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October 2016


PFCD: Initiating A Multi-Sectoral Response To Address The Growing Burden of NCDs

Partnership to Fight Chronic Disease (PFCD) has been working towards addressing the continuously growing burden of non-communicable diseases (NCDs) in India over the past seven years.

After engaging with over 150 key opinion leaders across all stakeholder groups over the past two years through regional consultations and inperson meetings, the PFCD released an evidence-based National Blueprint – “SANKALP – Disha Swastha Bharat Ki”, a one-of-its-kind initiative in India in October 2015. The members of the National Advisory Group and the Working Groups guided the development of this document by providing valuable insights. The National Blueprint is a result-oriented action plan with an objective to devise a framework to control and prevent the growing burden of NCDs in India through a collective multi-sectoral response.PFCD adopted a tiered engagement framework, including periodic discussions and interactive sessions with key decision-makers from the Government, both at the Center as well as some of the prioritized states. This included four regional multi-stakeholder consultations in 2014 and one in 2015. In the earlier part of 2015, the PFCD also held a focused discussion on Healthcare Financing titled “Innovative Models of Healthcare Financing for a Healthier India”, with participation from state and national-level policy makers, insurance specialists, economists, medical fraternity, academicians and others.

The Blueprint identifies three thematic tracks converging to form this evidence-based pathway, specifically: Policy and Surveillance, Strengthening of Healthcare Systems and Healthcare Financing. These three key aspects are imperative to meet the WHO 2025 goal of reducing premature NCD mortality by 25% by the year 2025.

PFCD India’s work in 2016 is focused on-

imgCollaborating with the Central government on NCD policy analysis and advocacy

imgWorking with state level health officials to apply the National NCD Blueprint recommendations

imgDevelopment of recommendations on healthcare financing through multi-payer approaches


A Static Health Budget? Move Forward with Institutional Change

– Dr. Meenakshi Datta Ghosh

India faces a grim reality with a growing double burden of disease. While communicable diseases remain an unfinished agenda, the growing incidence of non-communicable and chronic diseases is challenging. Small pox, guinea worm and polio have been eradicated, and cholera may be on its way out, but high fatalities across communicable disease have not abated. These include chest related diseases – pulmonary tuberculosis, acute respiratory infections, pneumonia – diarrhea, and malaria. Indians across all classes are vulnerable to a sharply rising incidence of ischemic heart disease, diabetes, strokes and cancers. Higher mortality in the working age population (15-64 years), and the epidemiological shift to chronic diseases, has huge implications for social and economic costs. Most disturbing is the fact that over 60 million of its 1.25 billion people are being pushed into poverty annually due to high out-of-pocket health expenditures, and in rural and urban India, about 47% and 31% of hospital admissions are financed by loans and sale of assets (WHO). India’s health system needs an urgent course correction.


A Static Health Budget? Move Forward with Institutional Change


Left to Right: Dr Indrani Gupta, Head, Health Policy Unit, Institute of Economic Growth; Dr Meenakshi Datta Ghosh, Former Secretary Government of India, Ministry of Panchayati Raj & Special Secretary, MoHFW; Dr Damodar Bachani, Deputy Commissioner (NCD), MoHFW participating in a panel discussion on healthcare financing.

Health expenditure should not be viewed solely as a cost. Does the illness of its citizens not cost India dearly? The Centre for Science and Environment’s publication ‘Body Burden 2015: State of India’s Health’ estimates for instance, that since 73 million working days are lost each year due to water-borne morbidity, water-borne diseases alone are responsible for an annual economic cost to India of some Rs 36,600 crore. Health expenditure needs to be seen as an investment in the individuals’ well-being and productivity, which actually delivers vast benefits to society and the economy. Healthcare services determine and drive the demand for industries supporting the pharmaceutical, biotechnology, medical devices and other related sectors. There is a resource crunch. Budgets for healthcare are increasingly slowly, and funds are spread thinly over competing requirements along the health chain and other sectors, which consume a lion’s share of the resources. In a country with over
1.2 billion people, this reality is unlikely to vastly change any time soon. Most health systems are challenged to ‘do more with less’. If more funds are not available, why not pursue an alternative approach? Can institutional change across the structure and delivery of healthcare become a central component of cost reduction? We believe that our priorities have been misplaced.
To address acute as well as chronic healthcare needs, focus on putting in place a healthcare system built around strong public primary care, cashless at the point of service delivery, with a clearly articulated supportive role for the private and indigenous sectors. To move forward along these lines, put in place all relevant Rules of Business, with treatment protocols and rationalization of cost and fee structure.

