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Hc in the new millenneum

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Hc in the new millenneum

  2. 2. 20th Century Ecstasy: unprecedented progress by medical sciences during last 4 decades Tragedy: EID like AIDS (a global crises) Trauma: Political unrest, human rights issues, disasters, inequalities, etc. Romance: eradication of smallpox & polio, information superhighway, mapping of human genome, breakthroughs in nuclear & molecular sciences including reproductive biology.
  3. 3. H AL H M E T : OST VAL UAB E P L SE L UB IC RVICE Health is fundamental to quality of life Health Services: a personal answer to personal needs Government should guarantee the existence of HC system providing equal, accessible, comprehensive & high quality care to all.
  4. 4. HEALTH: MOST VALUABLE PUBLIC SERVICE HC : largest industry & its sheer size & complexity makes change an evolution of mammoth proportions  No other sector reaches as many people, as the HS, its market being assured, whatever the odds. 
  5. 5. H AL H E T CARE T RANSF ORM ION AT  Epidemiological & demographic transitions  Improved Life Expectancy (aging)  A better-informed & more demanding populace  New technologies & expansion of scientific knowledge  Universal trend towards greater decentralization pro-market economic policies, purchaser-provider split, rapid expansion of Pvt. Sector, introduction of user charges.
  6. 6. GRADUAL DE CAY We have observed with considerable consternation the gradual but sure decay in Health services The outbreak of Malaria in virulent form, return of Dengue (Delhi-1996) & Plague (Surat1994), EID (Tuberculosis) are some clear signs of this decay.
  7. 7. DOUB E B L URDE OF DISE N ASE We are also living under two shadows – one of infectious diseases and the new and growing shadow of non-communicable chronic Diseases
  8. 8. DOUB E B L URDE OF DISE N ASE II T health transition is due to he combination of demographic & life style changes, industrialization & urbanization  A thorough review of NH & a P total revamping & restructuring of the health infrastructure 
  9. 9. DICH OM OT Y T large widespread health he infrastructure seems to be nonfunctional & unresponsive in many parts. Instead of moving forward to meet the health challenges, it is sliding backward.  E xtremely uneven health & development process in various parts of the country  One can hardly believe that they are part of same nation. E ven with in the states which are doing reasonably well there remain regions of darkness where little has changed since independence. 
  10. 10. L IVING ON T E E H DGE AN AGE OF DARKNESS & LIGHT   World has 450 billionaires: with the value of their combined assets now exceeding combined income of poorest 50% of world’s people These are obscenities of excess in a world where 160 m children are malnourished, 840 m live without secure sources of food & 1.2 b lack access to safe drinking water A KNOELEDGE-BASED SOCIETY  Basic immunization saves lives of > 3 m every year in developing countries
  11. 11. WE LIVE IN A WORLD OF DISTURBING CONTRASTS 3/4ths of the world’s people live in developing count. enjoy only 16% of the world’s income  More than 1B people lack the opportunity to consume in ways that would allow them to meet their most basic needs  More than 17 M people die every year from infectious & parasitic diseases(D,M,TB)  Challenges: reducing pop. growth, providing basic social services 
  12. 12. WE LIVE IN A WORLD OF DISTURBING CONTRASTS II More than 90% of HIV infected cases liv in developing country Developing countries witnessed unprecedented human develop. in past 30 years, it has covered as much distance during those 30 years as industrial world did in a century. But human deprivation remains Resources to be generated by cutting
  13. 13. CURRE H AL H ST US IN INDIA NT E T AT India’s public sector health expenditure today is Rs.10,000 crore per year (which is being spent on 4800 hospitals, 450000 beds, 11100 dispensaries, 21802 Primary Health Centers, 132285 Sub – centers & various preventive & promotive programs, including family planning) In India, life expect. has doubled from 32 yrs (1947) to 63 yrs. in 2000 & IMR declined from 146 to 70 Many disparities & distortions remain. Progress has been uneven Consequences: neglected areas, forgotten populations & overlooked issues.
