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Affordable Health Care

Healthcare in Budget 2017-18

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Health sector policy making is extremely challenging and complex. The backdrop for policy formulation are low public spending and high out of pocket expenditures. The out of pocket expenditure on health care as a proportion of total household monthly per capita expenditure was 6.9 percent in rural areas and 5.5 percent in urban areas. Depsite India providing free care in public hospitals for maternity, new born and infant care, the burden of out of pocket expenditures remains quite high. The major policy direction is to enhance public health expenditure to 2.5% of GDP (from the present low level of ~1%) in 5 years.

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The 2017 Union Budget estimates for health show an appreciable increase of more than 27%, from Rs. 37061.55 cr in 2016-17, the budget estimate for 2017-18 has been increased to   Rs. 47352.51 cr. Further the Government has prepared an action plan to eliminate Kala-Azar and Filariasis by 2017; to eliminate Leprosy by 2018, Measles by 2020 and to eliminate Tuberculosis by 2025.

The sustainable development goals envisage that the global maternal mortality ratio will be reduced to 70 per 100,000 live births. From a baseline of 560 in 1990, the Nation has achieved an MMR of 167 in 2011. From a baseline of 126 in 1990, the Nation has achieved an U5MR of 39 in 2014. In the run up to the 2017 Union Budget, Government has formulated an action plan to reduce IMR from 39 in 2014 to 28 by 2019, and MMR 167 in 2011 to 100 by 2020. The challenges remain in the six large States of Bihar, Uttar Pradesh, Rajasthan, Madhya Pradesh, Jharkhand and Chattisgarh which account for 42 percent of national population and 56 percent of annual population increase.

India has developed a vast organization for public health care delivery and Primary care services. Infrastructure and Human Resource Development in Primary and Secondary Care Hospitals has been a key priority area. The 2017 Union Budget seeks to upgrade 1.5 lakh health sub-centres to health wellness centers and introduce a nationwide scheme for pregnant women under which Rs. 6000/- for each case will be transferred.  These steps represent significant additions to the ongoing schemes for provision of free dugs, free diagnostics and free emergency care services and free transport system for the people. A well-functioning primary health system reduces the burden on high cost secondary/ tertiary care facilities and the 2017 Union Budget takes substantial steps in this direction.

AIIMS is a national and global brand – built on more than six decades of evolution and performance of our Institute. It is the bench mark for other centres of excellence in healthcare and academics, and a fountainhead of best practices in education, research and clinical standards. The unique status of AIIMSs has been reinforced in the 2017 Union Budget by significant infusion of financial resources for major expansion. India’s Apex Medical Sciences University has enabled us to address one of the great weaknesses of Indian society – the iniquitous utilization of modern health services. High out of pocket expenses on chronic conditions can push millions of people below the poverty line.

The Government has placed a lot of emphasis on creation of several AIIMS like Institutions across India. The 2017 Union Budget has proposed establishment of 2 new AIIMS in Jharkhand and Gujarat. This would provide a huge boost to tertiary care services in public sector. Additional resource allocations for primary, secondary and tertiary care sectors lays down a roadmap for India’s path to achievement of sustainable development goals. The replication of AIIMS is quite complex because of the high-end clinical services that it encompasses. It has been a challenge to get competent faculty especially at the senior level and to retain it. Infrastructure delays have affected the utilization.

Human resources represent a vital component of India’s health care. The 2017 Union Budget seeks to create 5000 Post Graduate seats per annum to ensure adequate availability of specialist doctors to strengthen secondary and tertiary levels of healthcare. The Union Government has indicated its commitment to take necessary steps for structural transformation of the Regulatory framework of Medical Education and Practice in India. The increased availability of PG seats along with a centralized entrance exam represent major steps in reform of medical education in the country. The expansion of postgraduate medical education is a priority as the shortage of PG medical seats in the country affects not only the availability of specialist doctors but also the ease of getting faculty for medical colleges.