To help matters along, address the following:

  • Place healthcare in the Concurrent List of the Constitution of India. Make prevention a critical fourth sub-system of health care, below primary, secondary and tertiary health care, for delivery of communication, information, and education on promotion of well-being and prevention of ill-health. Below PHC levels, there are millions of households without even the most minimal outreach on health care. A health service is not merely an illness service; healthcare services need to better prevent disease. Build upon socio-behavioral learnings, digital technologies, involve local authorities, and democratize all tasks and activities relating to prevention and promotion.
  • The draft National Health Policy 2015 recognizes that primary health care is the most critical link in the health care delivery system, but falls short of demonstrating government preparedness and willingness to make an almost asymmetrical investment in human resources (as has been done in Cuba), vis-à-vis capital intensive facilities. Fortunately and significantly, one long awaited institutional reform is now happening that will fix India’s medical education, and yield larger numbers of certified practitioners. A rare unanimity across the executive, judiciary and Parliament are seriously pushing towards augmenting the supply of doctors who are qualified and appropriately certified. A statutory national merit examination for entry into medical colleges (with online ranking), together with medical certification at the end of the five year course (via an exit examination], will help ensure that doctors meet minimum standards prior to gaining a license to practice.
  • To make that great leap in primary health care, borrow good management practices from the National Health Scheme of the UK. Declare primary care as a specialty in its own right. Introduce the nurse practitioner system, wherein the nurse practitioner an team are authorized to handle several clinical responsibilities including prescribing of antibiotics, as long as all procedures are implemented in strict compliance with established clinical protocols.
  • Give general practitioners (GPs) and family based medicine a unique status. Revise the outdated population norms for locating health facilities. Primary care settings will then become the fulcrum of patient management, with higher accountability, and better quality of care at reduced costs.
  • Make the private and public sectors wholly accountable through redressal mechanisms, malpractice or fraud laws, and a transparent regulatory framework. Identify appropriate competencies, develop contract management skills with clear definitions of basic and essential health services. At secondary health care levels, the network of individually run nursing homes, clinics and hospitals should be similarly regulated, inclusive of strict compliance with standards for quality of care and patient safety.
  • Implement evidence-based medicine (EBM) at the point of service. With a view to improving the quality of patient care, EBM is the systematic, scientific and explicit use and adoption of validated best evidence as well as practice, while making clinical decisions. This can be made mandatory only if continued medical education accreditation is institutionalized as a component of appraisal and linked to recertification or revalidation.
Author, Meenakshi Datta Ghosh is a former Secretary, Government of India, Ministry of Panchayati Raj; was also Special Secretary, Ministry of Health and Family Welfare
  • Tamil Nadu Medical Services Corporation (TNMSC) set up the country’s first technology-driven drug procurement and distribution system. States like Rajasthan have attempted to emulate this island of success. Rajasthan has reformed systems and expanded their procurement—to include even expensive cancer and cardiac drugs—so much so that people from neighboring states are travelling to take advantage of these services. Since states are unwilling to emulate best management practices, bring in health management technologies.
  • Harness the digital revolution to give patients the same level of access, information and control over health matters as they have, for instance, through online banking and travel services. Invest in setting up digital health hubs with kiosks across local settings so that patients can access online test results, appointment booking, prescriptions refills, and also engage in email consultation with clinicians. A hospital-centered delivery system may no longer provide all the answers.
  • Incentivize local manufacturing, bring in cost saving mechanisms, and lower distribution barriers so that India can make that great leap forward to move beyond the manufacture of generic drugs and emerge as (i) an innovation hub for affordable healthcare products and services; (ii) an export hub for medical devices, products and equipment, and (iii) possibly even an R&D hub for tropical diseases.

Roundtable Discussion on Health Care Financing: Need for a Multi-Payer Approach to Ensure Quality Health Care For All


The Partnership to Fight Chronic Disease (PFCD) organized a high-level roundtable discussion, titled “Need for a Multi-Payer Approach to Ensure Quality Health Care for All”, on August 17th 2016 in New Delhi. Several prominent experts including health economists, academics, insurance and public health specialists, patient groups, and representatives from industry deliberated on the need to increase public health spending and reduce the out-of-pocket expenditure on health.

The roundtable had two panel discussions; the first focused on analyzing mechanisms to increase public spending on health, while the second deliberated the need for a multi-payer approach and the role of the central government, states and commercial insurance providers in reducing out-of-pocket expenditure due to NCDs.

India lacks a comprehensive system of health care financing that would pool financial risk to share the cost burden. For most developing economies, a single public health care financing system cannot effectively cover the entire population, given the significant fiscal resources required to run and sustain such programs. While there are several barriers to quality health care, optimum financing for services continues to remain an area of concern. The government needs to consider diverse financing and reimbursement options to meet the health care needs of all citizens, including the expansion of commercial health insurance options, other innovative financing models, and public-private partnerships.

