An architect by profession and a founder member of Arvind Kejriwal’s Aam Aadmi Party, Satyendar Jain is Minister of Home, Health, Power, PWD and Industries. He may seem an unlikely choice to handle the health portfolio but he has managed to make a fair bit of progress on the AAP’s promises on the health front. In a frank discussion, he explains to Viveka Roychowdhury that Delhi’s healthcare system needed a revamp and why he is betting on an ATM-like master plan for ‘Anytime, Anywhere Health’
What are the priorities of the Aam Aadmi Party (AAP) when it comes to securing the health of Delhi’s citizens? What are the initiatives you have taken on this front so far?
We have increased the health budget by one and a half times in this year. Our first priority is quality healthcare for all. Both conditions are compulsory. It is not acceptable that there is no quality, nor that if we give quality healthcare, it is available to only some people. Why do we have to choose to give quality healthcare to only, say, five per cent of the population? And then showcase it as an achievement? Even if that five per cent is at the bottom level, it still means that the rest of the 95 per cent are out of this loop. Suppose that of 50 people injured in a bus accident, you decide to give compensation to only two of the injured people, and disregard the other 48 people. Is that right? So our government’s focus is first on quality healthcare and then providing this to everybody.
AAP recently launched Delhi’s first Aam Aadmi mohalla (neighbourhood) clinic this July. Isn’t this a revamped version of a primary care centre (PHC)? What is the rationale behind this initiative?
The concept of the mohalla clinic is that it should be close to people’s homes, within walking distance. This will be the first level of intervention for any health problem they have. Till today, our system has never thought of providing the first level of healthcare within walking distance of people’s homes. The existing clinics are quite far from each other and as a result, people most often have to travel two, three or even five kilometres to reach them. So that’s not a ‘neighbourhood clinic’ in the true sense, because it is not within a locality the patient is familiar with.
Our Aam Aadmi mohalla clinics are designed to serve the needs of a particular mohalla (neighbourhood). Each mohalla clinic will have a doctor, an auxiliary nurse midwife (ANM), a pharmacist as well as a lab technician for performing diagnostic tests. The doctor checks the patient, prescribes medicines, (most of which are available within the mohalla clinic) as well as, if needed, asks the lab technician to do the required tests. We plan to offer around 50 tests within the mohalla clinic, which will cover most of the basic and common illnesses.
During our trial runs, we thought that we could attend to 80 per cent of patients’ illnesses at the mohalla clinic and would need to refer the remaining 20 per cent (with more serious illnesses) to hospitals. But now our experience shows that 95 per cent of patients can be treated at the mohalla clinic itself and less than five per cent need to be referred to hospitals.
This has two benefits. Firstly, people get quality healthcare close to their homes. They do not have to spend on bus tickets or auto to travel to the clinic. Neither do they have to spend too much time to get their health check up done. Normally they would first spend on travelling to the hospital, then wait for upto two or even three hours for their turn. After meeting the doctor, they’d have to either buy medicines or go to a clinic to get lab tests done. They would get the test done the next day and the test reports the third day, then again wait a few hours to show the reports to the doctor, and only then the treatment actually starts. So for one illness, big or small, the patient has already spent two to four days.
But in the mohalla clinics, the patient gets a token number when they visit the clinic. They can either wait or go home because they can judge when their turn will come and they stay close to the clinic. At the next level, we are creating an app which will alert the patient when his turn has come. Then they can take appointments via cell phones through the app. So we aim to give the same services as already available for other tasks. If you can book flight tickets over the Internet or cell phones via apps, so why not here? The advantage of technology is that it smoothens the process as well as makes it cheaper. Today, we make manual entries in a registry, and each entry is done multiple times.
Secondly, we will make a health card for every citizen of Delhi and connect all health services online. A patient will be able to use this at a mohalla clinic, a polyclinic, a multi-speciality or super-speciality facility, all with the same health card. There is no need to carry the test reports, X-rays, etc. All the person needs to do is swipe the card, key in the number and since it will be biometrically enabled, give the thumb impression. The doctor can access all the health records of the patient at once, with graphs charting out his health indicators like blood sugar levels, blood pressure readings, previous medicines taken, current medication etc.
By when will the health card system be in place?
We are targeting for a year but it might take more time as this is a very tight deadline. But we are taking on tough targets because we believe that we have to aim for the highest level. So, we are looking at how we can achieve maximum quality and efficiency, in the least possible time and at the least cost. So it could be that while we aim for 100 per cent, we might achieve 95 per cent.
