17th September, 2019
Sri Y.S. Jagan Mohan Reddy
Chief Minister of Andhra Pradesh
Dear Sri Jagan Mohan Reddy garu,
I am happy to note that your government is committed to improvement of health and medical services in Andhra Pradesh. Initiatives for overhauling of services in government hospitals and transforming government hospitals into model hospitals are steps in the right direction to improve the healthcare system. It is also a right time and opportunity to consider in putting in place a robust, viable, economical, effective universal health care programme across the state with public-private-partnership.
Our public health system has not been able to meet the needs or expectations of our people, causing enormous misery, ill-health and pain, and is driving many people into penury and poverty. In order to revamp it and make it effective we have to recognize some of its strengths and weaknesses, and we must build on the strengths of the system, remove weaknesses, and create an architecture that can deliver quality care at a modest additional cost. While government spends only about 1% of GDP on healthcare, the people are getting Rs. 4-10 in the form of services for every rupee spent. Therefore, we should spend more, and wisely on public health.
We understand that the main issues in healthcare in Andhra Pradesh or in any other State in India are:
- Weak primary health system: Primary Health Center (PHC) and Community Health Centre (CHC) level is critical for family health and for giving patients confidence at first level hospital care for simple interventions. However, there is underutilization of the PHCs or CHCs. There is no credible government facility as first point of contact for family health services. PHCs are not considered by people as healthcare givers except for limited services like vaccination and family planning. Many doctors are not willing to work at the primary care level and even those who are posted there are generally absent or ineffective. There is no accountability or trust.
- Overcrowded and Underfunded Government Hospitals: In the absence of improvement in primary and family healthcare, there is overcrowding in tertiary care government hospitals. In most hospitals, nearly double the numbers of patients are admitted relative to sanctioned bed strength. Also thousands come as outpatients with simple ailments that should have been addressed by a primary care physician.
- Under-paid healthcare personnel: There is misallocation of our health manpower. India is producing about 60,000 doctors every year, and many of them are underemployed. Several MBBS doctors are willing to work for Rs.30-40,000/month in towns and cities.
Given these facts and circumstances, three broad approaches should be considered to radically improve healthcare delivery at a relatively low cost:
Build Primary Care : A network of 10 doctors to provide primary care for 70,000 – 1,00,000 population can be brought into public health system to establish practice in large villages or small towns, within about 10 km radius of the catchment population. Each family will have the freedom to choose the Family Physician (FP) of their liking. All basic healthcare needs of the family, as well as outpatient care, simple diagnostics and supply of drugs will be met at the FP level. The FP receives from government a capitation fee of, say Rs. 500/ head / year. As the families choose their FP, the doctor who is trusted by people gets paid on the basis of number of people registered with FP. Thus families have a choice, and FPs will have the incentive to serve well and earn the trust of the people. They get free drug supply and vaccines etc. from government. On an average, about 5000 patients can be registered with each FP. The patient will be seen by a hospital at CHC/private nursing home level or at district/tertiary level only on referral by the FP, except in emergencies.
Such a system will be economical and effective in providing quality healthcare at outpatient level. It will give adequate incentive to general practitioners to serve, and people will have choice of FP ensuring accountability.
Broaden Secondary Care: At the secondary level, integration and expansion of Aarogyasri by contracting small private nursing homes with complete choice and competition. The patients should have a choice of going to the CHC or any small private nursing home in which they have confidence. The CHC as well as private nursing homes will be reimbursed by government on pay-for-service basis applying standard costs and standard services model.
This will give patients choice, create competition among providers, improve quality of care, and meet most of the first level health care needs satisfactorily at a low cost.
Strengthen Tertiary Care: Substantial strengthening of tertiary level district and teaching hospitals where treatment is provided on referral basis. Encouraging private sector participation to acquire and build the infrastructure and lease to the government for a fee. Secondly, enhance the budget for teaching hospitals and district hospitals and increase budget of Centres of excellence and super specialty hospitals
These steps will substantially improve the infrastructure, basic amenities, hygiene and quality of care in tertiary and district hospitals.
The above initiatives can be achieved by increasing in healthcare expenditure by approximately Rs. 2,900 crores/year and would significantly improve care and patient satisfaction. Rs. 2,900 crore is a mere 0.27% of the State’s GSDP.
We urge you to consider the above model in revamping the healthcare of Andhra Pradesh. We will be happy to interact with the government to present details of this model and work with the officials to make it a success. I am enclosing a brief power point presentation outlining the healthcare reform proposals for your government’s careful consideration
With warm personal regards,
- Sri Alla Kali Krishna Srinivas — Deputy Chief Minister — Minister of Health, Family Welfare and Medical Education, AP.
- Dr.K.S.Jawahar Reddy, IAS, Principal Secretary, Health Medical & Family Welfare, AP.