Several prominent stakeholders from key entities including Institute of Economic Growth, The World Bank, WHO, USAID, NHSRC, AIIMS and Health Insurance TPA of India deliberated on the key issue of health care financing and suggested on these broad action areas:

  • Reallocation of resources to improve efficiency in spending and to enhance outputs/outcomes
  • Options such as performance-based/ results-based financing to maximize outputs/outcomes
  • States need to take a proactive role and develop their own health care financing system based on their demography and needs in order to achieve universal health coverage
  • Progressive taxation to expand the pool of available resources
  • Develop an India specific model for health care financing with a basic essential health package
  • Need for a comprehensive and diverse system of health care financing that pools financial risk and shares the cost burden
  • A balanced mix of public-private partnership in health insurance coverage
  • Appropriate regulatory and government policies in order to finance outpatient coverage and prescription medicines
The Government’s vision on health care needs to be well articulated so that better policies, models can be framed and incorporated into the health sector. The out-of-pocket expenditure are completely excluded in policy-making, therefore putting a big question mark on the government’s priorities.


Disease Burden, Health Service Coverage & Out-of-Pocket Expenditure for NCDs in India

Barriers to Universal Health Coverage

Most global and national policy documents focus on providing universal coverage for health and protection against financial hardships due to health care. The Tanahashi Framework (1978) provides a framework to study the barriers to universal coverage in a systematic manner. According to this framework, universal health coverage can be obstructed by five types of barriers to health care access:

Source: NSS 71st round survey on Social Consumption: Health

The disease classification and data used for this purpose have been drawn from the NSS 71st round survey on Social Consumption:Health. The analysis shows that the out-of-pocket expenditure per ailing person on cancer is much higher than any other NCD. Heart strokes have the second most expensive treatment. Meanwhile, expenditure on drugs constitutes an exorbitantly high proportion of the total OOP for any NCD, for any area, rural or urban. Also, proportion of expenditure on diagnostics is relatively high for cancer and heart strokes.

While comparing the out-of-pocket expenditure for hospitalized and non-hospitalized treatment, the share of cancer is the highest in both the cases. Additionally, the share of expenditure on drugs is about 25-30% of OOP for most NCDs.

Conclusion and Way Forward

The burden of NCDs on the Indian population cannot be denied. The loss in productivity and well-being as well as financial hardships associated with any disease burden are well known. Policy solutions should be based on prevention, diagnosis, care, treatment and rehabilitation of NCDs. This requires a multi-pronged approach which goes beyond curing a specific ailment and identifying more cost effective primary interventions.

There is a need to reduce the use of secondary and tertiary care to manage the burden of NCDs. Their prognosis, diagnosis, prevention and treatment should be built on greater dissemination of knowledge among health workers and the society alike. This will facilitate a greater availability and accessibility of health care for NCDs services are available to all population.

The author is an Associate Professor, Department of Economics, Indraprastha College for Women, University of Delhi



Affordable healthcare for all Live Mint
(August 19, 2016)

Dr Kenneth Thorpe, Chairman, PFCD said “India desperately needs a holistic care system that is universally accessible, affordable and at the same time effectively reduces OoP expenditure. Increasing private investment in healthcare for broader and more comprehensive insurance is necessary. Developing subscription-based primary healthcare clinics and plans are also options. At the same time, it is important to come up with viable mechanisms that will exempt the poor from payments and provide them both health and financial protection.”


Why India Needs Private Investment In Healthcare The Huffington Post
(August 9, 2016)

India’s public spending on health is one of the lowest in the world. The economic impact of non-communicable diseases is especially dire. Poverty is a significant risk factor for contracting NCDs, and these diseases can quickly lead to personal financial crises. Delayed diagnosis and treatment of NCDs such as diabetes, cardiac disease, lung conditions and cancers escalates costs, and amplifies long-term health and financial repercussions.

Dr Kenneth Thorpe, Chairman, PFCD said “A developing economy like India’s can’t afford to rely on a single public healthcare financing system to cover the entire population, especially in view of rising healthcare costs, and the limited access to private insurance policies and other options to fund medical needs. We need a comprehensive and diverse system of healthcare financing that pools financial risk and shares the cost burden.


Give priority to non-communicable diseases, says expert Governance Now
(August 18, 2016)

Highlighting the need to focus on NCDs in India, Dr. Kenneth Thorpe, Chairman, Partnership to Fight Chronic Disease, said that “NCDs result in lower productivity and lost economic output. Also, investing in prevention, primary care and coordinated care in India will improve health and increase economic growth. Government needs to create a roadmap for educating individuals about lifestyle disorders increasingly impacting health. Investing in health and education improves health outcomes and life expectancy.”

Dr Thorpe spoke at a round table conference on healthcare financing in New Delhi. It was attended by public health experts, economists, patient groups and hospital administrators to discuss innovative mechanisms for improved healthcare coverage and financing.



Healthcare Financing conference discuss need for multi-payer approach to ensure quality healthcare Express Healthcare
(August 18, 2016)

Dr Kenneth Thorpe, Chairman, PFCD said “India desperately needs a holistic care system that is universally accessible, affordable and at the same time effectively reduces OoP expenditure. Increasing private investment in healthcare for broader and more comprehensive insurance is necessary. Developing subscription-based primary healthcare clinics and plans are also options. At the same time, it is important to come up with viable mechanisms that will exempt the poor from payments and provide them both health and financial protection.”


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