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‘We are destined to make huge strides in public health,’ says JP Nadda

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The PMSSY plans to create tertiary healthcare capacity in medical education, research and clinical care, says Union Minister of Health and Family Welfare

JP Nadda, Union Minister of Health and Family Welfare, speaks to Deputy Editor Amita Shah about the Narendra Modi-led government’s ambitious projects to make health care more accessible to the poor and to address numerous odds plaguing health care delivery services in the country. “Let’s not be negative, dedicated efforts are being made and we are very much on our way to achieve the targets,” he says, emphasising that a new beginning has been made by the NDA and that its efforts will bear fruits. Edited excerpts:

Tell us about the status of government initiatives in reducing out-of-pocket expenses (OOPE) of people forced to rely on private hospitals thanks to a lack of resources in government-run ones?

Bringing down OOPE is one of the top priorities of NDA government and thereby the following initiatives/schemes/ programmes are being implemented by MoHFW through its flagship program, the National Health Mission (NHM). These initiatives not only provide drugs at no cost or subsidized cost but also manage the drug procurement and inventory. These are:

Free Drugs initiative - The initiative has been launched with an objective to put in place systems such as facility wise Essential Drug List (EDL), robust procurement system, IT backed logistics & supply chain management, proper warehousing and necessary drug regulatory and quality assurance mechanisms, standard treatment guidelines, prescription audit and grievance redressal systems etc, to ensure provision of quality free essential drugs. Detailed Operational Guidelines for NHM- Free Drugs Service Initiative have also been released to the States on 2nd July 2015. So far all States have notified free drug policy. As part of it model IT application, Drugs and Vaccines Distribution Management Systems (DVDMS) has been developed by CDAC and shared with the States. 17 States are implementing the DVDMS application.

Free Diagnostic Services Initiative: Support is provided to States for providing essential diagnostics free of cost in public health facilities. Operational Guidelines on this initiative have been released on 2nd July, 2015. Five States, namely, Andhra Pradesh, Karnataka, Maharashtra, J&K and Tripura, have already adopted the model as per the national guidelines.

Pradhan Mantri Dialysis Program: Under this, every facility will have 6 dialysis machines and will be extended up to 10 machines per facility. So far, 1,069 Dialysis Units and 2,319 Dialysis Machines have been made operational from which 1.43 lakhs patients have availed services. Also nearly 17.29 lakhs dialysis sessions have been conducted. Affordable Medicines and Reliable Implants For Treatment (AMRIT).

The AMRIT outlets provide drugs for cancer and cardiovascular diseases along with cardiac implants at a 60% to 90% discount on prevailing market rates. 84 stores have been opened and more than 30.68 Lakhs patients served till July, 2017. More than Rs 164.10 crore savings to the patients - medicines and implants costing more than Rs. Rs 287.87 crores sold for less than Rs. 123.76 crores.

Besides these specific programmes, to ensure healthy mothers and children across their life cycle, under programs such as PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan), JSSK (Janani Shishu Suraksha Karyakram), RBSK (Rashtriya Bal Swasthya Karyakram), RKSK (Rashtriya Kishor Swasthya Karyakram), free screening, clinical services, counselling, transport to and fro and between facilities et al. are provided absolutely free of cost to the mother and child across every life stage.

Also free ART for HIV/AIDS is provided to each and every patient at the public facilities and so is the TB medicine. As regards vector borne disease, free drugs are provided at every facility and LLINs (Long Lasting Insecticide treated Nets) are provided free of cost in endemic areas.

Since our country faces the double burden of communicable and non-communicable diseases, we run an exclusive program to manage lifestyle diseases i.e. through the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS), we plan to upgrade 1.25 lakh sub-centres to wellness centres for comprehensive primary care including screening of NCDs; this year 6000 shall be upgraded. At these centres, free of charge population-based preventive screening for five common NCDs (Hypertension, Diabetes, and Cancers of oral cavity, breast and cervix) shall be carried out in 125 high priority districts.

Non-Communicable Diseases (NCDs) or lifestyle diseases are rising rapidly in both urban and rural India. What is the government going to do about this?

It is true that India is experiencing rising burden of Non-Communicable Diseases (NCDs), causing significant disability, morbidity and across all sections. In order to combat the major NCDs, MoHFW runs the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke under which strengthening infrastructure, human resource development, health promotion, early diagnosis, management and referral services are being provisioned for. As part of it, funds are being released to the States with Centre to State share ratio of 60:40 (except for NE and Hilly States, where the ratio is 90:10). So far:

- 365 district NCD cells and 356 district NCD clinics have been established
- 103 cardiac care units, 71 day care centres and 1871 CHC level NCD clinics have been setup
- The tertiary care cancer centers (TCCC) scheme, 20 state cancer institutes (SCI) and 50 TCCCS envisaged and
- So far five TCCC and six SCI have been supported with financial assistance under the scheme.

