1. HEALTHCARE IN THE NEW
MILLENNEUM
SYED AMIN TABISH

2. 20th Century
Ecstasy: unprecedented progress by medical sciences
during last 4 decades
Tragedy: EID like AIDS (a global crises)
Trauma: Political unrest, human rights issues,
disasters, inequalities, etc.
Romance: eradication of smallpox & polio,
information superhighway, mapping of human
genome, breakthroughs in nuclear & molecular
sciences including reproductive biology.

3. H AL H M
E T : OST VAL
UAB E P L SE
L UB IC RVICE
Health is fundamental to quality
of life
Health Services: a personal
answer to personal needs
Government should guarantee
the existence of HC system
providing equal, accessible,
comprehensive & high quality
care to all.

4. HEALTH: MOST VALUABLE PUBLIC SERVICE
HC : largest industry & its
sheer size & complexity makes
change an evolution of
mammoth proportions
 No other sector reaches as
many people, as the HS, its
market being assured,
whatever the odds.


5. H AL H
E T CARE T
RANSF
ORM ION
AT
 Epidemiological & demographic transitions
 Improved Life Expectancy (aging)
 A better-informed & more demanding
populace
 New technologies & expansion of scientific
knowledge
 Universal trend towards greater
decentralization pro-market economic
policies, purchaser-provider split, rapid
expansion of Pvt. Sector, introduction of user
charges.

6. GRADUAL DE
CAY
We have observed with
considerable consternation the
gradual but sure decay in Health
services
The outbreak of Malaria in
virulent form, return of Dengue
(Delhi-1996) & Plague (Surat1994), EID (Tuberculosis) are
some clear signs of this decay.

7. DOUB E B
L URDE OF DISE
N
ASE
We are also living under two
shadows – one of infectious
diseases and the new and
growing shadow of
non-communicable chronic
Diseases

8. DOUB E B
L URDE OF DISE
N
ASE II
T health transition is due to
he
combination of demographic &
life style changes,
industrialization & urbanization
 A thorough review of NH & a
P
total revamping & restructuring
of the health infrastructure


9. DICH OM
OT Y
T large widespread health
he
infrastructure seems to be nonfunctional
& unresponsive in many parts. Instead of
moving forward to meet the health
challenges, it is sliding backward.
 E
xtremely uneven health & development
process in various parts of the country
 One can hardly believe that they are part
of same nation. E
ven with in the states
which are doing reasonably well there
remain regions of darkness where little
has changed since independence.


10. L
IVING ON T E E
H DGE
AN AGE OF DARKNESS & LIGHT


World has 450 billionaires: with the value of
their combined assets now exceeding
combined income of poorest 50% of world’s
people
These are obscenities of excess in a world
where 160 m children are malnourished, 840
m live without secure sources of food & 1.2 b
lack access to safe drinking water
A KNOELEDGE-BASED SOCIETY

Basic immunization saves lives of > 3 m every year
in developing countries

11. WE LIVE IN A WORLD OF DISTURBING CONTRASTS
3/4ths of the world’s people live in
developing count. enjoy only 16% of the
world’s income
 More than 1B people lack the opportunity to
consume in ways that would allow them to
meet their most basic needs
 More than 17 M people die every year from
infectious & parasitic diseases(D,M,TB)
 Challenges: reducing pop. growth, providing
basic social services


12. WE LIVE IN A WORLD OF DISTURBING CONTRASTS II
More than 90% of HIV infected cases liv
in developing country
Developing countries witnessed
unprecedented human develop. in past 30
years, it has covered as much distance
during those 30 years as industrial world
did in a century.
But human deprivation remains
Resources to be generated by cutting

13. CURRE H AL H ST US IN INDIA
NT E T
AT
India’s public sector health expenditure today is
Rs.10,000 crore per year (which is being spent on
4800 hospitals, 450000 beds, 11100 dispensaries,
21802 Primary Health Centers, 132285 Sub –
centers & various preventive & promotive
programs, including family planning)
In India, life expect. has doubled from 32 yrs (1947)
to 63 yrs. in 2000 & IMR declined from 146 to 70
Many disparities & distortions remain.
Progress has been uneven
Consequences: neglected areas, forgotten
populations & overlooked issues.

