are questions that demand intensive
research in order to attract health care workers across different
institutional settings and also for understanding and planning for
human resource development in the health sector.
Increasing productivity: Apart from training and educating the
large number of new health professionals, how should one increase
the productivity of existing health care personnel? In this area “Task
Shifting” emerges as a significant learning from the experiences on
AIDS , TB Control and Prevention initiatives.Polarization of field staff
in various natural health programmes for effective health care
delivery system; this demands shifting from ‘single disease focus
‘ to system strengthening approach. In addition, the extensive use
of information technology to unburden healthcare professionals
from administrative jobs like recording, compiling and maintaining
physical records would be a positive step.
Technology based education and training: In today’s context,
it is necessary to apply information technology to reach out to large
numbers of people and to be able to upgrade their skills and
competencies using e-learning solutions.
ICONHSS
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Health Financing: Three key issues emerged
presentations and discussions under this theme:
l
l
l
from
the
various
Who finances: Who shares the burden of health care financing?
This is a very important question for debate, given the fact that
in India currently, about 72% of the health care expenditure is
borne by private household. This puts the poor and the
marginalized at a definite disadvantage, as their ability to seek
“private health care” is almost negligible. It is therefore extremely
important to find a collateral or support for financing at the
individual and family level, across class but more importantly for
the already disadvantaged.
How is financing done: How does one finance health care
delivery in India? How should one make service delivery institutions
accountable for effective health care? Would “pay for performance”
(P4P) be a workable idea in a diverse and complex country like
India? These are some of the critical questions that need deeper
discussions while a certain level of consensus is already coming
up around Mass Insurance and the use of payment vouchers as
workable alternatives.
When is financing needed: What is the right time for financing?
The current situation is that the household pays at the time of an
illness, which increases the stress in terms of coping with the illness
and organizing finance at the same time. In fact, due to payments at
the time of an illness, a large number of people choose ‘not’ to seek
proper health care or are forced to sell their assets, which often times
pushes them below the poverty line. In this context, there is a need
to develop systems for health care financing to support people in
times of critical illness and the need for care, and such measures can
infact serve as a social security blanket for the poor.
Governance: The presentations under this theme provided a rich
diversity of issues that need attention within the governance domain,
along with an integrative perspective on health systems strengthening
within this context.
l
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Value based governance: The pillars of governance are the values
on which it is based and these are the ‘values of democracy’. It
is agreed that there has to be a pro-poor bias in governance. This
focus is in fact emerging due to a plethora of data suggesting that,
due to corruption and malpractices, a significant amount of benefits
never reach the marginalized population of a country. For instance,
Transparency International claims that in some countries, upto twothirds of hospital medicine supplies are lost to corruption and fraud.
To overcome such a situation there has to be an emphasis on
“ethics and values” in the discourse on health care governance.
l
l
Transparency: The lack of transparency in health care governance
not only leads to the misuse of systems but also the decisionmaking powers entrusted with authorities. To be able to ensure
effective health care governance, the process of human resource
management; procurement and financial management have to be
transparent.
Accountability: For effective governance it is important that the
decision makers are accountable to the people on whose behalf
they are making the decisions. However, at present, the
accountability mechanisms are either non-existent or weak, with
the exception to the access and use of the “Right to Information”,
which is a very important tool available for ensuring accountability
within the system.
Building Synergies: The discussions under this theme highlighted some
important issues that need to be considered in the path of building
synergies of thought and action between country health systems and
global health and development initiatives (GHIs).
l
l
GHIs establish a parallel system: The fact that GHIs end up
establishing a parallel system to the national health system is the
result of their focus on linking funding with various performance
indicators. As a consequence, donor supported vertical programs
deliver better results; however, they also end up establishing a
parallel system which is not necessarily a positive practice.
Implementing learning from GHIs: The need to learn from GHI
experiences and mainstream these into national health systems is
an important agenda for action. Infact, a performance based
approach of GHIs is considered to be responsible for effective
ICONHSS
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implementation of vertical programs, while budget and population
focused National Health Programs do not seem to deliver as per
expectations.
l
Strategies of integration: What are the key strategies for
achieving effective integration of GHIs and National Health
Systems? The answer to this question would depend on various
factors. For instance, research by the Global Fund recommends that
it is easier to integrate the Malaria program with a National Health
Program as compared to the HIV Program. Similarly, at the
operational level, there is a greater possibility of integration at the
grass root level among delivery organizations.
Health Systems Research: The presentations in the area of health
systems research focused on issues such as, why we need research, what
are the effective tools of research, experiences from the field and the gains
so far. Some of the key issues that emerged after the discussions were:
l
l
The necessity of health system research: It was discussed that
there was a need for an increased focus on health system research
both at the micro and macro level. At the micro level, the research
should focus on individual patients and practitioners, while at the
macro level the focus should be on health systems including their
efficiency and effectiveness.
Gains of health system research in India: It was observed that
over a period of time India has gained from various health system
research initiatives at various levels, particularly in the development
of diagnostics; new drug development (Centchroman, Arteether)
and preparation of a genetic atlas of Indian tribes.
In addition to the issue based conference sessions, there were several
other sideline events organized as part of the conference experience:
Poster Display and Presentations
The poster displays at the conference were a treat to see, ponder over
and take back as ideas for sharing and replication. Apart from informal
corridor discussions on the poster displays around various themes
associated with HSS, there was also formal time built in within the
20
conference agenda for the
presenters to share their
poster concept and content.
These posters were judged
by a panel and awarded
prizes at the end of the
conference.
Field Visits
After the end of the formal
conference, a group of 50
participants from Tamil Nadu, Orissa, Kolkata, Delhi, Kerala, Gujarat,
Malaysia, and Denmark spent a day for field visits to four selected sites
(in Chennai) under the TNHSP, to understand the practical operations of
the health systems process. The key purpose was to expose the
conference participants to some of the best practices in the area of health
care in the state of Tamil Nadu. The sites included the following:
m
An upgraded 24 hour Primary health centre (PHC),
Medavakam - a unique example of Public-Private Partnership, with
the local panchayat, an NGO, some business houses and the state
government coming together to provide quality service.
m
Tambaram Hospital – an example of a government hospital
where information systems are being developed to systematize and
upgrade the infrastructure and services in line with an accreditation
process by the NABH.
m
Emergency Management Rescue Centre (EMRC), Triplicane
– another best practice example of PPP, EMRC is a 24x7 ambulance
service run through a professionally managed call centre cum
emergency care unit.
m
Tamil Nadu Medical Services (TNMSC) Corporation, Warehouse,
Anna Nagar – a well-maintained and managed warehouse, that
serves as a demonstrative example of why the drugs and
equipment procurement process of Tamil Nadu is considered as one
of the best in India.
ICONHSS
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Exhibit stalls
Twelve partner organizations and associates of TNHSP set up
demonstration, information and networking stalls at the conference venue
so that participants could interact with staff from the projects, understand
best practices and also have access to useful print and audio-visual
resources that they could use for learning and/ or replication. The stalls
received a good amount of footfalls with enthusiastic participation from
speakers and delegates alike.
Outcomes and Recommendations
The Chennai Declaration has emerged as a consensus document of the
conference participants, including members of the government, civil
society, private sector representatives, donors, academicians, student
community as well as other interested stakeholders and is a unique
outcome of the conference steered by the state of Tamil Nadu. This
declaration is infact a framework for the way forward, and one that the
organizers and signatories to it have pledged to implement, review and
strengthen beyond the conference not just in Tamil Nadu but across the
boundaries of the state.
Collating the lessons from various experiences shared at the conference,
some important recommendations have emerged:
22
m
Health financing is a priority for meeting the goal of Health for All.
This includes the need to increase the health budget; improve
effectiveness and efficiency of public health expenditure; and
reduce out of pocket expenditure. Health financing investment
should specifically allocate for the components of Health Systems
Strengthening.
m
Need to make the prevention and management of NonCommunicable Diseases (NCD) a part of the existing public health
care system.
m
Need to build evidence to inform policy making and improve health
systems’ performance.
m
Need to improve the quality of service through accreditation of
hospitals.
m
Need to develop a comprehensive health workforce plan & Welfare
mapping.
m
Need to enhance the use of information technology to provide
effective health are governance and allocate additional resources
for the same.
m
Involvement of the local community in health governance is a
positive factor and should be supported.
m
Need to Strengthen Health Systems Research.
m
Need to enhance synergy between different stakeholders in the
health sector for better coordination.
ICONHSS
2010
23
CHAPTER 1
B
Background
A
cross the world, there is an increasing consciousness on the need
t
o
enhance health systems as the core area for achieving the necessary
quality and quantity of health care for our people. There are increasing
concerns about the outcomes, performance, responsiveness and equity
of health systems, while there continues to be a defined commitment for
investments in health. There is an overall acceptance that health based
interventions should be made more and more people-focused. And, many
believe that health systems strengthening would help in filling the gaps
between policy and reality on the ground.
It is this perspective that led the Tamil Nadu Health Systems Project
(TNHSP) of the Health Department, Government of Tamil Nadu (India)
to plan an International Conference on Health Systems Strengthening,
from May 6 - 10, 2010, at Chennai, Tamil Nadu. Organized by the Health
Department of a State, the conference was the first such effort of its kind
in the India.
The objectives of the conference were threefold:
✳
To discuss implementation issues in enhancing health systems with
respect to service delivery, financing, human resources, and
governance.
✳
To share international experiences for promoting cross-learning of
good practices in health systems strengthening.
✳
To guide national and state policies for improving health systems,
governance.
The conference adopted the definition of the World Health Organization
on health systems, as its base for discussion and debate, i.e. “all
24
organizations, people and actions whose primary intent is to promote,
restore or maintain health”. In other words, health systems are a means
to an end. The components of the health system and their interrelationships, determine the end, which is improving the health status
of people. In 2007, the World Health Organization identified six blocks
as constituting a health system, including:
Service Delivery: This is the most visible part of the health system, both
to the clients and the general public. Effective access, coverage and quality are some of the key issues in health service delivery.
Health Workforce: Health systems are human resource intensive. A
responsive, fair and efficient workforce enables the best health outcomes
possible, given the available resources and circumstances.
Health Information: This enables the conversion of data into
information and knowledge to inform policies and programs; and most
importantly use this information to put in place an efficient and quality
health system.
Medical Products, Vaccines and Technologies: Clients need to have
access to the best quality, rational and cost-effective medical products,
vaccines and technologies.
Financing: To enable equitable provision of health care and ensure that
clients are not subjected to financial risks and impoverishment, while
accessing health care.
Leadership and Governance: To ensure strategic policies, effective
oversight; and, most importantly, accountability of the health system.
For the purpose of the conference, it was decided to focus on four of
the building blocks of the health systems’ definition (as above), as the
conference themes:
m
Health Service Delivery: The service delivery component is
concerned with how inputs and services are organized and
managed – to ensure access, quality, safety and continuity of care,
in a variety of health conditions, across different locations and time
frames.
ICONHSS
2010
25
m
Health Finance: Methods adopted to finance health care have an
impact on the equity, and on the risks and impoverishment that
clients could face in accessing health care.
m
Health Workforce: There is a severe shortage of workforce in
health systems, which has had a direct bearing on the health
outcomes in several communities.
m
Governance: There is a strong causal relationship between good
governance and better development outcomes. Governance is a
multi-dimensional concept that is anchored in all the other issues
of health systems.
In addition, the conference also looked at issues of positive synergies on
global health development initiatives and health systems research
as agenda for discussion and action.
The methodology of the conference included a mix of different verbal,
visual and experiential elements based on the above mentioned themes
- plenary presentations, symposium and panel discussions; poster
displays and interactions; exhibit stalls for material distribution and
demonstration; and field visits. The participants also got cultural glimpses
of dance and music from different parts of India, along with an informal
opportunity for social and professional networking during evening events.
The conference developed its own theme song with a visual messaging
based on its themes and a dedicated website (www.iconhss.com) that
provides details of the conference before, during and after the event.
Spread over a five day period (6th to 10th May), the conference included
a pre-conference day of sharing around the TNHSP and a post-conference
day of field visits that gave participants a direct exposure to some of the
TNHSP initiatives around HSS.
The main conference was divided into ten sessions (including two parallel
sessions) spread over three days (7th to 9th May), and witnessed very
informative and insightful presentations. These were based on invited
abstracts and posters around the four themes of the conference, some
of which were selected for presentation during the conference. The
speakers at the conference came from the government, hospitals, medical
and academic institutions, NGOs, private sector health industry, donor
26
agencies, and included policy makers, researchers and practitioners.
Speaker profiles and details of the abstracts received are accessible on
the conference website, along with the detailed presentations made during
the conference.
The field visits to some of the key intervention sites of the Health
Department, Government of Tamil Nadu, in and around Chennai, gave
the participants a first hand experience of health systems’ issues and
implementation processes. These visits made the whole conference a very
meaningful experience.
The conference invested in wide outreach efforts, including newspaper
announcements as well as street hoardings and displays which gave the
event the necessary publicity. These efforts paid off in that, the conference
received tremendous interest and support by the print and audio-visual
media, both locally and nationally, not only covering and reporting on the
conference1 but also interacting with and interviewing key speakers and
guests (especially senior government officials from GoI and the GoTN)
as well as national and international speakers. All participants were
provided with hospitality and travel support so that they could attend this
conference.
A conference kit of presentation abstracts and speakers’ profiles, program
schedule and stationary was provided to each of the registered
participants. Being an international conference, the organizers made sure
that the participants had all the important logistic support including access
to computers and internet services. The conference was also widely
recorded on a real time basis to serve as a documentation of the process
and participation.
The participants at the conference included senior government officials
from health departments of over ten states of the country, planners,
policy makers, academicians, donor representatives, technical experts,
doctors and other medical personnel, NGO workers and students, media
persons, etc. from across the country and the world.
1
See highlights of press coverage in Chapter 8.
ICONHSS
2010
27
CHAPTER 2
P
Pre-Conference
T
he genesis of ICONHSS took place from within the Tamil Nadu Health
System Project (TNHSP) and it was appropriate to spend a preconference day sharing experiences and learning among the partners of
various health systems projects in India. This pre-conference workshop
also laid the basis for enhancing cross-sectoral and indepth learning
around health systems strengthening from other states.
The pre-conference inaugural session was opened by Dr. (Capt.) M.
Kamachi, Expert Advisor, Tamil Nadu Health System Project (TNHSP),
who welcomed the dignitaries, participants and acknowledged the
contributions of partners. He mentioned that this day was dedicated to
understand the needs and problems of health systems in India. The goals
and achievements of TNHSP were highlighted.
Mr. V.K. Subburaj, I.A.S, the Principal Secretary to the Health and Family
Welfare Department, Government of Tamil Nadu, introduced the context
within which the ICONHSS was being organized. He shared that Tamil
Nadu’s achievements in the area of Health Care were being seen as best
practices not just in India but also globally, and that the TNHSP was a
very significant project of the state government. Talking about the
availability of money for implementing such a project, he added that the
successes that can be seen today were due to increased budgets and
allocations in the health sector.
“We have constructed new buildings across the state. All hospitals
look very modern. But India is the capital of all diseases and still
we have not sufficiently planned for manpower to take care of this
huge population. We have only 350 medical colleges. There is a
huge shortage of manpower nationally”.
In Tamil Nadu, Mr. Subburaj shared that the state government had been
able to create a large number of medical colleges to cater to the increasing
demand of the health sector workforce.
28
“In fact, we need to encourage the establishment of new colleges.
We have brought in health insurance. Apart from addressing
manpower issues, we also need to create systems to take care
of bio-medical waste. We have improved on delivery systems. We
have achieved more than 99 % success in safe child birth. We
have been awarded by various organizations both nationally and
internationally”.
Ending on a positive note, Mr. Subburaj said that the state government
is committed to making the best of health care available to all citizens,
including the poor.
Prof. Dr. Mayil Vahanan Natrajan, Vice Chancellor, of the TN Dr. MGR
Medical University reviewed the WHO definition of health systems, while
adding that as an academic institution they would like to take important
steps to strengthen the health systems in the country. Making an
important point he said that, “we need to create the human resource to
take care of health needs and to do this, it would be a good idea to also
review the curriculum of medical colleges so that it matches the skills
that need to be developed.”
Dr. Preeti Kudesia, Senior Public Health Specialist, World Bank talked
about the commitment of the World Bank for towards knowledge sharing
and knowledge management. Tracing the history of the World Bank’s
involvement in the health sector, she shared that it began its first project
in the state of Andhra Pradesh in 1996.
“We have learnt a lot since then and till date worked in 10 states
of India. We have tried to learn from these experiences and use
the recommendations in newer projects. We have learnt that
strengthening Health Systems is the key and if this is done
effectively, the quality of health delivery would be enhanced. In
case of infrastructure apart from building and acquiring new it is
important to maintain the existing, for example it is important
to maintain a hospital building, and the same is true with
equipment. We need to have the systems in place to ensure the
maintenance of infrastructure”.
Dr. Kudesia raised a few important questions that she hoped this
conference would help answer, i.e. Are we being able to provide quality
ICONHSS
2010
29
health care to poor? How can we ensure that the poor are able to access
quality health care? She expressed hope that this conference would be
a true learning and sharing experience.
The inaugural was followed by a session that looked at an overview of
“how health systems are functioning in the country” and some experiences
from World Bank Projects.
Overview of Health Systems in India: F
ocus on Quality
Focus
This session was chaired by Dr. Preeti Kudesia, Senior Public Health
Specialist, World Bank and Dr. Sunil Nandaraj, National Professional
Officer - Health Systems Development, WHO, who made the key
presentations on the theme, with coordination support by Dr. Satish
Kumar, Associate Director (Technical), SAATHII.
Dr. Sunil Nandraj, National Professional Officer Health Systems
Development, WHO elaborated on Health systems blocks i.e. service
delivery, health workforce, health information, medical products, financing,
and governance. He mentioned that “people” are at the centre of how
well India meets its health systems goals. Some changes are now visible
in this respect - for example, life expectancy has increased from 30 years
at the time of independence to over 63 years today. He also mentioned
that in India the estimated percentage of deaths due to communicable
diseases is as high as 36%, and at the same time death due to cardiac
diseases is 29%. So we are hit from both ends.
Some other concerns are that there is no rationale for the kind of money
that is charged by private players in the health care industry and the
increasing cost of care is becoming a huge problem. Only 0.84% of the
GDP is spent for public expenditure on total health, while 72% of the
total health care expenditure is financed by private households.
The greatest failure of our system has been the failure of providing
affordable quality health service to our poor and the lack of manpower.
Dr Nandraj ended with two key questions, that need an urgent response
“How would India quickly reduce the communicable disease burden?”
and “How would India provide affordable quality health care to its large
population?”
30
Dr. Preeti Kudesia, Senior Public Health Specialist, World Bank shared
insights on health systems in India based on the World Bank
experience. She mentioned that the World Bank started its work in Health
care in India with the ICDS program in the early 1980s. Soon it realised
that the missing link was secondary care and based on this understanding
it started its work in various states of India. This initiative was named
“Health systems”; and it focused on improving the efficiency and quality
of services, and enhanced access to, and equitable services for
disadvantaged populations.
The World Bank was responsible for bringing in the ethics side of health
delivery in the definition of health systems and focusses on issues like
service norms, infrastructure, equipment, and drugs and supplies.
The World Bank learnt that getting the structure and equipment etc.
organised was easier, however, getting the manpower in place was the
key challenge and hence it stressed on this dimension as well. They learnt
from their study at Karur that both private and public hospitals were
available in the same areas, which meant they were not complimenting
one another. They also understood that in health systems strengthening,
the Information Systems were weak, so they introduced full computerization.
Additionally, looking at the
doctors’ inherent inability
to cater to hospitality
functions like cleaning,
laundry, diet and security,
the World Bank supported
PPPs in this area. It brought
in the culture of looking at
the data, and learning from
it, to improve the service
delivery. Dr. Kudesia
observed
that
public
hospitals had started going
in for accreditations which was a positive trend. From the findings from
the World Bank Andhra Pradesh experience, it saw that people were not
getting quality service, and therefore the decision was taken to train public
health professionals to be more customer centric. All these experiences
had one focus - to enhance the quality of health care through
strengthening health systems.
ICONHSS
2010
31
Good P
ractices from the W
orld Bank F
unded Health
Practices
World
Funded
Systems P
rojects in India
Projects
This session was chaired by Dr. Preeti Kudesia, Senior Public Health
Specialist, World Bank and Dr. V. Kumaraswami, Officer-in-charge,
National Institute of Epidemiology, Chennai.
The presentations at this session included the following:
Public Private Partnerships in Karnataka: Mobile Health Clinics,
by Mr. S. Selva Kumar, I.A.S., Project Director, Karnataka Health
Systems Development and Reforms Project
Hospital Accreditation – the Uttar Pradesh Experience, by
Dr. R.K. Singh, Ram Manohar Lohia Hospital, Uttar Pradesh
Health Management Information Systems in Tamil Nadu, by
Dr. T.K. Amarnath Babu, Medical Officer, Tamil Nadu Health Systems
Project
Rajasthan Health Systems Development, by Dr. P. C. Ranka,
Additional Director, Rajasthan Health Systems Development Project
Bio-medical Waste Management in Rajasthan, by Dr. Kalpana Vyas,
Officer, Rajasthan Health Systems Development Project
u
32
Public Private Partnerships
in
Karnataka: Mobile
Health Clinics: This
presentation was made
Mr. S. Selva Kumar,
Project Director, who
shared that the conception of this project had
its roots in the fact
that, in remote areas,
people have to walk
miles to reach a PHC. The mobile health clinics were therefore set up to
provide basic health care services as a PHC would.
This service had been outsourced to NGOs, trusts, or private players,
and each clinic covers 10 villages in a week, particularly focusing on
antenatal and prenatal care. The once a week village visit is however not
sufficient as there are too many patients for a single visit.
Audience speaks…
( )
Sharing an observation in response to the
above presentation, Dr. Ranka, a speaker from
Rajasthan mentioned that they had three
mobile surgical units for the last 40 years
conducting basic surgeries etc. and this helped
them reach out widely.
Other participants also raised some questions
in response to the presentation by Mr. Selva
Kumar.
Q: The cost of mobile hospitals is very high so
how are you managing?
A: We have gone along with the private
partners and they have worked out the costs
accordingly. We have also given away our
mobile units to private players. We have also
noticed that some of the places that these
mobile units are serving are such that the
villagers cannot reach the nearest PHC so
they are very effective.
Q: Does this (availability of mobile clinics)
reduce the health seeking behavior of the
patients?
A: Our experience is suggesting that it is not
reducing the health seeking behavior.
Q: Is it possible to conduct routine tests in
mobile clinics?
A: We have not done so far but we are willing
to try.
ICONHSS
2010
33
u Hospital Accreditation – the Uttar Pradesh Experience: Making his
presentation, Dr. R.K. Singh defined accreditation as “A public
recognition of the achievement of accreditation standards by a
healthcare organization, demonstrated through an independent
external peer assessment of that organization’s level of performance
in relation to the standards set by NABH”. He presented the case of
accreditation of Ram Manohar Lohia Hospital in Lucknow. He mentioned
that their focus was on safety, effectiveness, patient centeredness,
timeliness, efficiency and provision of equitable healthcare. The focus
on safety and disposal of bio-medical waste was infact a great
achievement of this accreditation process. He also shared that going
forward INR 954 lakh had been allocated for 13 PHC’s and 16 hospitals
are to be accredited.
u Health Management Information Systems in Tamil Nadu: Dr. T.K.
Amarnath Babu, Medical Officer Tamil Nadu Health Systems Project
showcased this project as a solution to issues arising from the manual
records in the hospitals and PHCs. These records were not being kept
well and were not organized. As a result any evaluation of performance
was not possible. To take care of this concern the “Hospital
Management Systems and Health Management Information Systems
(HMIS)” were designed. In implementing these systems the mindset
change among hospital staff was one of the key challenges for the
successful adaptation of the new system. The most important
achievement of the project was to get a government order issued for
doing away with manual registers. Dr. Amarnath Babu further informed
that this project was also planning to implement e-Learning modules
so that HMIS could be used extensively.
u Rajasthan Health Systems Development: Presenting their
experience, Dr. Ranka spoke about the “Rajasthan Health Systems
Development Project Interventions and Convergence on Quality
Improvement”. He mentioned that the Health Department, Government
of Rajasthan, aimed at matching health standards of its population
with that of any state in the country or with one of the best developing
countries in the South Asian region by the year 2020. Dr. Ranka
informed that currently in Rajasthan the total bed strength is 43870;
233 facilities have been renovated with a novel concept of one
institution in each administrative block; a Health systems improvement
process has been introduced and the state is working towards
developing Health Management Information Systems.
34
u Bio-medical Waste Management in Rajasthan: Shared insights on
this experience, Dr. Kalpana Vyasa said that like most states, in
Rajasthan also, ‘Bio-medical waste management’ was not paid much
attention to until the Supreme Court of India issued the orders for
the same. In Rajasthan the Health Care Waste Management (HCWM)
project was using the systems approach to handle its intverventions
in this area and is focussing on
encouraging interdepartmental
coordination for greater effectiveness of the project. She mentioned
that 13000 health personnel were trained in 2006-07 under the
development drive initiated under the project.
Integration of Chronic Disease P
revention and Management in
Prevention
Public Health
This session was chaired by Dr. K. Srinath Reddy, President, PHFI and Dr.
Thanikachalam, Sri Ramachandra Medical College & Research Institute,
Chennai.
Overview of Prevention and Management of Chronic Diseases in
India, by Dr. Thanikachalam, Sri Ramachandra Medical College &
Research Institute, Chennai
Experience from Tamil Nadu Pilot Programs (Cardiovascular
Diseases and Cervical Cancer), by Dr. Raja, Medical Officer, TNHSP
Experience from Tamil Nadu Pilot Programs (Cardiovascular
Diseases), by Dr. B. Bharathi, Medical Officer, TNHSP
Results of Hypertensions Screening Program Tamil Nadu, by Dr.
Prabhdeep Kaur, Scientist, National Institute of Epidimiology
Results of Cancer Cervix Screening Programs, by Dr. A.
Somasundaram, DD (Research), Directorate of Public Health
Prevention and Treatment of Cervical Cancer and Hypertension
in 4 districts of Tamil Nadu - Cost analysis, by Dr. Beena Varghese,
Head, Research Development & Adjunct Additional Professor, PHFI
Health Systems & Communicable Diseases - Path Ahead, by Mr.
S. Ramanathan, Director-Strategic Planning and Partnership, APAC
ICONHSS
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35
Overview of Prevention and Management of Chronic Diseases in
India: Dr. S. Thanikachalam, Chairman & Director Sri Ramachandra
Medical College & Research Institute shared that it was once thought that
cardiac problems were the diseases of the rich, however, the experience
is now showing otherwise. He presented findings of a study conducted
by him in which it was found that almost on all indicators of CAD, the
rural population was ahead of the urban population. He said that people
are moving to the cities due to economic opportunities and this is marking
a shift in the trends of chronic diseases.
According to Dr. S. Thanikachalam, as a result of our growing GDP, the
life expectancy has grown; however, the disease burden on the country
is also increasing and lifestyle diseases are especially on the rise. He
forecasted that as compared to the year 2000, by the year 2015 almost
in all age groups, the percentage of CAD would almost double. The cost
of CVD would be in the range of INR 200 billion. He emphasized that there
was an urgent need to detect the cardiac abnormalities at an early stage
to be able to control the disease.
(
36
Audience speaks…
Q: Can you suggest some screening process at
the PHC level?
A: Steps such as measurement of blood
pressure, sugar level etc. are all that can be
measured at the PHC level.
Q: If we have to prioritize, where should we
put our limited resources?
A: The resources needed are not too much.
Even paramedics can be trained to take
blood pressure and suggest medications for
instance. Also people should be told to
reduce salt intake and not re-heat oil
repeatedly. Action at these levels would
already help a great deal in curtailing these
problems.
)
u Experience from Tamil Nadu Pilot Programs (Cardiovascular
Diseases and Cervical Cancer): Dr. Raja, Medical Officer, TNHSP
presented the case of a pilot project undertaken by TNHSP in the area
of CVD prevention. He said that by 2020, India would have the highest
incidence of diabetes & heart disease in the world. He mentioned that
the key causes of CVD were: smoking, high cholesterol, and one’s
lifestyle, and prevention was the only way out.
