Chikitsa -Revamping The Health Sector of Maharashtra 2015

A Book By-Dr Shyam Ashtekar
(MD-Community Medicine)
CHIKITSACHIKITSA
REVAMPING
THE HEALTH SECTOR
OF MAHARASHTRA
AN ENGLISH SUMMARY OF MY
MARATHI BOOK
Granthali Publication-Mumbai, May 2015

Outline of this PowerPoint document
A. Introduction
B. Maharashtra Situation &
Challenges
C. System Context &
Abbreviations
AYUSH Ayurveda, Yoga, Unani, Siddha and Homeopathy
BEmOC Basic Emergency Obstetric Care
CET Common Interest Test
CME Continuous Medical Education
CSR Corporate Social Responsibility
EmOC Emergency Obstetric Care
ESIC Employees State Insurance Corporation
ESIS Employees State Insurance Scheme
FDA Food and Drug Administration
HR Human Resources
MCI Medical Council of India
2
C. System Context &
argument for change
D. Suggested10-point plan
E. Summary & Comments
F. Contact, author info.
5/27/2015CHIKITSA-Revamping the Health Sector of Maharashtra-Shyam Ashtekar
MCI Medical Council of India
MMC Maharashtra Medical Council
NHS National Health Scheme
OOPE Out of Pocket Expenditure
OPD Out Patient Department
PCP Public Charitable Partnership
PCPNDT Pre-Conception and Prenatal Diagnostic Techniques (Act)
PG Post Graduate
PHC Primary Health Center
PPT Public Private Partnership
PSU Public Sector Unit
RGJY Rajiv Gandhi Jeevandai Yojana
RSBY Rashtriya Swasthya Bima Yojana
SHI Social Health Insurance
SPV Special Purpose Vehicle
UHC Universal Health Care

Cover page
Blurb
(A) Introduction3
Blurb
What this book offers

The Cover Page-A Rubicube
The rubicube says it all-
we have to manage the health
sector with given resources
and opportunities,
4
and opportunities,
recombining various factors
and bringing on new
equations and partnerships

On the Blurb
The complexity of health medical sector , with its
technology, costs and insurance sector implies
that free care for all is an impossible
proposition that no government can start or
manage, like crossing a chasm in half a step..
We should rather develop participatory health
care schemes (Social Health Insurance)
5
care schemes (Social Health Insurance)
towards affordable care of good quality,
while improving free care for BPL.
This book gives a graphic plan of how the new
state Government can to go about
incremental health sector reforms for
Maharashtra in the given situation

What This Book Offers
A situational analysis of the
health sector of Maharashtra
in 2015- the mix of private
public health care sectors,
status of each sector, the
medical education, ESIS,
insurance, Governance,
Plan for affordable health
care for all through
participatory schemes (free
care for poor retained and
improved) rather than the
6
insurance, Governance,
administration
A global perspective of
health systems within welfare
and socialist states, liberal
economies, developed vs
poor nations, the problems of
state run or US like models
improved) rather than the
unattainable goal of free
care for all through taxes.
A graphic approach on how
to develop health sector of
Maharashtra , from 2015 to
5 and 10 years later.

Maharashtra-General
Health-Achievements-
(B) Maharashtra-Situation & Challenges7
Health-Achievements-
Health-Challenges
Situation- Health Mumbai

Maharashtra- General
Maharashtra is a progressive and somewhat
industrialized, urbanized (50%) state in India.
The state spends Rs 10000 crores per anum on all
health sector, and people spend (OOPE) about 3 times
this.
Central and state Tax funds for health have remained
8
Central and state Tax funds for health have remained
scarce for six decades in India, and states are unable
to meet the gap. The state has a debt of 3 lakh crores
and 17% revenue shortfall.
Wide inequality from metros to tribals
Nearly 50% urbanized

Maharashtra Health 2015-Achievements
Well spread network of health care,
ambulances
Supply of doctors/hospital beds-(1doc:600
people),
9
More Medical & AYUSH colleges than any
state
Favorable decline in home births, mortality
(CDR, CBR, IMR, MMR), Child malnutrition
(except some 20 blocks)