14. H
ealthcare E
xpenditure
HC system absorb 8% of the total world
product
 Industrial countries spend 90% of this amount,
with average per capita exp. of $1500 on HC as
compared to $41 in developing countries
 India spends 1.6% of GDP (even lower prop.
spent on PH
 The institutional base is weak, NGO’s are
underutilized, & finally pvt. sector is gigantic,
virtually completely unregulated & offers some


15. THE DRIVERS OF CHANGE

Drivers of change in
developed world are reaching
limits of welfare state
exhausting traditional
methods of containing cost &
expecting increasing

16. THE DRIVERS OF CHANGE II
No HC system in the world is
stable
Growth of Middle Class,
greater demands from the
middle class, & globalization
of economies are driving

17. E IDE IOL
P M OGICAL P RSP CT
E
E IVE F
OR H
C
M
ANAGE E
M NT
Population’s ability to benefit
from HC
An understanding of the
characteristics of pop. (tends in
size, demographic & social
characteristics/distribution of
exposures that could influence

18. E IDE IOL
P M OGICAL P RSP CT
E
E IVE F
OR H
C
M
ANAGE E II
M NT
Assess how & when HN are
distributed throughout a pop. &
evaluate the use & efficiency of
interventions
Assessment based on incidence &
prevalence on one hand &
effectiveness of HC on the other

19. M DICAL E
E
DUCAT
ION
M
edical education is at the
cross roads today.
 Society wants to respond to
people’s HN with interventions
that are relevant, efficient,
affordable & equitably
accessible to all its members.


20. M DICAL E
E
DUCAT
ION II
Doctor of the future:
 A caregiver
 Communicator
 Decision maker
 Community leader
 A good manager
 Med. Uni. should introduce accountability,
creative autonomy, quality & new
methodologies, for preparing future doctors
to function properly in society.

21. M DICAL E
E
DUCAT
ION - III
Agenda for action:
 Setting up of a National HR Dev.
Comm.
 A comprehensive ban on Med.
College expansion
 Strengthening MCI to control fall in
standards
 Examination reform

22. M DICAL E
E
DUCAT
ION - IV
Developments in ME include:
 Curriculum planning (PBL, TBL, Community
orientation)
 Assessment (performance-related/objective
structured Clinical Exam./assessment of
critical thinking)
 Teaching & learning (simulation, computerassisted, multimedia)


23. E E
M RGING INF CT
E IOUS DISE S
ASE

Leading cause of death worldwide/17 m
die/year

Malaria, TB, Dengue, Hem. Fever,
Hepatitis, JE, Ebola Virus, Hanta virus,
yellow fever, E. Coli 0157, Kala-azar,
plague, BSE threaten lives of millions of
people
 An outbreak of Cholera in Mexico-300
deaths, plague in India: loss of
$1.7m/Zaire & entire world dodged a
bullet in 1995 - outbreak of Ebola

24. E E
M RGING INF CT
E IOUS DISE S II
ASE
Tackling EID:
 Pro-active & planned approach should
include
1. Preparatory state
2. Alert phase
3. Response phase
4. Follow-up phase
 Information system be developed.
 Comprehensive communication strategy
 Infrastructure & capacity building

25. H
ealth Services in Rural Areas
80 % rural population utilize 20% resources &
20% urban population gets 80% resources
 Basic goal of decentralized planning is to
eliminate poverty, ignorance & ill-health,
improve the QOL of people & raise their
standard of living
 HS pro vide d sho uld be :
- accessible, available on a continuing
basis,
acceptable culturally & socially,
affordable


26. H AL H OF W E CH DRE & E DE Y
E T
OM N/ IL
N
L RL
Social, health & nutritional status of the most
vulnerable sections of society reflect the real
index of development. India ranks 135th in the
list
 Marginalisation of women
 Children are the future of a society
 India has the dubious distinction of having
highest no. of infant deaths in the world.
 Elderly persons: 7.6% population is likely to
increase