He elaborated on the need to conduct behavioral change interventions
in schools, through awareness classes, drama and creation of ‘Heart
Clubs’. He also shared that they had organized special lectures at
workplaces, and even created “Heart Clubs” at workplaces, reached
out to the community through melas (fairs), group meetings, rallies,
radio etc. Counseling high risk groups by IPC has been an important
step towards disease management.
Through the project they have reached 19000 students, sensitized
3441 persons and screened 11,31,041 patients for hypertension in 98
health facilities. Among the challenges faced have been getting
permissions from the officials of the department of education and
convincing managements at workplaces, to reach respective target
groups; however, the involvement of labor officers and district officials
has helped the project reach out.
u Experience from Tamil Nadu Pilot Programs (Cardiovascular
Diseases): Dr. B. Bharathi, Medical Officer; TNHSP mentioned that
India had about 27% of all the new cervical cancers diagnosed in the
world. While implementing this project, they faced some challenges
viz. difficulties in creating awareness in remote areas and low
acceptability of screening by women; however, this did not stop them
from going ahead and as a result of their persistent efforts, so far
TNHSP has screened 196,559 people in Theni and 291,525 in Tanjavur
districts and this is a huge achievement.
v Results of Hypertensions Screening Program Tamil Nadu: Dr.
Prabhdeep Kaur, Scientist, National Institute of Epidimiology made a
presentation on the results of hypertension screening program under
TNHSP. She shared multiple insights from her experience. For instance,
very few people were aware about hypertension being such a highly
ICONHSS
2010
37
prevalent disease. In fact, cardiovascular diseases accounted for 25%
of all deaths in rural areas. She also brought to the fore the issues
regarding the accuracy of sphygmomanometer vis-a-vis electronic
Blood Pressure apparatus.
Another problem cited by her was that it was difficult to retrieve
individual patient data, with the current recording systems. About 1012% people screened had hypertension, but it was disappointing that
1/3 of the patients never came back. However, 50% of the patients
were following up with the project staff and this is an achievement.
According to her, during the screening process, people with 90/140
BP reading were put on medication.
The key learning from this program was that PHCs were able to
diagnose and treat hypertension as well as GH and they need to use
IT more efficiently to be able to retrieve the data.
v Results of Cancer Cervix Screening Programs: Dr. A Somasundaram
focused on lessons learnt from the evaluation of a pilot project on
cancer cervix screening, Tamil Nadu. He mentioned that under the
project a total number of 488084 patients were screened and
awareness generation was done mainly through interpersonal
communication and self help groups.
“We learnt that continuous training at all levels is needed
as there is a lack of supervision of village link volunteers
(VLCs). The capacity and the utilization of VLC was not
sufficient and needed to be enhanced.”
u Prevention and Treatment of Cervical Cancer and Hypertension
in 4 districts of Tamil Nadu - Cost analysis: Dr. Beena Varghese
informed the conference participants that the objective of their study
was to calculate the cost of screening and preventing the Cervical
Cancer and to provide the model for replication and scaling up. Dr.
Varghese mentioned that the cost of screening one woman worked out
to be INR 124 (annuitized cost) and INR 102 (recurring cost), which
was worth it for the kind of data that was generated to provide
necessary health care.
38
“We reviewed available financial data, and had detailed
discussions with project staff. All the non-recurring cost
towards ‘start up - procurement, training development of
training modules’ were annuitized using a 3 year lifetime
value. Annual recurring costs - those required on a regular
basis were used as is and this gave us the required data.”
Health Systems & Non-Communicable Diseases - Path Ahead: Mr.
S. Ramanathan, Director-Strategic Planning and Partnership, APAC stated
that post the implementation of TNHSP’s pilot project to screen Cervical
Cancer in 4 districts of Tamil Nadu, they were focusing on how to scale
up and what the future actions should be. Mr. Ramanathan mentioned
that the key issues raised at district consultations included discussions
on Personnel, Equipments and their maintenance, and Supply &
availability of drugs. Based on the study he proposed that TNHSP should
go in for additional financing of the project and take a comprehensive
approach to address the issues at hand. He said that in the area of
personnel - 2000 additional staff nurses need to be engaged; more
equipment needs to be provided; and going forward, the focus would
be on maintenance. TNHSP would also need to support the TNMSC to
strengthen drug procurement & management systems.
Mr. Ramanathan also shared the intent of the State of Tamil Nadu to launch
school based interventions i.e. introducing a chapter on CVD in
curriculum; targeting school children of class 7,8,9 in 10000 schools of
the state. There is also a thought to work with the labor department for
advocacy on CVD and CACX, as also involve self-help groups to raise
awareness and actions around these diseases especially in rural areas.
Talking about the challenges faced, he mentioned that the key barrier in
getting women to undergo screenings were the men in their family, so
they have decided to involve men in getting their women screened.
ICONHSS
2010
39
CHAPTER 3
C
Conference Process and
Presentations
3 . 1 Inauguration
The conference was inaugurated in the presence of Prof Thiru K.
Anbazhagan, Hon’ble Minister of Finance, Government of Tamil Nadu; Thiru
M.R.K. Paneerselvam, Hon’ble Minister for Health and Family Welfare,
Government of Tamil Nadu; Ms Syeda S. Hameed, Member, Planning
Commission, Ms. Sujatha Rao, I.A.S., Secretary, Ministry of Health and
Family Welfare, Government of India; Mr. Thiru V.K. Subburaj, I.A.S,
Principal Secretary to the Government of Tamil Nadu (Health and Family
Welfare Department); Dr. Mukesh Chawla, Sector Manager, Human
Development Network, The World Bank; Ms. Erin Soto, Minister –
Counsellors for International Development, USAID-India; Prof. Giridhar J.
Gyani and Dr S. Vijayakumar, Special Secretary to Government Health and
Family Welfare Department, Tamil Nadu and Project Director, Tamil Nadu
Health Systems Project (TNHSP).
In his welcome address, Mr. Subburaj, acknowledged the presence of
the dignitaries, Honorable Finance Minister and the Honorable Minister of
Health and all other
speakers and delegates at
the
conference
and
expressed his thanks to
the World Bank, USAID
and other donors for
extending their support to
organize this conference.
He stated that one of the
key objectives of this
conference was to share
the experiences of Tamil
40
Nadu’s health department with other states of India and the world.
However, to do so at an international scale by a state government
department was a first for the nation.
Drawing from the Tamil Nadu experience, he shared that proper
infrastructure and equipment, made it possible for them to achieve
success in their project along with the collaboration with multiple
stakeholders. Giving an example, he added that, the reduction in the
prevalence of HIV from 1.3% to 0.2 % has been achieved because of
the support of USAID to these interventions. Further, two state
government hospitals in Tamil Nadu have received medical accreditation
and another 10 hospitals are being prepared for accreditation.
Recounting the past, Mr. Subburaj shared that in the initial phase, the
TNHSP was not doing well, and the World Bank rated it as not successful.
However, with the support and guidance of World Bank, Tamil Nadu has
managed to become the best performing state and the TNHSP has now
also received an extension for the next 3 years. In this context, the
ICONHSS is an important milestone for health systems strengthening in
the state of Tamil Nadu. He wished and hoped that all the delegates would
find this to be a very useful conference.
Dr. Mukesh Chawla
shared a statement from
the Director of the World
Bank acknowledging that
the Tamil Nadu project
has set the highest
standards
of
implementation on health
systems strengthening.
The state had used
$90Million for this project
to date and owing to its
success has been allocated $130Million for the next three years.
Mr. Girdhar J. Gyani, Secretary General, Quality Council of India,
NABH, talked about the importance of “accreditation” in the health sector.
Considered to be an activity that was only meant for private hospitals,
accreditations of public hospitals came up as a surprise initially.
ICONHSS
2010
41
“Whatever happens in public hospitals ‘publicly’, happens
in private hospitals ‘privately’. No private sector interest has
as yet come into the arena of Rural Health and this remains
a governmental responsibility”.
Speaking about the changes that are taking place in the hospitals
undergoing accreditation, Mr. Gyani narrated an incident where a senior
doctor who went for auditing the accreditations got very emotional
noticing the dedication and commitment of the personnel of the two
government hospitals he visited. Mr Gyani announced that two Tamil Nadu
government hospitals in Sholingur and Namakkal have received NABH
accreditation. He acknowledged the fact that Tamil Nadu has taken the
lead in partnering with the Quality Council of India to come forward for
a stringent accreditation process for which only private hospitals usually
took efforts.
Ms. Erin Soto, Minister–Counselor for International Development,
USAID India acknowledged the success of the USAID supported health
projects in Tamil Nadu since the mid-1990’s, especially by APAC.
She mentioned the five challenges that need to be tackled in the health
sector along with some
suggestions for meeting
these difficulties: Lack of
skilled Human Resources technical, managerial and
public health professionals
(need investment in this
area for education and
training);
Limited
Investment and use of
Information Technology in
Health systems (could
incorporate a shift to electronic methods, raising awareness through
mobile phones and web based management systems); Lack of
Transparency and Accountability in operations (needs collaborative and
coordinated efforts to achieve this); Lack of adequate Finance and
financial barriers for health care (could use micro finance, insurance and/
42
or vouchers to take care of private expenditure on health care); and Lack
of Infrastructure (wherein there is a need to promote public private
partnership).
Ms. Soto added that the shift towards health systems strengthening
comes with the commitment to improve the quality of life of our global
citizens and she expects this conference to provide a concerted direction
in this area.
Ms Sujatha Rao, Secretary, Ministry of Health and Family Welfare,
Government of India congratulated the Government of Tamil Nadu on
organizing this international conference. On this occasion, she said that
she was reminded of one of the key recommendations of the Bhore
Committee report (1946), in which it was stated that “no one should be
denied health care due to
their ability to pay”. She
reiterated the validity of
the Bhore report even
today as this conference
was being organized
around some of the key
issues of concern then.
Ms Rao also mentioned the
President
of
India’s
announcement regarding
India’s annual health report, which would be released soon.
Talking about funding in the health sector, Ms. Rao added that, “we are
one of the 5 countries in the world that spend less than 1% of the Gross
Domestic Product (GDP) on health. We spend less than 50% on health
compared to the global norm of about 2% of the GDP. We are working
towards increasing this amount and need more funding to make it
happen”. She mentioned this to be a significant challenge and
acknowledged the need to look at available options, asking whether health
insurance is one of the keys to achieve this goal?
Infact there are different health insurance products that various
governments are implementing, she added, but there is a need to look
at how at regulating the companies offering these products to ensure that
ICONHSS
2010
43
the service providers are not over diagnosing, over prescribing etc. and
it is essential to control the premium rates from increasing unnecessarily.
The other related issue emerges from the latest National Statistical Survey
Organization (NSSO) report which suggests that about 8% of our people
are being pushed below the poverty line due to private expenditure on
health. For example, for people who have worked all their life and saved
money, their entire pool of resources usually get finished due to one
episode of cancer or cardiac disease in the family.
“We would need to discuss the challenges before the
National Rural Health Mission (NRHM) and the road ahead
at this conference so that these issues can be tackled
adequately”.
The next big challenge faced is one of Human Resources. “Our current
HR is about 10% of what is desirable and a norm. We need to have
credible, well-trained paramedics at the community level and not just
doctors. Medical doctors should be available to deal with higher levels
of diseases”.
Ms. Syeda S. Hameed, Member, Planning Commission, in her
keynote address, congratulated and thanked the World Bank and the Tamil
Nadu government on their efforts and achievements in the health sector.
She mentioned that the
11th Five Year Plan
document prepared by the
Planning Commission has
envisaged an integrated
approach for health care.
In fact, the allocation to
health care has increased
manifold, especially as the
country needs to focus on
deprived areas to address
the health needs of the
poor.
44
“We need to adopt a system centric approach to take care of
mental health, care for elderly etc. apart from basic health
care. People sitting in Yojana Bhawan (Planning Commission)
need to have their ears to the ground and learn from the field”.
Talking about the involvement of women as being central to achieving the
highest level of health care, she added that women would bring that
change and Tamil Nadu should become the leader in this area of involving
women in providing health care to its people. She shared the experience
of Maharashtra where they sampled five districts and found that because
of community participation, not just health but all other developmental
indicators improved. Therefore, when looking at Tamil Nadu, the state
government’s effort at creating a health care cadre is commendable and
needs to be further enhanced. She also shared that the Planning
Commission has referred to some of the best practices of Tamil Nadu
such as the procurement policy for drugs and the fillip to traditional Indian
Medical Practices such as Siddha and Ayurveda.
Ms. Hameed acknowledged the need to ensure that health services reach
the remotest corners of the country and also for innovative financing to
be able to provide health care to all. Ending with a note of faith and wishes
for a new global health scenario through collective efforts such as this
conference, Ms Hameed quoted the poet Rumi:
...Like a small creek which stays clear
Which does not stagnate…
But finds a way
Through numerous details deliberately...
Thiru. M.R.K. Panneerselvam, The Hon’ble Minister for Health and
Family Welfare, Government of Tamil Nadu spoke about the emerging
trend of Government hospitals being transformed into temples of health
care for the sick. Elaborating on the changes taking place in government
hospitals, he specially mentioned the efforts at training human resources,
organizing waste segregation and disposal etc. to meet necessary
standards of hospital management. He mentioned that the Government
of Tamil Nadu is increasing its health budget annually, as “the life of all
is important and needs to be saved”.
ICONHSS
2010
45
“The health budget
for Tamil Nadu has
doubled from Rs.
1,951 crores in
2006 – 2007 to Rs.
3,888 crores in
2010 – 2011. Our
effort is to provide
the best possible
care.”
Lauding the Hon’ble Chief Minister who started the “Kalignar Health
Insurance Scheme for life saving treatments”, the Health Minister shared
that under the scheme, the government has provided free medical
treatment to 1.44 crore poor families, and over 88,025 people have been
operated upon (with claim amounts of INR 250 crores).
The World Bank supported 524 crore project has helped the state improve
infrastructure of all the secondary care hospitals and this project has
brought out an operating standards’ manual for common diseases in Tamil
Nadu. The Government has also provided INR 6000/- to more than 2
million pregnant women in the state, and, in 2009, financial assistance
was given to children suffering from AIDS. He added that the provisioning
of emergency ambulance services has had an unprecedented impact on
the minds of the public in the state (the lives of 21000 people have been
saved since its start 18 months ago), and it was the introduction of such
historic schemes that has made Tamil Nadu one of the best states in the
country in health program implementation.
The Hon’ble Minister assured the audience that the government of Tamil
Nadu would take forward the recommendations of this conference in order
to improve the access and quality of care to its people.
Prof. Thiru K. Anbazhagan, The Hon’ble Minister of Finance,
Government of Tamil Nadu, was invited to give the inaugural address
to mark the formal beginning of the International Conference on Health
Systems Strengthening. Expressing his happiness on the occasion, the
Minister reaffirmed the commitment of the Hon’ble Chief Minister of Tamil
Nadu in providing health care for pregnant women, children and the poor.
More than INR 1000 crore is being spent to provide financial benefits to
pregnant women from below the poverty line.
46
Tamil Nadu is committed to achieve the Millennium Development goal
(MDG) of “Health for All”.
Tamil Nadu is the only state
to have the maximum
medical colleges, and its
goal is to establish one
such college in each district.
Under the National Rural
Health Mission (NRHM),
nurses have been provided
with cell phones and a SIM
card, and this has helped
save many lives. In Tamil
Nadu, even caesarian
operations at the Primary Health Centre (PHC) are conducted by hired
specialists under the NRHM.
The Minister added that all PHCs are provided with computers and internet
and now a lot of the data is received online. Prof. Anbazhagan recalled
the various successful schemes of the Tamil Nadu Government in the
Health arena, from the mobile medical units to the Varummun Kappom
scheme and from medical colleges in each district to screening school
children for eye problems. These are important strides made by the state
government in the health sector and this conference would further add
value to these efforts.
“Anyone who needs quality health care irrespective of
whether they are rich or poor, in urban or rural areas, what
gender they belong to, should be able to get such quality
care. This is something that the state of Tamil Nadu is
committed to. We are doing this through the jewel in the
crown – the Kalaignar Insurance scheme and we would like
to reiterate this commitment. This conference will be a sure
success towards the next step of strengthening health
systems.”
ICONHSS
2010
47
Award Ceremony
With the conference having
been formally inaugurated,
the organizers felicitated
the dignitaries with tokens
of appreciation and respect
in the traditional style of
Tamil Nadu.
This was followed by an
awards ceremony in which
the Hon’ble Minister of
Finance, Government of
Tamil Nadu gave away some important awards. Two “Lifetime achievement
awards” were given on this occasion. Ms Sujatha Rao, Union Health
Secretary was conferred the award for her work with the National AIDS
Control Organization (NACO) in streamlining and charting the course for
the future and her role as Union Health Secretary. Dr. P. Padmanabhan,
Special Advisor, Public Health Administration, National Health Systems
Resource Center, was also given this award, as being the brain behind
the 3-nurse model PHCs, facilitating cancer screening with the VIA
technique and now working to improve the health systems of the Northern
states of India based on the Tamil Nadu experience.
Representatives from the two hospitals (Sholingur and Namakkal) that
had fulfilled the criteria for NABH accreditation were also formally awarded
their accreditation at this ceremony.
The inaugural session
ended with a vote of
thanks
by
Dr.
Vijayakumar, I.A.S.,
Chairman, Organizing
Committee, ICONHSS, to
all the dignitaries, partners,
collaborators and delegates
who had come to attend
this
international
conference.
48
India Meet - P
riorities for Health Systems Strengthening in
Priorities
India and F
inancing for Universal Access
Financing
The conference began with a session titled ‘India Meet’, in which speakers
were invited to make presentations on Priorities for Health System
Strengthening in India and Financing for Universal Access.
The objectives of this session was to discuss:
●
Strategies of making health care available to the rural and
marginalized population;
●
Ways of financing the universal access; and,
●
Challenges and issues in making health care available.
This session was chaired by Ms Sujatha Rao, Secretary, Union Ministry
of Health and Family Welfare and Dr. Mukesh Chawla, Sector Manager,
Health System Strengthening,World Bank with them making key
presentations along with Mr. V.K. Subburaj, IAS, Principal Secretary to
Government, Health and Family Welfare Department, Tamil Nadu. The
session coordinators were Dr. Jerard M Selvam, Professor, Dept. of
Epidemiology, The TN Dr. MGR Medical University and Dr. Sai Subhasree
Raghavan, President, SAATHII.
3.2 Priorities for Health Systems Strengthening in India
Ms. Sujatha Rao, Secretary, Union Ministry of Health and Family Welfare
made a presentation on Working together for Healthy India, in which
she elaborated on the gains and challenges of various government
programs. She mentioned that in Tamil Nadu, HIV has been contained
however, there is still a lot to be done, especially in the arena of controlling
communicable diseases like Tuberculosis. A lot of training, education and
campaigns are needed to stop addiction to tobacco, alcohol etc.
Ms Rao emphasized on the importance of providing quality health care
to the poor and marginalized people of the country. She specified that
even if people are poor, they would not come to a health facility which
is badly maintained (e.g. with dogs running all over the place or
unhygienic conditions prevailing). If government facilities work effectively,
people would start using the services provided there.
ICONHSS
2010
49
In the same vein, she mentioned the focus on better human resource
recruitment by the government, e.g. under NRHM about 100,000 health
care professionals have been appointed all over India. She informed the
participants that India has about 7 lakh “ASHAs” - community based
women health workers who are able to motivate women to come to PHCs
for accessing better health care and such efforts need to be further
enhanced.
She added that there is also now an increased budget allocation for health
across the board. Ms. Rao mentioned that health is a local issue and has
to be planned at local levels, responding to local needs. With this
perspective in mind, the government has provided local flexibility in the
use of funds to be able to respond to needs emerging from the field.
Another issue that the government is targeting relates to the lack of
reliable data which becomes a bottleneck in effective planning. She
highlighted that much of Tamil Nadu’s success stories in the health sector
have come due to its ability to collect and analyze data using Health
Management Information Systems (HMIS).
50
( )
Audience speaks…
Q: Why don’t we involve medical colleges in
the process of strengthening health systems?
A: We would be very keen to do that. We
will take it up with the Medical Council of
India.
Q: How are these instruments i.e. tobacco tax
etc. being incorporated in the health budget?
A: The Ministry of Finance is not allowing
directly earmarking the sin tax to the health
budget. They are saying that as long as you
get the money you need, this is not
important.
Q: We have a dual burden on health communicable and non-communicable
diseases. What is the policy of the government
on non-communicable diseases?
A: So far our focus has been to reach out
to the poor sections of society with the
emphasis on communicable diseases.
However, recent data suggests that noncommunicable diseases are increasing among
the poor and now we are trying to undertake
certain steps to prevent these diseases. We
are trying to diagnose the diseases i.e.
cancer and cardiac problems at the PHC level
and empower PHCs to play a role in disease
control.
ICONHSS
2010
51
Providing an Overview of Health Systems Strengthening (HSS), Dr.
Mukesh Chawla, Sector Manager, Human Development Network, The
World Bank, Washington started with a definition of HSS, as “translating
money into activity”. Dr Chawla elaborated upon the need for innovation
in healthcare.
“At the end of the day the only way that we can strengthen
our health systems is through innovation. We need to
innovate to be able to provide the health care within our
limited resources”.
Dr Chawla elaborated on four areas where innovation is needed:
1. How do we raise more money – for example, should we put in INR
1000/ for every child born in the country and let financial experts
manage this? We need to apply business solutions to health care to
be able to solve the problem of providing health care to poor.
2. How do we deliver – especially at remote locations? When we are
not able to provide care at the time it is needed, many women die
for example. So how should this be managed.
3. How do we tackle the shortage of human resources - there are
enough examples from different countries that we need to learn from
to innovate and produce trained human resources for health care.
4. What are the accountability structures - we need to innovate in the
area of accountability and transparency. We need to know what works,
and how it works?.
In the background of a conceptual presentation as above, it was
interesting to hear the presentation on Health systems Strengthening:
Experiences from Tamil Nadu. Mr. V.K. Subburaj, Principal Secretary
to Government, Health and Family Welfare Department, Tamil Nadu. He
presented the key indicators of Tamil Nadu’s health program and informed
the conference gathering that Tamil Nadu’s infant mortality is much lower
compared to the rest of the country. He added that there is a strong
political will to achieve higher health standards, and a focus on achieving
the millennium development goals in the state of TN.
52
Mr. Subburaj mentioned the attempts being made to integrate PHCs with
the day to day life of residents. For example, within the PHC premises,
they conduct a “Bangle” ceremony for new brides in the community, and
this becomes an opportunity to create awareness on the PHC facilities.
Another issue that Mr. Subburaj highlighted was on transparency and
accountability, mentioning examples of the maternal death review
conducted by the district collector and the transparent procurement
process in Tamil Nadu. Further, he shared that, “automation” is playing
a big role in effective management of health service delivery and HMIS
is being implemented across the state to raise the quality and quantity
of health based data in Tamil Nadu.
“We are confident that the data generated from this
automation would help in providing insights for effective
management of service delivery. 1421 PHCs are now
connected with computers and Internet and this is a
significant step in enhancing technological access for health
care”.
Mr. Subburaj informed the audience of the state government’s efforts in
managing human resource issues, including the provision of compulsory
rural postings for doctors and nurses and compulsory government service
for three years for private post-graduates.
“We have increased the compensation levels for the doctors
to be able to attract and retain good talent”.
This presentation by Mr. Subburaj made it amply clear that the state of
Tamil Nadu was not only committed to HSS, but had clear outputs and
statistics to present its case.
ICONHSS
2010
53
3 . 3 Financing for Universal Access
Adding to the governmental steps, how could the private sector remain
behind? This was highlighted by Dr. Devi Prasad Shetty, Chairperson,
Narayana Hrudayalaya Group of Hospitals who made a presentation on
Private Sector Investment in improving Access to Health care. Dr.
Shetty spoke about the opportunities and challenges in the health care
industry in India. He stated that this industry invest about US$ 4.5 trillion
and USA is expected to spend upto 20% of its GDP on health. In fact,
health care is the third largest employer in America and provides an
opportunity to employ a large number of women. He mentioned that
health care is the only industry where a young woman from a low economic
background (employed as a nurse in USA) can earn INR 1.5 lakh per
month. This industry is non-cyclical, and 15 of the 20 fastest growing
occupations in the USA today are in the health care industry.
Moving on to spending
issues, Dr. Shetty added
that in India alone, we
require 2.5 million heart
surgeries annually, while
we conduct only 80,000
per annum and the
remaining are not done
due to affordability issues.
However this is changing
now because of the
availability of health
insurance, and it is estimated that, with increasing volumes, the costs
will come down. For example, the most profitable hospitals are not five
star type hospitals, but those that attract a large number of patients.
He predicted that in the coming few years, India will become the largest
mass health care provider in the world.
“We would disassociate health care from affluence. We can do it
because we produce the largest number of doctors and nurses
annually. We dreamt of INR 5/- insurance per month scheme and
today we have 5 million farmers as members of this scheme. What
was once done with mobile phones in the country, we are going
to do with Health care”.
54
Expanding on the issues
related to financing for
health care and drawing
from
country
level
experiences, the next
presenter, Dr. Ganga
Murthy provided valuable
information on National
Health Accounts current trends and way
forward. Dr Murthy
shared that NHA is a tool
designed to explain the health accounts of an economy through a set
of tables that organize, tabulate and present health expenditure by
identifying the linkages between sources, agents, providers and functions,
through a set of matrices.
She also elaborated on the role of NHA which includes:
1. Tracking the flow of resources for all segments in the health sector
- public, private, activities, providers etc;
2. Expenditure Monitoring - Rigorous classification of types & purposes
of all health expenditure & actors; scientific approach to collection,
classification and estimation of fund flow; Analysis of segment-wise
trends;
3. Providing evidence base for financing healthcare - Source of funds;
Strength of individual segments; Distribution of health expenditure
amongst different segments; Composition of Out of Pocket Expenses;
Nature of interventions required.
“We need to have an appropriate financing strategy to
provide health care. Some of our challenges include the
scope of National Health Expenditure – should hygiene and
nutrition be included in our definition, for instance? Capacity
building is another challenge and we need to identify
research institutions within and outside the government to
build a database for collecting and compiling information
relating to NGOs, firms & local bodies involved in health
care”.
ICONHSS
2010
55
Dr. Ravi Duggal’s presentation on Out of pocket expenditure and
Financial strategies for universal access came in logical progression
to the discussion around NHA, as an important strategy for health care
financial management.
Dr. Duggal mentioned that India is the highest spender in the area of
private financing for health care and one of the lowest spending countries
on public financing of health care. Health care continues to be a
substantial burden for poor households in the country. Despite this trend,
public investment in health care has been stagnant at the level of less
than 1% of GDP; while private expenditure is expanding – moving from
2.27% to 5.4 % in the last 14 years. Expressing his disappointment with
the private sector, Dr. Duggal said that the private sector gets a large
amount of governmental subsidy but does not pass the benefits to
poorer sections of the society. In fact, the government has not managed
to make private players accountable and this makes the picture worse.
On the issue of mobilizing more money he suggested that we should raise
additional resources by applying health cess of 2% on the turnover of
health degrading products like cigarettes, beedis (local cigarettes), paan
masalas, guthka (chewing tobacco) as well as on vehicles, road tax. etc.
Dr. Duggal mentioned the need to bring more people under social
insurance and advocated the model of universal access to health care.
He suggested that anything designed only for the poor will not work, hence
the new model should not try to target a particular economic sector,
instead it should be designed for all!
The two sessions as part of the India Meet were very informative and
interactive as expected and
from them emerged some
useful recommendations as
mentioned below.
At the end of the session
Dr. Duggal read out the
Chennai Declaration for the
participants to accept and
second. The full text of
the adopted declaration is
in Annexure E.
56
R ecommendations from the India Meet
☯ There should be an increased focus on providing quality in
health care services to the poor.
☯ PHCs should function as a centre point for community
health care and interact closely with local communities
so that they can fulfill their health care needs as far as
possible.
☯ Innovation is necessary to provide effective health care,
using limited human, financial and infrastructural resources.
☯ A larger number of people should be trained as health
care technicians and paramedics.
☯ To take care of the shortage of human resource, the
current staff like ASHAs should be trained to play more
enhanced roles.