  14. 14. H ealthcare E xpenditure HC system absorb 8% of the total world product  Industrial countries spend 90% of this amount, with average per capita exp. of $1500 on HC as compared to $41 in developing countries  India spends 1.6% of GDP (even lower prop. spent on PH  The institutional base is weak, NGO’s are underutilized, & finally pvt. sector is gigantic, virtually completely unregulated & offers some 
  15. 15. THE DRIVERS OF CHANGE  Drivers of change in developed world are reaching limits of welfare state exhausting traditional methods of containing cost & expecting increasing
  16. 16. THE DRIVERS OF CHANGE II No HC system in the world is stable Growth of Middle Class, greater demands from the middle class, & globalization of economies are driving
  17. 17. E IDE IOL P M OGICAL P RSP CT E E IVE F OR H C M ANAGE E M NT Population’s ability to benefit from HC An understanding of the characteristics of pop. (tends in size, demographic & social characteristics/distribution of exposures that could influence
  18. 18. E IDE IOL P M OGICAL P RSP CT E E IVE F OR H C M ANAGE E II M NT Assess how & when HN are distributed throughout a pop. & evaluate the use & efficiency of interventions Assessment based on incidence & prevalence on one hand & effectiveness of HC on the other
  19. 19. M DICAL E E DUCAT ION M edical education is at the cross roads today.  Society wants to respond to people’s HN with interventions that are relevant, efficient, affordable & equitably accessible to all its members. 
  20. 20. M DICAL E E DUCAT ION II Doctor of the future:  A caregiver  Communicator  Decision maker  Community leader  A good manager  Med. Uni. should introduce accountability, creative autonomy, quality & new methodologies, for preparing future doctors to function properly in society.
  21. 21. M DICAL E E DUCAT ION - III Agenda for action:  Setting up of a National HR Dev. Comm.  A comprehensive ban on Med. College expansion  Strengthening MCI to control fall in standards  Examination reform
  22. 22. M DICAL E E DUCAT ION - IV Developments in ME include:  Curriculum planning (PBL, TBL, Community orientation)  Assessment (performance-related/objective structured Clinical Exam./assessment of critical thinking)  Teaching & learning (simulation, computerassisted, multimedia) 
  23. 23. E E M RGING INF CT E IOUS DISE S ASE  Leading cause of death worldwide/17 m die/year  Malaria, TB, Dengue, Hem. Fever, Hepatitis, JE, Ebola Virus, Hanta virus, yellow fever, E. Coli 0157, Kala-azar, plague, BSE threaten lives of millions of people  An outbreak of Cholera in Mexico-300 deaths, plague in India: loss of $1.7m/Zaire & entire world dodged a bullet in 1995 - outbreak of Ebola
  24. 24. E E M RGING INF CT E IOUS DISE S II ASE Tackling EID:  Pro-active & planned approach should include 1. Preparatory state 2. Alert phase 3. Response phase 4. Follow-up phase  Information system be developed.  Comprehensive communication strategy  Infrastructure & capacity building
  25. 25. H ealth Services in Rural Areas 80 % rural population utilize 20% resources & 20% urban population gets 80% resources  Basic goal of decentralized planning is to eliminate poverty, ignorance & ill-health, improve the QOL of people & raise their standard of living  HS pro vide d sho uld be : - accessible, available on a continuing basis, acceptable culturally & socially, affordable 
  26. 26. H AL H OF W E CH DRE & E DE Y E T OM N/ IL N L RL Social, health & nutritional status of the most vulnerable sections of society reflect the real index of development. India ranks 135th in the list  Marginalisation of women  Children are the future of a society  India has the dubious distinction of having highest no. of infant deaths in the world.  Elderly persons: 7.6% population is likely to increase 
  27. 27. CONT ROL OF COM UNICAB E DISE S M L ASE        Good environmental sanitation Prompting Healthy life styles Undertaking control or Eradicating Programs Proper Organizational Set-up with Effective Leadership Strengthening General Health Services Comprehensive & vibrant Epidemiological services Disease specific measures for control of high priority infection (TB, Malaria, AIDS, RTI,
  28. 28. POPULATION STAB: A DILEMMA India has crossed the billion mark  Unchecked pop. growth negates all progress made  Tremendous pressure on resources  With present growth, India will have 1600 m faces in 2025 that will be deprived of constitutional guarantee of health/ education/nutrition/ 
  29. 29. POPULATION STAB: A DILEMMA II Nearly 1/3rd of children >16 are forced to lead an impoverished life/150 m were denied basic HC/226m drink contaminated water/640m do not have access to basic san. & 50% of world’s illiterates  Eradicate illiteracy & Communicate effectively  Eliminate corruption 
  30. 30. T EP H RIVAT H AL H SE OR E E T CT Today, HC has become fully commodified  A fairly large investment by Pub. Sector (that is otherwise inadequate) is being wasted  Pvt. Sector responsible for 3/4th of HC  Given current ethical standards Pvt. Sec. doesn’t provide quality at reasonable cost 