Maharashtra Health 2015-Challenges
High costs of care.
Overindulgence, unfair practices?
Tertiary care in corporate sector.
Decline/stagnation of quality of med-education
and care
10
Deterioration of public institutions
Decline of ESIS
Oversupply & urban clustering of consultants.
Shortfall of nurses and paramedics
Rising load of non-communicable diseases,
ageing and costs of care

Situation -Mumbai
(Based on Praja Foundation Report)
Stable level/decline, of
malaria, TB, diabetes, high BP
About 11-44% medical/other
posts vacant in public health
institutions, HR discontent!
Only major public hospitals
About 7-8% of family
income spent on health,
across income groups
Medical insurance cover
12% (poor families) to
11
Only major public hospitals
for tertiary care, second rung
hospitals only deals with
general and mother-child
Huge presence of Pvt care in
all three levels
12% (poor families) to
32% (rich families)-
average 20% families
Satisfaction score for Pvt
care is 84%, and 68%
for Public health facilities

Guiding principles
Reality check-welfare state-global map
( C) Systems Context & Argument for
Change
12
Reality check-welfare state-global map
Health spend of OECD and India
Overview of health systems-NHS, SHI, US, India
Limitations of private insurance model
Argument for Change

Guiding Principles for Health Care
1. Emphasis on primary and preventive care more than hospitals
2. Scientific (evidence based) and rational.
3. Ethically sound (see MCI code)
4. Humane, sympathetic
5. Affordable-for Govt and Citizens
13
Affordable-for Govt and Citizens
6. Protection for poor/needy families (good quality free care)
7. Preserve and restore AYUSH in health care.
8. Health is Right with Responsibility and participation (legal
right to health care is problematic)
9. Use existing public facilities neatly before launching new big
projects.
10. Review needs, costs, practices, outcomes, options etc

Reality check of Welfare state (>20% of
GDP) limited mainly WESTERN economies
14

The Health
spend in OECD
countries (6-
15%) and
15
15%) and
India (4%) with
3:1 Pvt-public
share

Overview of Health Systems (1)
NHS (UK) 9% of GDP-
Yet Serious delays in care
SHI (Germany) 9% GDP-
No serious crisis
16

Even in UK NHS-delay and costs (at
9% of GDP) are threatening-17

Overview of health systems (2)
USA ->17%
of GDP on
Health
Care,
18
Care,
More with
Obamacare

Overview of health systems (3)
India’s
Mixed care
(4% of
GDP)-30%
19
GDP)-30%
Public,
70% Pvt
Care

SHI systems are more participatory, stable
and rooted in the society-From R Saltman
An insider’s perspective..
The attraction of the SHI approach for both citizens and policy-
makers appears, on initial viewing, to be based on 3 structural
characteristics.
•SHI..seemingly private in both the funding and delivery of
health services.
20
health services.
•SHI systems ..self-regulating, managed by the participants
themselves (e.g. sickness funds, physicians and, to a lesser
degree, patients).
•SHI ..perceived as stable in organizational and esp. financial
terms.
This stability often appears to be the most highly prized of all
the outcomes associated with SHI systems.

Limitations of Private Insurance Model
No involvement of Govt
Only 3-32% people are
med-insurance covered
in India (Mumbai
average 20%)
21
average 20%)
80% business with
Indian PSUs
Premiums rise annually
20% overheads
Overbilling, conflicts

The Argument for change
WE can plan and manage to get good quality
care in primary-secondary-tertiary structure
harnessing the Public-Private spend, improving
the functioning of public institutes, and
reorienting institutional arrangements mainly
22
reorienting institutional arrangements mainly
with not for profit sector.
And we need do all this within a public health
framework of health sector management in a
changing India.
Need to make our public institutes efficient and
responsive.