☯ Mass insurance schemes should be implemented so that
health care is affordable for all.
☯ Health tax should be added on health deteriorating
products to meet some of the financial gaps.
☯ Governmental spending on health care should be
increased from the current level which is less than 1%
of the GDP.
ICONHSS
2010
57
3 . 4 Health Service Delivery
Going ahead from the presentations in the India Meet, the conference
now moved towards its 10 thematic sessions. The first of these included
a plenary of presentations on Health Service Delivery.
In recent years, as decision makers have become more aware of the
problems in the health sector and the interdependence of health and
development, a higher priority has been given to delivering health services
and meeting the health needs of the poor. Strengthening health services
is now recognized as a priority for countries to be able to meet the basic
health needs of their people, especially for poor and vulnerable
populations. A challenge in most low and middle income countries (LMICs)
remains in finding ways to enable the many actors in the health sector
to address these basic health needs more effectively. Progress on the
Millennium Development Goals (MDGs) and on disease-specific programs
depends on the ability of health systems to provide services (Jha et al.
2002; World Bank 2007; WHO 2007; GAVI Alliance 2007). Yet decision
makers have little evidence to guide their decisions about how to most
effectively, equitably and affordably provide health services.
It is in this context that a number of eminent speakers were invited for the
ICONHSS to elaborate upon the issues and challenges in Health service
delivery.
This session was chaired by Ms. Girija Vaidyanathan IAS, Mission
Director, NRHM and Project Director, RCH-Tamil Nadu and Dr. K. Srinath
Reddy, President, PHFI and was coordinated by Ms. Gayatri Oleti,
Director – Strategic Planning and Partnerships, APAC and Dr. Sathish
Kumar, Associate Director (Technical), SAATHII.
Objectives of this session:
●
●
●
58
To review the current status of health care delivery at the
national, state, and local levels.
To share in-country and international experiences to
promote cross-learning and good practices in health care
service delivery systems.
To assess the possible areas of intervention for improving
service delivery in public and private health sectors.
Global Experiences of Health Services Delivery, presented by Ms.
Kerry Pelzman, Director, Office of population, Health and Nutrition,
USAID/ India.
Health Services Delivery in India: Issues and Challenges,
presented by Dr. Sundaraman, Executive Director, National Health
Systems Resource Center.
Quality of health care, presented by Dr. Preeti Kudesia, Senior Public
Health Advisor, World Bank.
Role of insurance in enhancing access to quality health care,
presented by Dr. Prakash, Medical Director, Star Health and Allied
Insurance.
Challenges in delivery of services for prevention and control of
non communicable diseases, presented by Dr. K Srinath Reddy,
President, PHFI
The key issues that emerged from these presentations helped provide
a holistic picture of the state of health service delivery globally, nationally
and locally:
☯ Health service delivery challenges need to be looked at in the “context” of the increasing global burden on health care. For instance,
Malaria alone infects more than 300 million people worldwide and kills
more than 900,000 people annually. 90% of these fatalities are children below 5 years. Similarly, more than 9.2 million people get infected with Tuberculosis (TB) every year, and more than 1.7 million
people across the globe die from TB.
On the other hand, non-communicable diseases are increasing at an
alarming proportion across the world. Thus the world is facing a
huge burden to provide for the increasing health care needs of its
population.
☯ The “quality” of service provided is an issue of great concern,
especially as it is accepted that the poor are also entitled to and
expect a certain level of quality in terms of cleanliness, hygiene,
ICONHSS
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comfort, respect
and
access
to
competent health
professionals and
m e d i c a t i o n .
Providing for this
basic level of Quality
is thus emerging as
an area of focus in
health care delivery
systems - to be
able to make the
systems perform effectively.
☯ The third issue is related to the “double burden of disease”.
With the onset of non-communicable diseases, the entire system
has come under strain - with increased workload on the one hand,
and, on the other hand, it is also driving up the cost of health
care. In fact, the cost is also going up because of increasing use
of high technology in health care. The challenge that remains is
to keep health care affordable for the poor and marginalized people
in the country.
☯ The fourth key issue in effective service delivery is related with
“Financing”. This is related to the nature and extent of disease
and disease control in the country. Therefore, in India, the
prevalence of both communicable and non-communicable diseases
(NCDs) is significant, putting the country under a “double burden”.
The NCDs, particularly, cardiovascular diseases are affecting the
Indian population in its productive years, leading to the loss of
earning capacity and creating a burden of increased paying for
medical expenses. In fact, this process is pushing people into “neopoverty” and there is an urgent need to address the same through
systematic financial investments. One of the possibilities here could
be the use of ‘Insurance’, as an effective way of ensuring effective
Health Service Delivery and there are several examples of this
working on the ground.
60
Summary of Presentations
Global Experiences of Health Services Delivery, by Ms. Kerry Pelzman,
Director, Office of population, Health and Nutrition, USAID-India
Ms. Kerry Pelzman’s presentation focused on the Global Health Burden.
For instance, malaria kills 900,000 people annually mostly children below
5 yrs. In case of HIV, 3 million people are infected annually. She said
that mortality in developing countries is due to communicable diseases
and there are several challenges to service delivery. One such challenge
is the shortage of 4 million health professionals globally and informed that
the projected additional cost to achieve millennium health goals is US$36
to 45 billion USD.
She also elaborated about some of the global initiatives in service delivery
and in quality care, especially vis-à-vis global experiences in increasing
health access. Her key message to the audience was that, “health
programs must prioritize pro-poor investments; investments in other
sectors can multiply health outcomes”.
Health Services Delivery in India: Issues and Challenges, by Dr.
Sundaraman, Executive Director, National Health Systems Resource
Center.
Dr. Sundaraman compared high performing states of India with poor
performing states. At the national level, he noted that, the rate of decline
of IMR has started reducing in recent years. The Maternity Mortality Rate
(MMR) in Punjab is the worst among high performing states. With regards
to Public Private Partnerships (PPP), he mentioned that these should be
pro-poor initiatives. He mentioned that among the low performing states
(like UP and Bihar), the investment in Health care was less during 1993
to 2004, when there was no recruitment of manpower in the health sector
in these states.
In the area of health management information systems, Dr Sundaraman
mentioned that there is a major effort to build a nation wide system,
and for the success of HMIS it is important to use this information for
decentralized program planning and management. He added that most
public health failures are “design failures”, and take place due to
administrative and technical incompetence - not due to the so-called
implementation problems (due to errant employees etc).
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61
(
Audience speaks…
Q: Which countries
ourselves with?
A: BRICs
what we
However,
more with
should
we
compare
(Brazil, Russia, India, China) is
can compare ourselves with.
we should compare ourselves
China as it is very similar to us.
)
Quality of Health Care, by Dr. Preeti Kudesia, Senior Public Health
Advisor, World Bank.
Dr. Kudesia focused on defining quality as being in “Conformance to
requirements”. She mentioned that the quality health circles concept can
be applied in the health sector too. She also described the key ingredients
of quality in health care i.e. standards & protocols, target setting,
mechanisms and indicators to track quality.
Role of Insurance in
Enhancing Access to
Quality Health Care by
Dr. Prakash, Medical
Director, Star Health and
Allied Insurance.
This presentation focused
on “how do poor people
fund their healthcare
expenses”. Dr. Prakash
informed the audience that,
only 6% of poor households are able to fund medical expenses from their
current income; 63% borrow and 12.6% sell their assets, leading to rural
indebtedness. He reiterated the importance of good quality and affordable
health care for the poor. Sharing the features of the mass insurance
program being run by Star health and Allied Insurance in Andhra Pradesh,
he said that this was turning out to be a very attractive one due to its
universal converge and cashless treatment facility. In fact, the insurance
package covers the cost of “screening, testing and diagnosis, medical
treatment, surgery and follow up”. So far, Star has processed claims to
the tune of INR 1766 crore.
62
(
)
Audience speak…
Q: What is the role of empanelled hospitals
in screening and mobilizing patients?
A: One of the key roles of empanelled
hospitals is to mobilize and screen the
patients. There is great demand by hospitals
to participate in the program and this is an
entry criteria. We have made it mandatory.
Q: What is the drop out rate of the hospitals?
A: We look into the case of death in these
hospitals and after investigation if they are
found responsible, we punish them and also
de-list them.
Challenges in Delivery of Services for Prevention and Control of
Non Communicable Diseases by Dr. K Srinath Reddy, President, PHFI.
Non-communicable diseases are one of the major challenges of public
health today and many of these diseases are estimated to grow in the coming
years. For example, the number of people with hypertension would grow
manifold by 2025. Some of the key causes of these diseases are consumption
of tobacco, reusing cooking oil etc. In a study it was found that among
students, the addiction to tobacco is starting early on and, further, tobacco
consumption is increasing among women. Various studies suggest that the
urban poor are also increasingly becoming victims of Cardiovascular Diseases
(CVD).
According to the World Health Organization, there are severe economic losses
due to Coronary Heart Diseases (CHD), Strokes and Diabetes in India (20062015) and 40% of CVD patients lost their main sources of income according
to a study conducted in Kerala. Dr Reddy suggested that we should audit
the use of technology (to be able to weed out the unnecessary use of
technology) in CVD and thus reduce the costs of providing health care in this
area. He recommended that we should learn from the AIDs program and
adopt “task shifting” to be able to make the CVD healthcare accessible and
affordable.
ICONHSS
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63
(
64
Audience speaks….
Q: Often the rural poor do not have choices
like palm oil which can help reduce such
health problems.
A: We need to educate the poor on all
available options. We also need help motivate
them make the right choice and at the same
time, make the right food available at
subsidized prices.
Q: Is there anything being done by the
government to stop the production of tobacco
and related products?
A: Tobacco is more addictive to the
Government compared to individuals! We
also need to provide alternate occupations to
beedi workers.
)
R ecommendations from the session
☯ Health programs must prioritize pro-poor investments.
☯ All State Governments should encourage and adopt mass
health insurance schemes on the line of Andhra Pradesh
and Tamil Nadu.
☯ Build a national level HMIS for effective service delivery.
☯ Health service delivery institutions should incorporate
“Quality Circle” concept and practices to improve their
services.
☯ Draw lessons from the AIDs program and adopt “task
shifting” to be able to make the CVD healthcare
accessible and affordable.
☯ Reduce the unnecessary use of technology in CVD and
thereby the costs of providing health care in this area.
Symposium on Service Delivery2
The plenary on service delivery was followed by a symposium on the same
theme which provided an opportunity for members of the audience to gain
in-depth knowledge of some best practices and experiences in the field.
Summaries of these presentations are shared in this section. The session
was chaired by Dr. Bimal Charles, Project Director, APAC-VHS and Dr.
D.C.S. Reddy, NPO-HIV/AIDS Surveillance, WHO, with the coordinators
being Dr. L. Ramakrishnan, Country Director, SAATHII and Dr. Reba,
CDC, India.
The presentations at this symposium included the following:
Access to health care for vulnerable population, by Dr. Lipika Nanda,
FHI, Hyderabad
Ensuring Equitable Health Care: Experience from Public Private
Partnership Initiatives, by Ms. Sofi BergKvist, International School
of Business, Hyderabad
2
This symposium was held as parallel session (V B) along with another session on Human
Resource (V A) on Day Two of the conference.
ICONHSS
2010
65
Care at times of Critical Emergencies, by Dr. Guruswamy, Chief
Executive Officer, Tamil Nadu Health Systems Project, Chennai
On Under-reported Deaths & Inflated Deliveries: Making Sense
of Health Management Information Systems (HMIS), by Dr.
Upendra Bhojani, Institute of Public Health, Bangalore
Community based Filarial Lymphoedema Morbidity management,
by Dr. Sairu Philip, Associate Professor, Dept. of Community Medicine,
T.D. Medical College, Alappuzha
Irrational Prescription Practices in Public Health Facilities, by
Dr. Habib Hasan, Public Health Foundation of India (PHFI)
Equipment Maintenance in a Government Health Care Facility, by
Dr. A. Kumaresan Deputy Director, Equipment Cell, TNHSP
Citizens Help Desk – a Karnataka Health Systems Development
and Reforms Project (KHSPRP) initiative, by Dr. Selva Kumar,
Project Administrator, KHSDRP & Mission Director NRHM.
The session began with the
Chair, Dr. D.C.S. Reddy
setting the ground rules viz.
time management of their
presentations
and
requested the speakers to
focus on Access, Equity and
Quality of the products in
service
delivery.
Presentations by eight
speakers from across the
country and the world
followed.
Dr. Lipika Nanda, FHI, Hyderabad shared experiences on the Access to
health care for vulnerable population from Andhra Pradesh (AP). Dr.
Nanda started with presenting some background information on the state,
including its demographic profile and health infrastructure. She stated
that although AP has a large number of PHCs and Community Health
Centers (CHCs), these are not enough and there is a need to invest in
infrastructure. She elaborated upon the reforms started in the decade of
66
the 1980s when institutions like the APVVP, Health University, DME were
formed, followed by structural and programmatic reforms in the 1990s
to 2004, and then the sectoral reforms with the present APHSRP through
DFID support since 2007. She added that the result of these initiatives
has been a progress in the health indicators of Andhra Pradesh.
However, access to quality health care is still an issue in the state due
to several reasons, including lack of qualified health professionals,
secondary and tertiary care being over-utilized, PHCs & Sub-centers being
underutilized due to non-availability of doctors in rural areas, lack of
accessible all-weather roads in tribal areas etc. Dr Nanda suggested
various ideas on the ways to improve the situation e.g. Public-Private
Partnership, Insurance, outsourcing diagnostics etc. to be able to fill the
gap in adequate service provisioning.
Ms. Sofi Berg Kvist from the International School of Business, Hyderabad
and representing Access Health International made a presentation on
Ensuring Equitable Health Care: Experience from Public Private
Partnership Initiatives. She focused on equity in health care, defining
it as “Any person, irrespective of income, caste, religion and gender has
the right to access affordable quality healthcare”.
Ms Kvist highlighted four specific cases of Public-Private partnership (PPP)
in Andhra Pradesh i.e. EMRI; Chiranjeevi; HMRI; and the School Health
Program. She noted that the majority of PPPs in India are focused on
women, children and poor. The important thing here is that for PPPs to
work efficiently there should be institutionalized mechanisms for periodic
reviews; there has to be a design for voluntary renegotiation of any
existing onerous PPP contract; and an assessment to educate policy
makers about its effectiveness.
Dr. Guruswamy, Chief Executive Officer, Tamil Nadu Health Systems
Project, Chennai shared the Tamil Nadu experience on Care at times of
Critical Emergencies, focusing on the emergency care service (EMS)
introduced in Tamil Nadu3. This service was started with the vision that
“Every emergency should get appropriate care irrespective of their socio
economic status.”
3
A field visit was organized at the end of the conference to the EMRC which services Tamil
Nadu through the 108 number.
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The mission is to provide FREE emergency ambulance service to all
sections of people in Tamil Nadu; to cater to all emergencies reported
at the EMS number 108; to provide quality pre-Hospital care and to
transfer patients within the “Golden Hour” and “Save Lives”.
The key reasons for starting this service were the lack of Organized
Emergency Care; commercialized Private Operators; no accessibility to
Rural people; the poorest of the poor Unable to avail the service; increase
of Life style related emergencies and increasing RTA.
Currently, the service deploys 385 ambulances across the state of Tamil
Nadu and the emergency service is managed through a 24x7 call center.
At present, the service is used across the state, both, in rural and urban
areas. The detailed performance indicators for input, process and output
are constantly monitored for high quality performance. The service has
received an overwhelming response especially because of the awareness
generation programs launched to motivate the rural population to start
using the service, which has resulted in a high usage of the service.
Dr. Upendra Bhojani, from the Institute of Public Health, Bangalore made
a presentation titled On Under-reported Deaths & Inflated Deliveries:
Making Sense of Health Management Information System (HMIS),
based on a study conducted in Orissa and Karnataka. The study looked
into the process and quality of data collected, analyzed under the Health
Management Information System (HMIS). It was noted that the quality
of data recorded is not reliable. There is under reporting and inflation
of certain data. Also, the staff is not well trained to record, analyze and
use the data effectively. Going forward, it was suggested that key
indicators should be developed to be able to track relevant data and the
staff should be trained for effective recording and analysis of the data.
68
( )
Audience speaks…
Talking about the use of HMIS, members of
the audience mentioned that some of them
face server connectivity issues and the lack of
dedicated computer trained staff, and there is
a need for investments in this area.
An interesting question that came up was with
regard to the Unique Identification (UID)
coming in – would this solve the problems of
data triangulation and presentation? The
speakers shared that it was too early to predict
the outcome of UID for HMIS but the
components could be factored in.
Another concern of the audience was with
regard to the correctness of the data. How
does one ensure that the ANMs are filling in
the information uniformly, are there differences
in understanding what is to be included, etc.
The speakers shared that understanding the
data correctly is very crucial and therefore it
may be good to build the capacity of health
staff to review and present the data.
Dr. Sairu Philip, Associate Professor, Dept. of Community Medicine, T.D.
Medical College, Alappuzha brought in an experience of Community
based Filarial Lymphoedema morbidity management, focusing on
the experience of partnerships among self-help groups (SHGs) in the
prevention and treatment of Filarial Lymphoedema. This strategy focused
on morbidity management and mass drug administration.
The process followed was simple - the first step was to identify the
volunteers, the next to conduct an initial survey to line list the patients;
followed by the formation of SHGs based on geographical feasibility;
conduct of initial Filarial Lymphoedema Morbidity Management clinics; and
follow-up meetings once a month. There are 13 self-help groups
functioning at present, covering 600 patients in the community. As a result
ICONHSS
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69
of this change there is
better patient compliance;
those who have benefited
are now ardent supporters;
there is greater sense of
belonging; and it is a
platform to ventilate
feelings etc.
Dr. Habib Hasan, Public
Health Foundation of India
(PHFI) shared evidence
from Tamil Nadu and Bihar on Irrational Prescription Practices in Public
Health Facilities, highlighting a very significant aspect of service delivery
systems. The key objectives of the study were to examine budgetary
allocation on drugs & associated inefficiency; assess competitiveness of
medicine procurement price in the two states; generate evidence on
availability & stock-outs; analyze prescription & dispensing pattern; and
explore alternate policy options.
The study covered 60 public health facilities in these states and concluded
that, there is a need for capacity building of health professionals for
rational drug use; implementation of Standard Treatment Guidelines at
the facility level to improve patient outcomes, and rationalization of
medicine prescriptions. He pointed out that prescription practices not only
depend on medical training, but also on the availability of medicines at
the facility level, as well as conducive policies and health systems’
performance.
Dr. A. Kumaresan Deputy Director, Equipment Cell in Tamil Nadu Health
Systems Project focused on the initiatives taken in the area of Equipment
Maintenance in a Government Health Care Facility4 under the TNHSP
project. He pointed out that for effective health care it is critical to ensure
the proper upkeep of equipment. Sometimes the lack of availability of
the right equipment can be fatal for a patient. The presentation elaborated
upon the Procurement and Tendering processes; the Annual Maintenance
Contract (AMC) process; Supply and installation process; Preventive
Maintenance; Breakdown Maintenance etc.
4
A field visit to one of the largest warehouses (Anna Nagar) under the TNHSP was undertaken
at the end of the conference.
70
Some of the key steps taken at TNHSP to ensure efficiency at this level
include: appointment of 10 Bio Medical Engineers; Tool kits & in-service
training; Creations of an Equipment Inventory and regular updates;
Monitor technology specification and installation; Regular visits to the
Hospitals; PM & BM done for equipments out of AMC; Supervision of
Warranty/ AMC agencies; validation of Local agencies’ quotations;
“Hospital–Agencies–TNMSC” co-ordination to reduce the breakdown time;
providing End user training; Harvesting & utilizing functional spares from
condemned equipments; and Periodical reports to the District and State
Office, etc.
Dr. Selva Kumar, Project Administrator, KHSDRP & Mission Director
NRHM, presented an overview on the use of public health services through
the example of the Citizens Help Desk – a Karnataka Health Systems
Development and Reforms Project (KHSPRP) initiative. The
presentation noted that despite the fact that Government hospitals are
the most economical and crucial source of health care for common people,
a large number of people do not use the facilities because of lack of timely
and quality care. As a result, the poor often go to private hospitals, even
when they cannot afford it. Some of the other problems vis-à-vis the gaps
in usage of public health services are due to lack of awareness of services
(especially free drugs and treatment available or applicable user fee); long
waiting time to meet the doctor and get treatment; demand for speed
money by some elements; lack of awareness on how and whom to
complain and lack of confidence (among patients) to assert rights for
corruption free treatment.
It was in this context that the Citizens Help Desk project was launched
by the KHSPRP, with the
objective of improving
services at Government
hospitals by educating the
public about the available
facilities and the services;
monitoring the quality (e.g.
time taken by doctors to
attend a patient, availability
of free drugs etc.) of
health care provided;
providing feedback to
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authorities and to enhance transparency and accountability. The Citizens
help desk provides information and guidance to patients on the facilities,
charges etc; collects feedback from patients on the quality of service;
registers grievances with regards to health services through helpline,
email, and letters drop box; refers grievances to concerned officials; and
acts as a channel of communication to the “Arogya Raksha Samiti/ Rogi
Kalyan Samiti”. This service is outsourced to NGOs, private health
agencies or trusts. Dr Kumar pointed out that the results of this initiative
are very positive and encouraging and the project sees this as a replicable
model.
Audience speaks…
( )
This presentation received a good response
from the audience who felt that it highlighted
the concerns of patients, an oft neglected
subject in discussions such as those held in this
conference.
One of the participants shared that due to
overload and lack of effective communication
skills among the health staff, they do not
realize the disconnect between ‘having
information and not giving it’ to patients or
carers, so this kind of an initiative is important
as an institutional system.
It was also suggested that Medical Social
Officers should be included in every hospital to
provide the social support necessary in health
care work.
In response to a suggestion on the use of an
interactive voice recorder (IVR) to document
patient interactions, the speaker pointed out
that since most complaints are registered in
person at the hospital desk itself, so IVR would
not really help in such a case.
72
Summarizing the symposium on service delivery, it was pointed out
that “Delivery” is the ultimate visible aspect of any health systems
functioning and a culmination of different elements in the health care
industry. There are good and innovative practices coming out from the
various projects and there is a need to standardize some of the best
practices, keeping in mind that what may be true in one place may not
work in others, so there would be a need to adapt the practices based
on local situations.
Both prescription and HBIS reflect that, though some new actions have
been suggested, these continue to remain the same as they were two
decades ago. The question is why this is so? Are the models being
suggested not implementable? Similarly, a lot of action research is
undertaken which shows us positive results but when we go back to the
field we find the same problems…replication is not that easy!
And yet, we have some great ideas and experiences here which we cannot
stop at, but must continue to experiment with, so that efficient and
effective quality care is delivered to those in need.
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73
3 . 5 Human R
esources
Resources
Human resource is one of the critical factors in the provision of health
care, directly influencing the performance of health-care systems.
Accessible health care requires well-trained and well-motivated physicians
and nurse workforce of an adequate size that are able to deliver safe,
high-quality medical services. With the changing demographic and disease
profile of the country, India needs to add a significant number of health
professionals to meet this demand. There are various estimates of
shortfall in health care human resources. One estimate (based on the
population in year 2008) as per the norms of Government of India puts
the short fall at 4,04,925, another estimate as per IPHS norms arrives
at a shortage of 11,44,633 health professionals.
The ICONHSS made an attempt to discuss this very important aspect
of health systems through a plenary and symposium with state, national
and international hence experiences being shared.
Objectives of this session:
●
To highlight emerging issues and best practices in the
production, recruitment, retention and capacity-building of
medical and paramedical staff, especially, in India’s public health
system.
The session was chaired by Dr. Michael Friedman, UPHSMO CDC, Atlanta
and Dr. Mala Rao, Director, Indian Institute of Public Health Hyderabad.
The coordinators of the session were Dr. Mini Jacob, Reader, The TN
Dr. MGR Medical University and Dr. L. Ramakrishnan, Country Director,
SAATHII.
Dr. Michael Friedman shared his thoughts and ideas on the Development
of public health workforce and its relevance to India. The other
presentations at this session included:
Financial and non-financial incentives to attract health workers
to rural areas: Evidence from discrete choice experiments,
presented by Dr. Kara Hanson, Reader, Health, London School of
Hygiene and Tropical Medicine.
74
Health & Human Resources: Priorities in India, presented by Dr.
Padmanabhan, Advisor Public Health Administration, NHSRC.
Which doctor for Rural India? An assessment of task shifting
in primary health care, presented by Dr. Krishna Rao.
The key issues that emerged from these presentations provided a
comprehensive idea of the nature of human resource management issues
in the health sector, including recommendations for making the necessary
inputs at the state and national level.
☯ The
nature
of
workforce:
One
significant discussion
related
to
the
competencies that India
needs in providing
quality health care to its
large population. This
question is directly linked
with the strategy of
providing health care,
which include two key approaches – the Clinical approach to health
and the Public health approach. The clinical approach to health is
focused on curative health and hence dependent on qualified
doctors and nurses; while the Public health approach is focused
on preventive health and hence demands more “feet on the street”
kind of health professionals, who focus on awareness generation
and providing basic health care.
☯ Strategies for attracting and retaining: The next question
related to attracting and retaining health professionals and
particularly on how to motivate them to provide services in remote
rural areas. It was noticed that there is hardly any research
available on what strategies work in attracting and retaining health
care workers in India, and this may actually help in understanding
and planning for human resource development in the health sector.
☯ Increasing productivity: Apart from the training and education
of a large number of new health professionals increasing the
ICONHSS
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75
productivity of existing health personnel was a key topic of
discussion. In this area “Task Shifting” emerged as the most
significant learning from the experiences of AIDS control and
prevention initiatives. Another dimension articulated here was the
demand for a greater use of information technology to unburden
health professionals from administrative jobs of recording,
compiling and maintaining physical records.
☯ Technology based education and training: Using information
technology to reach out to a larger number of people to be able
to upgrade their skills and competencies using e-learning solutions
emerged as an important area of focus. It was felt that there is
a great possibility to use the latest technology to increase the
outreach and effectiveness of education and training for health
sector personnel.
Development of Public Health Workforce - Relevance to India, by
Dr. Michael Friedman, UPHSMO CDC, Atlanta
“If we do not have sufficient human resource than all plans
remain on paper”. For Dr. Friedman, there is a direct corelation between the number of health workers and the IMR
and MMR. He mentioned that Thailand spends about 2% of
its GDP on health and has achieved a life expectancy of 75
years which is only 2 years less than USA that invests 15%
of its GDP on health. So what is the secret that we need
to know to achieve these figures?
“Do we want to take a clinical approach to health or public
health approach?” Public health has attributes such that it,
prevents epidemics and the spread of disease; protects
against environmental hazards; promotes and encourages
healthy behaviors. We need to understand this holistic
definition to strengthen our efforts in the health sector of
India.
Further, we mentioned the need to look at the constitution
of the public health worker. When we think about health
76
workers, we think about Doctors, Nurses etc. but actually
health workers are people like community workers and we
need to invest in them. Training a clinical professional in
public health is almost impossible, so we need to understand
the need to train people at the community level.
The other area of focus needs to be the creation of a public
health law for the country; right now we only have this in
Tamil Nadu which is a great start but its needs to be allIndia.”
( )
Audience speaks…
Q: What is the role of district level doctors
working at the PHC?
A: Are there doctors in rural PHCs? Do we
know what their job is? What is that they
need to do when they are there? We need
to fix accountability and create structures to
ensure that they do the job required.
In public health education, distance learning
may not help; it should be more hands on
experience that we would need to focus on.
Q: There is strong presence of the private
sector in the health sector so should we let
the private sector do clinical work, while the
government does public health, as there is
more money to be made in clinical work?
A: The private sector is organized and
motivated to do clinical work and the
government should play a greater role in
public health. For years doctors were trained
in counseling against smoking; however it
was not effective, while public health
education through campaigns has achieved
far better results.
ICONHSS
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77
Financial and Non-financial incentives to attract Health Workers
to Rural areas: Evidence from Discrete Choice Experiments, by Dr.
Kara Hanson; Reader, Health, London School of Hygiene and Tropical
Medicine.
In setting the context of her
presentation, Dr Hanson
mentioned that there is an
absolute non-availability of
people, performance, and
incentives to attract the kind of
human resource needed in the
health sector. She questioned
the kinds of people that are
recruited in this sector as they
don’t fit the requirements for
an efficient public health system.