The collaboration between Medical Colleges and Medical Research is being firmly established. India has 32 publically funded Department of Health Research institutions. The emphasis is on evidence for policy, medical product innovation and basic research; operations research; drug discovery; frugal innovation; antimicrobial resistance; partnerships for research; and creation of databases.

The Health for All policy that the Nation had envisaged in the mid 1970s, continues be relevant to this day.

*Author is a senior civil servant, an IAS officer of 1989 batch, presently serving as Deputy Director Administration, AIIMS New Delhi.

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Making of AIIMS: The Parliament Debate

AIIMS Diamond Jubilee Celebrations conclude this month

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9th May 1956: Rajya Sabha had concluded the marathon 4 day debate on the AIIMS Bill 1956. Rajkumari Amrit Kaur in her reply to the debate spoke thus – “I want this Institute to be a unique Institute, and to be able to give our people – the young men and women doctors – the opportunities for study for post graduate education that they have not uptil now been able to have in their country. I want this to be something wonderful, of which India can be proud, and I want India to be proud of it.” The Deputy Chairman Rajya Sabha posed the Question “that the Bill be passed”. The motion was adopted, and thus AIIMS was born fifty years ago.

Introduction

The AIIMS Act 1956 provided for the establishment of the All India Institute of MedicalAll_India_Institute_of_Medical_Sciences_(Logo).jpg Sciences. It was enacted by Parliament as Act no 25 of 1956 and has a mere 29 Sections. The Business Advisory Committee of Lok Sabha had allocated only 60 minutes for discussion and passage of the Legislation. The Bill aroused tremendous enthusiasm amongst Members of Parliament and was debated for 3 days from 18th to 21st February 1956 in the Lok Sabha and 4 days from 3rd May to 9th May 1956 in the Rajya Sabha. The Parliamentary records of the debate run into over 800 pages.

Moving the Bill in Lok Sabha

18th February 1956: When the Minister of Health Rajkumari Amrit Kaur rose in the Lok Sabha to move the Bill, she did not have a prepared text of her speech. She spoke from the notes that she carried and from her heart. “It has been one of my cherished dreams that for post graduate study and for the maintenance of high standards of medical education in our country, we should have an institute of this nature which would enable our young men and women to have their post graduate education in their own country. It will provide under graduate study to only a very limited few. The major emphasis will be on post graduate study and specialization.” The two special features of the Institute, which is the first of its kind in India and the first of its kind in Asia, are prohibition of private practice of every form and to pay the doctors reasonably high salaries to compensate them for the loss of private practice. The doctors of AIIMS would devote their whole time not only to teaching, not only to serving the patients who come to the hospital but also to research. All the staff and students were to be housed in the campus of the Institute in the best traditions of the Guru-Sishya ideal to stay in close touch with each other.

The Debate

The Members of Parliament across party lines in the Lok Sabha overwhelmingly supported the revolutionary changes in medical education envisaged by the AIIMS Bill 1956. Commencing the debate Dr. Rama Rao Member of Parliament from Kakinada, said the Institute should have more under-graduate seats, given that very limited opportunities were available in India. T.S.A.Chettiar Member of Parliament from Tiruppur said that the composition of the Institute should provide that the majority of the members should be non-officials. In addition to accounts being submitted to Parliament, the Institute should lay an annual report of its activities in both the Houses of Parliament. This proposal of T.S.A.Chettiar was incorporated in the AIIMS Act by a subsequent amendment. He further said that practical training for doctors in rural and urban areas cannot be provided on the campus of the Institute and the Institute should have a hospital where practical training can be provided. This is reflected in the Community Health Centre at Ballabhgarh, (in the vicinity of Delhi) which is administered by the Institute where undergraduate doctors are sent for practical training.

