Health Care Delivery Comparisons- 3

Medical Practice in the US,UK, Saudi and India:

Medical Practice in the US,UK, Saudi and India A perspective 1979 to 2011 Uday Pathak

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Poornamadah , Poornamidam Poornaat Poornavashishyates Poornasya Poornamadaya Poornmeva Vyashishytea

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रांची : सरकारी डाक्टर 60 की जगह अब 62 साल में रिटायर होंगे। स्वास्थ्य मंत्री ने सोमवार को इसकी स्वीकृति दे दी है। डाक्टरों की कमी को देखते हुए निर्णय लिया गया है। संचिका मुख्यमंत्री व कैबिनेट की स्वीकृति को भेजी जाएगी। डाक्टर बाबू अब 62 साल में रिटायर होंगे Dainik Jagaran 15 th Feb, 2011 रांची , जाब्यू : स्वास्थ्य मंत्री हेमलाल मुर्मू ने खूंटी के सिविल सर्जन डा. ओपी आर्या को निलंबित करने का आदेश दिया है। सोमवार को मामले की विस्तृत समीक्षा के बाद उन्होंने उक्त कार्रवाई की। धनबाद में एसीएमओ के रूप में डा. आर्या के विरुद्ध लाखों रुपये के गबन के अलावा महिला कर्मियों के साथ दु‌र्व्यवहार के आरोप थे। विभाग में मामले की कार्रवाई चल रही थी। इस बीच आर्या का पदस्थापन खूंटी के सिविल सर्जन पद पर कर दिया ल्ल शेष कृष्ठ 15 कालम 4 कर गया। डा. आर्या पर पूर्व में लगे खूंटी सीएस का निलंबन

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The Millennium Development Goals (MDGs) originated from the Millennium Declaration produced by the United Nations . The Declaration asserts that every individual has the right to dignity, freedom, equality, a basic standard of living that includes freedom from hunger and violence, and encourages tolerance and solidarity [3] . The MDGs were made to operationalize these ideas by setting 8 targets 3 relating to Health, 2 to Education and 3 for poverty reduction as indicators order to achieve the rights set forth in the Declaration on a set fifteen-year timeline ending in 2015. With 50% funding by UN Agencies.

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Goal 4: Reduce child mortality rate Target 4A: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Under-five mortality rate Infant (under 1) mortality rate Proportion of 1-year-old children immunized against measles [17

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Goal 5: Improve maternal health Target 5A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Maternal mortality ratio Proportion of births attended by skilled health personnel

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Goal 6: Combat HIV/AIDS, malaria, and other diseases Target 6A: Have halted by 2015 and begun to reverse the spread of HIV / AIDS HIV prevalence among population aged 15–24 years Condom use at last high-risk sex Proportion of population aged 15–24 years with comprehensive correct knowledge of HIV/AIDS Target 6B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it Proportion of population with advanced HIV infection with access to antiretroviral drugs Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Prevalence and death rates associated with malaria Proportion of children under 5 sleeping under insecticide-treated bednets Proportion of children under 5 with fever who are treated with appropriate anti-malarial drugs Prevalence and death rates associated with tuberculosis Proportion of tuberculosis cases detected and cured under DOTS (Directly Observed Treatment Short Course

Population (UK, USA, India):

Population (UK, USA, India) Data from WHO statistical database.. “whosis 2002”

Government/ Private spending (USA, UK, India):

Government/ Private spending (USA, UK, India) Data from NHA. WHO .Jan 2005

DALE RANKING ( Disability Adjusted Life Expectancy):

DALE RANKING ( Disability Adjusted Life Expectancy) Country GDP per capita (in PPP terms - $) Health Expenditure per capita ranking (in $ terms) Health Level Ranking (DALE) Low Income Countries Sri Lanka 3530 138 76 Indonesia 3043 154 103 Pakistan 1928 142 124 Egypt 3635 115 115 India 2358 133 134 Middle Income Countries Russian Federation 8377 75 91 South Africa 9401 57 160 Brazil 7625 54 111 OECD Countries United States 34142 1 24 France 24223 4 3 Germany 25103 3 22 Japan 26755 13 1 United Kingdom 23509 26 14 Sources: The World Health Report – 2000 and UNDP Human Development Report – 2002 (UNDP)

Historical Overview:

Historical Overview USA Private Insurance ..1903 Railroad. TennCare,USA,1947, Roosevelt initiates Public Health bill, AMA boycotts Lyndon Johnson signs HR 1665 (Medicaid and Medicare ) 30 th July 1960 Unable to bear costs.. 2002 Bush, moves to privatize Medicaid and Medicare. NHS (UK) born 5 th July 1948 to provide health ,based on need , not on the ability to pay. Considered a right of every citizen. Health care rationed. Queues develop, skyrocketing costs, shortage of doctors and nurses. Indian Independence 15 th August 1947, Health under the State chapter.No plans, mission or goals. No accountability.