  31. 31. CH ANGING H AL H & H E T C P ARADIGM We have to look beyond so called predominantly reductionist biomedical model of HC to a holistic model that puts human being in the center  The total participation of its citizens  Progress is easiest made if we r tuned in with national genius  New ideas are being discussed:  (Birth with a future/dying with dignity/rationing of care/total body systems conditioning)
  32. 32. CH ANGING H AL H & H P E T C ARADIGM QUAL Y M IT ANAGE E M NT In medicine poor quality is expensive  Patient safety can not be compromised  We can no longer afford high cost of low quality  Quality management is scientific 
  33. 33. EMERGENCY HEALTH CARE Emergency Situations requiring immediate attention occur frequently  Bhopal Gas tragedy/Earthquake in Latur & Gujrat/Cyclone in Orrisa/Rail Accidents  When managed appropriately, good chance of survival  Preserving life, disability limitation  Emergency preparedness/EMS/CATS 
  34. 34. MENTAL HEALTH Mental illness is not a personal failure. Rare is the family that will be free from an encounter with mental disorder. Neuropsychiatric conditions accounted for 10% of burden out of an estimated 39% of all DALYs Wide gap between availability & implementation of effective interventions Theme of WHD 2001: “Stop exclusion, Dare to care” New understanding, new hope: combining science & sensibility to bring down barriers to care & cure Mental health care needs less costly technology
  35. 35. Mental health - II • • • • • • • • • Provide treatment in primary care Make psychotropic drugs available Give care in the community Educate the public Involve communities/families/individuals Establish national policies, programs Develop human resources Link with other sectors Support more research
  36. 36. DE L M NT & T E E VE OP E H NVIRONM NT E The achievement of sustained & equitable dev. remains the greatest challenge facing human race >1 B people still live in acute poverty & suffer Inadequate access to resources Essential task of dev. Is to provide opportunities In developing countries 30% of pop. Lack access to safe water & 60% to basic sanitation >90% of waste water discharged into streams/rivers resulting in water borne dis. Air pollution from industrial emissions, car exhaust etc. kills >2.7m people/yr. Domestic solid waste – 50% remains uncollected Cost of environmental degradation in India: 6% of GDP
  37. 37. DE L VE OPM NT & T E E E H NVIRONM NT E -II Excess CO2, Methane etc. trap heat are accumulating in troposphere. Global Warming Priority should be given to: 1/3rd of world’s pop. that has inadequate san. & 1 B without safe water 1.3 B people who are exposed to unsafe conditions caused by soot & smoke 700m women/children who suffer from indoor air poll. Hundreds of millions of farmers livelihoods depend on good environmental stewardship Millions of deaths each year from dirty water &
  38. 38. HUMAN DEVOLOPMENT & GENDER EQUALITY History is likely to judge the progress in the 21st century by 1 major yardstick:is there a growing equality of opportunity between people & among nations The most persistent disparity has been Gender Disparity Women still continue 72% of world’s poor & 2/3rd of worlds illiterates Human development if not engendered, is endangered Investing in Women’s capabilities & empowering them.
  39. 39. E RADICAT ING P OVE Y RT Poverty has many facts. It is much more than low income. It also reflects poor health & education, deprivation in knowledge, etc The world has the resources & know how to create a poverty-free world in less than a generation Over the past 3 decades more than a dozen developing countries have shown that it is possible to eliminate absolute poverty Poverty is not to be suffered in silence by the poor.
  40. 40. INVESTING IN HUMAN DEVELOPMENT •Countries must invest liberally in human development so that they are ready to face the challenge of Globalization • Globalization is integrating consuming markets around the world. But it is also creating new inequalities • The time has come to create a new world that is more humane, more stable, more just Components of Human Development paradigm:
  41. 41. T ARDS DE L ING A CIVIL OW VE OP SOCIE Y T Consumption levels of more than a billion poor people must be raised Strong civil society alliances should be built to protect consumer rights What is the meaning of growth if it is translated into the lives of the people Empowering people – perticullarly women – is a sure way to link growth &
  42. 42. RESPONDING TO THE CHALLENGE Need for better resource allocation & need for improved utilization of funds  Employment & income generation  Secondary & tertiary medical care (subsidy for poor)  PHC for All  Fiscal incentives for backward areas (to encourage pvt. Practitioners to open clinics in remote areas  
  43. 43. RESPONDING TO THE CHALLENGE Reaching the Out reach  Panchayat raj  User costs (China exp.),Use of pub. facilities by vulnerable sections can increase despite increase in user charges, if quality is improved as (e.g. Pakistan)  Contracting out  Fiscal incentives for backward areas (responsibility of Govt.), increased pvt.