1. Governance
2. Human Resources
Health Expenditure and constraints/comments
(D) The plan, suggestions23
3. Health Expenditure and constraints/comments
4. A proposed SHI model
5. Primary care
6. Free and affordable hospitals
7. Drugs, AYUSH and technology
8. Preventive programs
9. Care of special groups
10. Small family and demography
11. Review of medical Acts/laws

The Reform program- 10 sector radar
2
3
4
5
6
7
8
9
10
Governance/admin
Affordable Hospitals
Participatory Health
Schemes
Small family
Review medical acts
24
0
1
2
Schemes
Primary Care
HR
Drugs/techno/AYUSH
Prevention and
Nutrition
Care for Special
group
2015
2020
2025

1. Governance and administration
Integrate Medical education and Public Health depts
(Also FDA)under one minister, Pr secretary
Remove disadvantages of Public Health Dept HR vis a
vis Med Ed & Research, establish mutual exchange of
doctors/staff
Involve village panchayats to own and manage
25
Involve village panchayats to own and manage
subcenters
Convert subcenters into Ayurvedic Dispensaries
Encourage Municipalities to start, own and manage
financially sustainable hospitals/health centers
(Need to merge National Health Mission into Health
Dept)

2. Human Resources
Serious quality gaps in
Medical education, CETs
PG Entrance Exam playing
havoc with graduate
learning, skills, attitudes
both in Govt/Pvt institutes
Can we legally scrap CET
& PG Entrance Exam, restore
importance of board &
grad exams?
Review of syllabus
Better administration of
26
learning, skills, attitudes
both in Govt/Pvt institutes
Overproduction of doctors
& AYUSH grads but
undersupply of
nurses, paramedics
Serious distortion of ratio
basic doctor : Post Grad
Better administration of
colleges- and training
Expand Nursing education
Paramedic Council and
institutions
RESEARCH??

2.Health Services Doctors get a rough deal
Compared to doctors in Medical
Education dept, Health
Services Doctors get a rough
deal,
27
Stay rural, 40% less pay
Stagnate-fewer promotions &
opportunities
30% on annual contract-for
years

2. HR-General Issues
Long pending demands of
resident doctors and rural
medical officers-with or
without financial implications
need to be attended.
Vacant positions despite
28
Vacant positions despite
oversupply of doctors
A good HR management and
leadership is necessary for
improving compliance and
quality of care in
PHCs, hospitals and colleges

3. Public Health Exp (crores) Maharashtra (2013-14)
Budget Est -Public Health Exp in Mah 2013-14 (cr Rs)
Secretarial services 105
Public Health dept 3395
National health Mission 101
Jeevandayi Yojna* 695
ESIS 220
Mah AIDS control scy 418
Secretarial
services
1%
Public Health
dept
34%
admin
and
others
0%
BMC and other
municipal
bodies
25%
29
Mah AIDS control scy 418
FW 684
Med Ed and Research 1624
Ayurveda etc 223
FDA 66
admin and others 22
BMC and other municipal bodies 2500
Total 10053
National health
Mission
1%
Jeevandayi
Yojna*
7%
ESIS
2%Mah AIDS
control scy
4%
FW
7%
Med Ed and
Research
16%
Ayurveda
etc
2%
FDA
1%
0%

Health Care Finance
Maharashtra spends about 10000 cr on all public health care-
of which is about 25% is from Municipal bodies
About 30000 cr possibly comes from Private expenses (OOPE)
Free Care for All is a daunting challenge due to constraints on
state (& central) budgets (need 20-30000 cr more for this)
30
state (& central) budgets (need 20-30000 cr more for this)
..Even then we cant guarantee delivery of good care.
Tax based health care models have other problems that the
UK NHS is facing for the last decade(s)—delays, queues, rising
costs, inefficiency etc– All this at 9% of GDP)
No Indian Govt can start and manage such a Free -UHC, and
there can be no retreat if any Govt starts a Free-UHC

