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Monday, May 6, 2019

India's healthcare system - a story over infographics

There are two kinds of people who work in public health. I think of them as the “Market-Facing Types” and the “System-Lens Types”. The first kind believes that answers to the toughest global health challenges will only be found through market-based solutions. Solutions that include strategic pricing, supply-chain efficiencies, increased access to bottom of pyramid (BoP) markets, economies of scale and profitable private investments. The second lot believes that responsibility for healthcare provision lies squarely with elected governments and public systems, which admittedly are flawed and fragile; building and strengthening these systems is the only long-term, patient-centric and just solution to healthcare challenges. In the long-term, we’ll probably find that the two perspectives need to co-exist, work together and hold each other accountable, but for now, as in other conflicts, each side shakes its head at the other, calling it “na├»ve”, “narrow”, etc. 

Eight years ago, I started my career in public health bang in the middle of the market-facing lot and was, for the longest time, unable to see beyond that particular point of view. I’ve found myself creeping towards the middle recently though. Maybe it comes from spending time with friends who work in places where markets seem like distant realities, places where people live with zero access to formal healthcare, places where an easily treatable illness can easily be the cause of death and debt. 

I began 2019 with a goal to better understand healthcare systems. I have an excellent learning ground too – I live in India, home to the largest pool of healthcare needs, and perhaps the most complex health infrastructure in the world. In this article, I plan to summarise my big picture understanding of India’s healthcare system, under four heads:
  1. What are the major events in India’s healthcare system evolution? 
  2. What does the healthcare infrastructure in the country look like? As in, how is the healthcare delivered?
  3. What are the governance mechanisms? In other words, where will the innovation and change come from?
  4. What are the big healthcare issues to think about? 
Here goes, #1: Evolution and timeline:
Infographic #1: Timeline

These are only the events that interest me the most, so I admit there are some important ones that I’m missing out. My work has been primarily in infectious diseases, specifically TB and HIV, so events relevant to these are what jump out at me. It is absolutely fascinating to me - 
  • that a report submitted in 1946 continues to be the basis of not only current health structures, but also ongoing policy discussions,
  • that we started to talk about the need to engage with the private sector only in 2002,
  • that 19 years after the government launched the pulse polio program, India was officially declared polio-free. This gives me hope for TB eradication. But not too much - the plan was to eliminate kala-azar and filariasis by 2017 and leprosy by 2018 (spoiler alert: we didn't) 
Part 3: What are the governance mechanisms in healthcare? Who does what?
Part 4: What are the biggest issues in healthcare?

Tuesday, April 30, 2019

The Terror of the Bridge Course

“Bridge Courses” for care providers continue to sit squarely on the divisive lines among Indian healthcare experts. One side sees it as the path-breaking innovation that access denied communities desperately need, the glue that will fix our broken healthcare system, the one ring to bind us all in a smooth patient care pathway of quality primary care, efficient referral networks and focused secondary and tertiary care systems. The other side, equally passionate, is convinced that it will lead to large-scale malpractice, patient mismanagement and exploitation. I’m interested in examining this burning issue, and there are three questions I’d like to explore: 
  1. What is a bridge course, and why does the government of India keep proposing it?
  2. Why do my doctor friends dislike it so much?
  3. Could there be redemption for this “innovation” after all?
What is a bridge course?
Everyone knows this, but let’s say it again anyway – India has a shortage of qualified doctors. Bridge courses have often been mentioned among GOI's approaches to address the issue. In early 2017, the national medical council (NMC) proposed to build a mid-level cadre of healthcare workers by providing a six-month long “bridge course” to a variety of non-MBBS personnel who are part of India’s healthcare universe: AYUSH providers, nursing cadres, pharmacists and others, including informal providers (some state governments call such informal providers UMPs or unregistered medical practitioners, a far better term than “quacks”, which brings in unnecessary derision and makes the debate shallow). Post-training, these “bridged course trained providers” - let’s call them BPs - would be given conditional licenses to provide primary care and referral services in underserved areas. Anecdotal evidence indicates that a large proportion of the country's healthcare - primary care as well as emergency services - is already managed by UMPs. Bridge courses have the potential to make the system formal, accountable and transparent. 