At these facilities till June 2017, around 92.3 Lakh persons were screened for common NCDs. Among them, 7.53 lakh (8.11%) were diagnosed to be Diabetics and 8.88 lakh (9.58%) were Hypertensive. Around 35000 Cardiovascular disease patients were identified in NCD Clinics and CCUs. Around 8000 patients of common cancers like Oral, Cervical & Breast Cancers were identified and referred for treatment. Around 22 lakh persons underwent counselling for health promotion and prevention of NCDs. Other initiatives under the programme include, Interventions on prevention and management of Chronic Obstructive Pulmonary Disease (COPD) and Chronic Kidney Disease (CKD), the two major causes of death due to NCDs.

MoHFW has also commissioned two studies with the Indian Council of Medical Research for undertaking surveillance and monitoring of burden of diseases and for survey on prevalence of risk factors of NCDs.

For comprehensive management of lifestyle related disorders, a pilot project on ‘Integration of AYUSH with NPCDCS’ has been initiated in six districts viz. Bhilwara (Rajasthan), Gaya (Bihar), Surendranagar (Gujarat), Lakhimpur-Kheri (Uttar Pradesh) and Krishna (Andhra Pradesh) and Darjeeling (West Bengal). Synergy is being harnessed between the Allopathy system under NPCDCS and the alternative systems of medicine under AYUSH, for prevention and management of ‘lifestyle-related’ common NCDs. Besides health promotion and patient management services at the NCD/Lifestyle Clinics, training on Yoga is also provided through an integrated Yoga programme. The government is planning to expand NPCDCS-AYUSH integration project to more districts of the country.

Further, pilot intervention has been initiated for the prevention and control of Rheumatic Fever and Rheumatic Heart Disease under the platforms of NPCDCS and RBSK (Rashtriya Bal Swasthya Karyakram), in three select districts (Gaya in Bihar, Firozabad in Uttar Pradesh and Hoshangabad in Madhya Pradesh). Training of Trainers has been done in the three districts. This intervention would be scaled up to other districts in a phased manner.

Another initiative is the integration of RNTCP with NPCDCS, wherein the “National Framework for Joint Tuberculosis-Diabetes collaborative activities” is being developed to articulate a national strategy for ‘bi-directional screening’, early detection and better management of Tuberculosis and Diabetes comorbidities in India. A National Multi-sectoral Action Plan (NMAP) for prevention and control of NCDs is developed to guide multi-sectoral efforts towards attaining the national NCD target.

How come you’ve failed to meet targets to eliminate/reduce communicable diseases including measles?

As a country we have much to celebrate and feel motivated from viz. the defeat of smallpox, elimination of polio and neonatal tetanus, and significant reduction in cases of measles, among other diseases. We are well on course to eliminate other diseases also. With a target to free India’s children from the highly contagious measles disease by 2018, the Measles-Rubella (MR) vaccine has also been launched this year. The scale-up is happening rapidly, covering five states in the first phase, eight more in the second and across the country over the next couple of years. India stands committed to its targets regarding reduction in child mortality. Ministry is also committed to eliminate TB by 2025. You will be surprised to know that India’s progress on tackling TB is faster compared to the global progress. We have rapidly expanded diagnostic services with 628 CB NAAT and 69 quality assured laboratories across the country. Moreover, we have rolled out programmatic Management of Drug Resistance TB services across the country with more than 1086437 presumptive DR-TB cases examined, more than 88608 diagnosed and more than 83899 cases have been put on treatment last three years. The TB programme will also be introducing shorter MDR-TB regimen and have already introduced new drug for drug resistant TB.

So let’s not be negative, dedicated efforts are being made and we are very much on our way to achieve the targets.

Why is there a softer approach towards tobacco companies?

My ministry has taken commendable steps for tobacco control such as by enhancing the size of specified health warnings on tobacco products by covering 85% of the principal display area of the packages of tobacco products with effect from 1st April, 2016; regulating the depiction of tobacco use in films/television. Ministry of Health & Family Welfare also hosted the Seventh Session of the Conference of the Parties (COP7) to the WHO Framework Convention on Tobacco Control (WHO FCTC) in November 2016. It was the first occasion that a Conference of Parties (COP) meeting was held in India which signals a strong commitment of the Government of India to increase international co-operation and awareness of the WHO FCTC globally and especially in the WHO South-East Asia Region.

We are also working very closely with other ministries to prohibit use of Tobacco, however rehab of farmers does not fall under the purview of Health Ministry and you may direct your question to the appropriate authority.

Which are the medical technologies that the government hopes to introduce in India to cut costs and improve efficiencies? And how do you plan to meet the huge demand for specialists?