Dr. Hanson shared that in the absence of any study on retention
strategies of health workers; human resource planning cannot be
effective.
“We need more rigorous evaluations of the impact of
various strategies used to attract and retain health workers”.
She mentioned ways of studying the impact of human resource strategies.
One way is to use “Discrete choice experiments” in HR research; this
would help in designing appropriate policy and strategy changes. She
informed the audience of a three country (South Africa, Thailand, and
Kenya) study conducted by CREHS, wherein, the findings were that, some
financial incentives along with preferential training created higher levels
of attractiveness for rural postings. She also learnt from this research that
people born in rural areas tend to choose more of the rural postings.
78
(
)
Audience speaks…
Q: Did you consider any other possibility
between rural and urban?
A: The cognitive demand of creating more
options was too much.
Q: What kind of training is motivating people
to choose rural postings?
A: Health workers are hungry for training
and education, and so we have focused on
short term training which has attracted
many people.
Q: You said that when people were offered
financial incentives plus education, it worked
well. I am wondering what is the role of
providing educational facilities to children of
health workers?
A: Anecdotal mentions did come. I think
tailoring to local context is very important.
Health & Human Resources: Priorities in India, by Dr. Padmanabhan,
Advisor Public Health Administration, NHSRC
Presenting three important challenges in health care: 1. Communicable
diseases; 2. Newly emerging non-communicable diseases, and, 3.
Shortage of health workers, Dr Padmanabhan talked about some of the
issues that need urgent attention in India vis-a-vis human resources in
the health sector. He informed the audience that India tops the list of
maternal deaths and there is a co-relation between the availability of a
health worker and the mortality rate. NRHM has added a large number
of personnel in the system. However, there is still big gap between the
demand and the supply.
Dr. Padmanabhan highlighted the challenges of Human Resources i.e.
shortage, migration, imbalances - skewed distribution, contractual staff,
lack of enabling environment, delay in recruitment of doctors, regular
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vacancies are not filled, no transparency in recruitment and transfers, and
lack of
professional HR managers. He mentioned some of the steps
taken to improve the above situation initiatives such as walk-in-interviews
for doctors to be appointed in Haryana, restructuring cadre of doctors,
incentives for doctors working in difficult areas like Chhattisgarh, etc.
(
Audience speaks...
Q: Why are we talking only about the medical
aspect, why are we not talking about Human
Resource manpower for behavior change, for
aspects where medical inputs are not needed?
A: We are still struggling for providing the
basic health services at PHC level. However
there are efforts going on to have more
ASHAs.
Q: We do produce a large number of nurses,
but are they available in India, since many of
them migrate.
A: There is a great need of Nurses in the
north of the country. We need to look at
nursing education to become more
systematic.
)
Which doctor for Rural India? An assessment of task shifting in
primary health care, by Dr. Krishna Rao
Dr Rao highlighted the fact that most of the health workers are in the
private sector. There are various experiments to make doctors work in
rural areas i.e. compulsory postings in rural areas etc. Providing a historical
perspective he shared that, LMPs were abolished after the Bhore
committee report. Presenting the study conducted to compare performance
of different types of primary health workers, Dr. Rao suggested that the
Allopathic Doctors are not performing any significantly better, compared
to the doctors in Ayush and RMAs. He mentioned that placing a certified
physician may not make the PHCs work more effectively; a much more
holistic approach is needed.
80
In her final words as Chair of this session, Dr. Mala Rao, urged the
delegates of the conference to understand that:
“Public health needs to become everyone’s responsibility.
We need to invest in competence based training. We need
to also look at the challenges for public health that are
emerging due to global warming and climate change”.
(
)
Audience speaks…
Q: What kinds of teachers are teaching in the
medical institutes?
A: There is a variation and thus there would
be a difference in the level of performance
depending on from where the doctors have
received their training.
Q: There is a lot of discontentment about the
presence of AYUSH doctors within the medical
practice.
A: There are issues as you mentioned,
however AYUSH doctors are more acceptable.
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R ecommendations from this session
☯ India should adopt the “public health” approach to health
care instead of the “clinical care” approach, as it would
be cost effective and also easy to train and depute
personnel in remote and rural areas.
☯ There is a need to undertake systematic research on
“attracting and retaining” health professionals in the
country.
☯ In order to motivate health workers and paramedic, we
should invest in their continuing education.
☯ There is a need to bring in speed and transparency in
appointing, deputing and promoting health professionals
i.e. doctors and nurses.
☯ Health professionals deputed in difficult and remote
areas should be provided with appropriate incentives.
☯ Learnings from AIDS control programs should be applied
in health delivery in terms of shifting of tasks from
Doctors to nurses to paramedic staff.
☯ Public health should be promoted at the same level as
environmental issues. It should become everyone’s focus
area.
82
Symposium on Human Resources5
The plenary on Human Resources was followed by a symposium on the
same theme which provided an opportunity for members of the audience
to gain in-depth knowledge of some best practices and experiences in
the field.
The session was chaired by Dr. Dr. Kara Hanson, Reader, Health Systems
Economics, London School of Hygiene and Tropical Medicine and Dr. K.S.
Jacob, Professor and Head, Department of Psychiatry, CMC, Vellore. The
session was coordinated by Dr. Mini Jacob, Reader, The TN Dr. MGR
Medical University and Dr. Geetha Joseph, Scientific Affairs Specialist,
CDC, India.
In addition to these presentations there was a panel discussion on the
theme, moderated by Ms. Sheena Chhabra, Chief, Health System Division,
USAID- India, with the following speakers:
Dr. Thamma Rao, Advisor Health, Human Resources, NHSRC;
Dr. Sunil Nandraj, NPO - HSD, WHO;
Dr. Gerard La Forgia, Lead Health Specialist, World Bank;
Ms. Meena Gupta, Former Health Secretary of Orissa;
Dr. Abhay Shukla, Coordinator, Saathi-Cehat, India.
In the first presentation on Innovative methods in Medical education
Dr. Vinod Shah, Co-ordinator, Department of Distance Education, CMC
talked about the need for innovation in two areas: 1. Absolute shortage
- due to quality; and 2. Shortage due to the urban-rural divide. In order
to fill such gaps, steps like the post graduate distance learning program
on Family Medicine, taken by his Institute are significant as it has brought
in 210 students this year into the course nationally. There is also a need
to train medical professionals in teaching methodology and innovation is
the key here, especially through the use of use of technology i.e. elearning, video conferencing etc. Dr Shah mentioned that the impact of
this program is that the income levels of doctors have gone up and doctors
have become more ethical (e.g. they no longer take kick-backs from
pharma companies etc.)
5
This symposium was held as parallel session (V A) along with another session on Service
Delivery (V B) on Day two of the conference.
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(
Audience speaks…
Q: We are conducting courses on family
education but people are not joining. There are
only two admissions this year, what should we
do?
A: Our experience is that we have given
admission to 210 doctors for Family
Education, maybe it is because we are
conducting the program at the national
level.
)
The second presentation on Availability, Motivation and Capacity
Building of Nurses was delivered by Dr. Lata Venkatesan, Principal,
Apollo College of Nursing, Chennai with experiences from the private
sector. She shared the challenges of nursing at Apollo Hospitals,
mentioning the “skill gap” as the key issue. In the past, she said that
they had Doctors and Nurses, but now they also have Technicians.
However, this does not reduce the need for nurses whose numbers are
reducing constantly due to the high marketability of nurses (especially
international demands), lack of integrated responsibilities, corporatization
of health care, job dissatisfaction due to less compensation and maldistribution.
Statistically speaking, the number of nurses graduating per year are
15750, of which about 13000 get absorbed in the private sector and
abroad.
Apollo Hospitals has been investing in retention strategies for nurses to
handle this shortage issue by creating new designations (Director of
nursing, Dept. NSG officers, Case Managers) and capacity building efforts
such as:
84
❖
Orientation program
❖
Preceptorship Program
❖
Specialization training
❖
Leadership Development
❖
Conferences and workshops
Dr. Venkatesan added that medical graduates need to be prepared with
knowledge and skills that are in tune with the rapidly evolving health care
delivery systems as this would help them find the right kind of placements
and make them stay in their jobs as well.
Ms. Preeti John, Senior Faculty, LAICO, Aravind Eye Care System Madurai,
was the next presenter in this session. She shared the experience on
Innovative Human Resource Practices for Effective Health Service
Delivery. With 850-1000 surgeries conducted and 6000 outpatients
attended to daily, Aravind is the largest eye care service provider. Dr. John
said that this was possible through consistent efforts at ensuring
continuous availability of staff; optimal performance and retention of staff.
To ensure the flow of HR into the system, Aravind continuously looks at
“the kind of HR competencies needed for delivery of eye care”. The
institution invests in creating new cadres. Where there is lack of trained
HR, Aravind “builds” local potential.
Ms. John mentioned that the
HR department makes a
comprehensive forecast of
human resource needs to be
able to work out its hiring
strategy in advance. In the
recruitment of fresher’s at the
entry level, Aravind focuses on
“culture and attitude fit” more
than skill fit. For attracting
new talent, Aravind uses “word
of mouth” publicity, talks and placement interactions in schools, in order
to select the right kind of candidates. They also reach out to parents
of these trainees to educate them on their responsibilities to ensure
parental support.
At Aravind, the ratio in staffing is 1:5:5, the result being that the
productivity of Aravind’s surgeon’s has zoomed ahead, in comparison to
eye surgeons from other countries.
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( )
Audience speaks…
In response to a participant’s question
regarding the mismatch of availability of
human resource and dealing with burn out,
the speaker shared that Aravind has some set
standards for dealing with such issues.
“In case there is overload, we go for
additional staffing. Whenever there is low
demand on workforce. We have training
programs, team workshops, sabbaticals etc.
to ensure that there is no burn out.”
Another participant asked a question about the
availability of a working tool for ensuring
fitment with the organization. To this, Ms. John
added that Aravind has a process in place to
ensure the right fitment.
“We let a person spend a week with us before
the person is hired. This helps the person
make up his/ her mind and also gives us the
opportunity to observe the persons’ attitude
towards health care”.
Dr. (Capt.) M. Kamatchi, Expert Advisor, TNHSP, made a presentation
on the Rationalization of Human Resources in Tamil Nadu. He gave
the participants an insight into the kind of efforts that this state is making
to ensure that its health systems function effectively. He started with
mentioning that in a government set up, getting a position approved is
difficult and filling these vacancies is even more difficult. In this context,
the Government of Tamil Nadu decided to hire 2200 doctors at one go,
and in order to provide impetus to recruitment, they conducted walk-in
interviews for doctors and ran special schemes for recruitment of doctors
in the hill areas.
The state government also took steps such as shifting specialist doctors
from a PHC and ESI facility and initiated a major recruitment drive for
pharmacists, laboratory technicians and drivers; and at the same time,
86
outsourced the class 4 staff. In the area of rationalization of staff, they
divided the district hospital into different categories and worked out
service and staffing norms etc. To prevent attrition, they introduced
incentives in the employment package, including incentives on regularization
into the service and legally allowed private practice.
Going forward, Dr. Kamachi said that they need to provide HR projections
for the next 10 years and create a comprehensive HR policy, focusing on
recruitment, training, transfers, promotions, successions etc. One of the
critical steps that must be taken is rationalizing all posts in all institutions
and also developing a competency databank.
Dr. Shakil Ahmed, Assistant Professor, Department of Community
Medicine, Chettinad Hospitals and Research Center, Chennai, made a
presentation on Leadership Qualities among Health Care Providers.
His insights were a valuable addition to this session as he elaborated on
why leadership is important in health care. Defining leadership as “the
quality which makes a person stand different from other workers”, he said
that the leadership is a vital component of health management practices
and must be focused on to create a conscientious health cadre.
Dr. Ahmed presented the findings of a study conducted on leadership
competencies in association with XLRI, as part of which a one week
training program was conducted by XLRI.
Dr. G.V. Ramana Rao, Executive Partner, GVK, EMRI, Andhra Pradesh
presented the case of GVK EMRI’s two year program in Advanced
Emergency Medical Technician (EMT-A), referring to the need for
Development of Emergency Medical Technicians Cadre to enhance
health systems. The Emergency Medical Service (EMS) is “A network of
services coordinated to provide aid and medical assistance from primary
response to definitive care, involving personnel trained in the rescue,
stabilization, transportation, and advanced treatment of traumatic or
medical emergencies. Linked by a communication system that operates
on both at local and at regional level, EMS is a system of care, which
is usually initiated by citizen action in the form of a telephone call to an
emergency number6.”
6
This emergency number is 108 and many participants got a bird’s eye view of EMRC during
the field visit.
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Dr. Ramana Rao informed the audience that there are 4 million deaths
per annum due to the absence of the following four facilities, which EMRC
now provides:
v
Access to a universal toll-free number;
v
Availability of Life Saving Ambulance in short distance;
v
Affectionate Care by trained paramedics (Compassion, Action,
Reassurance & Energy);
v
Affordability by every citizen independent of income, religion and
community (free services).
The two year program tailor made to resource the EMRC takes in science
graduates and the EMTs get placement in various kinds of health care
institutions, so that the line of care is established across sense, reach
and care!
Mr. S. Swaminathan, Senior program manager, SAATHII- Chennai shared
an experience on the Sequence of Care and Task Shifting in Primary
Health Care, with evidence from Karur district. He introduced the
participants to the Integrated Management of Adolescent and Adult illness
(IMAI) package which is a capacity-building package to promote
decentralization of chronic, acute and palliative HIV care. He mentioned
that in IMAI, SAATHII adopted the following strategies:
1. Capacity Building:
•
Five day training followed by clinical mentorship visits;
•
Same topics for doctors and paramedics, taught at different
levels;
•
Emphasizes clinical team approach and systematic sequence of
care.
2. System Strengthening: Documentation,
essential supplies and drugs at facilities.
referrals,
supply
of
3. Community Involvement: Involvement of PLHIV as Expert Patient
Trainers of healthcare providers.
88
A unique feature of IMAI is the involvement of Expert Patient Trainer (EPTs)
in training doctors, nurses and counselors through simulated case-studies
in skill-stations.
Mr. Swaminathan suggested that going forward, there is a need to
examine the utility of this approach for strengthening care and treatment
(not confined to HIV) in rural public health systems.
Dr. R Shankar, Professor and Head, Department of Sociology,
Bharathidasan University, Trichy made a brief presentation regarding
Sociological interventions in Health Service. One of the key points
that emerged from his presentation was that over a period of time, our
traditional systems of health care have got destroyed and we need to
revive the same.
Summarizing the symposium on human resources, it was pointed
out that “Human Resource” is a key to deliver effective health care and
a critical component of health system strengthening initiatives. There are
some good practices being followed by organizations like Aravind Eye
Care, there are also several initiatives in the area of education and
development of human resources for health care. Organizations like GVK,
Apollo, are investing in the training and development of health
professionals. The Government of Tamil Nadu has also taken several
initiatives in the area of rationalizing the health workforce and to reduce
the human resource shortage in the state.
Despite all these efforts, it was felt that a lot needs to be done as the
enormity of the problem of shortage of human resources is huge and
needs immediate action by both Governmental and Non-Governmental
bodies.
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3 . 6 Health Care F
inancing
Financing
Financing is the most critical of all determinants of a health system. The
nature of financing defines the structure, the behavior of different
stakeholders and quality of outcomes. It is closely and indivisibly linked
to the provisioning of services and helps define the outer boundaries of
the system’s capability to achieve its stated goals.
Health financing is achieved through a variety of sources: (i) the tax-based
public sector that comprises local, State and Central Governments, in
addition to numerous autonomous public sector bodies; (ii) the private
sector including the not-for-profit sector, organizing and financing, directly
or through insurance, the health care of their employees and target
populations; (iii) households through out-of-pocket expenditures,
including user fees paid in public facilities; (iv) other insurance-social and
community-based; and (v) external financing (through grants and loans).
While taxation is considered the most equitable system of financing, as
tax is a means of mobilizing resources from the richer sections to finance
the health needs of the poor, out-of-pocket expenditures by households
is considered the most inequitable.
Under a system dominated by out-of-pocket expenditures, the poor, who
have the greater probability of falling ill due to poor nutrition, unhealthy
living conditions, etc. pay disproportionately more on health than the rich
and access to health care is dependent on ability to pay.7
Without adequate and consistent health financing not much can be
achieved in the health sector, least of all in respect to health systems
strengthening. It is in this context that a number of eminent speakers
were invited to elaborate upon the issues and challenges in Health Care
Financing.
Objectives of this session
●
●
7
90
To address the allocation of public funds for health care and their
utilization.
To discuss the role of the private sector in health finance, which
includes health insurance, PPP models, the cost of seeking private
health care and regulation of private health care.
Financing and Delivery of Health Care in India – K.S. Sujatha Rao.
This session was chaired by Dr. Mukesh Chawla, Sector Manager HDNHE, The World Bank and Dr. Sunil Nandraj, National Professional
Officer-Health Systems Development, WHO.Session was Coordinated
by Dr. Jammy Rajesh, Associate Director, PHMI & Dr. Jerard M. Selvam,
Professor, The TN Dr. MGR Medical University.
The different presentations on Health Care Financing as this session
included:
Global perspectives of health care financing and its relevance
to India, presented by Dr. Mukesh Chawla, Sector Manager HDNHE,
The World Bank, USA.
Performance based funding, presented by Dr. Gerard La Forgia,
Lead Health Specialist, The World Bank
Public health spending in health care - benefit incidence
analysis in states of Tamil Nadu and Orissa, presented by Dr.
Muraleedharan, Professor, Department of Humanities and Social
Science, IIT, Madras.
Along with the above speakers there was a Panel Discussion with three
eminent speakers:
Mr. Babu. A. IAS, Chief Executive Officer, Aarogyasri Health Care
Trust, Government of Andhra Pradesh.
Dr. Devadasan, Technical Advisor, Institute of Public Health, Bangalore
Dr. Shakthivel Selvaraj, Health Economist, PHFI, New Delhi.
The three key issues that emerged from these presentations included
the following:
☯
Who finances: Who shares the burden of health care financing?
This is an important question for debate, especially given the fact
that in India currently, about 72% of health care expenditure is
borne by the private household, the poor and marginalized are at
a definite disadvantage. Their ability to seek “private health care”
is almost negligible and therefore it’s important to find a collateral
or support for financing at the individual and family level, across
class but more importantly for the already disadvantaged.
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☯
How is financing done: How does one finance health care delivery
in India? How should one make service delivery institutions
accountable for effective health care? Would pay for performance
(P4P) be a workable idea in a diverse and complex country like India?
These were the critical areas of discussion during this theme
session, with a certain level of consensus coming up on a Mass
Insurance Plan and use of payment vouchers as a workable
alternative.
☯
When is financing needed: What is the right time for financing
whom? The current situation is that the household pays at the time
of an illness, which increases the stress in terms of coping with
the illness and organizing finance. Due to payments to be made
at the time of an illness, a large number of people choose not to
seek proper health care or are forced to sell their assets, which
often times pushes them below the poverty line. In this context,
it’s important that systems are developed for health care financing
to support people in times of critical illness and need for care, and
even serves like a social security blanket for the poor.
Global perspectives of Health Care Financing and its Relevance to
India, by Dr. Mukesh Chawla
Dr. Mukesh Chawla defined Health Financing as “more money for health”.
Dr. Chawla said that solving the puzzle of health care financing is an
extremely difficult one which a lot of people are trying to figure out, but
have not succeeded. He said that standard principles of economics do not
readily apply in health care financing. This complication arises because
it is difficult to put a value on uncertainty and fear; similarly there is a
huge gap between the willingness and ability to pay. He said that despite
all these difficulties we need to focus on this concern as ‘illness’ is an
unacceptable state of mind and body and demands immediate attention.
Dr. Chawla mentioned that it is difficult to define how much allocation
of money is enough to take care of national health financing. Appropriate
financing has to answer four key questions: 1. What are the underlying
principles that govern who pays and when?; 2. What mechanisms exist
or can be created in order to collect, pool, redistribute and purchase health
92
goods and services?; 3. How best can we allocate finite resources for
infinite needs”, and 4. What do we do if the resources generated by the
best of systems are not enough?
Performance based funding, by Dr. Gerard La Forgia, Lead Health
Specialist, The World Bank
Dr. Gerard stated that P4P (pay for performance) is “Transfer of money
or material goods conditional on taking a measurable health related action
or achieving a predetermine performance target.” He further elaborated
on the fact that the payers could be government, health programs,
insurers, communities etc. He specified different ways of paying and the
impact of different ways of paying.
Dr. Gerard shared some global examples e.g. Haiti where providers paid
fixed fee plus bonus for achieving performance targets. In Rwanda, the
case focused on institutional deliveries, with bonus payments being paid
on a ‘fee for service’ basis. In Brazil, the case focused on chronic disease
management, wherein the goals referred to tobacco use reduction. Brazil
also pays for hospital accreditation.
Public Health Spending in Health Care: Benefit Incidence analysis
in states of Tamil Nadu and Orissa, by Dr. Muraleedharan, Professor,
Department of Humanities and Social Science, IIT, Madras
Dr. Muraleedharan started with the question: Do the poor benefit from
public spending on healthcare in India? Sharing that his study focused
on the above question in TN and Orissa, he mentioned that it was found
that in TN, the public spending is benefiting the poor; similarly, in Orissa
public spending is increasingly becoming less pro-rich.
Following these overview presentations, a Panel Discussion was
organized with three speakers sharing experiences related to spending
on health and working with different insurance models – a PPP
initiative as undertaken by the Government of Andhra Pradesh through
the Aarogyasri Health Care Trust; a community health insurance scheme
run by an NGO; and options for health care financing.
u
Mr. Babu. A. IAS, Chief Executive Officer, Aarogyasri Health Care Trust,
Government of Andhra Pradesh shared that since 80% of health
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expenditure is private, health care insurance becomes a critical tool in
providing effective health care to poor. Mr. Babu presented the Rajiv
Aarogyasri scheme, which covers 2.03 crore families. Each family is
insured for upto INR 2.00 lakh annually for cashless treatment, with
the total cost being borne by the government. Under the scheme, the
total amount claimed upto date is INR 1773 crore.
u
Dr. Devadasan, Technical Advisor, Institute of Public Health, Bangalore
shared an example of a community health insurance (CHI) scheme
run by an NGO. There are about 100 CHI schemes in India and they
appear to be effective in meeting people’s needs. In fact there is
statistical evidence that more of the insured families are using hospital
services than otherwise, indicating a positive impact of the scheme.
u
Dr. Shakthivel Selvaraj, Health Economist, PHFI, New Delhi shared
that out of pocket expenses are not a choice; they are infact a forced
option. He stated that household financing of health care is inefficient
because an incident of illness and the payout happens at the same
time. He suggested that due to household financing about 39 million
families are pushed below the poverty line. He also presented options
for financial risk protection i.e. public financing, tax based financing,
social health insurance, and enhanced access to medicines.
94
( )
Audience speaks…
Q: Should government increase health insurance?
Dr. Devadasan: The issue is not about insurance, it is about
providing healthcare without paying at the time of illness. We could
use both tax and insurance for financing.
Q: Can India provide universal health care with its limited resources?
Dr. Mukesh Chawla: Yes, we can. I know it is going to be a tedious
process. The moment we provide insurance, the use of health
services would jump up immediately, the governmental cost will
shoot up before it normalizes, however the key issue is “do we
have the supply side capacity in terms of doctors, nurses, hospitals
etc.?”
Q: What is the role of the government in Latin America in regards
to financing?
Dr. Gerard La Forgia: The government is both provider and
regulator. I think India should focus on reaching the poor and also
the government should reach out to private sector.
Q: Is insurance an answer to India’s problems?
Mr. Babu: Insurance alone would not work, it has to be a mix.
Q. No one talks about the limitations of insurance?
Dr. Gerard La Forgia: There is no perfect insurance system. They
are all work-in-progress systems, constantly improving.
Mr. Babu: I do not understand why insurance is considered nongovernment. The insurance money is going to government
hospitals also. To answer the other question, we need to regulate
the cost side of insurance. Even USA is moving towards that. We
have managed to reduce the cost of certain procedures to almost
50%.
Q. In the pay for performance format what indicators should be used
in India?
Dr. Gerard La Forgia: If you want to reduce infection then you
have to connect your payment to those indicators; if you want to
control chronic diseases then connect the payment with those
indicators. So it depends on what is important for you and what
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you want to measure.
Concluding the session, Dr. Mukesh Chawla mentioned that financing is
what worries us all, we have lots of questions. However, we must
remember that health providers are very smart people; they will figure
a way out while the patient is desperate and ill-equipped, as a result,
someone has to provide the protection.
“I believe whatever works is fine; sooner or later people will
figure it out and will kill the solution and we will have to
create a new way”.
Recommendations from this session
96
☯
The country must ensure a separation between “paying
for health care” and “attending to the health crisis” as it
increases the burden and leads to avoidance of seeking
health care.
☯
We need to find a way of linking payments to the service
providers with the level of performance and quality
delivered.
☯
The government should increase its investment in public
health as studies in Orissa and Tamil Nadu suggest that
the expenditure in public health benefits the poorer
sections of society.
3.7 Governance
Good governance is perhaps the single most important factor in
eradicating poverty and promoting development. Governance is a multi
dimensional concept that is anchored on core issues like finance,
workforce, and service delivery. Governance relates to decisions that
define expectations and grant necessary power to execute those
aspirations.
In short, Governance can be defined as the “Existence of polices/ rules
that are beneficial to the public and being implemented sincerely and
systematically in a transparent manner and the system is accountable
to its action/ inactions.” The government is one important agent in
governance. Stated in other words “governance” is what a “government”
does.
A variety of problems that confront health systems relate to governance.
These include, for example, financial management practices that permit
corruption; unavailable information on planning, operations, and financing,
thereby reducing accountability; lack of capacity of civil society and
elected officials to hold health sector actors accountable; and failures of
MOHs and local governments to engage stakeholders in health decisionmaking and priority setting.8
There is enough evidence that there is a strong causal relationship
between good government/ governance and better development outcomes.
The Government of India is committed to achieving the Millennium
Developmental Goals (MDGs), which are heavily related to outcomes in
the health sector. In addition, the government is responsible for ensuring
that the health system functions well, international resources are used
efficiently and services are delivered to the poor so that the MDGs are
achieved. Since the public sector is the main source of health care for
the poor, its governance plays a decisive role in achieving the MDG goals.
The four building blocks of governance addressed are health policies,
effective and efficient implementation, monitoring & evaluation, feedback
and redressal mechanisms. Within the context of health systems
strengthening, the conference theme on governance crosscuts the other
themes that have been discussed.
8
Health Systems 2020. USAID. http://www.healthsystems2020.org/section/topics/governance
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●
To examine governance issues in Service Delivery
●
To examine governance issues in Health Financing
●
To examine governance issues in Human Resources
The session was chaired by Dr. C.A.K. Yesudian, Professor and Dean,
TISS and Ms. Meena Gupta, Former Health Secretary, Orissa. The
coordinators for the session were Mr. P. Rajendran, Program Manager
(Research), APAC and Mr. Arvind Kumar, Project Management Specialist,
USAID-India.
The different presentations at this session included:
Introductory Remarks on the Theme, presented by Dr. C.A.K.
Yesudian, Dean School of Health Systems Studies, TISS.
Global Perspectives on Health Governance, presented by Dr.
Pamela Rao, Senior Health Systems Strengthening Advisor, USAID.
Role of Information Technology in Health Governance, presented
by Mr. P.W.C. Davidar, IAS Secretary Information Technology, Tamil
Nadu.
Community Based Monitoring of Health Services - Evolving
Model of People Centered Health Systems Governance, presented
by Dr. Abhay Shukla, Coordinator, Saathi-Cehat, India.
The presentations under this theme provided a rich diversity of issues
that need attention within the governance domain and also provided an
integrative perspective on health systems strengthening within this
context.
☯
98
Value based governance: One of the key points of deliberation
in this session centered on the “values” of governance. It was felt
that the governance of health care systems has to be based on
the ‘value of democracy’. There has to be a pro-poor bias in
governance. This focus is infact emerging due to a plethora of data
suggesting that because of corruption and malpractices, a
significant amount of benefits never reach the marginalized people
of a country. For instance, Transparency International claims that
in some countries, upto two-thirds of hospital medicine supplies
are lost to corruption and fraud. To overcome such a situation there
has to be an emphasis on “ethics and values” in the discourse on
health care governance.
