AMCHAM 2nd ConferenceHealthcare equity in India: Keychallenges and enablers

Hyderabad, September 20th 2014For discussion purposes only

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India

S. Korea

Bangladesh

Thailand

SriLanka

Brazil

Bangladesh

SriLanka

Brazil

S. Korea

Thailand

India

1950 Today

The great Indian growth story subdued by the healthcarerealities

1950s

Today

21.0*US$ bn

1,876.8*US$ bn

~ 90 times bigger economy today and among top10 nations in the world by GDP (nominal)

Poorly ranked healthcare systemin the world

Nominal GDP numbers; 2014 GDP from World bank; 1950 estimates from Ministry of Statistics and Programme Implementationhttp://en.wikipedia.org/wiki/Economic_history_of_India#GDP_estimate; healthcare rankings from http://timesofindia.indiatimes.com/india/India-in-healthcare-hall-of-shame-ranked-worst-among-peers-and-neighbours/articleshow/18805659.cms and WHO ratings

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Beneficiary of healthcare

~31% of population withaccess to

• ~ 70% of care infrastructure

• 4 lakh doctors accross 120 cities1

• multiple formats of care delivery

~ 69% of the population with

• 30% sub centres, 36% PHCs2

functional

• limited available manpower3

only 24% of doctorsonly 47% of nursesonly 12% of specialist doctors

• # PHCs w/o a single doctor : 2,5334

Unaddressed and the underservedAccess to care: 31% of Indianpopulation outweigh the rest

1. http://www.moneycontrol.com/news/cnbc-tv18-comments/ims-survey-reveals-skewed-doctor-density-across-india_929890.html

2. McKinsey report on Indian Healthcare3. Why Are India’s Young Doctors Refusing To Serve in its Villages –

Yahoo News 23 Aug 20134. http://www.tenet.res.in/Publications/Presentations/pdfs/Healthcare_in

_India.pdf

The realities to be addressed sooner…...

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…. as Indian healthcare is at the cusp of fighting ‘the today’, yetneeding to gear up for ‘tomorrow’

CD* &Vector borne

*Communicable Diseases

Water

Maternal & child

NCD,lifestyle related

DemographicShift

Otheremergencies

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HealthcarePenetration

Populationreach

Conditionreach

• Socially excluded sections• Economic vulnerable sections• Demographic vulnerable• Physical vulnerability

S

I

R

E

F

Screening

Identification

Referral

Enable

Follow up

• Gender based• Age related• Community based• Endemic• Acute & Chronic

The fight is relevant if and only if there is healthcare equity

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Healthcare Policy: The steer wheel

Healthcare Financing: The fuel

Healthcare Delivery: The axle

Institutional Reforms Health Service Norms Monitoring and Governance Approvals & guidelines

Community Participation Human Resources for Health Health infrastructure Healthcare ICT Quality of care

Financial adequacy Financial Protection Sustainable financing mechanisms

Enablers to make the 3 dimensional approach a reality

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Assurance of quality care for all

Uniform accreditation and licensing mechanism

Define governance mechanism to monitor and track care outcome

Facilitating private participation in care policy and delivery

Accessibility

Availability

Affordability

Awareness

Acceptance

Accountable

Theimmediate

TheNext Dos

Policy: The healthcare policy to address certain contingentfactors of healthcare equity and saturation

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61.6%

38.9%Low

incomecountries

WorldMedian

India

32.5%

46.6%

Government Out of pocket• RSBY

• Rashtriya ArogyaNidhi

• CGHS

• ESIS

• Yeshasvini Co-operativeFarmers Health careScheme, K’taka

• Rajiv Aarogyasri, AP

• Vajapayee Arogyasri ,K’taka

• Apka Swasthya Bima YojnaDelhi

30.5% 60.0%

• ~ 1/3 of Indianpopulation iscovered**

• Prepaid healthinsurancepenetration inIndia @ ~ 4%**

Central Schemes

State Schemes

Financing: Non adequate & scattered Government financing -stretching the out of pocket pay for care in India