MoHFW has harnessed technology a big way and following are a few initiatives to give you a picture of the same:

National Health Portal (NHP) is functioning as Citizen Portal for Healthcare providing Health related information to citizens and stakeholders in different languages (currently six languages). A voice portal, providing information through a toll-free number 1800-180-1104 and Mobile App has also been launched. It serves as a single point access for information on Health and Diseases including health messages; on Regulations, Standards, Policies, Programs, Commissions etc.; Directory Services – Hospitals, Blood Banks, Ambulances.

Hospital Information System (HIS) is being implemented in hospitals for automation of hospital processes to achieve better efficiency and service delivery in Public Health facilities up to CHC level.

Online Registration System (ORS) is a framework to link various hospitals for online registration, payment of fees and appointment, online diagnostic reports, enquiring availability of blood online etc. As on date, around 124 hospitals including Central hospitals like AIIMS –New Delhi & other AIIMS (Jodhpur; Bihar, Rishikesh, Bhubaneswar, Raipur, Bhopal); RML Hospital; SIC, Safdarjung Hospital; NIMHANS; Agartala Government Medical College; JIPMER etc. are on board ORS. So far around 10,80,771 appointments have been transacted online Mera Aspataal’ (My Hospital) application is an IT based feedback system to collect information on patients’ level of satisfaction using a multi-channel approach viz. Short Message Service (SMS), Outbound Dialing (OBD), Web Portal, and Mobile Application. The application automatically contacts the patient (outpatient after the closure of the OPD and the inpatient at the time of discharge) using the above tools to collect information on patients’ level of satisfaction. Till date around 890 hospitals have been covered.

Mother and Child Tracking System (MCTS) / Reproductive Child Health (RCH) application is an individual-based tracking system across all the States & UTs to facilitate timely delivery of antenatal and postnatal care services and immunization to children with an objective of improving IMR, MMR, & morbidity. As on 30th September, 2017, a total of 70.27 lakh pregnant women and 7.97 crore children aged up to 5 years are being followed up for delivery of due services using MCTS / RCH portal.

Kilkari application has been launched to deliver free weekly audio messages about pregnancy, child birth and care. Assam, Bihar, Chhattisgarh, Delhi, Haryana, Himachal Pradesh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand are presently covered under Kilkari. Approximately 8.65 crore successful calls (average duration of content played in each call: approximately 1 minute) were made under Kilkari as on 23rd September, 2017.

Mobile Academy is a free audio training course designed to expand and refresh the knowledge base of ASHAs and improve their communication skills. Launched in 2016, Bihar, Chhattisgarh, Delhi, Haryana, Himachal Pradesh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand are presently covered under Mobile Academy. A total of 99,008 ASHAs registered in MCTS / RCH portal have started the Mobile Academy course, out of which 79,450 (i.e., approximately 80%) ASHAs have completed the course as on 23rd September, 2017.

ANM on Line (ANMOL) a tablet based application for Integrated RCH Register which allows ANMs to enter and update data for beneficiaries of their jurisdiction has been piloted in the State of Andhra Pradesh and Currently 11,890 ANMs in Andhra Pradesh are using ANMOL. It is being further rolled out in MP ns Telangana.

TB Patient Monitoring System “Nikshay” for tracking of individuals for treatment-adherence has been implemented across all States for monitoring of TB patients. Also a Missed Call Centre facility with Toll Free No: 1800-11-6666 for reaching to unreached TB patients has been started, for counselling and treatment support.

Tobacco Cessation Programme is a mobile-based interventional initiative for counselling and helping people to quit tobacco, by giving a missed call to 011-22901701.

mDiabetes Program is a mobile-based initiative for prevention and care of diabetes by giving a missed call to 011-22901701. Currently more than 1.08 lakhs users are registered for mDiabetes

E-CGHS card enables self-printing of CGHS cards from any location.

SUGAM by Central Drugs Standards Control Organisation (CDSCO) enables online submission of applications, their tracking, processing & grant of approvals online mainly for drugs, clinical trials, ethics committee, medical devices, vaccines and cosmetics. Provides a single window for multiple stakeholders (pharmaceuticals industry, regulators, citizens) involved in the processes of CDSCO.

Drugs and Vaccines Distribution Management System (DVDMS) (‘eAushidhi’) deals with purchase, inventory management and distribution of various drugs, sutures and surgical items to various District Drug Warehouses of State / UT, District Hospitals (DH), their sub stores at CHC, PHC etc by automating the workflow of procurement, supply chain, quality control and finance department in State / UT level.

Mobile Apps: Various mobile apps have been launched viz.

- Indradhanush Immunization (for immunisation tracker)

- India Fights Dengue (enables a user to check Dengue Symptoms, get nearest Hospital / Blood bank information and also share feedback)

- NHP Swasth Bharat (information dissemination on Disease, Lifestyle, First Aid)

- NHP Directory Services Mobile App. (provides information related to Hospital and Blood banks across India have been hosted.