☯
Transparency: Another area of discussion is the need for
transparency in health care governance. Lack of transparency leads
not only to the misuse of systems but also the decision-making
powers entrusted with authorities. To be able to ensure effective
health care governance, the processes of human resource
management; and the procurement and financial management
have to be transparent.
☯
Accountability: For effective governance it is important that
decision makers are accountable to people on whose behalf they
are making the decisions. However, at present, the accountability
mechanisms are either non-existent or weak, with the exception
to the access and use of the “Right to Information”, which is a
very important available tool for ensuring accountability within the
system.
Introductory Remarks, by Dr. C.A.K. Yesudian, Dean School of Health
Systems Studies, TISS
Dr. Yesudian talked about the evolution of health care governance. After
independence, the governance was guided by the Bhore Committee
report. However, later, the mistrust model got evolved and the highlight
of this model was the family planning program. The next shift in the
governance framework took place around 1978 under the influence of
Alma Ata declaration. In 1993, with the 73rd and 74th Amendment of the
Indian Constitution, the governance framework moved toward decentralized
planning. Another major shift happened in 2005 under the National Rural
Health Mission (NRHM) wherein the Public-Private Partnership (PPP) model
was encouraged.
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Tracking the growth and changes in health governance in the last 65 years
of the country, Dr Yesudan spoke about the determinants of Governance
– it has to be based on the values of the democratic principle of
participation and the principles of equity. The other key determinants are
transparency of polices, e.g. HR, Financial and Purchasing polices, as well
as transparency to the public and the Right to Information. He also
mentioned that the financing instruments i.e. health insurance, food
tokens etc. and the delivery mechanisms are moving from government
hands into the PPP model, which can have varied impacts on the health
system. Dr Yesudan also elaborated on some other determinants of
governance i.e. regulations of private practice, drug control, technology
assessment and decisions, clinical trials and vaccine trials, and quality
control (including accreditation and health outcomes).
Global Perspectives on Health Governance, by Dr. Pamela Rao,
Senior Health Systems Strengthening Advisor, USAID
Dr. Pamela Rao began her
presentation with a story of
Laxmi Bai, a poor and ailing
woman from eastern India and
through her traced all that is
ailing in the health machinery
(issues related to physical
access to health facilities, limited
health workers, absenteeism,
poor quality, sock out, informal
payment systems etc). The
story presented these health care governance concerns from the
perspective of a poor person. Dr. Rao further went on to define Health
Governance: “Leadership and Governance involves ensuring that strategic
policy frameworks exist and are combined with effective oversight,
coalition-building, the provision of appropriate regulations and incentives
attention to system design and accountability.”
She elaborated on the links of health financing systems with policy objectives,
system functions and overall goals. She spoke about an aspect of governance
which was not sufficiently covered in the conference, i.e. “Health Commodities”.
She said that US$ 4.4 trillion is spent worldwide on health services each year
and this amount is a powerful magnet for corruption. She informed the
100
audience that Transparency International claims that in some countries upto
two-thirds of hospital medicine supplies are lost due to gaps in this area. She
estimated that about 10 – 25% of global spending on public procurement
of medicines is lost to corruption. In this background, Dr Rao suggested that
a value based Health Systems approach will help lay a strong foundation for
informed governance.
( )
Audience speaks…
Q: The distance to the PHC is a key issue that
comes up all the time. Who is going to solve
this and who is responsible.
A: Dr. Yesudian - Government is taking a lot
of steps to solve this problem through
provision of transport etc.
Q: Is there a regulation to ‘regulate’ the role
of international development agencies in policy
making nationally?
A: Dr. Yesudian - There is hardly any role
that a donor plays in influencing policy
making in India.
Q: What is the role of self-help groups in policy
making and governance?
A: Dr. Rao - It is important, and Tamil Nadu
and Andhra Pradesh are cited as providing
sufficient examples of involvement of citizen’s
voices in policy making.
Role of Information Technology in Health Governance, by Mr.
P.W.C. Davidar (I.A.S.) Secretary, Information Technology, Tamil Nadu
“Effective Governance is dependent on Quality of information.
In most states although a lot of health related data is
collected, it rarely gets used due to being buried in manual
registers and files”.
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Dr. Davidar shared that in the absence of an online Health Management
Information System (HMIS), important information related to patient
history is not available on the spot and real time information remains a
dream. He said that in a non-IT enabled environment, Doctors and Nurses
end up spending more time writing records and less time with the patient.
Due to the lack of such information, health institutions and policy makers
also cannot do any kind of effective disease mapping or research.
Explaining the scope of HMIS and the process of developing this system
for Tamil Nadu, Dr. Davidar shared that it is designed on open source
software, is web based and UID compatible. The state government has
infact issued facilitation orders for this to be mainstreamed, e.g.
discontinuing manual registers and ensuring public health reporting only
through HMIS.
(
Audience speaks…
Q: How do you ensure the use of data
generated?
A: We would be putting in place a group to
analyze the data and convert it to useable
information.
Q: How do you plan to use handheld devices
for data capturing?
A: Our principle is to use the technology
based on what we need and not to pick up
the fanciest device available.
)
Community Based Monitoring of Health Services - Evolving a Model
of People Centered Health Systems Governance, by Dr. Abhay Shukla,
Coordinator, Saathii-Cehat, India.
Dr. Shukla talked about the fact that our current form of governance is
minimally representative, people get a voice only once in 5 years, when
the time to elect the new representatives comes and the rest of the time
they are ‘governed’, not heard. He also shared that all powerful actors
– political representatives, officials and public health experts – act ‘on
102
behalf’ of people while people themselves remain marginal and submissive.
However, in order for effective HSS, people must come to the centre of
the health system and ‘claim’ this system as the real owners, and decide
the priorities. He said that people need to be at the center of governance
and they need to demand accountability of the system.
In this background Dr. Shukla mentioned the “Jan Swasthya Abhiyan” a people’s health movement, as a significant learning example. Under this
initiative of community monitoring of health services he informed the
gathering that the emphasis is on Primary Health Care and the Right to
Health, through a comprehensive approach to health systems strengthening
and focus on the social determinants of health. He elaborated on the
structure and the composition of the monitoring committees, the
monitoring process and the monitoring tools (such as the Village health
calendar for instance). In this monitoring process Dr. Shukla mentioned
the critical role being played by the media and added that the process
was being used for planning as well.
Highlighting some of the achievements so far, he talked about the
establishment and capacity development of a coordinated network of civil
society organizations working in 23 blocks across five districts. Asking an
important question, “does all this lead to any change”, he said that there
is change that can be witnessed today - corruption has reduced and there
is improved dialogue between civil society organizations. Dr. Shukla ended
his presentation with summarizing the challenges and limitations of the
Community Based Monitoring (CBM) process, mentioning that CBM alone
cannot tackle systemic issues such as staffing, corruption, etc.
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(
Audience speaks…
Q: The village monitoring tool
complicated and difficult to use.
was
too
A: Initially it was too complicated and later
with the involvement of the community we
simplified it, wherein only simple math is
required, no calculation of percentage etc.
Q. The Government wanted us to organize
public health monitoring but we found it
difficult
A: Community organizating cannot be done
by a government order; it has to be a
movement.
Q: Is there an
management?
example
of
better
fund
A: In jan sunwais (public hearings), the fund
management issues are discussed
threadbare.
)
The overview plenary on Governance was followed by a Panel Discussion
to discuss different aspects such as Planning, Human Resource Policies,
Management, Corruption, Regulations and Monitoring within the health
systems framework of discussion.
The panelists included Dr. Thamma Rao, Advisor Health, Human Resources,
NHSRC; Dr. Sunil Nandraj, NPO - HSD, WHO; Dr. Gerard La Forgia, Lead
Health Specialist, World Bank; Ms. Meena Gupta, Former Health Secretary
of Orissa; and Dr. Abhay Shukla, Coordinator, Saathi- Cehat, India. The
discussion was moderated by Ms. Sheena Chhabra, Chief, Health System
Division, USAID- India.
Ms. Chhabra to Dr. Thamma: What are the key issues that you see in
governing the health workforce and how can we expand the workforce?
Dr. Thamma: One of the key issues in health workforce management
is that we do not estimate what kind of manpower we would need
104
in future, hence we are not able to plan effectively. Most of the time
people do not know what is expected out of them and they learn about
their role only on the job.
Ms. Chhabra to Dr. Thamma: What do you think are the solutions?
Dr. Thamma: State level health plan has to be prepared. Also I would
like to ask why the Factories Act is not applied to the health sector?
Ms. Chhabra to Dr. Sunil Nandraj: What are the some of the measures
that we have in place to govern the private sector?
Dr. Sunil Nandraj: There is no law that stops anyone from starting
a nursing home. Anyone can start it. Similarly there is no standard
in using technology, so I feel that the state has failed in its duty.
Ms. Chhabra to Dr. Sunil Nandraj: Who can play the role?
Dr. Sunil Nandraj: Governments are not playing the role of regulator.
For instance, in Uttar Pradesh the government has handed over the
entire public health system to the private sector.
Ms. Chhabra to Dr. Gerard La Forgia: What we really mean by Governance?
Dr. Gerard La Forgia: Starting his response with a light hearted joke,
Dr Forgia talked about a patient on an operation table who requests
the surgeon and his team that “I would like to be counted as one of
your successes”. Dr Forgia then put a question to the audience– what
if the surgery does not succeed? Who is going to be responsible? This
is exactly what we mean by effective governance, success or failure
is a systems’ issue but governance is the key with four main
components working together: 1. Information; 2. Accountability; 3.
Standards; 4. Incentives. From this, Dr Forgia implied that if the team
in the operation theater has clarity about these 4 parts, the chances
of success would be improved!
Ms. Chhabra to Dr. Gerard La Forgia: How do you improve governance
in case of HR recruitment, promotion etc?
Dr. Gerard La Forgia: You first have to detect what is the issue, is there
work shirking, we need to get that information. Secondly, we should
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apply the principle of pay-for-performance (P4P). When we have a clear
separation between pay and performance things do not get done.
Ms. Chhabra to Dr. Abhay Shukla: How do you look at patient rights in
case of private hospitals?
Dr. Abhay Shukla: We have to create awareness about patient rights
and we have to start this dialogue with the Medical Council of India
as well so that it can take some institutional steps in the direction.
We have done some of this work in Pune.
Ms. Chhabra to Dr. Abhay Shukla: How is this “patient rights issue” applied
in case of single doctor clinics?
Dr. Abhay Shukla: We did that in one district and noticed that 10 out
of 9 doctors did not have a degree to practice.
As this session ended, Dr. Sunil from the audience made an observation
that the Lok Sabha had passed the Clinical Establishment Act the week
before this conference and it would definitely impact on the operations
at the ground level.
106
( )
Audience speaks…
Q: How do we strengthen our monitoring
system to ensure quality of service?
A: Go for HMIS
Q: Would these small clinics in remote areas
service or shut down in the light of the new
Bill on Clinical Establishments passed in May
2010?
A: Health is a state subject and this Bill will
only be used only in Union Territories. The
standards of health care should not be
dropped because of the size and intent of
clinics.
Q: In TN the open positions are less than 5%,
so we need to adopt such best practices in
other parts of the country as well.
A: I must congratulate TN for keeping the
vacancies less than 5%. In Bihar, recruitment
is being done electronically; in Haryana they
can walk into the district head office on a
Thursday and get appointed on the spot. A
lot of states have also started using VAS
based solutions.
Q: What would they like to prioritize among
all the things covered so far?
A: Sir, please remember that India is a huge
country and we would have a mix of
solutions. At the state level, we may be able
to prioritize.
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Ms. Meena Gupta, Former Health Secretary of Orissa made some
important concluding remarks for this session. She pointed out that
certain issues are central for governance at the local level:
1. Availability of health personnel;
2. Giving panchayats (local self-governing institutions) the authority
to give salaries and thus have control over health personnel.
3. Availability and distribution of adequate medicines is a problem
everywhere – there is a problem of quality, supply and access.
Elaborating on these issues,
Ms. Gupta said that there is a
need to look at why PHCs in
remote areas have not worked.
There could be several reasons
for this – the fact that a PHC
has to be set up with a given
population criteria; and the lack
of doctors and basic services
at most PHCs. The possibility
of having less staff creates a
situation of absence.
Experience shows that it’s not easy to enforce that doctors go and work
in remote areas and there aren’t enough incentives in terms of
compensation or social needs. Also, as long as there is a threat of transfers
there would always be a problem of locating medical personnel in required
areas. An option could be to invest in improving communication in remote
areas with doctors who can give people the kind of care they need.
108
☯
Governance in the health service should be value based.
Indicators for good governance should be identified and
used extensively.
☯
The principles of “democracy” should be adopted in the
process of health care governance.
☯
The governance process should be transparent in terms
of appointment of human resources, procurement and
financial management.
☯
There should be community participation in the process
of governance of health service delivery.
☯
Community based monitoring (CBM) of health service
delivery ensures effective delivery of health service and
transparency and reduces the scope of corruption.
☯
Use of Information technology (health management
systems) empowers decision makers with correct and
timely information, hence, should be encouraged by all
states.
☯
The principle of ‘pay for performance’ should be
incorporated as it would not only ensure better access
and use of services but also good governance.
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3 . 8 Positive Synergies between Health Systems and Global
Health and Development Initiatives (GHIs)
Since the international community adopted the Millennium Development
Goals (MDGs) in 2000, total development assistance for health has more
than doubled and many governments of low-income countries have
increased their spending on health. At the same time, the landscape of
public health has been transformed by the emergence of billion-dollar
global health initiatives (GHIs), for the most part focused on specific
priority diseases. In 2007, investments through these GHIs accounted for
23% of external financing for HIV, 57% for tuberculosis, and 60% for
malaria. These investments have resulted in a striking expansion of some
key health interventions, from which millions have benefited9.
However, in many countries the national health system has not managed
to deliver as expected. Along with that the focused approach of GHIs has
placed new demands on national health systems, revealed weaknesses
in those systems, and rekindled debates on how countries can best
combine disease-specific programs with broader agendas to improve the
health of their people10.
There is a felt need to bring in greater synergies between national health
systems and GHIs and invited speakers at this session shared some of
their ideas, experiences and suggestions on the subject.
l
l
Exploring the impact of vertical programs (TB, HIV/AIDS, RCH,
Infection Control) on health systems
Understanding the integration and synergy between vertical
programs and health systems.
The session was chaired by Mr. Chandra Mouli I.A.S., Secretary,
Department of AIDS Control and DG, NACO and Mr. Prasada Rao, Director,
UNAIDS Support Team for Asia and the Pacific, UNAIDS. The session was
coordinated by Dr. Sai Subhasree Raghavan, President, SAATHII and
Dr. Sree T. Sucharitha, Medical Manager, SAATHII.
9
Initial summary conclusions: maximizing positive synergies between health systems and
Global Health Initiatives – WHO
10
Interaction between Global Health Initiatives and health systems: Evidence from countries –
WHO 2009
110
The presentations at this session focused on the following topics
of discussion:
Role of Global Fund funding on Health Systems Strengthening,
presented by Dr. Edward Addai, Director of Monitoring and Evaluation,
Global Fund
Recommendations from the Positive Synergies Initiatives,
presented by Dr. Badara Samb, Coordinator, WHO
Framework for Integration of Chronic Diseases as part of Public
Health Services, presented by Dr. Preet Dhillon, Senior Scientific
Officer, SANCD
The speakers highlighted some important issues that need to be
considered in the path of building synergies of thought and action between
health systems and global health and development initiatives.
☯
GHIs establish a parallel system: The fact that GHIs end up
establishing a parallel system to the national health system is the
result of their focus on linking funding with various performance
indicators. As a consequence, on the one hand, donor supported
vertical programs land up delivering better results; however, they
also end up establishing a parallel system which is not necessarily
a positive practice.
☯
Implementing learning from GHIs: The need to learn from GHI
experiences and mainstream these into national health systems
emerges as an important point of discussion. In fact, a performance
based approach of GHIs is considered to be responsible for effective
implementation of vertical programs, while the budget and
population focused National Health Programs have not delivered as
per expectation.
☯
Strategies of integration: What are the key strategies for
achieving effective integration of GHIs and National Health
Systems? The answer to this question would depend on various
factors. For instance, research by the Global Fund recommends that
it is easier to integrate the Malaria program with the National Health
Program as compared to the HIV Program. Similarly at the
operational level there is a greater possibility of integration at the
grass root level of delivery organizations.
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Summaries of Presentations
Overview: Mr. Chandmouli, IAS, Secretary, Department of AIDS Control
and DG, NACO provided an overview on government and donor
cooperation in India over the years. He said that India has had donorassisted health programs for the last 30 years. Many of the current vertical
programs on AIDS, TB, Immunization, etc are also supported by various
donors. He shared that the passage of time we have developed a model
of working together with donors. However, one of the key issues of
concern is how many vertical programs should we have, because when
a donor exits, the program tends to close down.
Role of Global Fund funding on Health Systems Strengthening,
presented by Dr. Edward Addai, Director of Monitoring and Evaluation,
Global Fund
Dr. Addai spoke about the role of funding from Global Fund on health
systems strengthening. He shared that the Global Fund has been set up
to make rapid, sustainable and a significant contribution in the fight
against HIV/AIDS, TB and Malaria in countries of need, and has, since
2002, committed US$ 19.3 billion for 144 countries on these diseases.
The Global Fund also contributes to poverty reduction as part of the
Millennium Development Goals (MDGs). In India, Global Fund has
contributed USD 1 billion till date and India is one of the key beneficiaries
of the Global Fund.
Dr. Addai talked about an interesting 19 country research study
commissioned by the Global fund to understand the effects of its
investments on national health systems. The key objectives of the study
were to describe how the Global Fund-supported programs interact with
the national health system and national disease control programs;
illustrate the extent of integration of Global Fund-supported programs into
the national health system and disease control programs; identify
synergies/ system-wide effects between the Global Fund portfolio and the
country’s health system.
The research findings suggested that the extent of integration depends
on multiple factors i.e. disease control programs e.g. Malaria is more likely
to be integrated than TB, and least for HIV; Epidemiological situations;
Health systems functions; Country Governance Model of Disease control
112
programs; and Relative financial contribution of the Global fund to the
national program.
Dr Addai also explained the HSS funding framework of the Global Fund,
which would be an important arena of investment going forward.
Recommendations from the Positive Synergies Initiatives, presented
by Dr. Badara Samb, Coordinator, WHO
Dr. Badara Samb, talked about the challenges to scale-up services for
HIV, TB, Malaria and Immunization. Focusing on the WHO definition of
health systems, he mentioned that we should not look at the five blocks
in isolation; in fact it is important to look at the interaction of these blocks.
He raised a key question for the audience to think about - should we
move from disease specific spending to health system focused spending?
He also drew attention to the relationship of monitory investment with
health results, wherein he noted that there is a positive correlation
between a country’s health expenditure and its life expectancy.
Another interesting point raised by Dr Samb was that, when the money
starts coming from external donors, local governments start to reduce
their own investment in health, which may not be a healthy trend literally
and figuratively speaking.
Dr. Samb presented five recommendations based on his research findings
– Infuse HSS agenda with ambition and speed; Extend GHI targets and
agree on indicators; Improve alignment of planning process; Generate
more evidence; and Ensure a sustained rise in national and global health
financing.
(
)
Audience speaks…
Q: Is there a consensus on health system
indicators?
A: There is a lot of work going on this area.
Currently there are about 250 indicators,
and WHO is working on it. However there is
no consensus today.
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Framework for Integration of Chronic Diseases as part of Public
Health Services, presented by Dr. Preet Dhillon, Senior Scientific Officer,
SANCD.
Dr. Preet Dhillon shared data
on the changing patterns of
mortality
in
developing
countries. She mentioned that
the World Health Organization
and the World Bank have
emphasized that, chronic
diseases in low and middle
income countries need to be
taken seriously. Her projection
suggested that by the year
2030, deaths due to cardiovascular disease in India would reach 36%
compared to 29% in the year 2005. She said that in India these diseases
set in at a younger age and impact the working population unlike on the
retiring population in western countries. She added that in the context
of the growing disease burden, integrating chronic diseases into health
systems is a rational response.
Further, speaking on integration, Ms Dhillon pointed out that this can be
done at the functional, organizational, professional and clinical level. In
fact, effective surveillance needs integration. She specified three models
from the US experience which can be utilized for chronic disease
management: Kaiser Model; Ever Care model; and Chronic care model.
She concluded that the chronic diseases prevalent in India are preventable
and public health workers like ASHAs can also be of help in this area.
(
114
Audience speaks…
Q: Do you feel mass implementation of yogic
practices would reduce the exposure to life
style concerns?
A: We need to conduct more research on the
benefits of these practices, but we must
expose kids to healthy behavior.
)
Taking forward the issues spelt out by the speakers of the Positive
Synergies plenary session, the program turned interactive with the Panel
Discussion on Translating Recommendations of the Positive
Synergies Group into Action, with speakers including, Dr. Sundaraman,
Executive Director, NHSRC; Dr. Vikram Rajan, Health Specialist, SASHD
The World Bank, India; Ms Pamela Rao, Senior Health System
Strengthening Advisor, USAID, USA. The panel was moderated by Dr.
Sai Subhasree Raghavan, President, SAATHII.
Dr. Sai Subhasree Raghavan to Dr. Sundaraman: How are you going to
use all the different players providing money?
Dr. Sundaraman: The investment in Health is definitely increasing, and
there have been some changes over the years. In the 80s, UN agencies
were playing the big role; in the 90s the World Bank started playing
that role; and since 2001, global funds have started playing this role.
What is important is that we look at the politics of this shift, while
accepting the kind of funding that’s coming in. One way of integrating
could be to create a global fund on health systems strengthening.
However, one must keep in mind that it is not that easy to integrate
we know that from experience. For example, when you introduce a
vertical program it draws away the human resources and weakens the
health service delivery. In a country like Africa where 40% of financing
is from global funds this logic may work but in a country like India
where investments by global funds is less than 2% of public spending
it does not make sense.
“Some coordinated fund would help however much more focus
on systems strengthening would be needed, so that there is
coordination at the level of planning, monitoring and moving
forward”.
Adding to Dr. Sundaram’s response, Dr. Edward Addai shared that the
issue of financing is being approached incrementally. Everyone wants to
join hands and create an integrated fund to create better results and a
lot of people are talking about a Global Fund for Health.
Dr. Sai Subhasree Raghavan to Dr. Vikram Rajan: How are you going
to integrate your efforts with a National program?
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Dr. Vikram Rajan: The challenge is to see how these two programs
converge, where on one hand, we have verticalized programs, on the
other hand is the generic program. Health in India is a state subject,
and the health systems have to be driven by the states. There are
pilot projects going on where health workers are performing some
roles such as in preventing chronic diseases and based on our
experience we would be able to promote similar efforts.
(
Audience speaks…
Q: With so many contractual staff being hired across the country,
when NRHM funding stops how would continuity be established?
A: There are many ways to reach sustainability; one way could
be change in the ratio of financing between state and the centre.
Q: When a system is already vulnerable, is it able to make choices?
A: To move on pay for performance, we need to develop the
organizational capacity.
)
Mr. Prasada Rao, Director, UNAIDS Support Team for Asia and the Pacific
in his closing thanked the panelists for their insightful presentations and
responses to the audience questions.
116
☯
Government run national health care programs should
learn from the GHIs’ target and performance based
approach.
☯
At the grass-root level there should be greater amount
of integration between GHIs and national program staff.
☯
Public health staff should be made responsible for
building awareness and encouraging behavior change to
control the spread of chronic diseases.
☯
A global health fund should be set up to promote
integrated approach on health service delivery.
3.9 Health Systems R
esearch
Research
This last session of the conference brought into perspective a very
important area of attention for medical practitioners and policy makers,
as research forms the foundation of both normative and empirical data
necessary for health systems strengthening to be realized.
The session was chaired by Dr. Vishwa Mohan Katoch, Secretary to
Government of India & Director-General, ICMR and. Session
Coordinators: Ms. Sheena Chhabra, Chief, Health Systems Division,
PHN, USAID and Dr. Sree T. Sucharitha, Medical Manager, SAATHII
The presentations under this
theme included the following
and looked at the importance
of research not only as a data
providing exercise but a process
that would build on health
systems experiences through
the input and output of
knowledge.
Health Systems Research:
An overview of Methods
and Approaches, by Dr Kara Hanson, Department of Global Health
and Development, London School of Hygiene and Tropical Medicine.
Priorities in Health Systems Research, by Dr. Tej Paul Ahluwalia,
M.Sc., DCA, PGDIJ, PGDIM, Ph.D., D.Sc. (Honoris causa) Dy. Director
General (Sr. Grade) / Scientist-F & Chief, Division of HSR, ICMR, New
Delhi
Data for Decision Making, by Dr. Ujwal Raj on behalf of Dr. S.
Venkatesh, Deputy Director General, NACO
Health Systems Research – some Thoughts, by Dr. Arti Ahuja,
I.A.S., Commissioner and Secretary, Govt. of Orissa; MPP (health
policy), MPH
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Dr Kara Hanson Health Systems Research: An overview of Methods
and Approaches, talked about the purpose, definition, scope,
methodology and challenges of production of new knowledge to improve
how societies organise themselves to achieve health goals. She explained
that the scope of health systems research is at different levels: the Micro
level focusing on the Individual patient and practitioner; at the meso level
focusing on Organisations; and at the Macro level focusing on Health
systems. She provided an elaborate explanation on the methodology and
steps of ‘Systematic Literature Review’, as being extremely important for
building one’s knowledge base.
The presentation concluded with a summary stating that health systems
research aims to generate evidence for policymakers and programme
managers; is multidisciplinary, with standards of rigour drawn from
particular disciplines; focuses on systems thinking – complex interventions
with unanticipated consequences; and includes research ON policy as well
as FOR policy.
Dr. Tej Paul Ahluwalia elaborated on the Priorities in Health Systems
Research and explored a gamut of issues that are central to organizing,
conducting and analyzing outcomes of health systems research. It began
with a definition of health systems as follows: “The health system, includes
all public and private sectors/ institutions which directly influence and
support the health of people, embedded in the wider environmental
context that was described in different shapes in different societies, but
everywhere individuals form part of a network of family and community
members who are concerned about their health. This network prescribes
or advises how to prevent illness and what to do in case of ill health.
In many societies, mothers and grand mothers are key figures in early
childcare. They determine nutritional and hygiene practices, alert children
to dangers, provide care in case of disease, and teach children the basics
of self-care.”
Further, the presentation highlighted the gains of health systems research
in India particularly in the Development of diagnostics; New Drug
Development (Centchroman, Arteether); Preparation of a Genetic Atlas
of Indian Tribes; etc. Dr. Ahluwalia articulated the challenges in health
systems research in India. For example, how can health research
contribute to reducing the inequities in health between various segments
118
of the Indian people? How are the priorities to be determined, at what
level (national, state, district), and how often?
Dr. Ujwal Raj focused on Data for Decision Making and epidemiological
profiling of the HIV/AIDS situation at the district and sub-district level
using data triangulation (DT). Dr. Ujwal defined “Data Triangulation” as
an analytical approach that synthesizes data from multiple sources, to
improve the understanding of a public health issue and guides
programmatic decision-making to address the issue.
By putting different bits of information from different sources into a
meaningful framework, it explains and improves the understanding of the
HIV/AIDS scenario in the district. By providing answers to vital program
questions, DT helps in taking effective decisions for planning and
implementation of HIV prevention & control efforts. Some of the important
examples of data use in the National AIDS Control Program (NACP) are
District Categorization for Priority Attention; Development of Annual
Action Plans (District Plans à State Plans à National Plan); Development
of new program strategies (Migrant Strategy, Mid-media IEC strategy,
Strategy of Link ART Centers etc.); Strategic Information Management
System - a new web-based integrated data management system to assist
in decision-making.
Some of the important outcomes of this effort, Dr Venkatesh pointed out
included, training of approximately 500 district level officers in data
cleaning, analysis and use of data for programmatic decision-making;
Systematic compilation of all the data related to HIV for each district at
one place for future use; Enhanced understanding among the program
managers of the HIV epidemic in the state and different districts; thorough
Quality Checks, Cleaning up & validation of Program data since 2004;
better use of data in developing District & State Annual Action Plans;
development of Framework for Reprioritization of districts under the
program; prioritization extended up to the Taluka/ Block level with high
priority talukas identified; and Identification of Information Gaps at the
district and state level for planning Strategic Information Activities.