Towards a Social Health Insurance model
Affordable care is feasible, free care for
all is NOT feasible
It will be better to step up public health
care with innovative participatory
models, low cost hospitals run by Medical
colleges, local bodies, non-profit
Choose the right model and approaches
31
colleges, local bodies, non-profit
bodies, ESIS and CSR for rural hospitals
etc- The supply side!
Expand RSBY, ESIS and RGJY (Jeevendayi)
by allowing entry of middle class families
with attractive premiums and services- The
demand side.
Strengthen primary care, pre and post
hospital care

A Suggested financial Model Participatory
Health Care
32

4. Primary Care
Train professional paramedics for urban and rural
settings, home care etc
Select health subcenters can be handed over to
panchayats willing to run part-time Ayurvedic or
33
panchayats willing to run part-time Ayurvedic or
other dispensaries with 50-50 shared support and
small user fees
Evening OPDs in all public health facilities
Primary care info sources in Marathi
CME for General Practitioners

Expand Primary Care- Using the health
Subcenter
Hand over select health subcenters to panchayats
for part-time dispensaries with 50-50 shared
support and small user fees
We can appoint part-time Ayurvedic doctors to
34
We can appoint part-time Ayurvedic doctors to
health subcenters
We have 10000 subcenters, and a shared scheme
will cost only 500 crores per anum to the state, rest
borne by users/panchayats/CSR

Primary Care-ArogyaBanks (AB) or
Health Kiosks
In places where we don’t have even
health subcenters, we need some
quick-fix solution
Arogyabanks can serve this purpose
http://bharatswasthya.net/download
35
http://bharatswasthya.net/download
Trained paramedics (ASHA+ to ANM)
can take over Abs
AB will have 20 medicines for 50
common illnesses and some basic tasks

5. Free and affordable Hospitals
Manage the Rural Hospital for BMOC, and
for EMOC with mobile teams to give EMOC
Encourage genuine PCP (Public Charitable
Partnership) with start up assistance/CSR and
RSBY+RJGY schemes Public
PCPs
36
RSBY+RJGY schemes
Improve public hospitals with CSR, open
paid/insurance wards for middle
classes, incentives to in-service doctors/staff
Develop/Improve Govt/Pvt medical college
hospitals for tertiary care
Open up RSBY & RJGY for middle class
participation with affordable premiums.
Open and
Expand RGJY
for middle
classes
Public
Hospitals

6. Drugs, Technology & AYUSH
Set up an advisory committee to review
drugs/technology choices, costs and issue guidelines
Explore alternative technology options-old and new-
for important health problems
Promote Standard Treatment Guidelines, make these
available online,
37
Promote Standard Treatment Guidelines, make these
available online,
Periodic audit/studies/monitoring use of
drugs/technology in public and private sectors.
Use telemedicine (and mobile phones) for improving
patient care and education.
Promote AYUSH esp. at subcenter level, AYUSH
research

7. Preventive Programs
Open up preventive programs on
obesity, diabetes, hypertension, accidents, tobacco
use, alcohol addiction etc
Effective programs on mosquito- borne diseases, greater
citizen participation and responsibility.
Awareness and action program for preventing malnutrition
38
Awareness and action program for preventing malnutrition
from childhood to adolescents.
Commission studies on growth in child-adolescent age
groups using both secondary and primary data.
Water pollution, esp. hardness/chemical pollutants are an
important emerging problem.
Open defecation rampart in many districts, while programs
are not matching needs

8. Care of Special groups
People with old age, sex workers, risky occupational
workers, vimukta jatis, nomadic tribes need special
attention as regards health protection and
enhanced services may be with specially trained
paramedics
39
paramedics
Endangered tribes (like Kolam) need special care
programs
We need to understand malnutrition of various
tribes, specific causes if any and interventions

9. Small Family, Demography
The family size in both urban and rural population
(including general tribal population) has reduced in
Maharashtra, below the replacement level
However sex ratio at birth (894) declined, implying
continued son-selection. Need to go beyond PNDT
40
continued son-selection. Need to go beyond PNDT
Family size is still large in some tribal societies (like Bhils
and pavara) and minorities. This hurts the health of
women and children. Meet the unmet need!
Early age of marriage/child-bearing is a problem in
Marathwada districts--needs attention.
Also a general need of spacing of births.

