Prof. D K Gupta Vice Chancellor-CSMMU, (KGMU), LKO Professor and Head, Dept of Pediatric Surgery AllMS, New Delhi Health Care in developing world A Road.

Prof. D K GuptaVice Chancellor-CSMMU, (KGMU), LKO Professor and Head, Dept of Pediatric Surgery

AllMS, New Delhi

Health Care in developing world

A Road Map to Paradigm Shift

Where are we - todayWhere are we - today

• Health – Major Disparity in the world• India: Poverty, illiteracy, hygiene• Population explosion• Basic needs : ?? Food, water, education• New Epidemic: DM, HT, Trauma, Obesity, psychiatric

problems• Cancers: Infants, Children, adults, old age• 1 million pts. die globally /year : No help

• High expectations – why not ??

Chronic Disease BurdenChronic Disease Burden

• CDs result for 60% of deaths in 2005.

• >80% of deaths in low to middle income

countries (LMIC).

• NCDs are killing more people in their

prime adult years.

• TB, HIV and malaria account for 10% of

the global deaths.

Age at death region wiseAge at death region wise

Source: Global Burden of Disease, 2004 Update, used by permission

Major Causes of Death, World areaMajor Causes of Death, World area

Source: The Global Burden of Disease: 2004 update, WHO

Disease or InjuryDeaths/

million% of total

deaths

1 Ischemic heart disease 7.2 12.2

2 Cerebrovascular disease 5.7 9.7

3 Lower respiratory infections 4.2 7.1

4 COPD 3 5.1

5 Diarrheal diseases 2.2 3.7

6 HIV/AIDS 2 3.5

7 Tuberculosis 2.5 1.5

8 Trachea, bronchus, lung cancers 1.3 2.3

9 Road traffic accidents 1.3 2.210 Prematurity and low birth weight 1.2 2

Life style : factorsLife style : factors

Lack of Physical exerciseLack of Physical exercise• 2 million deaths worldwide annually. • A causal factor for;

• 10-16% breast , colon cancers, diabetes

• 22% of ischemic heart disease.

WHO Report: 2.3 billion overweight adults in the world

Over 700 million of them will be obese by 2015.

Overweight & Overweight & ObesityObesity

HypertensionHypertension

• Responsible for 13% of deaths world-wide.

• 26% of adults had hypertension in 2000,

• Expected to jump to 30% by 2025 globally

• 2/3 with HTN live in developing world.

Source: WHO Report on Global Tobacco Epidemic, 2008

Disease association with Disease association with Tobacco useTobacco use

Health Problems in developing Health Problems in developing worldworld

• 2/3rd Population is in developing world• 2 Billion children malnourished• Infection, diarrhoea, Malnutrition : ???• Congenital malformations (2%)• Cancers – presenting quite late• Trauma – common, 90% preventable• Life style disorders – common, early age

- Hypertension, Diabetes, Obesity, - Psychiatric / mental health disorders

Urban India – Medical TourismUrban India – Medical Tourism

Indian medical scenarioIndian medical scenario

• Vast country – limited health facilities• Facilities - Mostly in urban areas• Long distances / time to travel• Specialized services only to 20%

population• Expensive hospital stay/ medical services• Limited health insurance • No insurance for serious Cong. Mal.,

cancers, • High IMR, MMR, TFR

Indian scenarioIndian scenario• Population: 1.2 billion • India will cross China in 2030 ( 1.45 bn.)• > 400 million children <14 yr age• GDP health Share : 1.2%• Now increased from 1.2% to 2%

Special health issues Special health issues

• 80% villages: Poor overall development • Poor state of Primary, community &

district• Poor state of Medical college, Hospitals • Poor vaccination – in rural sector• Poor education, hygiene, literacy,

schooling• Inadequate Medical & Paramedical staff

Special health problems in Special health problems in IndiaIndia

• Mean Age : M- 65 : F- 57 yr• Old age: No shelter homes• Communicable diseases - • Snake bites• Disasters – Tsunami, Earth quakes, floods• Very high trauma – 90% preventable

90% accidents :90% accidents :Preventable in children Preventable in children

• News 26-7-2012

- KGMU Trauma Center caters to 5 neighboring

states & Nepal- 9 more trauma centers

Indian scenarioIndian scenario

- Preventive & Control programs : Govt. - Primary / Tertiary Health Care : Govt.- 80% OPD services by Private sector- 60% indoor beds in private sector• 80%: No access to modern health care• 70% cost born by the patient himself • Every 7th in the world - is an Indian

Medical/ Dental CollegesMedical/ Dental Colleges(recognized / un-recognized)(recognized / un-recognized)

Govt. sector

Private sector

Medical colleges ~ 360 in India

~160Mostly Old

~ 200- Mostly in 10 yrs

Dental Colleges ~ 357 in India

~ 38 ~ 320- Mostly in 20 yrs

Medical Graduation – 6 years

Post-Graduation -3 yrs more

Super-specialty – 3 yrs more ( Total 12 years) + Fellowship ??