Dr. Arti Ahuja made a presentation titled, Health Systems Research –
some Thoughts. Basing her presentation on a thorough knowledge of
policy level needs, experiences on the ground as an I.A.S. official of India,
ICONHSS
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as well as her own public health expertise, Dr. Ahuja’s presentation
focused on three key points in health systems research:
v
Context of research;
v
Incentives for research and,
v
Areas of research.
Looking at the context issue, she raised questions about the overall health
system of the country, mentioning the gap between knowledge and
implementation and the overall governance of the health system.
Talking about incentives for research she noted that while researchers are
interested in publications and providing policy inputs based on their
research, the policy maker’s focus is on effective service delivery in terms
of implementation and policy design. Coming to health systems research,
the focus areas could include Health equity; Distribution of health care
vs. fairness of process; SES gradient; Personal and social responsibility;
Incentives; International reforms; and Impact assessments.
She expressed hope that this conference would provide the starting point
for some meaningful research interventions that would help enhance
health systems and the health status of the country in the long run.
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☯
Health systems research both at micro and macro level
should be encouraged to generate information for policy
making.
☯
There is a need to set up a specialist unit to collect data,
analyze and report it to appropriate decision making
bodies.
☯
There is greater need of greater engagement between
research bodies and policy makers.
CHAPTER 4
O
On the Sidelines
The ICONHSS was a mixed format conference that gave participants an
opportunity to engage with several local organizations, learn from the best
practices under the TNHSP, network with people from across the country
and the world and get a direct glimpse of some of the workable strategies
for health systems strengthening.
One such learning came from the poster displays and presentations that
went set up in the conference corridor spaces; another through the
exhibits and stalls of organizations and projects implemented in Tamil
Nadu; and a third came from the field visits to four TNHSP sites in
Chennai. In addition, the cultural and social gatherings at the conference
venue between meals and snacks were opportunities for social and
professional networking.
4 . 1 Poster Display
In a day and age when visual and
creative communication speaks
more than a thousand words,
the poster displays at the
conference were a treat to see,
think about and take back as
ideas for sharing and replication.
Apart from informal corridor
discussions on the posters, there
was also time within the conference agenda for the presenters to share their
poster concept and content with participants, speakers and the judges (Dr.
Ahluwalia, ICMR and Dr. Bimal Charles, APAC-VHS) who identified winning
entries from among the posters.
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Poster Discussion:
Out of 20 Poster Displays, 16 were exhibited and following a poster discussion, three were
selected based on the scoring given for Evidence, Format and Oral. The list is as follows:
S.
No.
Title of the abstract
Name of the Author Institution
1
Insured yet vulnerable: Impoverish- Renu
ment due to out-of-pocket payments
for India’s Poor
2
Prevalence of Post-Traumatic Stress
Disorder (PTSD) among ambulance
personnel in Ahemdabad operations
of GVK-EMRI
Vibha
3
Innovative strategies to improve
tribal health in Tamil Nadu Experience sharing
K.
Shahrawat
Pandey
Gunasekaran
National Institute of
Health and Family
Welfare
GVK Emergency
Management and
Research Institute,
Secunderabad, India
Tamil Nadu Health
Systems Project,
Chennai, India
Poster Presentation:
Out of 92 Poster Presentations, five best Poster presentations were selected based on the
scoring given for Evidence and Format. The list is as follows:
S.
No.
Title of the abstract
Name of the
Author
Institution
1
Gynecological workforce initiative to
strengthen prevention of mother to
child transmission services – Private
medical college experience from
Andhra Pradesh
Srinivasa Varma
Kokkiligadda
2
Visual Methods: Promising Screening
Tools for Cervical Cancer in Low
Resource Setting
Bharathi Balaiah
Tamil Nadu Health
Systems Project,
Chennai
3
Public Private Partnership: an
innovative approach for
implementation of Janani Sahyogi
Yojana in Bhopal district
Neelam A. Toppo
NSCB Medical
College, Jabalpur,
Madhya Pradesh
4
Health system evaluation of trauma
care services in terms of resources
and geographical access in a rural
district in Kerala
Mohammed Asheel
5
Improving ANC and Institutional
deliveries: Experiences of Public
Private Partnership in National
capital region of Delhi
K.S. Nair
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National Institute of
Health and Family
Welfare, Delhi
4 . 2 Display Stalls and Exhibits
The conference space was
organized in a way that
participants got to pick up
materials and interact with
staff of TNHSP and some of the
local partners working on health
systems strengthening and
related issues. The display
stalls had print and visual
resources as well as some
demonstration through videos and people to people interaction.
The organizations who put the stalls included the following, details of
which can be tapped on their respective websites:
1. TN Health Systems Project (TNHSP) - www.tnhsp.org
2. TN State Aids Control Society (TANSACS) - www.tansacs.in
3. Aids Prevention & Control Project - www.apacvhs.org
4. Voluntary Health Services - www.vhs-chennai.org
5. NRHM State Health Society - http://mohfw.nic.in/NRHM/
State%20Files/tamilnadu.htm
6. Emergency Management & Research Institute - www.emri.in
7. Positive Women’s Network (PWN) - www.pwnplus.org
8. Star Health & Allied Insurance - www.starhealth.in
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4 . 3 Field V
isits
Visits
A group of 50 participants from Tamil Nadu, Orissa, Kolkata, Delhi, Kerala,
Gujarat, Malaysia, and Denmark spent a day of field visits to four selected
sites under the TNHSP to understand the practical operations of the health
systems process. This section provides a glimpse of the visits and the
key learning that participants gained from their interactions on site.
Upgraded Primary Health Care Center, Medavakam, Chennai
A unique example of Public-Private Partnership, the visit to this 24 hour
PHC (with routine OPD from 9 to 4 pm) was well received by the
participants who engaged in intensive discussions with staff and patients
at the centre.
Dr. Vanaja heading the PHC provided
a historical background and data
related to the establishment,
infrastructure set up, staffing,
functioning and financing of this PHC
which has gained tremendously by the
coming together of different partners.
The role of the NGO, Catalyst Trust;
the leadership of the local panchayat;
financing by different partners along visits by doctors from selected
private hospitals and committed support by the Tamil Nadu government
came across as significant pillars of strength. The PHC has also received
the FICCI award in health reforms and is considered one of the best such
facilities in the country as of date.
In terms of medical staff, while there are five MBBS doctors at the PHC,
it has a gynecologist, anesthetist and surgeon on call, who are paid for
their visits. Since the start of this new facility two years ago, the patient
strength has gone up from an average of 220 patients to 450 patients
coming in regularly. Infact, along with out-patients, the numbers of inpatients have also gone up and it also has a mix of people across class
coming into the PHC – agricultural labor, industrial workers, even
government staff and private citizens.
The ICONHSS participants at
infrastructure and cleanliness
concerned about its outreach
population than it should and
124
this field visit reflected that while the
of the facility is very good, they were
as it seems to be catering to a larger
seemed more like a Community Health
Center (CHC). The lack of a preventive care system and sole focus on
primary care was also a matter of concern for the visitors. Officials at
the PHC shared that there are plans to trifurcate the PHC outreach by
creating more sub-centers and the process is in motion but could take
time in the government’s line of operations. They pointed out that this
is the growth phase of the PHC, which is located in a new suburban area
with a growing population and it would bring in preventive care staff based
on the needs established.
“The PHC looks like a private clinic, but its sustainability is due
to the continuity of Catalyst Trust and the amazing support of
the panchayat leaders. In the long run however it would be good
to have a backup plan to achieve that community participation
and mobilization is the key as this would create ownership of the
PHC by the people.”
Dr Prakash
An important learning for the participants was that this PHC came across
as an effective PPP model! Many participants were very impressed by the
PHC and what the private players and voluntary organizations’ entry could
bring into an existing government facility.
Key Learning from the PHC visit
☯
PPP has created a fully functioning PHC which is able to
provide quality service to the community.
☯
More PHCs should be managed in the PPP framework.
☯
There is a need to reach out to the community to increase
the use of various facilities available at the PHC.Tambaram
Hospital, Chennai
The visit to this hospital provided the participants with a firsthand view
of the infrastructure and maintenance of a typical government hospital
which is making attempts at being systematized and upgraded in line with
an accreditation process by NABH. The hospital currently services a large
number of patients in comparison to the other medical college hospitals
due to its central location in Chennai city. It is one of the few hospitals
which is being managed through an organized information system – HMIS
and this makes it an important part of the TNHSP.
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Many of the conference
participants felt that though
this is a secondary level hospital
it is doing a lot of the medical
college hospitals work as the
load is very high here.
They also reflected on the fact
that this hospital is going
through the accreditation
process will help in organizing
its health management systems, in terms of motivating the people who
work here to improve the very systems, and this also would a bargaining
tool for finance from the government… it’s a dynamic process in that
sense. But its yet a long way for this hospital to be following even basic
norms, its like any other government hospital anywhere… lacking
segregated dustbins, having broken windows, dirty infrastructure and
facilities, lack of necessary medical equipment, staff not following basic
dress codes nor patient handling norms and shortage of support staff.
The only visible change seems be that the OPD chit is computerized!
“A bad hospital has become a good hospital…”, “Working
wise it’s the same as a block level hospital and so also in
terms of maintenance and cleanliness. One of the steps they
can take at the hospital is to have a token charge which
can be used to build a hospital corpus. But once the public
tastes something good like we saw at the PHC then going
back won’t work.”
Dr Prakash
Key Learning from the Hospital visit
126
☯
The process of “accreditation a hospital” channelizes the
energies of the staff and motivates them to give their
best.
☯
Use of HMIS helps in organizing the service delivery in
terms of timely procurement of medicines and effective
interaction with out patients.
Emergency Management Rescue Centre (EMRC), Triplicane, Chennai
“Your right to safety”…Call 108 emergency! With a focus on Sense, Reach
and Care, this 24x7 ambulance service is organized and run through a
professionally managed call center cum emergency care unit.
EMRC has a fleet of 385 ambulances (with a pilot as driver and an
emergency technician), servicing 32 districts in Tamil Nadu. A minimum
of 8 ambulances service one district depending on the population and
geography, some places may have more ambulances on call. Part of the
fleet of ambulance’s are equipped with advanced life support infrastructure
and others with basic life support systems.
The call center runs with a staff strength of 110, rotated in 9 hour shifts
and trained for 45 days initially, with a refresher 6 months later. The center
works with GIS but is already testing the GPS so that it can help track
the physical locations better. At peak time, the center has 100 calls on
waiting but 99.9% calls are picked up on the first ring.
From the call center staff that picks up an emergency call to the
communication officers who take in basic information from the caller at
a medical emergency site (SENSE), and transfer it to the dispatch officers
who instruct the ambulance closest to the emergency site to move
(REACH), the whole process takes 90 seconds of action. The data is
further transferred for perusal by the emergency aid physician’s team
(CARE) and the police representatives (for medico legal cases) at the
center.
As per need, the paramedic on duty in the ambulance is advised by the
doctors team on the care to be given while transporting the injured to
the nearest treating facility, usually
this being a government hospital
and the police is sent to the
location for necessary follow up.
In situations where the ambulance
takes an injured person to a
private facility, the first 24 hours
of hospital stabilization costs is
covered by the government, after
which the patient can be moved
on their request or decision.
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Running since the past two
years, the call center receives
almost 30000 calls per day of
which 3000 are usually
emergency calls and the
remaining could be a mix of
test and enquiry calls by people
to this number provides a
functional service; crank calls
and also calls for fun sake by
many people who call 108 for
an ambulance to a particular place, then on reaching are told of another
location, etc. The conference participants at the field visit were informed
that 9% calls are un-availed dispatches, as by the time the ambulance
reaches a site, either the traffic police, or people on the road or the injured
may move towards a hospital on their own or in an autorickshaw.
The center has tracked that, at a minimum it had taken 3 minutes for
an ambulance to reach a call site and an average 21 minutes for reaching
the point of an accident or injury. The journey to the hospital usually
varies depending on traffic and location of the nearest treating facility.
The EMRC team shared about an interesting and sensitive aspect of this
service, which involves follow-up. At the time of hospital admission, EMRC
fills a patient form which is brought back to the center for the doctor’s
team to designate as critical and non-critical. Critical patients are followed
up after 48 hours to check their status and these are counted as ‘life
saved by 108’, if alive.
Reflecting on the coordination issues of the service, one of the key
problems faced by the service is the traffic on the road and the fact that
the traffic police often don’t wait for the ambulance to arrive on the site
and send the injured off on their own.
Future plans vis-à-vis expansion of the ambulance fleet, computerized
linkages between the ambulance and the doctors’ team, GPS installation and
enhanced coordination between different service-providers were shared with
the visitors. The participants were informed how this entire project is funded
by the Government of Tamil Nadu under TNHSP and is a successful model of
a privately managed health system with government funding and one among
such services across 11 states of India.
128
The participants at the field visit were very impressed by this endeavor
of the TNHSP, as they talked to the call center staff, the GVK management
team and the doctors.
One of the members of the documentation team gave a suggestion that
EMRC must create greater awareness among the public about ‘giving way
to the ambulance on the road’ and this can be done by involving auto
rickshaws, driving school services, the audio-visual media as this is an
area of consciousness and awareness that’s lacking for those who drive
on the road and often causes delays in the ambulance reaching an injured
person or the hospital as the case maybe.
Key Learning from the EMRC visit
☯
This is another example of PPP, and shows how the
participation of private players improves the quality of
service provided.
☯
The staff motivation is driven by “how many lives we have
saved”. This same kind of feeling and accountability needs
to be created among other service providers and
hospitals.
☯
Information systems management is a key to the success
of such a service.
Tamil Nadu Medical Services Corporation (TNMSC) Warehouse,
Annanagar, Chennai
One of the largest government warehouse of medicine in Tamil Nadu, and
one among 25 warehouse in the state, this facility supplies medicines to
17 institutions in the state, including all Medical Colleges and big hospitals.
The officials at TNMSC warehouse shared that they stock medicines worth
INR 3-4 crores at a time, have a cold storage and a TANSACS storage
unit along with the rest of the medicines and a generator facility. The
warehouse is physically planned to keep away rats and moisture to prevent
damage to the medicine stock.
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The participants of the field visit were very happy with the organized
nature of this warehouse and even looked at records of in and outgoing
medicines, the cold storage unit of the warehouse and were informed of
the upcoming computerization of medicine stock and bar coding which
is part of the warehouse information systems management under TNHSP.
The TNMS model presented during the conference session reflected itself
in practical terms during this visit as an inspiration for the whole country.
Key Learning from the W
arehouse visit
Warehouse
130
☯
The use of modern technology in storage, record keeping
and dispatch is enhancing the overall management of the
warehouse.
☯
The use of IT has enabled the warehouse to undertake
efficient and timely procurement.
CHAPTER 5
V
Valedictory Function
T
he International Conference on Health Systems Strengthening
concluded with a formal Valedictory function which was presided over
by Thiru K.S. Sripathy, I.A.S., Chief Secretary to Government of
Tamil Nadu and other invited dignitaries from the Government of India
and Government of Tamil Nadu.
Mr. Simpson Cornelius, PHMI and representing the conference
secretariat conducted this session inviting and thanked the dignitaries
and delegates for their participation in making this conference a great
success.
Dr. Bimal Charles, Co-Chairman, Organizing Committee ICONHSS,
welcomed the dignitaries to the concluding function and thanked them
for their presence. He shared that this conference had been a very
interactive one and at par
with any international
conference.
The function began with a
rappoeteurs’ presentation by
Dr Sai Subbhashree,
President, SAATHII on the
issues, discussions and
recommendations that made
the conference complete.
Dr. V.M. Katoch, Secretary, Department of Health Research &
Director General, ICMR, New Delhi, Government of India applauded
the state government of Tamil Nadu for organizing the ICONHSS and said
that it was the best state in the country to take such an initiative. It
has in fact shown the way in its commitment to achieve the MDGs and
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the target to improve health goals of the country. He added that while
some of the Indian states have achieved a lot in the health sector, there
are some states where we are at the worst level globally. This is despite
the fact that the system is the same. So what was going wrong? Dr
Katoch suggested that long term planning comes with the vision of the
future and it is in this context that HSS becomes important.
The valedictory address was delivered by Thiru K. Chandra Mouli, I.A.S,
Director General, National AIDS Control Organization, Government
of India, New Delhi, who said that, in the last couple of years, the
country has achieved a lot in the area of Health. However there are many
states who have not achieved “Health for All” goals by 2000. The states
that have done well have done so because of their hard work, he added.
Further, Mr. Chandra Mouli said that, “In the course of the conference
I am sure you would have discussed about various indicators of health
across state. The challenge lies in getting everything done. The Chennai
declaration read out today is topical however it needs to be put in
practice. I congratulate the organizers to have so successfully brought
all the experts from across the world and have such a great conference”.
This was followed by the presidential address from Thiru K.S. Sripathy,
I.A.S., Chief Secretary to Government of Tamil Nadu, who shared
that Chennai is becoming a health capital of India today. He said that
we are a complacent kind of people, hence a word of caution. We need
to do a lot. In the Chennai
declaration
we
have
mentioned that 3% of the
GDP should be allocated.
“I have nothing against
this expectation; however
I would like to highlight
another aspect, what is
the quality of air and
water today? We first
pollute and then want to
fix it. It is always an expensive proposition. What about
prevention? What has happened to cleanliness and basic hygiene
and nutrition”?
132
The Chief Secretary urged the organizers and delegates at the conference
to add into the declaration the points regarding the need to keep the
environment clean, maintaining the basic hygiene, and maybe with that
change even a 1% allocation may be enough. In Tamil Nadu he added
that if you visit some of the hospitals now; you would notice that due
to a high focus on cleanliness and patient care, the overall quality has
improved manifold.
“If we have an open attitude towards alternative systems of medication
and encourage these, it would also be a significant step.” With these
words the Chief Secretary once again congratulated the organizers of the
ICONHSS for this effort.
Dr. S. Vijayakumar, I.A.S., Chairman, Organizing Committee,
ICONHSS gave the vote of thanks marking the formal closure of the
conference. He said that it has been a learning experience to organize
this conference. He acknowledged the contribution of the political
representatives of the central and state government, the senior
government officials, all the partner organizations, organizing committee
members, hospitality and venue personnel, the media and above all, the
speakers and participants at this conference.
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CHAPTER 6
V
Recommendations and
Ways forward
T
he International Conference on Health Systems Strengthening has laid
the basis for a new way of thinking and managing health systems
by its unique structuring, showcasing best practices from the state of
Tamil Nadu and other parts of the country, creating a synergy between
different stakeholders within and outside the government from the local
to the international level, and above all, making a public commitment to
take things forward in the form of the Chennai Declaration.
The Chennai Declaration has emerged as a consensus document of the
conference participants including members of the government, civil society,
private sector representatives, donors, academicians, student community
as well as other interested stakeholders and is a unique outcome of a
conference held at a state level in India. This declaration is the framework
for the way forward, and one that the organizers and signatories to it
have pledged to implement, review and strengthen beyond the conference,
not just in Tamil Nadu but across the boundaries of the state.
The declaration was duly signed by all concerned and submitted to the
Chief Secretary to the Government of Tamil Nadu during the valedictory
of the conference.
134
Chennai Declaration
The International Conference on Health System Strengthening, meeting
of various stakeholders in Chennai, Tamil Nadu, on the 7th of May, 2010,
reiterates the need for improving health systems at national and state
levels, hereby makes the following declaration:
I. The conference affirms that India has made progress in increasing
access to health care to her citizens. It has improved the public
sector health care infrastructure and provided services through
frontline volunteers and workers, including Accredited Social Health
Activists (AHAs) and Auxiliary Nurse Midwives (ANMs). There has
been increase in budget allocation for health. National and state
governments have begun to address out of pocket expenditure
and to protect people from impoverishment due to illness.
Initiatives have been made in delivering health care by involving
private sector/ civil society through public-private partnerships.
II. It observes that the country is facing double burden of noncommunicable and communicable diseases along with perinatal
morbidity and mortality in many parts of the country. The current
public health care expenditure and utilization is not uniform across
the country. The distribution of human resource for health is
uneven across the country and skewed towards urban area. Health
outcome indicators also vary within the country reflecting
differential input and access to health care.
III. It reaffirms the need for concrete, effective and timely action to
strengthen the health care system in the country. It needs to affirm
the values and principles of health care, which include equity,
solidarity, social justice, universal access to services, multi-sectoral
action, community participation and improved governance as the
basis for strengthening health systems and urge to;
a. Give priority to increase the public health care expenditure
to a minimum of 3% of the national GDP.
ICONHSS
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135
b. Enhance budget utilization capacity through strengthening
governance, increasing accountability and transparency in
the system and modernizing health directorate function.
c. Review and reform human resource policies and procedures
for effective investment in human capital including,
recruitment, retention, incentives, continuing education /
capacity building and performance enhancement.
d. Partnerships with private sector to leverage investment of
resources, service delivery capacity and technological
strength for contributing to public health goals.
e. Strengthen and enforce laws and regulations for ethical and
high quality health care in public and private health care
settings.
f.
Enhanced role for health system information and research
for evidence based decision making in the health sector and
ensuring data availability, use and dissemination.
g. Focusing on vulnerable populations and bridging gender and
equity gaps.
IV. We believe that the above recommendations would be the starting
point to embark on the process of health systems strengthening,
resulting into better health outcomes for the country. These
recommendations will be followed by establishing a cross-sectoral
national working group to define the agenda for health system
strengthening, support facilitatory process and policies, monitor
implementation and report progress to the highest level of health
planners, policy makers and political leaders.
136
R ecommendations
With the Chennai Declaration as a commitment and framework for the
way forward, this final section of the report collates and presents the
key issues and suggestions that emerged from the presentations made
at the ICONHSS.
First, the areas of consensus that have emerged as important
outcomes:
☯
Health financing is a priority for meeting the goal of Health for
All. This includes the need to increase the health budget; improve
effectiveness and efficiency of public health expenditure; and reduce
out of pocket expenditure leading to neo-poverty.
☯
Health systems strengthening should be done holistically. It should
be coordinated, well-financed and result oriented.
☯
Program managers and policy makers have to prioritize health
system strengthening parallel to their program implementation.
☯
Prevention and management of chronic diseases should become
part of public health.
☯
Bring in speed and additional resources for health system
strengthening.
☯
Build evidence to inform policy making and improve health systems’
performance.
The conference accepted the WHO definition of health systems, as the
basic framework for action, consisting of six operational blocks i.e. service
delivery; health workforce; information; medical products and technology;
financing; leadership and governance. The World Bank’s definition of
health systems, incorporating the four functionalities i.e. resource
management; service provision; health financing; and stewardship has
also been accepted as a guide for working on these issues.
The participants at the conference agreed to focus on “Health Systems
for Results”. There was a general agreement that it is important to have
strong health systems to be able to ensure equitable access of effective
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health interventions and a continuum of care to save and improve people’s
lives.
Elaborating on the present status of health many of the speakers
pointed out that the recent state of health statistics is not in keeping
with the economic growth that India has witnessed. The data on the health
performance of the country is dismal – for example, 58% of pregnant
women and 79% of children are anemic; 46% children are underweight
and only 44% children are protected against the six vaccine-preventable
killer diseases. There is a huge disparity in the state of health in various
parts of the country; some regions are performing fairly well, while other
regions are performing at a much lower level. These facts and figures
reaffirm the need for health systems strengthening even further.
Drawing from the conference inputs, certain key strategies can be
suggested to achieve health sector goals and filling the existing gaps:
☯
Organize health care: The Government of India needs to play a
critical leadership role in addressing and regulating the health sector
(including the private sector) and health systems. There is a need to
develop an all-encompassing health legislation that can form the
framework for governing health care in this country.
☯
Increase National Health Budget: The government should consider
an increase in the national health budget from the current 0.9% to
2-3% by the year 2012. The states should also increase their health
budgets simultaneously.
☯
Improve effectiveness and efficiency of health expenditure:
There is an urgent need to increase the full utilization of funding within
the public health sector and this could be done through various tested
methods and best practices in the field, such as:
138
❖
Evaluating the feasibility of performance based funding and
adopting the same.
❖
Using innovative ways of public-private partnerships for enhancing
coverage and increasing utilization.
❖
Financing for clean drinking water, sanitation facilities and related
activities through the public health budget.
☯
☯
☯
Reduce out of pocket expenditure and the causal poverty
❖
Review the various options available to tackle the situation of 78%
out of pocket health expenditure, e.g. models of mass insurance
and other tools available and adopting the suitable one.
❖
Create accountability within the private sector for providing free
health care to the poor in exchange for receiving subsidies.
❖
Apply a 2% additional tax on health degrading products.
Service Delivery: Different models of service delivery should be
adopted by different states based on their local needs. For example,
Tamil Nadu should focus on geriatric care and NCDs while tackling
maternal mortality, whereas states like Jharkhand should focus on
maternal mortality. Specifically, the recommendations on this theme
would include:
❖
Ensuring good quality service delivery is dependent upon setting
targets, standards and protocols and establishing the mechanisms
and indicators for tracking the change.
❖
Improving the quality
accreditation services.
❖
Increasing access to quality specialized health care through PublicPrivate partnership based insurance.
❖
Support initiatives by the government to facilitate provision of
healthy food for the poor and encouraging behavioral change for
the prevention of NCDs.
of
service
through
establishment
of
Health Workforce: During the conference it was highlighted that
there is a huge shortage of trained health workforce in the country.
The problem gets pronounced due to high migration of health
professionals to other countries. There is also the increasing
preference of choosing the private sector for employment over the
public sector due to urban locations, compensation and other benefits.
The appointment, transfer and promotion process in the public sector
are not considered transparent and deter people from seeking
employment here.
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The different presentations and discussions during the conference
have provided some recommendations that need attention at the field
and policy level:
☯
140
❖
Develop a comprehensive health workforce plan;
❖
Revamp the current human resource policies both at national and
state level;
❖
Develop a human resource framework for the country;
❖
Make Government service and rural postings mandatory for a few
years;
❖
Provision of full salary for government doctors undergoing PG
education;
❖
Regularization and on-time scale based pay promotions for
contractual doctors;
❖
Time bound promotions;
❖
Multi skill training of MBBS doctors;
❖
Use of AYUSH doctors in PHCs;
❖
Use of rural medical assistants;
❖
Establishment of family medical programs;
❖
ASHA upgradation - provide ANM’S training for ASHA, provide nine
month mid-wifery course for ASHAs and other educational
opportunities;
❖
Development of Nurses - Increase the number of nursing and
medical schools, nurses with experience can be chosen for Bachelor
of Rural Medicine and Surgery (as a new course) and provide
distance education opportunities to upgrade the skills of nurses.
❖
Additional steps should be taken to increase the capacity of health
professionals, e.g. establish skill labs in district hospitals, start
bridge courses, provide e-learning solutions, create mobile trainers
for SBA training for nurses and ANMs etc.
Governance: One of the key components of health system
strengthening is governance. Transparency International has estimated
that in certain countries upto two thirds of hospital medicine supplied
are lost to corruption. US$ 4.4 trillion spent worldwide on health
services each year is a powerful magnet for corruption. Different
presentations articulated the following recommendations:
☯
☯
❖
The use of information technology is critical to be able to provide
effective health care governance and additional resources should
be allocated for the same.
❖
The involvement of the local community in health governance has
shown positive results and this needs to be encouraged.
❖
Regulation of the private sector is a critical area for stable
governance of the health sector. In fact, the new Clinical
Establishment Bill is a step forward in this direction.
❖
There should a rigorous system in place to check corruption in
health governance systems.
Positive Synergies: Coordinating and interlinking all the efforts in
health systems strengthening, both, at the country level and
internationally, would provide the desired results in achieving health
for all.
❖
Among the conference recommendations is the demand for a Global
Health Fund to strengthen health systems.
❖
A systematic involvement of community health workers in the
prevention and diagnosis of chronic health diseases would also build
synergy for health based action at a local and national level.
❖
The need to have a greater alignment between country level health
system strengthening and health programs and global health
initiatives has emerged as an important area of attention for the
future.