Another advantage of taking everything online is that we will be able to understand exactly what is happening where, and track everything. For instance, if stocks of a particular medicine in the mohalla clinic are depleting, it will trigger a restock request. So supply chain issues will also get sorted out. We are not reinventing the wheel as most of these systems and processes are already being used in the private sector.
The third advantage of the mohalla clinic system is that it will reduce the crowds in hospitals. Right now, it is becoming difficult to differentiate between crowded railway platforms and hospitals. Each bed is shared by two, sometimes three patients. If you don’t have space for patients, how can you treat them? And even if you do manage to get treatment, you will not be able to rest physically or mentally due to lack of space, so how will you get cured?
So, we have to increase our capacity. Right now, after 68 years of Independence, we have 10000 hospital beds in Delhi. We are going to add the same number of beds in the next two and a half years, meaning that we are aiming to double our capacity. We hardly have any capacity when it comes to emergency. ICU or accident beds are hardly 1000 beds of the total 10000 beds. Once this is increased to 20000 beds, around 7000-8000 beds will be for emergency/ ICU beds.
You have set a deadline of launching 1000 mohalla clinics within one year, by July 2016. Will you have the staff to man these clinics?
As I said before, we are looking at how we can achieve maximum quality and efficiency, in the least possible time and at the least cost. If you visit the first mohalla clinic, you will see that it has been planned so well that in a small space, we are able to fit in a lot. It is air-conditioned, looks good but without an extra inch of space. It may be small but it is well-designed for maximum utilisation of each and every inch. If everything is compactly designed, the running expenses too will be less. That is our target. So we are also looking at the future maintenance of such units when we design and set them up.
What about the criticism that the existing 200-odd clinics are mostly defunct and are not staffed?
We are upgrading them into polyclinics where each one will have four to five specialists.
In a recent interview to Indian Express, Union Minister of Health and Family Welfare Jagat Prakash Nadda, in response to the question that the health budget had been reduced, had said that the states have been given the funds, but they do not have the plans. When the AAP campaigned for the Delhi elections, the party manifesto had 17 points related to health. So, what is the progress on each of these promises?
We’ll try to achieve all of these in these two and a half years, barring one or two and also expand these 17 promises to 70. I’ve already said what we are doing on the mohalla clinics, increasing bed capacity and computerisation fronts. Budget allocation (for health) has already been increased.
We said we would fill existing vacancies of 4000 doctors and 1500 paramedics, while abolishing contractual postings. This is already under process and will happen in a year’s time. We’ve already recruited 1500 paramedics.
Are the doctors employed in the mohalla clinics permanent employees?
We are studying many models so it’s difficult to comment right now.
The APP manifesto had also promised free 100 per cent immunisation of infants and young children. What is the status on this?
We have already started this initiative, where we run an immunisation camp for seven days each month. Our target is to complete 100 per cent of the immunisation population in one year or one and a half years.
The manifesto also said that special eye and dental care clinics would be set up in all public hospitals in Delhi.
We are opening 250 dental clinics and this will also happen in the same time span.
What about plans to set up a 24-hour helpline manned by well qualified staff in every government hospital in Delhi?
In one year’s time, by July 2016.
What about the promise to centralised the procurement of pharmaceutical drugs and equipment?
This has already happened.
What about plans to provide a free ambulance service across Delhi, even for patients from private hospital?
This will take another six months, by February-March 2016. My speed and the speed of my government is fast, but the system has not yet caught up! There is always resistance to change but now they have realised that our announcements and plans are well thought through and backed by a lot of planning. I am seeing a slow change in attitude.
We have proved that we can achieve what we promise. For instance, we have increased the number of beds in the government hospital at Burari from 200 to 800. The cost of setting up the first 200 beds was Rs 90 lakh per bed but the cost of the additional 200 beds was just Rs 15 lakh per bed. So, now they realise that intentions are more important than the cost. And this is not the only example, we are doing the same in the (public) hospitals in Ambedkar Nagar and Dwarka. We will change all of Delhi’s (public) hospitals and you will not feel that you are in a public hospital. Of course, it won’t be like a private hospital but if we are today at the D or C level of infrastructure, we will move up to the B then A level.
The biggest thing is that now we have proved that this is doable, easily. And now everyone also feels that it should happen. There was the intial disbelief that this could never happen. Anyone’s first reaction to change is to resist it. That is Newton’s law of inertia: to resist change, to remain in the same position. We have to push away this inertia.
Moving on to the promise to open more pharmacy shops to dispense generic drugs?
We will be starting this on a trial basis and will roll this out as well in the next year or two year’ time.