Expenditure as a % of total spend on healthcare*

* WHO World stats 2014 report. Data from 2006-2012 average; ** Healthcare financing stats from WHO Worldhealthcare stats 2014

Indicative schemesnot exhaustive

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5%

23%

54%

14%

44%

217%

Total spend by the poor per episode as a % ofaverage House hold expenditure*

Spending by poorfor healthcare

Acute care

Chronic care

OPD treatment

IPD treatment

Acute care

Chronic care

IPD treatment

OPD treatment

Gov

t.Fa

cilit

ies

Priv

ate

Faci

litie

s

Financing: Lack of apt financing can be taxing for the poorand it’s time India develops a formal care financing model

* Understanding the health care access in India- IMS health consulting report 2013

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Financing: Surprising examples present a key learning forIndia: Transition to a centralized integrated insurance model

Social insurance modelin Thailand*

a. Integrated and centralized insurance model

b. Covers 48mn beneficiaries i.e.~80% of thepopulation

c. Comprehensive package that covers preventiveservices, promotive, ambulatory and inpatient care

a. ~ 88,000 households were prevented from fallingbelow the poverty line (4-5 years since inception)

b. Well-controlled diabetic patients increased from12.2 to 30.6 per cent (4-5 years since inception)

c. Well controlled hypertensive patients increasedfrom 8.6 to 20.9 per cent (4-5 years since inception)

Universal health coverage"Mutuelles de Santé** - Rwanda

a. Integrated and centralized insurance model

b. Preventive and curative packages

c. Maternal and child, HIV care given moreemphasis

a. Only country in Sub-Saharan Africa on aprogressing to meet MDG by 2015

b. Life expectance rose from 28 to 56 years

c. HIV prevalence maintained at only 3percent for the last 7 years

* VOLUME 18: Successful social protection floor experiences by Thaworn Sakunphanit Worawet Suwanrada; ** http://www.csmonitor.com/World/Africa/2013/0327/In-tiny-Rwanda-staggering-health-gains-set-new-standard-in-Africa

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Financing: While best practices can be explored, Indiacan potentially look at a tiered approach

Fina

ncia

l sec

urity

& In

com

e

High

Low

Stat

e H

ealth

Sch

eme

High

Low

Informal sectorPoor and Low incomeclass

Middle and workingclass

The RichFringe benefits from

state

Social insurancethrough contributory

approach

Apportion tax moneyapproach

Economicclass

Potential insuranceapproach

Recreated and contextualized representation; original from Social Security guidelines by JICA

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5+ KMs

5+ KMs

OPD

IPD

62.5%

34.0%

Staff absent on atypical day**

40 to 44.5percent

Percentage of ruralPopulation*

DoctorsOthermedicalstaff

Accessdenial

Accessdenial

Availabilitydenial

Availabilitydenial

Delivery: The poor, especially in the rural areas face myriadchallenges of care availability and accessibility……

* Understanding the health care access in India- IMS health consulting report 2013** http://m.aljazeera.com/story/20147308234358102

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INDIA

HospitalBeds Doctors

WorldMedian

9.0

Nurses

WHOThreshold

7.0 17.1

23.0 23.0

28.428.0-30.0 12.8

ShortagePer WHOthreshold(As on date)

~ 1.2mn ~ 7,00,000

… and it’s an enormous task for the Government alone toaddress the challenges

Per 10,000Population(2013-2014)

19.0

Sufficient

http://www.who.int/hrh/fig_density.pdf?ua=1; 2014 WHO Healthcare statshttp://archive.indianexpress.com/news/india-has-1-govt-hospital-bed-for-879-people/1159306/

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Delivery: ICT platforms can play a pivotal role in bridgingthe gaps in care availability and accessibility