Health Systems Research: It was noted during the conference that
the use of “Data” is critical for effective decision making and policy
formulation in the health sector. There is an urgent need for prioritizing
research areas, identifying mechanisms to conduct large scale
research, training on research methodology and funding for large scale
research projects. Moving in the right direction, the conference
participants were informed that the Ministry of Health and Family
Welfare at the GoI has recently included a department of research in
the Ministry.
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At the end of the conference, one of the looming questions in many minds
was whether all these efforts would help ensure health for all? The
conference provided the answer to be YES! And, this comes from the
fact that the various participants and stakeholders of the health sector
have learnt about some of the best practices from various states at the
conference, i.e. Tamil Nadu, Gujarat, Andhra Pradesh, Kerala, Uttar
Pradesh, Assam, Karnataka, Orissa, Rajasthan etc. and also from abroad.
It is clear that the way ahead requires positive and affirmative action
and follow-up on each of the recommendations that have emerged from
the conference, and the state government of Tamil Nadu is committed
to this mission. It is now possible to find ways to learn and scale up
from the available best practices across the country to be able to achieve
our goal.
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CHAPTER 7
T
The Conference Experience
–Vignettes from Participants
T
his report has brought together the content, processes and outcomes
of the conference as documentation, both, for posterity and follow
up on ideas and commitments made. However the report would be
incomplete without sharing some feedback from participants, speakers
and even the organizers without whom the flavor and essence of the
conference would have been missing. This sharing is also important to
take forward positive feedback and get a sense of some of the critical
feedback, so that these can be overcome at a future time and place.
Strategic conference… positive experiences and challenges for
future
The conference has gone beyond my expectations in terms of
content, participation and scale. I was one of the skeptics in the
team. I have been impressed by the participation and enthusiasm
generated during the conference including in the poster displays.
I do feel we lost out on time and space for discussion on the
presentations. I am keen that this getting together will go beyond
the conference. I think the core group will have to work with the
Chennai Declaration and create actions around that. We can infact
feedback into each of our organizational spaces and places of work
so that the necessary outcomes are achieved. We need to
exchange best practices, actively share lessons and create a change
in mindsets. Since 1998 we have held conferences around our
different projects annually, so in that sense this is an 11th
conference but actually it’s the first of its kind for us as well. At
this scale I don’t know how many states can organize a conference.
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Health systems is the focus today, and we recognize that if health
systems are stable then all the other health sector issues can be
tackled. Every program has its own system and bringing it together
is a challenge. Health systems are the core, the backbone and
therefore we must work on this holistically. It has been an absolute
pleasure in working with the leadership of this conference – they
are all very enthusiastic.
Dr. Preeti Kudesia, World Bank
This is a great conference. For the first time I am seeing everyone
involved in deeply grounded in reality and there is a great ownership
of the conference. It would have been good if there was more time
for thematic break out groups. Keeping our ears to the ground;
listen, listen, listen is my mantra…give people a chance to say what
they want to share, let them get excited. There is a lot of creativity
that I have seen in this room, so much of action here in Tamil Nadu,
it’s great to see that people have not given up.
Dr. Mukesh Chawla, World Bank, Washington DC
This conference is a first step in health systems financing. Putting
some important issues on the radar, creating a thinking process!
A tremendous amount of follow up needs to happen. There is a
huge advocacy potential of the results of this conference. I have
heard anecdotes of very interesting work happening but didn’t get
a comprehensive picture and where the country is going. It would
be nice to know the details from higher level people. A critical
reflection of NRHM is a challenge! Parts of corporate America are
very self-reflective and demanding because their financial status is
dependent on that. That rigor needs to come into the health sector
here.
This conference has introduced some concepts, demonstrated
some experiences, there is a need to get into the nuances, there
needs to be specific focused thinking. This is an international
conference but I knew it would be an Indian focus. At some point
the international perspective needs to be heard from people across
the world and it would have been good if they had invited some
people from Brazil, Thailand, Africa; who have similar experiences
as India, this is a suggestion for the future. I must add that I
couldn’t envision an African country having such a global
partnership based conference. This brainchild of folks here is very
144
commendable. I would suggest that this does not become a onetime effort, there should not be a repeat of this conference but
the organizers need to think of smaller follow-up events, keep the
momentum that’s been built up. This would be effective if it
becomes a sustained effort at translation.
Dr Michael Friedman, USAID
There is tremendous excitement about the different experiments
in human resource development, service delivery, governance and
financing aspects of health systems. It would be good to generate
some good evidence as well. The audience at this conference has
been very engaged and it’s been a good mix of researchers and
practitioners. The location, the logistics, the food is fantastic. I do
think there should have been better time keeping so that there
was more discussion but I do understand that the balance is
difficult in this kind of an international conference.
Dr Kara Hanson, London School of Hygiene and Tropical Medicine
This is the beginning, it’s a very early stage yet, we are just setting
the framework of health systems strengthening. We need smaller,
well-targeted, discussion driven arenas beyond this first conference.
Ms. Sofi Bergkvist, International Business School, Hyderabad
Pay for Performance (PUP) is very important I feel. Health systems
financing and what you get back from these investments is my area
of interest in this conference. We have a scheme in Assam called
Mamoni, which is for ante natal care. This is the result of health
care investments. I found it interesting to learn about performance
incentives during the conference discussions. I was amazed by the
management of the mind-boggling logistics with over 500 delegates
attending.
Ms. Mallika Medhi, ED, NHRM, Assam
Tamil Nadu’s forays in health systems…
I have learnt a lot about Tamil Nadu and they are doing great work
in quality care, I am incredibly impressed. I am excited about the
management of information systems in health care and clearly Tamil
Nadu is way ahead of the curve in India.
Dr Gerard La Forgia, World Bank
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The Kerala model of health has been talked about a lot, but in the
last few years Tamil Nadu has done some very good work especially
in Health systems. Though Kerala had a historical advantage, our
pace of development in health systems has fallen behind because
we became complacent. At this conference I have realized the
importance of documentation. In Kerala we have not done that and
I wish that the Health Secretary of my state had come to this
conference as it’s about time that our Health systems are
strengthened. In fact I felt that the involvement of other states
was not that much especially the health secretary’s, who should
have definitely been made aware of the importance and scale of
this conference, though there were many partners from different
places involved.
I got to know about many models of HSS in this conference and
I was particularly excited about Discrete Choice Experiment (DCE).
I also hope that this type of exercise is undertaken in the future
as well. There must be an ongoing review of decisions made here,
especially the Chennai Declaration.
One point is related to the logo of this conference which is the
TNHSP logo, a positive factor for Tamil Nadu. However if this
conference is to continue and move to other states then a different
logo will be needed. In fact a new logo should have been designed
for this kind of an international conference. If such an event moves
to other states then a new logo will give the feel for the whole
nation will come. This has been a very innovative conference on
HSS and the papers presented were excellent, especially I liked the
concept of presenting models of systems development.
Dr Mohd Asheel, State Disease and
Control Monitoring Cell, Kerala
Useful in content and for networking…
The technical part of this conference was very good, but in terms
of management and support to us participants I am not satisfied.
One positive thing is that this kind of event was possible only due
to the coming together of different partners and not just the
government.
Dr Madhu, Faculty, UCMS, Delhi
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I had a very good learning experience on health care from this
conference, especially due to the presence of people from different
opinions and perspectives and a diverse range of efforts being
shared. Ms. Sonal Matharu, Governance Now magazine, Delhi
In India, the focus is still project linked, though now there is
emerging consciousness on ‘systems’, which affects the quality of
all programs. Such a conference helps policy makers see ‘systems’,
not just symptoms. There is an agreement that the issues are
systemic and need to be managed in that sense.
I am encouraged by the participation, especially the involvement
of the health department and the various government institutions;
and the students who would be the future of health systems
strengthening. I am impressed by the Chennai Declaration, to have
it as an output from such a conference, usually such declarations
come from some international events in places like Paris or New
York. Here this is a Health systems strengthening declaration and
Tamil Nadu is not just a state, its like a country and other states
should learn from Tamil Nadu. Dr Lipika Nanda, FHI, Hyderabad
We are working on systems in terms of services and facilities in
Orissa through civil society efforts so this conference has given
me some good learning. I have especially learnt how to undertake
interactions with government people and agencies effectively. D r
Mithai, Orissa
The conference has provided an opportunity to showcase the
health education manuals that have been produced under our
project. We have got a good response to our stall and display.
This has been a very well organized conference. Dr Colin Yarham,
Director – Health Education and Promotion International, Chennai
Insights into policy making and donor focus…
At this conference I was exposed to a range of thoughts, why
policies are made, what is the perspective of policy makers whom
one never gets to hear. The conference was an opportunity of
interaction between policy makers and other stakeholders, including
field workers and it helped in sensitization on both sides. HSS
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cannot improve health benefits, but this is a beginning. Health has
always been on the back burner even when the UN was formed.
If someone has INR 100.00 in their pocket, their immediate expense
will be on food, shelter and clothing. Unless health is affected they
won’t spend on it. There is a need to create collective
consciousness on the importance of health.
With increased
spending capacities and education, people have begun to spare
funds to think beyond subsistence so health starts becoming a
priority.
After seeing the PHC I am a bit unsure how it will be sustained
if the PPP stops working as optimally as it is currently or some
partner is unable to put in the money. There should be better
cleanliness and also there should be a reception areas for patients.
In the conference the focus was on tertiary care, not much on
bringing down the disease burden or on primary and secondary
care. Infact since the last one decade, hardly any health education
has been done systematically in the state, which was done by the
government and NGOs until then.
Today, the entire burden on these aspects of health care is on the
ANM and aanganwadi workers, who are not trained in communication
and awareness generation on general health, are overburdened by
their existing work and the books to maintain.
Infact in the last National Health and Family Welfare survey there
is evidence of decreasing immunization and breast feeding and
increase in violence against women and this is also because of the
limited focus on the RCH program now. The World Bank says that
NGOs should be involved, but the problem is that those groups
who have been working with the community for many years are
not involved, its newly set up NGOs who are engaged now. I am
worried about the state of HIV-AIDS also as the funds are now
decreasing and all that has been achieved would be lost without
adequate funds. Dr Saulina, TNHSP
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Sharing during the field visits...
The Tambaram hospital is being transformed to seek accreditation
by NABH, its actually reached a normal level of hospital functionality.
One of the steps that can be taken is to do mid-term checks to
ensure that the standards set now are at least maintained. The
HMIS is developed here but the care is wide and not very upgraded.
Dr Johnson, CMC, Vellore
This was a feel good conference, rather than going into issues indepth. It was also a take off event, and though there are various
initiatives happening across India and the world on HSS, that
amount of cross-sharing could not take place. This was also
because most of the participants were from the HIV-AIDS sector.
The other thing is that the focus was on dealing with sick people
and the conference did not look at quality of life issues. I found
that the PHC had several under-utilized spaces and though the
beneficiaries may get to know about it through word of mouth or
location, the PHC does not in itself reach out to the community.
People have to also take responsibility within hospital spaces.
People are core to the health system and they were not talked
about sufficiently.
Also I felt that though the Ayush doctors were talked about, the
other doctors were not talked about with due respect. The point
is that often their job descriptions and roles are not that clear as
the human resource management processes are not chalked out
that well.
Even with health finance I found that the focus was on sickness
and not wellness, but then towards the end everyone was talking
about it being a holistic approach so that was good.
Its important to recognize that it’s a failure of our public health
measures if more people are falling sick, as the focus should be
on the preventive aspects not just the curative part of health care.
How do you measure your success? How do people come into the
hospital, how many are outreached…we should be able to show
the numbers going down not up! Health care is only one aspect,
an intersectoral approach is needed. Like Michael Friedman was
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mentioning, we need to learn from Thailand which has not increased
its health workforce but improved its health care outcomes
nevertheless. The problem is that the preventive aspects of health
care are abstract, here they are showing infrastructure, numbers
etc. but its necessary to have a dedicated preventive system. There
is a mindset that if our hospitals are big then we are developed,
but the problem is that then we are not looking at how healthy
our people are. Each hospital has a catchment area, so one should
assess how the system is working by checking how the catchment
area is feeling, whether neglected or satisfied; is it coming to your
hospital or going to some other facility. A balance needs to be
established between preventive and curative health care provisioning.
Lakshmi, Phd student, Vellore
This was a wonderful and professionally organized conference
though by government. A lot of effort was put in managing the
proceedings, the agenda was very well organized and the themes
very relevant. Health is a very complex field and in this context,
the conference was commendable. It was also the first attempt to
showcase TNHSP and done very well.
I also found the TN Medical Services Corporation to be an example
of a unique model of health systems; the fact that are very few
vacancies in human resources is a good sign and the Info systems
are also organized very well. However with regard to the PHC we
visited there is a need to look at the quality of care even beyond
the infrastructure of the PHC as complacency should not set in.
Tamil Nadu should reach a stage where the public sector is better
than the private sector and nothing should stop them as they really
set a Health systems model for the entire country. I would like to
suggest that a technical assistance cell is created here which
documents all the experiences and models in the form of ready
made educational and learning modules in each of the areas,
whether hospital and/ or health management…almost like a ‘cook
book’ on a specific topic.
Also this cell could offer to make system models for other states
who come with baseline data and surveys, thus providing technical
assistance to other states interested in HSS. Infact the team from
150
such a cell could even visit a particular state to undertake a
situational analysis of their health system and even bring in people
for capacity building. The cell could serve as a place for planning,
mentoring and monitoring on a continuous basis.
Dr Krishnaswamy,
Gujarat State Health Systems Resource Center
Great logistics and coordination…
This was a good conference and gives us an idea on how to improve
our health systems. Here they have very good inter-sectoral
coordination.
Dr Rajgopal, Andhra Pradesh
The conference has been very well organized. Its been useful as
I have heard of various experiences, both in research and
implementation.
The only thing is that conference was heavily packed, many
sessions overran which could have been avoided. The conference
has been organized in a heritage town but most of us did not get
a chance to even see the temple and this should be kept in mind
in future.
I was impressed by the selection of the speakers and those who
attended as many of us could engage in corridor discussions. The
energy level at the conference was also very high and exciting.
Dr Muralidharan, IIT Madras
Learning and suggestions…
I am taking back a lot of learning’s…different opinions, arguments
and perspectives I heard and these were very useful.
Ms Manohara, Malaysia
The conference and the field visits have been very useful and
practical learning has happened. There is some hype also but overall
it was a very good experience being here. Dr Anirudh Lahiri, Kolkata
Focusing on Health systems is very essential and therefore this
first ever conference is very significant. Infact such a conference
should be organized annually or every second year. The organizing
group has done an amazing job with the logistics of this conference
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and in bringing together so many partners to work together and
do it well.
One suggestion is that a better time of the year should be chosen
to have such an international conference so that the weather is
better. In terms of technical content some improvements are
needed, to avoid repetitions and pick up best abstracts to enhance
the content. Many sessions went way over time and caused
inconvenience to the speakers and the audience and this should
be avoided. There can also be more parallel sessions for time
management and shortening the length of the conference.
Dr. Beena Varghese, PHFI
As social workers we are not working in health systems but are
interested in this because of it being related to health service
delivery. At this conference mental health was not covered, only
chronic and communicable diseases were focused on. What needs
to be seen is that though mental health is included in the overall
definition of health by WHO, it is not included in the definition of
non-communicable diseases.
Ms. Suja, Lecturer, Coimbatore
We came here because this topic is related to our college research
and useful for our studies and our work. Interacting with and
hearing different professions from different areas under one roof,
it’s been a great conference. One complaint however is that mental
health has not been included in health systems strengthening and
this is a gap.
Bijo and Riya, HIV project, Thrissur
My suggestion would be to kindly sensitize medical paramedics and
the statutory council of health sciences to include HSS in education,
training and assessment.
The other suggestion is that instead of every state making a HMIS,
why not make a National HMIS – this would become a shared
resource and so much money could be saved. I found that no one
was talking about health judgments and I recommend that a
discussion on these needs to be incorporated into HSS.
P. Thirumal A. Subramanian, Professor of Medicine,
Trichy Medical College
152
I came to this conference with expectations to hear about
experiences in this field and gather necessary information for use
as an academician. The pre-conference workshop was very
informative, some sessions added value but I was disappointed by
the presentations as they were not research studies but more a
documentation of experiences. The analytical components of the
presentations have been limited and they’ve been more descriptive
and information loaded. The sessions on Health Financing and
Chronic Diseases were useful, and especially the presentation from
the London School of Tropical Hygiene and Medicine. One of the
aspects that I was impressed by was the number of youngsters
at such an international conference which is very encouraging, like
we can see at TISS as well where we have a lot of health
professionals coming in to study health systems etc.
Dr Kanchan Mukherjee, TISS
From the organizing team…
I am satisfied. There has been a lot of preparation with every minor
detail being looked at while organizing this conference. Its been
appreciated by everyone. The outcomes are very good and useful.
It has given good inputs to all people who attended and I was
impressed that everyone attended all days, asked questions and
learnt a lot.
Dr Subburaj, Special Secretary, Government of Tamil Nadu,
Health and Family Department
We are happy because so many people were involved in making
the conference a success. Being Paediatricians we are used to going
into micro details and we were working with technocrat teams who
had communication and organizing skills. Earlier it was so many
different committees working on this conference with their specific
tasks but as the momentum was built we were all working with
each other, the common chord being Dr Vijayakumar.
We have made a crucial start and a better allocation of funds in
health systems will be an investment in increasing our GDP. When
people fall sick we are incurring expenditure but when we take care
of their health we are making a saving…that would be the real
investment for the nation.
Dr A. Kumaresan, TNHSP & Dr P. Punitha, ESI
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We wanted to ensure that there was no hitch anywhere… there
should be smooth sailing. Its been very good.
Ms Indhu Sivakumar, TANSACS
I feel great as I have been working for the past two years and
feel the value of my work now, especially with the poster prize.
I have screened over a 3 lakh women for cervical cancer in Chennai!
On the conference I would say one of the main strengths has been
the united way of working by the different people and committees.
One organization could not have done this on its own. Initially we
thought how will all these different committees work but now I can
say three cheers for Dr Vijayakumar. I wish we had a chance to
also sit in the conference and learn but I know that was not really
possible being part of the organizing group. Dr Bharthi, TNHSP
The international exposure through this conference has been wonderful.
We volunteered in this conference because it was a great opportunity
for us as future professionals. We also learnt about health systems
in various states of India. We have been managing our time here
between our exams and volunteering and its been worth it.
Students of St Thomas College as ICONHSS volunteers
154
CHAPTER 8
I
In the Press
The ICONHSS received a lot of interest in the print and visual media,
with correspondents covering not only the inaugural but also many of the
thematic sessions, the cultural programs and the valedictory session.
Some glimpses of the press coverage in English are included here, though
the conference also received a lot of local Tamil coverage as also coverage
in the Hindi and regional language media.
NIE 8, May 2010
The Hindu, 8, May 2010
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156
TOI, 8, May 2010
NIE, 9, May 2010
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News Today, 9, May 2010
158
News Today, 11, May 2010
SIFY ONLINE
’ 80,000 benefit from TN health insurance scheme’
2010-05-17 05:30:00
Chennai: Tamil Nadu has taken healthcare to the common
man, says Dr S Vijayakumar, IAS, special secretary at
the Health and Family Welfare department in Tamil Nadu.
The state has witnessed a healthcare revolution in the
last five years thanks to the Tamil Nadu Health Systems
Project (TNHSP) which was launched in 2005, he said.
Speaking to Sify.com on the sidelines of an international
conference on healthcare at Mahabalipuram, Vijayakumar
said the improvement of district and sub district hospitals
has made quality healthcare accessible to large number
of poor people in the state.
He said over 80,000 people benefited under the Kalaignar
Insurance Scheme, which was launched in July last
year.
Under the scheme, families whose annual income is
less than Rs 72,000 per annum will get an insurance
cover of Rs 1 lakh each for life saving treatment in
government and private hospitals.
which is available on dialing 108, has saved many poor
people. It has considerably reduced mother mortality
rate (MMR) in the state, claims Vijayakumar.
However, most calls to 108 are not genuine, an example
for how people misuse a facility for the needy, he said.
“About 90 percent of the calls we receive at the ambulance
call centres are pranks or hoaxes. However, we have
to respond to all calls and send ambulances. We have to
trust each caller because if we filter calls, it will be at the
cost of the people in emergency. That should not happen.
So our call centre executives have been instructed to
respond positively to each call,” he said.
Vijayakumar said that while private players have turned
Chennai into a healthcare destination for foreigners, the
government and private sector participation made quality
treatment affordable to the poor people in the state.
Irrespective of this achievement, there is need for
strengthening the healthcare sector in the state.
“There is need for better coordination of the different
components like government, finance, quality treatment
and information technology etc,” he said.
About Rs 250 crore has been spent for treatment of poor
people under the scheme, he added.
“© 2004 sify.com India Limited. All Rights Reserved.
This material may not be published, broadcast, rewritten,
or redistributed.”
Introduction of the free ambulance service is yet another
mile stone the state’s healthcare sector. The free service,
http://sify.com/news/80-000-benefit-from-tn-healthinsurance-scheme-news-national-kfkpxTadhea.html
ICONHSS
2010
159
Chennai Online http://www.chennaivision.com/newsdetails.php?id=4678
Delegates discuss health
May 11, 2010: The International Conference on Health
Systems Strengthening concluded in Mahabalipuram on
Monday, with the “Chennai Declaration” that organizers
described as being a historic document strengthen health
services. The Declaration stressed that there was a need
to increase public health care expenditure to at least 3
per cent of the GDP which is the minimum acceptable
level for public health. The conference saw the
participation of over five hundred delegates from India
and abroad, in the largest ever exercise of its kind in the
region. The ICONHSS 2010 was organized by the Tamil
Nadu government in collaboration with the Government
of India, World Bank, USAID, NACO, ICMR, SAATHII, APAC,
PHMI, WHO, National Rural Health Mission, Chettinad Health City, Star Health and e-health.
Tamil Nadu Chief Secretary, K S Sripathy, IAS, who presided on the occasion, said that Chennai was
becoming the health capital as far as India was concerned. Tamil Nadu was already allocating much more
than 6% of the GDP which was more than the 3% suggested in the Chennai Declaration. He suggested
that another inclusion in the Chennai declaration could be “improving” or spending a little more on the
atmosphere.” Recalling some of the achievements of Tamil Nadu in recent days, Mr Sripathy cautioned that
complacence should not set in. K Chandramouli IAS, Director General, National AIDS Control Organization,
spoke about the unbelievable change that had happened in the health sector in recent years. The declaration
is a topical and much-needed one and in the coming months review what has been done based on today’s
declaration. He congratulated the organizers for bringing in people from so many diverse backgrounds
and international experts. Dr V M Katoch, Secretary, Department of Health Research and Director General,
ICMR said that Tamil Nadu being a role model in its own way was the ideal place to hold such a conference.
“Tamil Nadu has shown the way in which the ideal health system should exist. Health needs a mass
movement and a partnership by everybody. When we all go back we have a mission and a mission to
fulfil.”
Dr S Vijayakumar, IAS, Chairman Organizing Committee, ICONHSS thanked the dignitaries for their support
and all the partners who had helped put the conference together. Describing the conference as a learning
experience, he said that they would also include nutrition besides atmosphere as an important component
of better healthcare.
Video: http://chennaionline.com/video/
index.aspx?vid=2027&Title=International%20Conf.%20Issue%20%27Chennai%20Declaration%27%20%20Part%20I&Page=0
160
A
Annexures
A. PROGRAM SCHEDULE - ICONHSS
Pre-Conference Workshop: Learnings from the Health Systems Initiatives in
India
Venue: Mini Auditorium Hall, Chettinad Health City, Kelambakkam
May 6, 2010
9.00 - 9.55 am: Registration
Session I: Inauguration of Pre-conference (9.55 – 10.45 am)
9.55 – 10.00 am: Tamil Thai Vazhthu (Invocation)
Topic
Time
Speaker
Welcome Address
10.00 - 10.05 am
Dr. (Capt) M. Kamatchi, Expert
Advisor, Tamil Nadu Health Systems
Project (TNHSP)
Objectives of the
workshop
10.05 - 10.15 am
Dr. S. Vijayakumar, I.A.S., Special
Secretary to Government, Health and
Family Welfare Department and Project
Director, Tamil Nadu Health Systems
Project (TNHSP)
Inauguration &
Inaugural address
10.15 - 10.25 am
Prof. Dr. Mayil Vahanan Natarajan, Vice
Chancellor, The TN Dr.MGR Medical
University
Presidential Address
10.25 - 10.40am
Mr. V. K. Subburaj, IAS Principal
Secretary to Government, Health and
Family Welfare Department, Tamil Nadu
Vote of Thanks
10.40 - 10.45 am
Dr. D. Gurusamy, Chief Executive
Officer, Tamil Nadu Health Systems
Project (TNHSP)
Tea Break: 10.45 – 11.00 am
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2010
161
Session II: Overview of Health Systems (11.00 - 12.35 pm)
Chairs: Dr. Preeti Kudesia, Senior Public Health Specialist, World Bank
Dr. Sunil Nandaraj, National Professional Officer - Health Systems
Development, WHO
Session Coordinator: Dr. Satish Kumar, Associate Director (Technical), SAATHII
Dr. Preeti Kudesia, Senior Public Health Specialist, World Bank
Time
Topic
Speaker
11.00 - 11.30 am
Overview of Health Systems
in India
Dr. Sunil Nandraj, National
Professional Officer-Health Systems
Development, WHO
11.30 - 12.00 am
Experiences of World Bank
Funded Health Systems
Projects in India
Dr. Preeti Kudesia, Senior Public
Health Specialist, The World Bank.
12.00 - 12.30 am
Discussion
12.30 - 12.35 am
Concluding Remarks
Chairs
Session III : Good Practices from the World Bank Funded Health
Systems Projects in India
Focus on Quality (12.35 – 3.30 pm including lunch break)
Chairs: Dr. Preeti Kudesia, Senior Public Health Specialist, World Bank
Dr. V. Kumaraswami, Officer-In charge, National Institute of Epidemiology,
Chennai
Time
Topic
Speaker
12.35 - 12.40 pm Introductory Remarks
Chair
12.40 - 01.10 pm Strengthening of Hospital
Systems: Rajasthan
Experience
1. Dr. P.C. Ranka, Additional Director,
Rajasthan Health Systems
Development Project
2. Dr. Kalpana Vyas, Officer, Rajasthan
Health Systems Development Project
1.10 - 01.25 pm
Public-Private Partnerships: Mr. S. Selva Kumar, I.A.S., Project
Karnataka Experience
Director, Karnataka Health Systems
Development and Reforms Project
1.25 - 01.40 pm
Discussion
1.40 - 02.15 pm
Lunch
2.15 - 02.30 pm
Hospital Accreditation:
Uttar Pradesh Experience
162
Dr. S.P. Ram, Director (National
programs) Department of Medical and
Health Services, Lucknow
Time
Topic
Speaker
2.30 - 02.45 pm
Discussion
2.45 - 03.00 pm
Health Management
Information Systems:
Tamil Nadu Experience
3.00 - 03.15 pm
Discussion and Concluding
Remarks
3.15- 03.30 pm
Tea Break
Dr. T. K. Amarnath Babu,
Medical Officer, Tamil Nadu
Health Systems Project
Session IV: Integration of Chronic Disease Prevention and
Management in Public Health (3.30 – 6.15 pm)
Chairs: Dr. K. Srinath Reddy, President, PHFI
Dr. Thanikachalam, Sri Ramachandra Medical College & Research Institute,
Chennai
Time
Topic
Speaker
3.30 - 04.00 pm
Overview of Prevention and
Management of Chronic
Diseases in India
Dr. S. Thanikachalam, Chairman &
Director (Cardiac Care Centre),
Professor Emeritus of Cardiology,
Sri Ramachandra Medical College &
Research Institute
4.00 - 04.30 pm
Experiences from Tamil Nadu
Pilot Programs (Cardiovascular
Diseases and Cervical Cancer)
Dr. Raja, Medical Officer, TNHSP
Dr. B. Bharathi, Medical Officer,
TNHSP
4.30 - 05.00 pm
Results from Tamil Nadu Pilot
Programs (Cardiovascular
Diseases and Cervical
Cancer)
Dr. Prabhdeep Kaur, Scientist, National Institute of Epidemiology
Dr. A. Somasundaram, DD (Research), Directorate of Public Health.