10 Review of Medical Acts
Several medical acts are either
ineffective or counterproductive.
Need to review PCPNDT, Clinical Est
Act, MMC (even MCI at central
41
Act, MMC (even MCI at central
level), consumer protection, legislation
regarding cross practice. Some laws are
hardly used-for instance act against
violence against doctors.

(E) Summary42

Summary & Comments
Health sector improvement calls for joint efforts from
State Govt, professional associations and users
A somewhat deconstruct plan of reforms based on the
10-sector radar-diagram (though many sectors are
variously interconnected).
Incremental effort on these lines can achieve free care
43
Incremental effort on these lines can achieve free care
for poor and affordable health care for all with a
participatory approach.
Free care for all is not feasible technically, legally or
financially. It may be a counterproductive, costly
model which no Govt with current and foreseeable
constraints can undertake or manage or even exit
from.

Comments from an economist (1)
Govts (in India) are working under severe financial
constraints, hence raising allocations see to be difficult. But..
Under the revised guidelines of the RBI on the priority sector
lending of banks, health care has been included for raising
loans at about 9% interest.
The total CSR obligation is placed at Rs.20, 000 crore worth
44
The total CSR obligation is placed at Rs.20, 000 crore worth
of funds. For Maharashtra a notional 10% of this is 2000
crores (theoretically the spend can be anywhere in India)
annually.
The state needs to raise a SPV to harness these funds &
credit facility, For instance, there can be an SPV for 400
rural hospitals, or all municipal hospitals or any social sector
task.

Comments from an economist (2)
The Govt of Maharashtra can formulate a model
design of the scheme with support of concerned experts
to create an institutional framework to take advantage
of both these provisions. Govt- corporate sector-banks-
public [community] participation.
Govt. of Maharashtra must do a mapping or inventory
45
Govt. of Maharashtra must do a mapping or inventory
of all the public hospitals/ dispensaries/ health care
centers [govt. or municipal] and assess their land, real
estates and other similar physical assets. Unutilized land
or infrastructure capacity of such facilities can be
leveraged under the four P model for expanding the
health services.

How to get this Marathi book
Contact details of author
Contact details, author info46
Contact details of author
Author information

How to get this Marathi book
Book-CHIKITSA Arogyasevanchi (By Dr Shyam Ashtekar)
ISBN-978-93-84475-38-3
Available at all Granthali Prakashan outlets. Granthali PAN No -
AAATG2479B,
You can purchase online at Cost per book Rs180/
(includes posting/courier)
Bank Name - IDBI Bank Branch- Dadar (East) Mumbai 400 014
IFSC Code -IBKL0000454 Account Name – Granthali
47
Bank Name - IDBI Bank Branch- Dadar (East) Mumbai 400 014
IFSC Code -IBKL0000454 Account Name – Granthali
Current Account No- 0454651000000356
1 Please transfer the amount in the Granthali Account by RTGS/NEFT
2..DO NOT forget to email to granthali02@gmail.com about sending the
said book, copies and address with phone number
3. Granthali will send the book after the confirmation of amount in about
one week by courier or post
4 For help you can call Ph022 24216050/24306624 between 11.30 to 5
pm all days except Sunday/holiday. Contact person shri Mahesh
or Smt Dhanashree on this number.

Author Information
MBBS (1978), MD, Community Health (1985)
Worked in rural health center, Municipal health
dept, medical college, NGOs, Community Health
networks, and as Founder Director of School of Health
Sciences at YCM Open University
Study of health systems of China, UK, Germany, USA in
1997-2000 with MacArthur Pop fellowship
48
1997-2000 with MacArthur Pop fellowship
Learning material / Marathi and English books for health
workers, paramedics, National ASHA program
Review of health systems, Nutrition programs, training
programs etc
Open info sites for primary care in Hindi bharatswasthya.net
, Marathi arogyavidya.net
Contact: 9422271544
Email-shyamashtekar@yahoo.com,
21 Cherry hills society, Anandwalli Nashik 422013

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