Shrimati Jayashri MP from Bombay Suburban said that the nursing college of AIIMS should be a path bearer for the other nursing colleges of the Nation. Shri Narayan Das MP from Darbhanga said that the Government must provide adequate finances to the Institute. Mohanlal Saksena who represented Lucknow in the House, said that the AIIMS was going to be an autonomous body and Parliament will not have much control over it. Several members also raised the need to incorporate Ayurveda, Homeopathy and other indigenous systems of medicine into the AIIMS which was a recurring theme in the Rajya Sabha debate also. Even as the Bill was put to clause by clause voting, Joachim Alva Member of Parliament from Kanara expressed concern that the Director who is to be appointed by the Government could perhaps be a retired politician – “a Khushamadi” who may not have done any teaching or operative work or anything of that sort for nearly two decades.

In her reply to the debate in Lok Sabha, the Health Minister, said that the Governing body would comprise of a majority of non-officials. She maintained that the name All India Institute of Medical Sciences was all inclusive and apt.  She assured the members that the selection of Professors by a Standing Selection Committee has been agreed to by UPSC. She further clarified that while Rules will be made by Government, Regulations dealing with a wide variety of subjects pertaining to administration will be formulated by the Institute. The AIIMS Bill was thus passed by Lok Sabha with a single amendment that AIIMS shall lay an annual report through Central Government in both Houses of Parliament.

The Bill’s Journey in Rajya Sabha

3rd May 1956: Introducing the Bill in the Rajya Sabha, the Union Health Minister Rajkumari Amrit Kaur said “The future of the Institute will lie in the hands of the Director, of the Professors and other Members of the teaching staff and students. I believe that it will be their devotion to duty, their desire to promote their work and their spirit of altruism that will actuate them to subordinate their personal considerations as I believe the noble profession of medicine should do to the fulfillment of the objectives in view, that will eventually create and maintain an atmosphere which is necessary for an Institute like this. I do therefore, hope that in presenting the Bill for acceptance by the Rajya Sabha today, the legal structure that is crafted may facilitate the progressive realization of improved methods of medical education in this Institute and through its influence the standards of different courses of professional training in the field of health throughout this country will be raised.” She informed Members that Dr. B.B.Dixit has been appointed as the first Director of the Institute given his research experience at the Haffkine Institute and the administrative experience as Surgeon-General of Bombay.

Concluding her introductory remarks, the Health Minister maintained that “Subject to such minimum control as the Government of India may exercise through its rule making power, the Institute will enjoy a very large measure of autonomy to fulfill its objectives.”

The Debate in the Rajya Sabha

Though the Members of the Rajya Sabha were overwhelmingly in support of the Bill, for establishing an All India Institute of Medical Sciences facilitating for higher instruction in modern medicine, yet many felt that the legislation lacked clarity and envisaged excessive delegation to executive authority in the Rules. Members said that out of 30 clauses in the Bill as many as 25 clauses contained the provision, “prescribed by Rules” and 11 clauses contained the provision “prescribed by regulations”. While delegated legislation comes with every Act, the AIIMS Bill sought extraordinary delegation to executive authority. The powers of the Medical Council to grant degrees and diplomas and the powers of the UPSC to conduct selections were delegated to the Institute. Several members expressed concern at the total omission of references to indigenous systems of medicine in the Bill and felt that the focus should also be on Ayurveda, Homeopathy and Unani systems of medicine. Biswanath Das Member of Parliament from Orissa said that the Health Minister who received inspiration from Mahatma Gandhi was making Ayurveda an untouchable system. Some Members also felt that the Dental College and Nursing College were not required at AIIMS and the focus should be on high-end research work.

Commencing the debate P.N.Sapru Member of Parliament from Uttar Pradesh said that “We cannot agree to the suggestion that the shaping of the Institute in its technical aspect should be entrusted to the Director and the Professors of the Institute acting as a medical faculty. There is danger, under a constitution of this character, of the academic faculty of the Institute developing into a closed corporation of mutual admiration. There must be representation of an expert character – representation of an outside expert character – provided in the constitution itself.”