Re-

imag

ine

Re-

engi

neer

Incremental

Purposive disruption

Care Transparency+

Care Traceability=

Care Accountability

Efficiency

Effectiveness

Expansion of care availability

Reduction of care costs

Business model innovation

Benefit Change

The dual benefits of ICT platforms in healthcare

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Health InformationHelpline

Re-imagine thepurpose ofcommunication

Healthcare informationaccess 24 hours,365 days

Covered 416mnpopulation

Care advices providedfor 26mn incomingcalls

Mobile HealthUnits

TelehealthModels

Re- engineerthe services

GPS tracking andunique beneficiarytracking ensuredefficient care outreach

Covered 45mnpopulation

Addressed 13.5mncare seekers

Re-imagine the teleconference platforms

Specialist care and

second opinion access

Change Impact on Care delivery Outcomes (Inception – till date)

Delivery: Case in point - Piramal HMRI leveraged ICT enabledcare delivery platforms through PnPP models

Screening / diagnosisof at least 5 chronicconditions

Care in neighbourhood to2Lac rural population

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Piramal HMRI Experience: A snapshot of ‘on the ground’care delivery

A Mobile Health Unit passing through difficult terrains toaccess beneficiaries in Assam

A pregnant woman receiving medical advice via teleMedicine in Adilabad, Telangana

Pregnant women board ‘Mobile Unit to reachtelemedicine centre for consultation in Andhra Pradesh

Trained executives attend to basic healthcare queries in ahot line centre in Hubli, Karnataka

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What facilitating role should policyaim and in what direction

What integrated framework is requiredto manage the overall ecosystem

What new integrationapproaches need to be developed

Where is the unused potentialand how to unbundle

Which components need support

How will the human resourceshandle ICT platforms

What areas of skills/training need tobe developed

GovernanceMonitoring & evaluationLegal, technical frameworks

Mobile networkInternet connectivityData compatibility

Device manufacturersTech. playersTelecomNetworkersImplementersFinancersProviders

DoctorsNurses, ANMParamedicsHealthcare workers

Critical factors for success of ICT enabled healthcare delivery:Our observations

What hybrid and innovativemodels need to be developed/deployed

How to speed up projects/players fromsuccessful pilot to scale

What optimum mix and scale need to bedeveloped for reducing costs

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1. Telemedicine Act

2. National standards & State guidelines• Electronic records

• Standardization of devices (POC/rapid diagnosis)

• Clinical data mgmt., data compliance & integrity

3. ICT infrastructure• Rural focus

• Unbundling and optimal use of existing infrastructure

4. Healthcare delivery model (esp Primary healthcare)• Focus on PnPP models for primary care delivery

• Single window clearance for healthcare PnPP projects

• Level playing/preferential access for pioneers during RFQ/Bidding

5. Fostering innovation• National level fora/platforms to contextualize new ICT platforms for care delivery

• Pioneers/inventors/industry to get a representation in planning and execution of new models

• National seed funding for ICT enabled healthcare pilot programmes

6. Capacity building of Health human resources (esp. last mile health workers)• State level platforms (with industry participation) to train manpower

• ICT enabled care delivery leveraging e-learning, voice based learning, podcasts etc.

Key areas of ICT enabled care needing attention

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Tomorrow transformed: Enabling model for equitable care inIndia

Government

Public healthFacilities PnPP/ PPP

Facilitators

Augment

Compliment

Last milereach

Private

Androiddevices

Helpline

Out reach throughICT Disruption

MobileAccess to careintervention

Access to careintervention

Direct to home

Chartdependencies

• Policy 80% contemporary, 20% futuristic• Role as a provider, insurer, enabler, governor Accommodating Private

in care policy

Createaffordability

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Piramal Swasthya is a registered non-profit organization based in Hyderabad, Telangana State. Piramal Swasthya is supported by PiramalFoundation and works towards making healthcare accessible, affordable and available to all segments of the population, especially those mostvulnerable. In order to achieve this goal, Swasthya leverages cutting edge information and communication technologies to cut costs withoutcompromising quality as well as public-private partnerships to scale its solutions throughout India and beyond.

Swasthya envisions a future in which all vulnerable groups have the necessary information to make informed decisions regarding their healthand affordable, available and accessible high quality health infrastructure to support the realization of those decisions.

© Piramal Swasthya All Rights Reserved