Why is the formal medical community so repulsed by the bridge course? 
About 5 minutes after the NMC submitted the bill to parliament,  Indian medical association (IMA) and other physician groups erupted in passionate protests to get the bridge course proposal scrapped. Their key argument was that patient care will deteriorate under a system where healthcare delivery is provided by non-MBBS personnel. How can someone trained over six-months provide care comparable to an MBBS doctor with five plus years of training? My knee jerk response was that less-than-perfect-care ought to be better than the no-care which is the current state of affairs in areas where BPs would serve, but I dug deeper to better understand my doctor friends’ reasons for resistance:
  • It will be an implementation nightmare: It will be nearly impossible to ensure training quality, the UMPs will provide low quality care, keep managing cases beyond their skill set, either not refer patients to qualified secondary care at all, or only refer them when it is too late. 
  • The UMPs will encroach on the qualified doctors’ work: Even though BPs are meant to provide services in underserved rural and urban areas, financial incentives might drive them to migrate to overcrowded urban areas. Hospitals, whose profits are under pressure now more than ever, may to prefer to save costs by hiring these providers rather than formal medical doctors. Urban patients, who have the tendency to "doctor-shop", may prefer to walk in into clinics run by these BPs for cheaper care.
  • These courses are a threat and disrespect to the medical profession: BPs may indeed solve some of the doctor shortage issue, but this may reduce government inclination to build new medical colleges or to improve the medical education infrastructure. Also, if such ‘short-cuts’ to education are available, why would young people invest their decades of their lives in pursuing medical education? As my articulate friend Dr. Sonal Verma puts it - "I favor fixing our broken roads rather than building yet another weak bridge". 

It would be simplistic to dismiss some of these issues as being doctor-centric rather than patient-centric. Healthcare system strengthening plans need to be firmly entrenched within these realities of the medical profession in India. The protests worked, and bridge courses were removed from the NMC bill in 2018. GOI instructed states to take their own decisions on training programs for lay providers. IMA seems to have won the battle, but war is far from over, and it might be premature to throw the idea into the “absolutely irrelevant” pile just yet. Ministry of Health and Family Welfare (MOHFW) has now (in April 2019) proposed a bridge course to train dentists to practice as MBBS physicians. This has led to a fresh round of protests.

Is there room for redemption?
Bridge courses might be inspired by what WHO calls “task shifting” - a process of delegation where appropriate tasks are moved from highly specialized to less specialized health workers. Task shifting has been implemented widely to address care delivery gaps in multiple areas, from HIV care to cardiovascular triage. Although recognized as a method to increase efficiency in healthcare, success rates vary across case studies and depend on a lot of related factors. Here’s my list, admittedly far from complete, of elements that need to be brought in before bridge courses become a part of India’s healthcare system:
  • Stringently developed, expertly delivered course content, with local customization as necessary 
  • Accountability not only in course content delivery but also in service delivery
  • Transparent referral networks based on digital tools that work
  • Incentive structures rooted in local social and cultural realities 
  • Advocacy and behavior change (​of all stakeholders including doctors, patients, other healthcare providers as well as communities) driven by evidence rather than rhetoric

Whether these bridges get built or burnt down will remain uncertain for now given the political landscape. It is important to note that the bridge course debate is central to the issue of healthcare access in India, and is relevant to other key questions: Is increasing the number of seats in medical colleges an efficient solution to doctor shortage? As more and more physicians prefer to get trained in specialized fields and immigrate to practice in the developed world or in tier 1 cities, who's responsible for primary care, especially in small towns and rural areas?

Given the limited evidence, the debate continues to be based on conjecture and expert opinion. Operational research, perhaps at subnational levels, would add valuable data to the conversation. It would great to see experimental models to measure the community health impact of a trained cadre of lay workers in selected districts or states. The experiments will neither be easy nor straightforward, but then game-changers seldom are.

Additional PHC (APHC) in eastern Bihar. The MBBS doctor assigned to the clinic lives in Patna. The rooms are filled with animal poop. For their healthcare needs, people in this village either call in the local informal providers, or walk to the nearest city, 10 km away, which has a PHC and private clinics. A bridge course trained provider might be useful for the villagers being "served" by this APHC [Image source: author]

Monday, March 4, 2019

Trekking over the Langtang trail over 5 days

Dates of our trek: 26 May to 1 June, 2018 (near perfect weather)

Day 3: Langtang village to Kyanjin Gompa
Difficulty level: I'm classifying this trail as a "special moderate". Easy because it's only 5 days long - 3 days uphill followed by 2 days downhill - and because like other “tea house trails”, it has comfortable, almost luxurious places to rest your weary bones every night. But it is difficult too because it has a few patches of starkly steep climbs. One of my favourite memories from the week is Rigveda craning her neck up to see the tea-house I was pointing at, the place where we were going to take our third and last break for the day. She stared at it for five seconds in silence, and then said - "let's not kid ourselves, Manjot, there's no way either of us is going to make it up there" (her exact words were, "dekho Manjot, ye hoga nai hum dono se, main bata rahi hoon". And this was the first day of our trek - things got much, much worse before they got better.