Participating in the debate, Dr Radha Kumud Mookerji, nominated Member of Parliament, sought clarifications on Clause 5 of the Bill which says that “AIIMS will be an Institute of National Importance”. He felt that the scope of National importance must be wide enough to cover all systems of medicine prevailing in the country – systems of medicine which have survived the onslaught of the ages. Similar views were expressed by H.P.Saksena Member of Parliament from Uttar Pradesh on clause 5. He said that the Institute of National Importance should demonstrate a high standard of medical education to all other medical colleges and other allied institutions in India. Dr. W.S.Barlingay an MP from Madhya Pradesh laid emphasis on the Objects of the Institute to develop patterns of teaching in medical education as a critical component of the Institute’s focus areas. He felt that the Institute could be attached to Delhi University which could grant diplomas and degrees as also get grants from University Grants Commission.

Passing of the historic Motion

In her reply to the debate, Rajkumari Amrit Kaur provided answers to the concerns expressed by Members. She argued that the Institute shall have the power to grant medical degrees, diplomas and other academic distinctions and titles under the Act of 1956. She maintained that Dentistry was has been a very neglected science in India and dentists have to go abroad to get first class qualifications. Hence a Dental College was attached to the Institute. Similarly she said, Nursing was the most neglected limb of the medical profession though it was an important hub. She said she had consulted UPSC on the recruitment to faculty posts. UPSC was of the view that because AIIMS will be a statutory non-government institution, recruitment will be outside the purview of UPSC. With regard to excessive delegated legislation being taken by Executive, she said that Parliament should give as much autonomy as it can to this Institute, which is going to be a pioneer venture. “Let us have elasticity and let us have autonomy…after all you are going to have an extremely good Governing Body which will lay down the policies which will be followed by the Institute and the regulations must be left to the discretion of the Institute itself…the Government will be in very close touch with the Governing Body. Trust your Government, Trust your Scientific People…”. She promised to develop an All India Institute for Ayurveda at Jamnagar and al All India Institute for Homeopathy in future as also a chair for History of Medicine.

The Bill was put to vote on the 4th day of the debate on 9th May 1956. Clearly, the Health Minister was exhausted by the 4th day of the debate. Even as the Bill was about to be passed Members continued to press for amendments in the clauses and it appears from a reading of the debate that the Health Minister showed some irritation in the House. Dr. Seeta Parmanand Member of Parliament from Madhya Pradesh said that “Sir, after all it is the right of this House, if at all they feel that something should be done by the Ministry, to criticize the Ministry. She called herself the Chief Servant of her Ministry. She is there to reply.”  Despite these moments of acrimony, the Bill received support from all the Members of the House and the motion to pass the Bill was adopted leading to the establishment of AIIMS,

*Author is a senior civil servant, an IAS officer of 1989 batch, presently serving as Deputy Director Administration, AIIMS New Delhi.

AIIMS GOES DIGITAL

The First Digital Revolution in Health Care

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Author : V. Srinivas

Introduction

Building strong Institutions is one of the major objectives of Good Governance. The Digital India initiative represents a landmark in ushering in the First Digital Revolution in Health Care at AIIMS. The successful implementation of the AIIMS e-Hospital Project and the AIIMS OPD Transformation Project, transformed AIIMS to India’s first fully digital public hospital. In 16 months of implementation since the launch in July 2015, the AIIMS e-Hospital project has had the largest footprint of Digital India projects.

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The creation of a patient friendly hospital has benefitted 35 lac patients till date, reducing wait times at the Hospital by nearly 6 hours, brought transparency to OPD appointments; created digital medical records and represents a sustainable and replicable model for hundreds of India’s Hospitals.

The Challenge

The very name invokes images of crowds, a sea of humanity that is present at the hospital doors, waiting from 3  in the morning, to rush for expert medical consultation at 8.30 am when the OPD opens.