USA Health in Crisis:

USA Health in Crisis 40% of the population, 33% Children without any health insurance. Every doctor has an average of 3 liability claims in his lifetime. Average wait time in ERs 4.5 Hours. More than ½ the patients do not have or have not visited their primary care provider. Medicaid and Medicare in financial crisis. Price of drugs up by 300% in 10 years. Managed care, HMOs, PPOs answerable to their shareholders not accountable to patients. Cost cutting has failed. No policy, No plan, failure of administration. Lobbies running government.

UK beset with problems:

UK beset with problems Rising costs of health care. Wait listing for procedures. Waits for more than a week to see GPs. Rationing of health care. Evidence based medicine.. No effect on cost. Privatization of health care.. Not working. ER’s inundated.

Hospitalization – Financial Stress:

Hospitalization – Financial Stress Only 10% Indians have some form of health insurance, mostly inadequate Hospitalized Indians spend 58% of their total annual expenditure on health care Over 40% of hospitalized Indians borrow heavily or sell assets to cover expenses Over 25% of hospitalized Indians fall below poverty line because of hospital expenses

Problems with Health Care INDIA:

Problems with Health Care INDIA Manpower shortage-Training issues, no recreditation. Quack Surgery and Medicine. IMC/IMA/IAP ? Uncontrolled Pharmacies, 3.5 lakh brand names for 120 Generic drugs. 50% spurious! Combination Medicines and Polypharmacy. Costs – Examination, Labs and Medications Insurance Fraud Kick Backs

Strengths & Opportunities for India:

Strengths & Opportunities for India Big City models working with hub and spoke structure Developing research capability, outsourced. NRHM and Panchayat Samities for Rural Health Growing hospital infrastructure Mature pharmaceutical industry, controlling both Govt. and Private Sector Increasing awareness and demand for health services, Willingness to pay for health Breakthrough on population front ( TN, AP etc) Effective military style campaigns (smallpox, pulse polio) Wide network of RMPs

Differential in Health Status Among States:

Differential in Health Status Among States Sector Population BPL (%) IMR/ Per 1000 Livr Births (1999 – SRS) <5Mortality per 1000 (NFHS II) Weight For Age - % of Children Under 3 years (,2SD) MMR / Lakh (Annual Report 2000) Leprosy cases per 10000 population Malaria + ve Cases in year 2000 (in thousands) Better Performing States Kerala 12.72 14 18.8 27 87 0.9 5.1 Low Performing States Bihar/ Jharkhand 42.60 63 105.1 54 707 11.83 132 Source: National Health Policy, 2002

Viable Models:

Viable Models Year 1971 1976 1986 1993 Infant Mortality Rate 176 52 49 19 Crude Birth Rate 40 34 28 20 Children Under Five Immunization, DPT & Polio 0.5% 81% 91% 92% Malnutrition: Wt for age 40.0% 30% 5% 5% Maternal Services Prenatal Care 0.5% 80% 82% 96% Deliveries by trained attendants <0.5% 74% 83% 98% Couples practicing family planning <0.1% 38% 60% 60% Chronic Diseases Leprosy Prev. (/1000) 2 1 0.1 Source: Comprehensive Rural Health Care Project (CRHP), Jamkhed

Challenges of the Future:

Challenges of the Future Immunization coverage ( TB: 68%, Measles: 50%, DPT: 70%, overall : 33%) Four major infectious diseases: Malaria, TB, HIV/AIDS, RHD Sanitation ( 70% households without toilets) Accountability in public health care High out-of-pocket health expenditure Alternative systems – integration Unqualified PMPs Mounting cost of hospital care Decline in General Physicians – over-specialization Ideal vs Optimal care Health manpower training – inadequacies Regional inequalities

Critical Issues:

How to involve community in rural health care How to provide effective and affordable family care to urban populations How to promote public-private partnerships How to extend care to poor Critical Issues

Lessons from Experience:

Answer to lifestyle diseases is education not drugs. More expenditure doe not mean better health Private Insurance care : but not feasible without compulsion and large organized labor……failed for 90% ..doesnt work in India unless we cheat. Community ownership, decentralization and accountability – key to better delivery of health. Private Health should complement Public Health. Future health care should address demographic transition Politicians should realize the economic impact of health. From the Paradigm of to Wealth, Health and happiness TO Happiness, Health and Wealth Lessons from Experience

“The Myth of a Healthy Tribal” Health Survey ICMR rural blocks, Kanke and Namkum Singh AK et al 1987 :