27. CONT
ROL OF COM UNICAB E DISE S
M
L
ASE







Good environmental sanitation
Prompting Healthy life styles
Undertaking control or Eradicating Programs
Proper Organizational Set-up with Effective
Leadership
Strengthening General Health Services
Comprehensive & vibrant Epidemiological
services
Disease specific measures for control of high
priority infection (TB, Malaria, AIDS, RTI,

28. POPULATION STAB: A DILEMMA
India has crossed the billion mark
 Unchecked pop. growth negates all
progress made
 Tremendous pressure on resources
 With present growth, India will have
1600 m faces in 2025 that will be
deprived of constitutional guarantee of
health/ education/nutrition/


29. POPULATION STAB: A DILEMMA II
Nearly 1/3rd of children >16 are forced to
lead an impoverished life/150 m were
denied basic HC/226m drink
contaminated water/640m do not have
access to basic san. & 50% of world’s
illiterates
 Eradicate illiteracy & Communicate
effectively
 Eliminate corruption


30. T EP
H RIVAT H AL H SE OR
E E T
CT
Today, HC has become fully
commodified
 A fairly large investment by Pub. Sector
(that is otherwise inadequate) is being
wasted
 Pvt. Sector responsible for 3/4th of HC
 Given current ethical standards Pvt. Sec.
doesn’t provide quality at reasonable cost


31. CH
ANGING H AL H & H
E T
C
P
ARADIGM
We have to look beyond so called
predominantly reductionist biomedical
model of HC to a holistic model that puts
human being in the center
 The total participation of its citizens
 Progress is easiest made if we r tuned in
with national genius
 New ideas are being discussed:

(Birth with a future/dying with dignity/rationing of
care/total body systems conditioning)

32. CH
ANGING H AL H & H P
E T
C ARADIGM
QUAL Y M
IT
ANAGE E
M NT
In medicine poor quality is
expensive
 Patient safety can not be
compromised
 We can no longer afford high cost
of low quality
 Quality management is scientific


33. EMERGENCY HEALTH CARE
Emergency Situations requiring immediate
attention occur frequently
 Bhopal Gas tragedy/Earthquake in Latur &
Gujrat/Cyclone in Orrisa/Rail Accidents
 When managed appropriately, good chance
of survival
 Preserving life, disability limitation
 Emergency preparedness/EMS/CATS


34. MENTAL HEALTH
Mental illness is not a personal failure. Rare is the
family that will be free from an encounter with mental
disorder.
Neuropsychiatric conditions accounted for 10% of
burden out of an estimated 39% of all DALYs
Wide gap between availability & implementation of
effective interventions
Theme of WHD 2001: “Stop exclusion, Dare to care”
New understanding, new hope: combining science &
sensibility to bring down barriers to care & cure
Mental health care needs less costly technology

35. Mental health - II
•
•
•
•
•
•
•
•
•
Provide treatment in primary care
Make psychotropic drugs available
Give care in the community
Educate the public
Involve communities/families/individuals
Establish national policies, programs
Develop human resources
Link with other sectors
Support more research

36. DE L M NT & T E E
VE OP E
H NVIRONM NT
E
The achievement of sustained & equitable dev.
remains the greatest challenge facing human race
>1 B people still live in acute poverty & suffer
Inadequate access to resources
Essential task of dev. Is to provide opportunities
In developing countries 30% of pop. Lack access to safe
water & 60% to basic sanitation
>90% of waste water discharged into streams/rivers
resulting in water borne dis.
Air pollution from industrial emissions, car exhaust etc.
kills >2.7m people/yr.
Domestic solid waste – 50% remains uncollected
Cost of environmental degradation in India: 6% of GDP

37. DE L
VE OPM NT & T E E
E
H NVIRONM NT
E -II
Excess CO2, Methane etc. trap heat are
accumulating in troposphere. Global Warming
Priority should be given to:
1/3rd of world’s pop. that has inadequate san. & 1 B
without safe water
1.3 B people who are exposed to unsafe conditions
caused by soot & smoke
700m women/children who suffer from indoor air
poll.
Hundreds of millions of farmers livelihoods
depend on good environmental stewardship
Millions of deaths each year from dirty water &

38. HUMAN DEVOLOPMENT & GENDER
EQUALITY
History is likely to judge the progress in the 21st century
by 1 major yardstick:is there a growing equality of
opportunity between people & among nations
The most persistent disparity has been Gender Disparity
Women still continue 72% of world’s poor & 2/3rd of
worlds illiterates
Human development if not engendered, is endangered
Investing in Women’s capabilities & empowering them.