Another promise was to increase outpatient hospital hours to include early morning and late evening timings to facilitate office going residents.
We’ll do this more through the mohalla clinics going forward because even if OPD hours in hospitals are increased, people would still need to travel to them, whereas the mohalla clinics will be more convenient.
The manifesto had also promised that while 38 hospitals had diagnostic centres, their testing and diagnostic services would be bolstered and 10 new diagnostic centres would be opened. What is the progress on this front?
We are changing this scheme to offer diagnostic services in all 1300 mohalla clinics. Currently, we aim to offer around 50 tests, which will be increased to around 100 tests.
Are these services provided by private players?
We are conducting a trial run and are looking at various models to see which one works best. Either the lab, equipment and staff are of the private player and they provide us the service or we buy the lab and equipment from them and run it with our own staff. We are studying both models right now to decide which one will give us maximum efficiency and quality at minimum cost.
But we have gone beyond the APP pre –election manifesto. In addition to the points already mentioned, we are doing a lot more. For instance, we are opening 70 panchkarma and naturopathy clinics, meditation centres, physiotherapy centres. The list is endless.
What are your future plans and initiatives?
Before we started our work in Delhi, we studied the health systems of the US, where even after spending 16 per cent of GDP on healthcare, many US citizens still face a problem. They are able to provide free services to only 45 per cent of their citizens. OECD spend nine percent of GDP on healthcare. Whereas in India, including the private sector, it’s only four to five per cent. We’ve also studied the health systems of Canada, Latin America and specifically Brazil, Cuba; few countries in Europe and the UK’s NHS. But we realised that we would have to make our own system because our demography and needs are different. We have of course incorporated the good aspects of their systems.
We have many health policy experts from other countries offering to study our system and help us set policies. We have enough policies in our country but there are gaps in the implementation of these policies. We need these experts to study the implementation gaps and tell us how to fix them. We know where we stand today and where we want to be in two years, but help us to solve the problems along the way.
We’ve been preparing for this from December 28, 2013 (the day Arvind Kejriwal took oath as Delhi Chief Minister). It’s like APJ Kalam’s quote: Dreams are not those that you see in your sleep but those that will not let you sleep. My wife jokes that this applies to me! The dreams that we dreamed of on December 28, 2013 will not allow us to sleep; we will stay awake and fulfill these dreams. It’s been 19 months now (since the APP took office) and we have done many things. We are confident that we will change Delhi’s healthcare system.
We will have to make our own healthcare system for Delhi. The existing healthcare system of primary healthcare centre, a secondary hospital and tertiary specialty care hospital system does not suit Delhi’s needs. It was designed for a larger area, a state whereas the NCT has different geographical constraints. Therefore we’ll have to refashion it into a system with many mohalla clinics, then larger polyclinics, followed by a few multi and super speciality hospitals.
For example, take eye care. Today, there are around 33 eye care facilities in all Delhi’s public facilities with two to three eye doctors but none of them offer the full spectrum of eye care. So we will consolidate these to just seven or eight fully speciliased eye care centres of excellence (CoEs) with 10-12 doctors. Govind Ballabh Pant Hospital is well known for ortho care so we will designate it a CoE and then make four more like it. We’ll do the same in liver and biliary sciences. Today, we have islands of success; we will replicate these islands of success. We will repeat what is right, and fix what is wrong.
We’ve divided Delhi into five zones: north, south, east, west and central Delhi. Each unit will be self-contained. No one will have to go to another zone for multi- or super speciality care. All this calls for some reorganisation but it will allow us to make better utilisation of the resources available to us.
How will the mohalla clinics evolve in future?
Today, we avoid going to a hospital for upto 10 days even though we may be running a fever. We prefer to self-medicate. It is better that people get treated early and avoid coming to hospitals because hospital care can get expensive. These mohalla clinics will be particularly helpful for aged patients because these are almost at their doorsteps, they can go twice a week to check their blood pressure, sugar levels, etc. These visits cost a fraction of what would have to be spent if they need hospitalisation. These mohalla clinics will later double up as preventive healthcare centres once we start health awareness drives on Sundays.
We will use a lot of technology. This has never been done before so we are starting on a clean slate. This is good because we can directly use the latest and the best technology, rather than making do with obsolete systems. We are bypassing desktops and laptops and directly putting all our (health related) technology and apps on tablets.
Just as banks have opened ATMs everywhere to avoid overcrowding their banks, I want the mohalla clinics to be ATMs for health services: i.e. ATH, AWH: any time health, anywhere health.