Tough Life of a Institutional Tough Life of a Institutional Doctor Doctor

• Doctors are trusted & kept in high esteem • High expectations from the Role Models• Sacrifice – personal & family life• No working hours for doctors - indoor service • Tough life before, during and after operations• Must know Recent advances • Seminars, Journal clubs during training period• Preparing for Lectures, Conferences,

workshops,

What do people want from Govt.What do people want from Govt.

• Reliable & Affordable Medical services• Free treatment for major problems

- Cancer, Heart, Liver, kidney, transplant • Free treatment to all those who are poor• Institutions to be only as a referral

center• Availability of good quality Medicines

( 30-40% medicines are spurious)• Free Medicines to all pts. in PHC / CHC

( Generic: cost, control of quality, confidence)

Emphasis is on now ; Emphasis is on now ;

• Improvement in Mother & child care• Improve IMR from 57 to 37• Improve MMR from 388 to 200• Reduce TFR from 3.8 to 2.5• Filling the medical / staff vacant posts• Develop work ethos and culture• Improve competency level

Strategies to improve healthStrategies to improve health• Preventive and Therapeutic : Govt.

Responsibility(Polio eradicated recently)

• More doctors, nurses and paramedics• Medical college each of 626 districts• Generic and quality medicines – free to all• Corporate Hospitals – super-speciality• Medical Tourism

Additional health PlanningAdditional health Planning• Budget increased from 1.2% to 2%• Ambulance : Free services, Joint Control

rooms• Mid day meals for school children• Free Health for all Girl students• National Rural health Mission• National urban health Mission• Public Health Foundation – BPL, Insurance • Janani Baccha Suraksha Yojna (MCH Services) • National Disaster Management Authority

Govt. Recent efforts - Govt. Recent efforts -

• 6 new AIIMS like Institutes• Incentives for PG seats for rural doctors

(10 marks for 1 yr , max. 30 marks for 3 yr service)

• New Medical Colleges – Govt. / Pvt.• PPP Model for the Rural sector• Corporate Hospitals to have PG seats.• DNB – PG seats in Big hospitals• 13000 UG and 4000 NEW PG seats

Govt. New IncentivesGovt. New Incentives

• New Colleges of Nursing • Regional Institutes of Paramedical sc. 8

RIPS• BRHC- Bachelor Rural Health Care: 3 yr

course• 18 wk training for obst. and

anesthesiologists • 1 yr course in Cardiology, DM, Dialysis, • Insurance cover for all• Aadhar / BPL cards to poor population

Improving Health servicesImproving Health services

• Health services – PHC, CHC, District• Teaching Institutions – Govt. / Pvt.• Private sector - Major share in OPD & Indoor• 4 Tier Health care delivery Model - PHC, CHC, District, - State Level with specialists- National level Hospitals for referred cases- Institutes: Transplant, Heart, Liver, Kidney,

children

Improvement of Health servicesImprovement of Health services

Incentives to workers in PHC/CHC:• Local staff- others• Pharmacist, Ambulance driver• Physicians and Surgeon

Minimal available Medical infrastructure• Minimal facilities for the staff/ doctors• Due respect & responsibility • Trust, freedom and Autonomy

Alternate model - Alternate model - difficultdifficultCurative and Preventive Role• PHC : Doctors in Mobile Units, staff• Counseling on Preventive programs• National disease control program• Vaccinations – mother & child care • Distributing free medicines • Referring serious pts. to higher center• NGOs, teleconferencing for help• Visitor Nurses / paramedics for FU

Role of NGs to bridge the gap

Education and Awareness - Education and Awareness - Parental counselingParental counseling

• Keeping children away from cooking area • Away from industrial hazards • Keeping medicines / acids away• Ban on strong acids and alkalis • Ban on washing soda• Use of Seat belts in vehicles • Use of Cycle helmets and reflecting lamps

Core Group Recommendations ;Core Group Recommendations ;

• Better designs : Roads, flyovers, school buses,

• Better House designs: with high walls, better doors, windows, toilet sheets, glass panes

• Adequate Covers – manholes, wells, • No to fire crackers around Deewali• No Kite flying from roof topsGupta DK. Chairman –

Core Group Recommendations to the Ministry, 3rd World Congress on Pediatric Esophagus , AIIMS, New Delhi. 2002

International Delegation Meets Hon’ble Prime Minister of India, health concerns of

Children

Other health related concernsOther health related concerns

• Safe drinking water to public• Garbage disposal from city & villages• Technically sound Roads and streets• Construction of Public toilets• Proper sewage disposal• Proper hygiene at Rly. stations• Measures to prevent CDs/ NCDs• Awareness on preventing trauma

Health indicators continue to be poor and Health indicators continue to be poor and high mortality rates of infants and pregnant high mortality rates of infants and pregnant

women women have been a cause of serious have been a cause of serious concern. concern.

“Government has decided to continue theNational Rural Health Mission for next five

years.

We are now proposing a new National Urban Health Mission in order to focus on the

health challenges in our towns and cities,“

Prime Minister of India, 2012

Increase in health Budget & Facilities

Give Respect &Responsibility

Road Map to improvement

Have Trust & commitment

Competency and care

Expect nothing from 21st century. Expect nothing from 21st century.

It is the 21st Century It is the 21st Century that expects everything from us.that expects everything from us.

(Gabriel Garcia Marquez)(Gabriel Garcia Marquez)