39. E
RADICAT
ING P
OVE Y
RT
Poverty has many facts. It is much more than
low income. It also reflects poor health &
education, deprivation in knowledge, etc
The world has the resources & know how to
create a poverty-free world in less than a
generation
Over the past 3 decades more than a dozen
developing countries have shown that it is
possible to eliminate absolute poverty
Poverty is not to be suffered in silence by the
poor.

40. INVESTING IN HUMAN DEVELOPMENT
•Countries must invest liberally in human
development so that they are ready to face
the challenge of Globalization
• Globalization is integrating consuming
markets around the world. But it is also
creating new inequalities
• The time has come to create a new world
that is more humane, more stable, more just
Components of Human Development
paradigm:

41. T ARDS DE L ING A CIVIL
OW
VE OP
SOCIE Y
T
Consumption levels of more than a
billion poor people must be raised
Strong civil society alliances should be
built to protect consumer rights
What is the meaning of growth if it is
translated into the lives of the people
Empowering people – perticullarly
women – is a sure way to link growth &

42. RESPONDING TO THE CHALLENGE
Need for better resource allocation &
need for improved utilization of funds
 Employment & income generation
 Secondary & tertiary medical care
(subsidy for poor)
 PHC for All
 Fiscal incentives for backward areas (to
encourage pvt. Practitioners to open
clinics in remote areas



43. RESPONDING TO THE CHALLENGE
Reaching the Out reach
 Panchayat raj
 User costs (China exp.),Use of pub.
facilities by vulnerable sections can increase
despite increase in user charges, if quality is
improved as (e.g. Pakistan)
 Contracting out
 Fiscal incentives for backward areas
(responsibility of Govt.), increased pvt.

44. ACCREDITATION / REGULATING MEDICINE
Mushroom growth of Nursing Homes: a
source of concern because of substandard Pt.
Care & unethical practices
 1 or 2 room shops with a scant regard for
standards can not be accepted as HC
institutions.
 Assure consumers that no practitioner without
appropriate registration is treating a patient
 Establish credibility of service – develop

comp. standards

Aims: Vol. pursuit of Q/team building,

45. ACCREDITATION / REGULATING MEDICINE
Regulation of M & practice should
C
include:
Institutionally delivered HC
Clinical Audit/TQM/CQI
 MCI must be strengthened to improve
self-regulation
 Enhancing levels of medical
Accountability

46. Future Health Goals/Core values of Med Prof
Refocus recourses on those who need the
most
 Poverty reduction by investment in most
basic needs ( food, safe water, sanitation &
access to social service
 Universal HC for all
 Sustainable development
 Equity promoting
 Safe & healthy environments & living
conditions
 To enable all people to adopt & maintain
healthy l lifestyles & healthy behavior


47. Future Health Goals/Core values of Med Prof
CORE VALUES:
 Caring
 Commitment
 Compassion
 Integrity
 Competence
 Spirit of enquiry
 Confidentiality
 Responsibility
 Advocacy

48. M
ANAGE CARE
D
Developed in response to ever increasing HC costs
Important Tools of MC:

For managed demand
1.
Capitation
2.
Gatekeeper
3.
Advice line to patients
4.
User fees
5.
Consumer education

For medical management
1.
Utilization review
2.
Preadmission certification
3.
Greater use of cl. Pathways