5.00- 05.20 p.m.
Cost analysis of the Tamil
Nadu Pilot project on
Prevention and Treatment of
Non-communicable diseases
(Cervix Cancer and
Hypertension)
Dr. Beena Varghese, Head, Research Development & Adjunct
Additional Professor, PHFI
5.20 - 05.40 pm
Health Systems & NonCommunicable Diseases:
Path Ahead
Mr. S. Ramanathan, DirectorStrategic Planning and Partnership,
APAC
5.40 - 06.15 pm
Remarks
ICONHSS
2010
163
International Conference on Health Systems Strengthening
Venue: Chettinad Health City, Kelambakkam
May 7, 2010
Session I
: Inauguration of Conference (9.30 – 10.30 am)
Venue
: Sigapi Achi Convention Centre
Tea Break
: 10.30 – 11.00 am
Session II A
: India Meet - Health Systems Strengthening in India
(11.00 am - 12.15 pm)
Venue
: Mini Auditorium
Chairs: Ms Sujatha Rao, Secretary, Union Ministry of Health and Family Welfare
Dr. Mukesh Chawla, Sector Manager, Human Development Network, World Bank
Session Coordinators: Dr. Jerard M Selvam, Professor, Dept. of Epidemiology,
The TN Dr. MGR Medical University and Dr. Sai Subhasree Raghavan, President,
SAATHII
Time
Speaker
Topic
11.00 – 11.20 am
Priorities for Health Systems
Strengthening in India
Ms. Sujatha Rao, I.A.S., Secretary,
Union Ministry of Health and Family
Welfare
11.20 – 11.40 am
An overview of Health Systems
Strengthening
Dr. Mukesh Chawla, Sector
Manager, Human Development
Network, The World Bank
11.40 – 12.00 pm Health Systems Strengthening – Mr. V.K. Subburaj, I.A.S. Principal
Experiences from Tamil Nadu
Secretary to Government, Health
and Family Welfare Department,
Tamil Nadu
12.00 – 12.15 pm
164
Remarks
Chairs
Session II B: India Meet - Financing for Universal Access
(12.20 – 01.35 pm)
Chairs: Ms. Sujatha Rao IAS Secretary, Union Ministry of Health and Family Welfare
Dr. Mukesh Chawla, Sector Manager, HDNHE, The World Bank
Session Co-ordinators: Dr. Jerard M Selvam, Professor, Dept. of Epidemiology,
The TN Dr. MGR Medical University and Dr. Sai Subhasree Raghavan, President,
SAATHII
Time
Topic
Speaker
12.20 – 12.30 pm
Introductory Remarks on
Budgetary allocation and Public
Health expenditure system in
India
Ms. Sujatha Rao, I.A.S.,
Secretary, Ministry of Health and
Family Welfare, Government of
India
12.30 – 12.45 pm
National Health Accounts - the Dr. Ganga Murthy, Additional
current trends and way forward Chief Economic Advisor, Government of India
Dr. Devi Prasad Shettty,
12.45 – 01.00 pm Private sector investment in
improving access to health care Chairman, Narayana Hrudayalaya
Group of Hospitals, Bangalore
1.00 – 01.15 pm
Out of pocket expenditure and
Financial strategies for
universal success
Dr. Ravi Duggal, Senior Trainer
and Health Analyst, International
Budget Partnership
01.15 – 01.25 pm
Concluding Remarks
Dr. Mukesh Chawla, Sector
Manager, HDNHE, The World
Bank
1.25 – 01.35 pm
Sharing of Chennai Declaration
LUNCH: 1.35 – 2.30 pm (Poster display)
ICONHSS
2010
165
Session III: Service Delivery (02.30 - 06.00 pm)
Chairs: Ms. Girija Vaidyanathan, I.A.S., Mission Director, NRHM and Project
Director, RCH-Tamil Nadu Dr. K. Srinath Reddy, President, PHFI
Session Coordinators: Ms. Gayatri Oleti, Director – Strategic Planning and
Partnerships, APAC and Dr. Sathish Kumar, Associate Director (Technical),
SAATHII
Time
Topic
Speaker
2.30 – 2.40 pm
Introductory remarks
Chairs
2.40 – 3.05 pm
Global Experiences of Health
Service Delivery
Ms. Kerry Pelzman, Director, Office
of Population, Health and Nutrition,
USAID – India
3.05 – 3.25 pm
Health Service Delivery in India:
Issues and Challenges
Dr. Sundararaman, Executive
Director, National Health Systems
Resource Center
3.25 – 3.45 pm
Discussion
3.45 – 4.00 pm
Tea Break
4.00 – 4..30 pm
Quality of Health Care
Dr. Preeti Kudesia, Senior Public
Health Specialist, The World Bank
4. 30 – 4.50 pm
Role of Insurance in Enhancing
Access to Quality Health Care
Dr. Prakash, Medical Director, Star
Health And Allied Insurance
4.50 – 5.10 pm
Discussion
5.10 – 5.40 pm
Challenges in delivery of services Dr. K. Srinath Reddy, President,
for Prevention and Control of
PHFI
Non-Communicable diseases
5.40 – 5.50 pm
Discussion
5.50 - 6.00 pm
Concluding Remarks
Ms. Girija Vaidyanathan, I.A.S.,
Principal Secretary, Special
Commissioner, MCHSW – Project
Director, RCH & Mission Director,
SRHM
Cultural Programme and Dinner: 7.00 – 9.30 pm at Radisson Resort Temple
Bay, Mamallapuram
166
May 8, 2010
Session IV: Human Resources (8.30 – 11.00 am)
Chairs: Dr. Michael Friedman, US Public Health Service Medical Officer, CDC,
Atlanta
Dr. Mala Rao, Director, Indian Institute of Public Health, Hyderabad
Session Coordinators: Dr. Mini Jacob, Reader, The TN Dr. MGR Medical
University, and Dr. L. Ramakrishnan, Country Director, SAATHII
Time
Topic
Speaker
8.30 – 8.50 am
Development of Public Health
Workforce - Relevance to India
Dr. Michael Friedman, UPHSMO,
CDC, Atlanta
8.50 – 9.40 am
Discussion
Dr. Kara Hanson, Reader, Health
Systems Economics, London School
of Hygiene and Tropical Medicine
9.40 – 10.00 am Health & Human Resources:
Priorities in India
Dr. Padmanaban, Advisor, Public
Health Administration, NHSRC
Dr. Krishna Rao, Head, Health
Which doctor for Rural India? 10.00 – 10.20 am An assessment of task shifting in Economics, Public Health
Foundation of India
primary health care
10.20 – 10.50 am Discussion
10.50 – 11.00 am Concluding Remarks
Dr. Mala Rao, Director, Indian
Institute of Public Health,
Hyderabad
Tea Break: 11.00 – 11.15 am
ICONHSS
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167
Session V:
Parallel Sessions (11.15 – 01.30 pm)
Session V A: Symposium on Human Resources (11.15 – 01.30 pm)
Venue: Gold Coast
Chairs: Dr. K.S. Jacob, Professor and Head, Department of Psychiatry, CMC,
Vellore and Dr. Kara Hanson, Reader, Health Systems Economics, London School
Session Coordinators: Dr. Mini Jacob, Reader, The TN Dr. MGR Medical University
Dr. Geetha Joseph, Scientific Affairs Specialist, CDC, India
Time
Topic
Speaker
11.15 - 11.30 am Innovative Methods in Medical
Education
Dr. Vinod Shah, Co-ordinator,
Department of Distance Education,
CMC
11.30 - 11.45 am Availability, Motivation and
Capacity building of Nurses:
Experiences from the Private
Sector
Dr. Lata Venkatesan, Principal,
Apollo College of Nursing
11.45 – 12.00
Systems Economics, London School
Financial and Non-Financial
Incentives for health workers:
Evidence from discrete choice
experiments (Ethiopia, Kenya,
South African and Thailand)
12.00 – 12.15 pm Innovative Human Resource
Practices for effective Health
Service Delivery - Experience
from Aravind Eye Care System
Ms. Preeti John, Senior Faculty,
LAICO, Aravind Eye Care System
12.15 – 12.30 pm Rationalization of Human
Resources: Tamil Nadu
Experiences
Advisor, TNHSP
12.30 – 12.45 pm Leadership qualities among
health care providers
Dr. Shakil Ahmed, Assistant Professor,
Department of Community Medicine,
Chettinad Hospitals and Research
Center, Chennai
12.45 - 1.00 pm Development of Emergency
Medical Technicians Cadre
Dr. G.V. Ramana Rao, Executive
Partner, GVK, EMRI, AP
01.00 - 01.30 pm Sequence of care and task
Mr. S. Swaminathan, Senior
shifting in Primary Health Care: Program Manager, SAATHII,
Evidence from Karur district
Chennai
1.30 – 1.45 pm
168
Sociological Interventions in
Health Service Delivery
Dr. R. Shankar, Professor and Head,
Department of Sociology,
Bharathidasan University, Trichy
Session V B: Parallel Session – Symposium on Service Delivery
(11.15 am – 1.30 pm)
Venue: Ball Room
Chairs: Dr. D.C.S. Reddy, NPO-HIV/AIDS Surveillance, WHO
Dr. Bimal Charles, Project Director, APAC-VHS
Session Coordinators: Dr. L. Ramakrishnan, Country Director, SAATHII
Dr. Reba, CDC, India
Time
Topic
Speaker
11.15 – 11.30 am Access to health care for
Ms. Lipika Nanda, Director, Family
vulnerable population – Experience Health International, Andhra
from Andhra Pradesh
Pradesh
11.30 – 11.45 am Ensuring equitable health care:
Experience from Public Private
Partnership Initiatives
Sofi K Indian School of Business,
Hyderabad
11.45 – 12.00 pm Care at time of critical
emergencies
Dr. Gurusamy, CEO, TNHSP
12.00 - 12.15 pm Under-reported deaths and inflated Dr. Upendra Bhojani, Faculty,
deliveries: Making sense of Health Institute of Public Health,
Management Information Systems Bangalore
in India
12.15-12.30 pm
Community-based Filarial
Lymphoedema Morbidity
Management: Successful
partnership through Self-Help
Groups
Dr. Sairu Philip, Associate
Professor, Department of
Community Medicine, TD Medical
College, Alappuzha
12.30 - 12.45 pm Citizens Help Desk at hospitals:
Empowering the public with
information and guidance
Mr. S. Selva Kumar, I.A.S.,
Project Director, Karnataka
Health Systems Development
and Reforms Project
1.00 - 1.15 pm
Irrational prescription in public
health facilities: Evidence from
Tamil Nadu and Bihar
Dr. Habib Hasan, Lecturer, Public
Health Foundation of India, New
Delhi
1.15 -1.30 pm
Equipment maintenance in health
care - Process, sustainability and
challenges
Dr. A. Kumaresan, Deputy
Director, TNHSP
Lunch 1.30 – 2.30 pm at Waters Edge Cafe
(Poster display)
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Session VI: Health Care Financing (02.30 - 05.00 pm)
Chairs: Dr. Mukesh Chawla, Sector Manager - HDNHE, The World Bank
Dr. Sunil Nandraj , National Professional Officer-Health Systems Development,
WHO, India
Session Coordinators: Dr. Jammy Rajesh, Associate Director, PHMI
Dr. Jerard M. Selvam, Professor, The TN Dr. MGR Medical University
Time
Topic
Speaker
2.30 – 3.00 pm
Global perspectives of health care Dr. Mukesh Chawla, Sector
financing and its relevance to India Manager-HDNHE, The World
Bank, USA
3.00 – 3.30 pm
Performance based funding
Dr. Gerard La Forgia, Lead Health
Specialist, The World Bank, India
3.30 - 3.45 pm
Public health spending in health
care: Benefit incidence analysis in
states of Tamil Nadu and Orissa
Dr. Muraleedharan, Professor,
Department of Humanities and
Social Sciences, IIT, Madras
3.45 - 4. 45 pm
Panel Discussion on Options for
Health Financing (Public, Private,
Community and Public-Private
financing)
Dr. Devadasan, Technical Advisor,
Institute of Public Health,
Bangalore
Dr. Sakthivel Selvaraj, Health
Economist - PHFI, New Delhi
Mr. Babu. A, I.A.S., Chief
Executive Officer, Aarogyasri
Health Care Trust, Government
of Andhra Pradesh
4.45 – 5.00 pm
Concluding Remarks
Chairs
Tea Break: 3.45 – 4.00 pm
Session VII: Poster discussion (5.00 - 6.30 pm)
Cultural Programme: 7.00 - 9.30 pm
Dinner: Savannah - 3
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May 9, 2010
Session VIII: Plenary on Governance (8.30 – 10.50 am)
Chairs: Dr. C.A.K. Yesudian, Professor and Dean, TISS
Ms. Meena Gupta, Former Health Secretary, Orissa
Session Coordinators: Mr. P. Rajendran, Program Manager (Research), APAC
Mr. Arvind Kumar, Project Management Specialist, USAID
Time
Topic
Speaker
8:30 – 8:40 am
Introductory Remarks
Dr. C.A.K Yesudian, Dean,
School of Health Systems
Studies, TISS
8.40 - 9.05 am
Global Perspectives on Health
Governance
Ms. Pamela Rao, Senior Health
Systems Strengthening Advisor,
USAID
9.05- 9.30 am
Role of Information Technology in
Health Governance
Mr. P.W.C. Davidar, I.A.S.,
Secretary, Information
Technology, Tamil Nadu
Government
9.30 – 9.45 am
Community Based Monitoring of
Health Services – Evolving Model
of People Centered Health
Systems Governance
Dr. Abhay Shukla, Coordinator,
SAATHII - CEHAT, India
9.45 - 10.40 am
Panel Discussion (Planning, Human
Resource Policies, Management,
Corruption, Regulations,
Monitoring)
Dr. Thamma Rao, Advisor, Health
Human Resources, NHSRC
Dr. Sunil Nandraj, NPO-HSD,
WHO
Dr. Gerard La Forgia, Lead
Health Specialist, The World
Bank
10.40 - 10.50 am Concluding Remarks
Ms. Meena Gupta, Former Health
Secretary, Orissa
Tea Break: 10.50 – 11.05 am
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2010
171
Session IX: Positive Synergies between Health System and
Global Health andDevelopment Initiatives (11.05- 1.30 pm)
Chairs: Mr. Chandra Mouli IAS, Secretary, Department of AIDS Control and DG,
NACO and Mr. Prasada Rao, Director, UNAIDS Support Team for Asia and the
Pacific, UNAIDS
Session Coordinators: Dr. Sai Subhasree Raghavan, President, SAATHII
Dr. Sree T. Sucharitha, Medical Manager, SAATHII
Time
Topic
Speaker
11.05 – 11.15 am Introductory Remarks
Mr. Chandrmouli, I.A.S.,
Secretary, Department of AIDS
Control and DG, NACO
11.15 - 11.35 am
Role of Global Fund funding on
Dr. Edward Addai, Director,
Monitoring and Evaluation, GFATM
11.35 - 11.55 am
Recommendations from the
Positive Synergies Initiatives
Dr. Badara Samb, Coordinator,
WHO, France
11.55 - 12.15 pm
Framework for Integration of
Dr. Preet Dhillon, Senior Scientific
Chronic Diseases as part of Public Officer, SANCD, India
Health Services
12.15- 1.15 pm
Panel Discussion on Translating
Recommendations of Positive
Synergies Group into Action
Dr. Sundararaman, Executive
Director, NHSRC
Dr. Vikram Rajan, Health
Specialist, SASHD The World
Bank, India
Ms. Pamela Rao, Senior Health
System Strengthening Advisor,
USAID, USA
1.15 - 1.30 pm
Concluding Remarks
Mr. Prasada Rao, Director
UNAIDS Support Team for Asia
and the Pacific, UNAIDS
Lunch: 1.30 – 2.20 pm
Waters Edge Cafe
Poster Display (1.30 – 2.20 pm)
172
Session X: Health Systems Research (2.20 – 4.45 pm)
Chairs: Dr. Vishwa Mohan Katoch, Secretary to Government of India &
Director- General, ICMR
Session Coordinators: Ms. Sheena Chhabra, Chief, Health Systems Division,
PHN, USAID and Dr. Sree T. Sucharitha, Medical Manager, SAATHII
Time
Speaker
Topic
2.20 – 2.30 pm
Introductory Remarks
Dr. Vishwa Mohan Katoch,
Secretary to the Government of
India, Director-General, ICMR
2.30 – 3.00 pm
Overview of Health Systems
Research
Systems Economics, London
School of Hygiene and Tropical
Medicine
3.00 – 3.15 pm
Priorities in Health System
Research
Dr. T.P. Ahluwalia, Deputy
Director-General, Division of
Health Systems Research, ICMR
3.15 – 3.30 pm
Data for Decision Making
Dr. Ujwal Raj on behalf of
Dr. S. Venkatesh, Deputy
Director General, NACO
3.30 – 4.30 pm
Panel Discussion on Priorities for
Health Systems Research in
India
Ms. Arti Ahuja, I.A.S.,
Commissioner and Secretary,
Govt. of Orissa,
Ms. Sheena Chhabra, Chief Health
Systems Division, PHN, USAID
Dr. Edward Addai, Director,
Monitoring and Evaluation, GFATM
Chairs
4.30 – 4.40 pm
Concluding Remarks
Tea Break:
(3.45 - 4.00 P.M.)
Session XI: Report back and Valedictory (4.45 - 5.45 pm)
ICONHSS
2010
173
B. List of Speakers
Hon’ble Minister of Finance, GoTN
Ms. Lipika Nanda
Hon’ble Minister of Health, GoTN
Ms. Sofi Bergkvist
Ms. Syeda Saiyidain Hameed
Dr. Gurusamy
Ms. Sujatha Rao
Dr. Upendra Bhojani
Mr. V.K. Subbaraj
Dr. Sairu Philip
Dr. Ganga Murthy
Mr. S. Selvakumar
Dr. Mukesh Chawla
Dr. Habib Hasan
Mr. Chandramouli
Dr. M. Kumaresan
Dr. S. Vijayakumar
Dr. Gerard La Forgia
Dr. Devi Shettty
Dr. Muraleedharan
Dr. Ravi Duggal
Dr. Devadasan
Ms. Kerry Pelzman
Dr. Shaktivel
Dr. Sundararaman
Dr. C.A.K. Yesudian
Dr. Preeti Kudesia
Dr. Pamela Rao
Dr. Prakash
Mr. P.W.C. Davidar
Dr. K. Srinath Reddy
Dr. Abhay Shukla
Dr. Girija Vaidyanathan
Dr. Thamma Rao
Dr. Michael Friedman
Dr. Sunil Nandraj
Dr. Kara Hanson
Ms. Meena Gupta
Dr. Padmanabhan
Dr. Edward Addai
Dr. Krishna Rao
Dr. Badara Samb
Dr. Mala Rao, Director
Dr. Preet Dhillon
Dr. Vinod Shah
Dr. Vikram Rajan
Dr. Lata Venkatesan
Mr. Prasada Rao
Ms. Preeti John
Dr. Vishwa Mohan Katoch
Dr. (Capt) M. Kamatchi
Mr. T.P. Ahluwalia
Dr. G.V. Ramana Rao
Dr. Arti Ahuja
Mr. S. Swaminathan
Ms. Sheena Chhabra
Dr. R. Shankar
174
C. ICONHSS Organizing Committees
Patron:
Thiru M. R. K. Paneerselvam,
Honorable Minister for Health and
Family Welfare, Government of
Tamil Nadu
Advisors:
Ms. Sujatha Rao, I.A.S., Secretary,
Ministry of Health and Family
Welfare, Government of India
Thiru K. Chandramouli, I.A.S.,
Secretary and Director General,
NACO
Dr. Vishva Mohan Katoch,
Secretary, DHR and Director
General, ICMR
President:
Thiru V. K. Subburaj I.A.S.,
Principal Secretary to the
Government of Tamil Nadu (Health
and Family Welfare Department)
Vice Presidents:
Dr. Girija Vaidyanathan, I.A.S.,
Mission Director, Tamil Nadu State
Health Society
Thiru. Ramesh Kumar Khanna
I.A.S., Principal Secretary &
Commissioner of Indian Medicine
and Homeopathy
Thiru. Shambhu Kallolikar I.A.S.,
Project Director, TANSACS
Dr. K. Gopal I.A.S., Managing
Director, Tamil Nadu Medical
Services Corporation
Dr. S. Vinayagam, Director of
Medical Education
Dr. (Flt Lt) P. Nandagopalsamy,
Director of Medical and Rural
Health Services
Dr. S. Elango, Director of Public
Health and Preventive Medicine
Chairman Organizing Committee:
Dr. S. Vijayakumar, I.A.S., Special
Secretary to the Government of
Tamil Nadu (Health and Family
Welfare Department), and Project
Director, TNHSP
Co-chairman, Organizing
Committee:
Dr. Bimal Charles, Project Director,
APAC-VHS-USAID India
Mr. P. Arvind Kumar, Project
Management Specialist – PHN,
USAID India
Technical Advisor:
Dr. Preeti Kudesia, Task Team
Leader, The World Bank
Secretary, Organizing
Committee:
Advisor, TNHSP
Joint Secretaries, Organizing
Committee:
Dr. D. Gurusamy, CEO, TNHSP
Dr. A. Kumaresan, Deputy Director,
TNHSP
Dr. T. Ilanchezian, Director –
Program Operations, APAC-VHS
ICONHSS
2010
175
Coordinators, Conference
Secretariat:
Mr. Simpson Cornelius, PHMI
Dr. Surabi R., TNHSP
Dr. Ravi Kumar, APAC-VHS
1. Coordination Committee:
Dr. Bimal Charles, Project Director,
APAC-VHS,
Dr. (Capt) M. Kamatchi, EA,
TNHSP,
Dr. V. Sukumar, EA, TNHSP
Mr. P. Arvind Kumar, Project
Management Specialist - PHN,
USAID–India
2. Registration Committee:
Dr. T. Selva Vinayagam, TNHSP,
Convener
Dr. K. Vinay Kumar, TNHSP, CoConvener
Dr. M. Raja, TNHSP
Dr. B. Bharathi, TNHSP
Dr. P. K. Amarnath Babu, TNHSP
Ms. V. Jaisee Suvetha, TNHSP
Mr. Pramod K., TSU-TANSACS
3. Finance Committee:
TM. S. Ramesh, TNHSP, Convener
Mr. Velumani, TANSACS, CoConvener
Ms. Shoba, APAC-VHS
4. Abstracts and Posters and
Publication Committee:
Dr. Mini Jacob, TNMMU, Convener
Dr. L. Ramakrishnan, SAATHII,
Co-Convener
Dr. Murali, Chettinad Health City,
Co-Convener
Dr. T. P. Ahluwalia, ICMR
Dr. T. Ilanchezian, APAC-VHS
Dr Jerard Maria Selvam, TNMMU
176
Mr.
Mr.
Mr.
Mr.
Mr.
Dr.
P. Rajendran, APAC-VHS
Saravanan, SIMU
Viswanathan, SIMU
Thaddeus Alphonso, APAC-VHS
Ebenezer, APAC-VHS
Karthikeyan, APAC-VHS
5. Program Committee:
Dr. Sai Subhasree, SAATHII,
Convener
Dr Jerard Maria Selvam, TNMMU,
Co-Convener
Ms. Gayathri Mishra Oleti, APACVHS, Co-Convener
Dr. Mini Jacob, TNMMU
Dr. Preeti Kudesia, The World Bank
Dr. Jammy Rajesh, PHMI
Mr. P. Rajendran, APAC-VHS
Dr. A. Satish Kumar, SAATHII
Dr. Sree T. Sucharitha, SAATHII
Dr. L. Ramakrishnan, SAATHII
Ms. Sheena Chabbra, USAID –
India
Dr. K. Vinay Kumar, TNHSP
Dr. Padmanaban, NHSRC
Dr. Devadasan, IPH, Bangalore
Dr. Ravi Kumar, APAC-VHS
6. Inaugural Function Organizing
Committee:
Dr. D. Gurusamy, TNHSP, Convener
Dr. Prabhu Clement, NRHM,
Co-Convener
Dr. K. Gunasekaran, DD, TNHSP
Dr. Jerard Maria Selvam, TNMMU
Ms. Uma Ravi Kumar, TNHSP
Support staff from TNHSP
7. Logistics Committee:
Dr. T. Ilanchezian, APAC-VHS,
Convener
Dr. K. Gunasekaran, TNHSP,
Co-Convener
Mr. N. Swaminathan, TNHSP
Mr. Bakthavatchalam, ARM
Mr. Hariharan, ICWO
8. Publicity / Media Coordination
Committee:
Mr. Tharani Singh, ADPH, Convener
Ms. Jayasree B., TAI
Ms. Indhu Sivakumar, TSUTANSACS
Mr. Pradeep, TNHSP
9. Committee to Coordinate with
Government Officials - Chennai:
Dr. Porkai Pandian, Convener,
Dr. Raja, Co-Convener
Mr. G. Gnanaselvam, TNHSP
Dr. D. Gurusamy, TNHSP
Dr. V. Sukumar, TNHSP
13. Transport Committee:
Dr. Ravi Babu, TNHSP, Convener
Dr. Nithyanandham, SIMU,
Co-Convener
Dr. D. Gurusamy, TNHSP
14. Volunteers Committee:
Dr. Rachna William, TANSACS,
Convener
Ms. Indhu Sivakumar, TSUTANSACS Co Convener
Mr. Satyan Rajkumar, TANSACS
Mr. Asokan, RRC - TANSACS
15. Catering Committee:
Dr. T. Ilanchezian, APAC-VHS,
Convener
Dr. Mrs. Punitha Kumaresan,
Co-Convener
10. Cultural Programme
Committee:
Ms. Indhu Sivakumar, TSUTANSACS: Convener
Dr. M. Kuppulakshmi, TNHSP
Dr. N. Chandravadana, TNHSP
Dr. Punitha Kumaresan
16. Exhibition Committee:
Mr. Pramod. K, TSU-TANSACS,
Convener,
Mr. Tharani Singh, ADPH,
Co-Convener
Mr. Pradeep, TNHSP
11. Field Visit Committee:
Dr. A. Kumaresan, TNHSP, Convener
Mr. Murali, TNMSC, Co-Convener
Dr. P. K. Amarnath Babu,
TNHSP239
17. Emergency Contact:
Mr. Thaddeus Alfonso
Dr. Ravi Kumar
Dr. Jerard M. Selvam
Conference Secretariat, ICONHSS
12. Reception Committee:
Dr. Mary Julia Jebakumari Solomon,
TNHSP, Convener
Ms. Indhu Sivakumar, TSUTANSACS, Co-Convener
Dr. B. Bharathi, TNHSP
Dr. S. Sivapriya, TNHSP
ICONHSS
2010
177
D. Partners and Collaborators
Government of India and Union Ministry of Health & Family Welfare
(www.india.gov.in/ www.mohfw.nic.in)
Government of Tamil Nadu and Tamil Nadu Ministry for Health and Family
Welfare (www.tn.gov.in/ www.tnhealth.org)
The World Bank (www.worldbank.org)
USAID India (www.usaid.gov/in)
AIDS Prevention and Control (APAC) Project – VHS (www.apacvhs.com)
National AIDS Control Organization (NACO) (www.nacoonline.org)
Indian Council of Medical Research (ICMR) (www.icmr.nic.in)
World Health Organization (WHO) – Country Office for India (www.who.org
Tamil Nadu State Health Society (www.tnhealth.org)
Solidarity and Action Against The HIV Infection in India (SAATHII)
(www.saathii.org)
The Tamil Nadu Dr. MGR Medical University (TNMMU) (www.tnmmu.ac.in)
Public Health Management Institute (PHMI) (www.phmi.org)
Chettinad Health City (CHC) (www.chettinadhospitals.com)
eHealth Magazine (www.ehealthonline.org)
Directorate of Medical Education (DME) (www.dmetn.org)
Directorate of Medical and Rural Health Services (DM and RHS)
Directorate of Public Health and Preventive Medicine (DPH and PM)
Tamil Nadu State AIDS Control Society (TANSACS) (www.tansacs.org)
Tamil Nadu Health Systems Project (TNHSP) (www.tnhsp.org)
178
E. Chennai Declaration
ICONHSS
2010
179
www.iconhss.com

iconhss report 2010

Transcription

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