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With an average of 10,000 OPD patients per day, 35 lac OPD patients per annum,  55 Departments, 640 faculty, 2000 resident doctors and 5100 Nurses,  AIIMS represents India’s behemoth in tertiary care super specialty hospitals.

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While the Institute led by highly driven professionals works with clockwork precision, the overwhelming patient loads have proved impossibly challenging for a manual system and required significant systemic changes in terms of improved digital practices and process re-engineering, as millions of India’s population seeks medical care at the Nation’s apex Medical Sciences University.

AIIMS – UIDAI – DeiTY Collaboration:

It was in January 2015 that the first step in the Digital AIIMS project was taken with the creation of an effective linkage between AIIMS, Unique Identification Authority of India (UIDAI) and the Department of Electronics and Information Technology (DeiTY).

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A unique health identification number for every patient visiting AIIMS was generated on an Aadhar platform. The patient could log into the AIIMS OPD Appointment System (ORS.gov.in) and submit a request for an appointment online using his Aadhar number. The verification of the demographic details of the Patient was based on the one-time password for the patient being transmitted to the mobile phone number of the patient registered in the Aadhar data base. The Unique Health Identification Number gave every Patient visiting AIIMS a Digital Identity. The Patient could use the UHID for his entire lifetime and every consultation visit was documented by the system.

The e-Hospital project proceeding at a modest pace, suddenly gained significant momentum with the launch of Digital India Initiative. There was a new urgency in DeiTY and NIC for expeditious development of the software so that the Online Registration System could be established. This was followed by the collaboration between AIIMS and Pay Gov for creation of a payment portal.

The e-Hospital project necessitated transparency in OPD appointments. AIIMS always encouraged walk-in patients and also had several follow-up patients coming for consultation. The streamlining of the new OPD cases began with 15 percent of the total new OPD appointments being given for online registration. The out-patient appointments of each of the Departments of AIIMS was placed online and every consultation room in the OPD was allotted a fixed number of OPD patients identified by name.

AIIMS – TCS Collaboration:

The AIIMS-TCS collaboration for the AIIMS OPD Transformation Project was conceptualized as a Corporate Social Responsibility Project in April 2015. It was only after several months of observations at OPD followed by conceptualization, discussions, capacity building, consensus building and software development that the TCS prescribed a model of AIIMS OPD transformation.

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The approach was to facilitate faster registration, to dissipate crowds with larger patient waiting areas, introduction of several new measures like fresh signages, screening at the entry point, patient care coordinators at the registration/ consultation areas and the rather unique exit OPD counters for all follow-up patients. Today, the AIIMS-TCS collaboration has provided the country with a role model for transforming OPD services at all major Central and State Government Hospitals.

The newly adopted model envisaged construction of a Patient Registration Center, with 50 Registration Counters each one equipped with a computer terminal loaded with e-Hospital software. It was constructed and operationalized in a record time of six months.

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Now the registration time was a mere 40 seconds for all new appointments with UHID numbers generated from the online registration system. Fast Track Queues were created where the patients who had already registered themselves under the online registration system could get their OPD cards and move quickly to the Patient Waiting Areas. Patient Care Coordinators ensured that Patients understood clearly where to visit during the entire process. The whole approach was one of empathy and efficiency. The successful operationalization of the Patient Registration Center meant that the waiting time in the Hospital had come down by nearly 6 hours per patient. The 3 am serpentine lines were no longer there. They were replaced by a more orderly queue system that commenced at 8 am and reached the OPD consultation rooms by 9 am.

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AIIMS attracts 10,000 patients per day but the patient waiting areas had only 2500 seating capacity. This meant that patients rushed to consultation areas without any wait time in a comfortable environment. The TCS model envisaged creation of seating spaces for an additional 3500 patients. Air conditioned Patient Waiting Halls were developed where the patients could comfortably wait for their turn to visit the OPD Consultation rooms.

