Health Care in developing world
A Road Map to Paradigm Shift
Prof. D K Gupta
Vice Chancellor-CSMMU, (KGMU), LKO
Professor and Head, Dept of Pediatric Surgery
AllMS, New Delhi
Where are we - today
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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 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 wise
Source: Global Burden of Disease, 2004 Update, used by
permission
Major Causes of Death, World area
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8
9
10
Disease or Injury
Ischemic heart disease
Cerebrovascular disease
Lower respiratory infections
COPD
Diarrheal diseases
HIV/AIDS
Tuberculosis
Trachea, bronchus, lung cancers
Road traffic accidents
Prematurity and low birth weight
Deaths/ % of total
million
deaths
7.2
12.2
5.7
9.7
4.2
7.1
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5.1
2.2
3.7
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3.5
2.5
1.5
1.3
2.3
1.3
2.2
1.2
2
Source: The Global Burden of Disease: 2004 update, WHO
Life style : factors
Lack of Physical exercise
• 2 million deaths worldwide annually.
• A causal factor for;
• 10-16% breast , colon cancers, diabetes
• 22% of ischemic heart disease.
Overweight & Obesity
WHO Report: 2.3 billion overweight adults in the world
Over 700 million of them will be obese by 2015.
Hypertension
• 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.
Disease association with Tobacco use
Source: WHO Report on Global Tobacco Epidemic, 2008
Health Problems in developing world
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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 Tourism
Indian medical scenario
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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 scenario
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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
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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 India
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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 :
Preventable in children
• News 26-7-2012
- KGMU Trauma Center caters to
5 neighboring states & Nepal
- 9 more trauma centers
Indian scenario
- Preventive & Control programs : Govt.
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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 Colleges
(recognized / un-recognized)
Govt.
sector
Private
sector
Medical colleges ~160
~ 200
~ 360 in India Mostly Old - 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 Doctor
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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.
• 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 ;
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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 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 Planning
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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 • 6 new AIIMS like Institutes
• Incentives for PG seats for rural doctors
(10 marks for 1 yr , max. 30 marks for 3 yr service)
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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 Incentives
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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 services
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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 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 - difficult
Curative 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 Parental counseling
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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 ;
• 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 tops
Gupta DK. Chairman –
Core Group Recommendations to the Ministry,
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3 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 concerns
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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 high
mortality rates of infants and pregnant women
have been a cause of serious concern.
“Government has decided to continue the
National 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
Road Map to improvement
Increase in health
Budget & Facilities
Give Respect &
Responsibility
Have Trust &
commitment
Competency and care
Expect nothing from 21st century.
It is the 21st Century
that expects everything from us.
(Gabriel Garcia Marquez)