For care delivery:
1.
Telemedicine

49. M
ANAGE CARE II
D
HC system can be grouped into
4 archetypes:
 Socialized medicine (UK)
 Socialized insurance (Canada)
 Mandatory Insurance (Japan)
 Voluntary Insurance (USA)
 An integrated & virtual system (brought
about by Disney & Microsoft). With this
system service can be provided any where,
anytime by HC provider.
 Informed Consumer

50. H
OSP AL A Center of E
IT xcellence
In India, out of total of 13692 hospitals:
4310(32%) are in rural areas & 9382 (68%)
are in urban areas. The Government owns
4235 (31%) of total hospital beds; local
bodies control 2.5% of hospitals
 At present India has 1 hospital bed per 1412
pop. Which is hardly sufficient to meet the
challenges posed by demographic &
epidemiological shifts. The overcrowding &
overstretching of service results in poor


51. Vision: T Scientific M
he
indset
Synergy between Science, Technology,
Organization & public Policy: has helped
bring about sea change in food, environment.
& agriculture.
The future will undoubtedly witness
revolutionary changes & new horizons opened
up by cutting-edge science
A vibrant, responsive & globally competitive
science system is crucial.
This calls for strong social support &
commitment to Science

52. Challenges







Hospital & Primary Health care
Technological revolution
Quality of care- CQI, ISO 9000 certific.
Rising costs of HC
Privatization of HC
Consumer protection & medical prof.
Market approach to health: there has to be an
paradigm shift from being “product oriented” to be
“client oriented”

53. Restructuring H
ealth care/ olistic approach
H
H IST AP ROACH
OL IC
P





Radical institutional reforms: HC extended to those who
need it most.
Investment in decentralized pop.-based systems / HSR /
develop Evidence-based HC.
HS: responsive to needs of all,cost-effective & affordable,
of high Q, humane, caring, culturally acceptable, innovative
in provision of services, sensitive.
Holistic concept covers human biology, personal behavior
(lifestyle), Culture, medical care system, psychological &
physical environment.
Disease prevention & Health promotion

54. Health Policy
2002
Objectives:
• To achieve an acceptable standard of good
health amongst the general population
• To increase access to decentralized Public
Health System by establishing new
infrastructure in deficient areas & by upgrading
the existing institutions
• Ensuring a more equitable access to health
services across social & geographical expanse
of country
• Increasing aggregate PH investment through a

55. Alternative Strategies
1.
2.
3.
4.
5.
6.




Hospital: from center of excellence to community support
Hospital without walls
Hospice
Home care (Self care)
Palliative care
Geriatric centers
Investing in health should be considered as an investment in
HRD to enhance productivity.
Create new intellectual capability, resource capability, social
justice & equity
A new mindset to speed up reforms, reaching out hard-to-reach
& helping hard-to help
By improving the prospects of the least of us, we can assure a
more productive, just & civil nation for all of us

56. INVE ING IN H AL H
ST
E T
Future Action:
 Ensuring value for money
 Poverty reduction
 Public health policy
 Strengthening national capabilities for
emergency relief
 Emphasis of long-term & comprehensive
strategies

57. IMPROVING HEALTH OF THE NATION
• Address the Burden of the ill-health among
very poor populations with emphasis on
RCH, Communicable Diseases, Nutrition,
Mental Ill-health, Injury, Non-communicable
Diseases
• Track & assess risks to health, & help
societies to take action to reduce them.
• Improve the performance of health systems.
• Encourage national policies which promote
health with contribution from economic,

58. H AL H E RYB
E T : VE
ODY’S RIGH ,E RYB
T VE
ODY’S
RE ONSIB IT
SP
IL Y
LET US RISE TO THE
RESPONSIBILITIES OF NEW
WORLD – A BRAVE NEW WORLD
THAT IS UNITED AGAINST THE
COMMON ENEMIES OF
HUMANKIND: POVERTY,
IGNORANCE & DISEASE. A
WORLD WHICH WE CAN PASS ON
TO OUR CHILDREN & THEIR
CHILDREN WITH THE
KNOWLEDGE THAT WE ROSE TO
THE RESPONSIBILITIES OF THE
NEW AGE.

59. LOOKING AHEAD