Initially, the new model was implemented in the Medicine and Pediatric OPD areas on a pilot scale in December 2015. The Clinicians would commence work at 9 am. Patients would reach the clinician’s rooms in an orderly manner. All multiple registration counters in these Departments were discontinued. The successful implementation encouraged AIIMS to introduce the model in all the 5 floors of the Rajkumari Amrit Kaur OPD covering all 55 Departments.

The most innovative feature of the new model was the introduction of EXIT OPD Counters. Patients who were recommended for advanced Laboratory Tests, Radio-Diagnosis, Virology and Pathology Tests as follow-up appointments, all of which could be scheduled from the EXIT OPD Counters. The Patient thus had a very orderly journey from the point of entry to the Hospital to the point of exit. Even the VIP Patients including the officials at senior position in government willingly went through the entire OPD Transformation Process and found the entire experience quite expeditious and satisfying.

Specialised Cadres

AIIMS transformed itself into a patient friendly hospital by its willingness to adopt the modern day digital practices and create specialized cadres who enabled rapid scaling up of the new technology. The Nursing Informatics Specialists provided the linkage between the Clinical Departments and the OPD appointments. Nurses with an aptitude for technology were deployed to coordinate between the Departments, OPD, Wards and the software professionals.

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The Patient Care Coordinators touched every patient entering the OPD with their empathy. They were the friends and guides who ensured patients followed the established protocols. They were also deployed to assist with the E-Kiosks to enable literate and tech savvy patients with appointments.

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The Data Entry Operators were deployed at Patient Registration Center and the EXIT OPD Counters. They were trained to handle cash collections simultaneously. Security Personnel were trained in Queue Management systems with a considerable degree of patience.

AIIMS–India’s First Fully Digital Public Hospital

Hitherto, the implementation of the e-Hospital project had not been orderly. For AIIMS to be a fully Digital Hospital, each of the e-Hospital modules needed to implemented in an orderly manner to create a comprehensively digital hospital. By June 2016, the e-Hospital module implementation in AIIMS was completed. The NIC took a big step forward in completing the AIIMS e-Hospital Project. NIC Teams from Tripura worked with each of the Departments in AIIMS in a prescribed time frame to transform AIIMS as India’s first fully digital public hospital. The modules comprised of Blood Bank module, Billing Module, In-Patient Department comprising admission and bed to bed management, Laboratory Module integrating 55 laboratories, establishment of nearly 200 Kiosks with Net Banking Facilities for ease of payments, Laundry Module for monitoring the central laundry operations, Store management for inventory purposes, Dietary Module for preparation of electronic diet charts for in-patients, and RIS-PACS (Radiology Imaging System – Picture Archiving Communications System) for exchange of radiology data.

The Titanic is Saved

The transformation of AIIMS to a patient friendly hospital under the Digital India Initiative can be compared to “Saving the Titanic”. Under the Digital India Initiative, a core team of officials collaborated cordially and constructively over a long period of time to make the First Digital Revolution in Health Care possible.

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There was considerable resistance from every possible quarters– patients, support and administrative staff, security apparatus and even some medicos had their share of doubt during the course of the implementation of the Project. Needless to say, now everyone is satisfied and happy. As the success story unfolds benefitting 35 lakh patients, in 12 months’ time, the hours and hours of effort put in by those involved in the project, are adequately rewarded. The Prime Minister launched the Online Registration System as part of the Digital India Initiatives in July 2015. Following a year of successful implementation wherein the project benefitted 35 lac patients, the Prime Minister mentioned the successful implementation of the AIIMS e-Hospital Project from the ramparts of Red Fort in his Independence Day Address this year. The AIIMS OPD Transformation Project has enthused several State Governments. AIIMS has been mandated to conduct on-boarding workshops for replication across all 12 Central Government Hospitals.

Thus the AIIMS Transformation Project represents India’s First Digital Revolution in Health Care. No doubt, it is a remarkable success story.

 

*Author is a senior civil servant, an IAS officer of 1989 batch, presently serving as Deputy Director Administration, AIIMS New Delhi.

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