- No More Tension Mobile App. (information on stress management related aspects)

- Pradhan Mantri Surakshit Matritva Abhiyan Mobile App. (for reporting pregnancy care related information from across states)

Standards & Regulation for development of “Inter-operable Electronic Health Records (EHR) System”

National eHealth Authority (NeHA) is being set up by MoHFW as nodal agency for formulation, adoption & regulation of eHealth Standards in India as well as work as nodal agency for all strategic eHealth initiatives in India.

Electronic health data privacy & security legislation having a comprehensive legal framework to protect ‘e-health data’ of an ‘individual’ (owner) is under drafting and consultation with stakeholders. NeHA is included in this draft legislation

EHR Standards (revised version of 2013 Standards) has been notified in December 2016. The EHR Standards include standards for Disease Classification, Medicine and Clinical terminology, Laboratory Data exchange, Digital Imaging and Communication etc. for semantic interoperability.

National Resource Centre for EHR Standards (NRCeS) is set up in order to augment facilitation for adoption of the notified EHR Standards in technical association with C-DAC, Pune for providing assistance in developing, implementing and using EHR standards effectively in healthcare IT applications in India. NRCeS would also support NeHA.

National Identification Number (NIN) a unique identification number, which a key requirement for achieving inter-operability and creation of EHRs, is being assigned to all health facilities (both public & private) to facilitate inter-operability among health IT systems deployed. So far more than 2.22 lakh Public Health Facilities have been allocated NIN. The process for setting up mechanism for allocating NIN to private facilities is underway.

Standards based National Drug Registry & Code is being developed by NRCeS and AIIMS Delhi.
Metadata and Data Standards (MDDS) for Health Domain is being finalized for approval and due notification thereafter.

Telemedicine

National Medical College Network (NMCN) is being established with the purpose of e-Education and e-Healthcare delivery, wherein 50 Government Medical Colleges are being interconnected, riding over NKN (National Knowledge Network – high speed bandwidth connectivity). National Resource Centre has been established at SGPGI, Lucknow.

National Telemedicine Network (NTN): It is envisaged to provide Telemedicine Services to the remote areas by upgrading existing Government Healthcare Facilities (MC, DH, SDH, PHC, and CHC) in States. In the current financial year 4 States/UTs (previous 7) have been provided financial assistance for providing Tele-Medicine services by establishes NTN.

Tele-Medicine Nodes at Pilgrim places: In line with the Prime Minister vision of using space technology to deliver health services, MoHFW & Department of Space (DoS) jointly have been taking steps to set up Satellite communication based Telemedicine nodes at various unreachable geographical locations including Chardhams and other important pilgrimage centres (Amarnath, Ayappa and Kedarnath)for health awareness, screening of non-communicable disease (NCD) and for providing specialty consultation to the devotees visiting these places. So far, Telemedicine nodes have been setup at Amarnath Cave-J&K, Ayappa Temple-Kerala, Dwarkadheesh Temple-Gujarat, Kashi Vishwanath Temple-U.P and Vidhyanchal Devi Temple, UP.

Tele-Evidence: Tele-evidence is a modality via which doctors can testify in the judicial process utilizing the video conferencing facility without visiting the courts in person. This service was launched by Hon’ble HFM on 30.12.2015 at PGIMER, Chandigarh. As per reports, till date more than 4000 Tele-Evidences have been successfully conducted. After this successful implementation MoHFW has decided to rollout the service in every State/UT.

Now about the 2nd part of your question i.e. plans to bridge shortage of specialists in the country. I will just state the numbers i.e.

Up-gradation of existing State Government Medical Colleges: A total of 22 Medical Colleges with 1715 MBBS seats have been approved.

New medical colleges attached with existing District/ Referral hospitals: MoUs received from all States/UT; 53 proposals approved so far at a total cost of Rs.10017 Crore (Central Share is Rs.6860.70 Crore). 5300 new MBBS seats to be created. Rs.1953.42 Crore released for 51 medical colleges. 5 new Medical Colleges i.e. at Port Blair (A&N Islands); Rajnandgaon (Chhattisgarh); Sarguja (Chhattisgarh); Gondia (Maharashtra); and Nahan (Himachal Pradesh) are functional.

The DNB seats, which are equivalent to MD/MS are 6739 in 2017-18 i.e. an increase of 2265 from 2016-17. Total UG (MBBS) seats stand at 67352 in 2017-18 which is an increase of 2169 seats from 2016-17.

The Medical Education program is further augmented by a dedicated program i.e. the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY). The PMSSY envisages creation of tertiary healthcare capacity in medical education, research and clinical care, in the underserved areas of the country. PMSSY has two components- setting up of new AIIMS like institutes in underserved regions of the country and up-gradation of existing Govt Medical Colleges (GMCs).

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