  44. 44. ACCREDITATION / REGULATING MEDICINE Mushroom growth of Nursing Homes: a source of concern because of substandard Pt. Care & unethical practices  1 or 2 room shops with a scant regard for standards can not be accepted as HC institutions.  Assure consumers that no practitioner without appropriate registration is treating a patient  Establish credibility of service – develop  comp. standards  Aims: Vol. pursuit of Q/team building,
  45. 45. ACCREDITATION / REGULATING MEDICINE Regulation of M & practice should C include: Institutionally delivered HC Clinical Audit/TQM/CQI  MCI must be strengthened to improve self-regulation  Enhancing levels of medical Accountability
  46. 46. Future Health Goals/Core values of Med Prof Refocus recourses on those who need the most  Poverty reduction by investment in most basic needs ( food, safe water, sanitation & access to social service  Universal HC for all  Sustainable development  Equity promoting  Safe & healthy environments & living conditions  To enable all people to adopt & maintain healthy l lifestyles & healthy behavior 
  47. 47. Future Health Goals/Core values of Med Prof CORE VALUES:  Caring  Commitment  Compassion  Integrity  Competence  Spirit of enquiry  Confidentiality  Responsibility  Advocacy
  48. 48. M ANAGE CARE D Developed in response to ever increasing HC costs Important Tools of MC:  For managed demand 1. Capitation 2. Gatekeeper 3. Advice line to patients 4. User fees 5. Consumer education  For medical management 1. Utilization review 2. Preadmission certification 3. Greater use of cl. Pathways  For care delivery: 1. Telemedicine
  49. 49. M ANAGE CARE II D HC system can be grouped into 4 archetypes:  Socialized medicine (UK)  Socialized insurance (Canada)  Mandatory Insurance (Japan)  Voluntary Insurance (USA)  An integrated & virtual system (brought about by Disney & Microsoft). With this system service can be provided any where, anytime by HC provider.  Informed Consumer
  50. 50. H OSP AL A Center of E IT xcellence In India, out of total of 13692 hospitals: 4310(32%) are in rural areas & 9382 (68%) are in urban areas. The Government owns 4235 (31%) of total hospital beds; local bodies control 2.5% of hospitals  At present India has 1 hospital bed per 1412 pop. Which is hardly sufficient to meet the challenges posed by demographic & epidemiological shifts. The overcrowding & overstretching of service results in poor 
  51. 51. Vision: T Scientific M he indset Synergy between Science, Technology, Organization & public Policy: has helped bring about sea change in food, environment. & agriculture. The future will undoubtedly witness revolutionary changes & new horizons opened up by cutting-edge science A vibrant, responsive & globally competitive science system is crucial. This calls for strong social support & commitment to Science
  52. 52. Challenges        Hospital & Primary Health care Technological revolution Quality of care- CQI, ISO 9000 certific. Rising costs of HC Privatization of HC Consumer protection & medical prof. Market approach to health: there has to be an paradigm shift from being “product oriented” to be “client oriented”
  53. 53. Restructuring H ealth care/ olistic approach H H IST AP ROACH OL IC P      Radical institutional reforms: HC extended to those who need it most. Investment in decentralized pop.-based systems / HSR / develop Evidence-based HC. HS: responsive to needs of all,cost-effective & affordable, of high Q, humane, caring, culturally acceptable, innovative in provision of services, sensitive. Holistic concept covers human biology, personal behavior (lifestyle), Culture, medical care system, psychological & physical environment. Disease prevention & Health promotion
  54. 54. Health Policy 2002 Objectives: • To achieve an acceptable standard of good health amongst the general population • To increase access to decentralized Public Health System by establishing new infrastructure in deficient areas & by upgrading the existing institutions • Ensuring a more equitable access to health services across social & geographical expanse of country • Increasing aggregate PH investment through a
  55. 55. Alternative Strategies 1. 2. 3. 4. 5. 6.     Hospital: from center of excellence to community support Hospital without walls Hospice Home care (Self care) Palliative care Geriatric centers Investing in health should be considered as an investment in HRD to enhance productivity. Create new intellectual capability, resource capability, social justice & equity A new mindset to speed up reforms, reaching out hard-to-reach & helping hard-to help By improving the prospects of the least of us, we can assure a more productive, just & civil nation for all of us
  56. 56. INVE ING IN H AL H ST E T Future Action:  Ensuring value for money  Poverty reduction  Public health policy  Strengthening national capabilities for emergency relief  Emphasis of long-term & comprehensive strategies
  57. 57. IMPROVING HEALTH OF THE NATION • Address the Burden of the ill-health among very poor populations with emphasis on RCH, Communicable Diseases, Nutrition, Mental Ill-health, Injury, Non-communicable Diseases • Track & assess risks to health, & help societies to take action to reduce them. • Improve the performance of health systems. • Encourage national policies which promote health with contribution from economic,