“The Myth of a Healthy Tribal” Health Survey ICMR rural blocks, Kanke and Namkum Singh AK et al 1987 “PLEASE close your eyes and think of an average tribal person in the native habitat. The mental image, most likely, will be of a healthy, strong, carefree man with a flute on his lips, and of a woman, with flowers in her hair, dancing happily on the wild beats of the drum. This stereotype of a tribal, held by most Indians, alas, is a hollow romantic myth . “

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“Deceived by the mirage of political promises and bypassed by modernization and development, overwhelmingly illiterate (81%), poor (58% having monthly income of Rs. 200 and less and another 31% between Rs. 201 and 400) and unhealthy (29% families reporting illness). Less than 8% of the children were immunized. two-thirds of the children under five were malnourished, 44% having severe malnutrition. A large majority of the sample (71%) took tobacco, in some form Most of them (89%) drank alcohol, mainly haria , a home brewed rice-beer. An average tribal woman married early at the age of fifteen and had six children, two of them dying in her life-time. The average tribal family had seven persons with only about two rooms. Deprived of basic physical facilities they lived in squalor and garbage, with pigs and hens, without electricity, sanitary latrines, ventilation, outlet for smoke, drainage and sewage. Less than 4% had scientifically correct knowledge of, and attitudes to, physical and mental health, diet and nutrition, and family planning and childcare. “ ICMR Report.1990 The Myth of a Healthy Tribal..Continued

State of the Worlds Children- Grant, Executive-Director of UNICEF:

State of the Worlds Children- Grant, Executive-Director of UNICEF Grant (1987) Can we really say that we must wait for the return of economic growth when over 3 million children a year are dying of diarrhoeal dehydration which can be prevented by basic family health education and by oral therapies costing less than a dollar? And can we really say that it is too expensive, that we must wait for economic development’ when 3.5 million children a year are dying of diseases which can be prevented by immunisation at an additional yearly cost which is less than the price of five advanced fighter planes. The cost of immunising third world’s infants works out at approximately five dollars per child. The cost of not doing so works out approximately five million deaths a year"

Summation:

Summation The Quality of health is superior in countries where there is a will of the people and its government to provide for essential health services to all not a few. A multipronged attack involving Sanitation, Education, infrastructure development, Vaccination, Independent source data gathering needed. A more empathic and committed attitude in the health care providers, who need to take on leadership roles in societal development and health causes . The Doctors and Nurses treating their responsibility not as a commercial activity, but as a service. In the area of public health, an improved standard of governance is a prerequisite for the success of any health policy.

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Lives of great men all remind us we can make our lives sublime, And while departing leave behind us footprints on the sands of time ……Longfellow

india:

india

“If you dump all the drugs and formulations listed in Materia Medica into the ocean, mankind will be that much better off and fish will be that much worse off” Jaiprakash Narain,:

“ If you dump all the drugs and formulations listed in Materia Medica into the ocean, mankind will be that much better off and fish will be that much worse off” Jaiprakash Narain, In Lok Satta .

Ranchi-1972:

Ranchi-1972 Choice of Profession? Osgood Schlatter’s and Me. Dog Bite Primitive Medicine..no CT, MRI, ECHO or PETS Primitive Pharmacy

Pune 1974-79:

Pune 1974-79 Culture shock Medicine Army Style..The Drills Outranked by Nurses

Ranchi-79-88:

Ranchi-79-88 Episiotomy to Perineotomy Inferior wall infarct Egg on my face PSM – 6months !- RMCH (RajNarain!) Lumbar Puncture to Kidney Puncture at HEC Hospital Foleys Folly Acute Abdomen- 2 anecdotes Tiptoeing over shit CCL–” The light has gone out I said, and yet I was wrong

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SAUDI-ARAB-1989 The Mosque and the King Free Medical Care Epiglottitis Polio Sabya strain Diphtheria and snake Bites The Bedouins or Badoos Rials The war begins

United kingdom:

United kingdom The Rectal and Aural Examination BNF Computers and M. Mode ultrasound Obesity and Apologies Child Abuse School Health System

usa:

usa My First day in ER.. Laceration Scalp HIV Clinic Fear of Litigation..Trial by Jury, Pediatrician’s tail insurance License and Accreditation, 360* Evaluation,PALS , NALS,ACLS,BLS ETC Health Insurance PDA’s, Laptops and wireless LANs, Mobiles, Pagers, Loud speakers Running Codes

Health Jharkhand 2011 and beyond:

Health Jharkhand 2011 and beyond Dr Uday Pathak MD, MRCP, MRCPCh, American Board Certified

Thank You:

Thank You 2/15/2011 40