Why Langtang? 
Now that I am done talking about the painful part of the trek (I make no promises, it may come up again), I can list the joys - breathing the pure mountain air scented with a thousand unknown herbs, walking with your thoughts against a backdrop of birdsong and riversong, having your eyes fill up with more shades of green than you thought were possible, connecting with people and your self in ways that are just not possible in places that are not the Himalayas - we all know these elusive joys which call us to the mountains again and again. We chose the trek also because its duration was perfect. I  needed to take only a week's leave and sandwiching it between two weekends covered two travel days and one recovery day. And as many bloggers informed us, traveling through this part of Nepal is an opportunity to contribute to the rebuilding that is still going on after the devastating 2015 earthquake. 

Planning the trek: Rigs and I planned the trek for 6 months, but that's just us. We had a shared folder with packing lists, iterating itineraries, trek company quotes, best dates, debates on whether to do it alone or with guide or with guide and porter both. Contrary to some blogs that we read who strongly urge you to do the trail alone, we recommend taking a guide even if you're a reasonably experienced hiker, and even though the path is fairly well-marked. There are some confusing forks on which you might not get hopelessly lost - all paths eventually get to the main trail (haha this could be a deep insight) -  but you might end up spending a lot of time on a longer, less picturesque route that tires you out. A guide will give you an anxiety-free mind space to focus on your self and the beauty around you, educate you about local culture, tell stories and if you're lucky, even become your friend.  

Our itinerary: 
Three days uphill - Syafrubesi > Lama > Langtang > Kyanjin Gompa
Two days down hill - Kyanjin Gompa > Langtang > Syafrubesi
The actual trek is only 5 days, but our trip was 9 days inclusive of days to travel to and from the trail. 

Day 0: Arrive in Kathmandu. 
Friday, 25 May - We stayed at the Oasis hotel, which was nice and comfortable, and located in Thamel, which is downtown Kathmandu, and which is where everything is.

Day 1: Travel by road from Kathmandu (1400 m) to Syafrubesi (2100 m)
Saturday, 26 May - Not the most comfortable road trip, no matter how optimistic I try to be. But the views were lovely. We took the jeep on the way up, bus on the way down (day 7), but neither is for the fainthearted. We stayed at the Noryang guest house, which was lovely. 

Day 2/Trek day 1: Trek from Syafrubesi to Lama Hotel (2400 m) - about 7 hours of walking.
Sunday, 27 May - Breakfast at Noryang was lavish and delicious and we started our trail at 7.30 AM in a fairly lighthearted way, oblivious to the steep horrors awaiting us this day. The trail to Lama is a gentle forest walk through marijuana (yes) fields but does have a few extreme slopes. The river was a noisy walking buddy throughout this first day. There are four guest houses on the way that one can stop and rest at. We stopped for lunch at the Bamboo hut tea at the Tom and Jerry guest house. Both were lovely and we took fairly long breaks, which meant that it was nearly 5 PM by the time we arrived at Lama hotel, where - I'm not joking - found solar-powered hot showers. 

Happiness is finding a hot shower behind a green door 
Day 3: Lama hotel to Langtang (3400 m) - about 6 hours of walking. 
Monday, 28 May - I was woken up by a bird singing and thought, man, how predictable is that? As it happens so often in the mountains, I had a sudden flash of insight. That there are three big reasons why I like hiking through the Himalayas. One, life just becomes so incredibly simple - sadness is a blister on your toe, happiness is the sight of a flat walk after a mad uphill climb. Two, food is a million times more delicious. Literally everything you eat feels like poetry in food. Three, my eyes love the high def views - the stark yellows and reds in the flowers, the stark greens in the trees, the skies so perfectly blue (except when it rains when the skies become an equally perfect, high definition grey). 

We left Lama hotel soon after 8 AM, walked through villages with pretty names - Riverside, Ghodatabela, Thansyab, Gumba - and arrived at Langtang by 3 PM. Although this is probably the most significant height gain of this trail, it felt gradual and easy, perhaps also because we had toughened up. We stayed at the Glacier guest house, run by a lovely man named Tshering Dorje. I strongly recommend the place. 

Day 4: Langtang to Kyanjin Gompa (4000 m) - about 4 hours of walking. 
Tuesday, 29 May - This is perhaps the easiest hike of this trail, with very gentle slopes. You know you're getting close to the tree line - trees start to get fewer and shorter. This is the day we crossed the villages that got the worst of the 2015 earthquake. It was a sobering hour as we walked through the rubble. We arrived at Kyanjin Gompa just before 3 PM. This hamlet has a at least a dozen guest houses and they all look comfortable. We stayed at the Nayakhanga guest house which maybe has the best views in the village. It may or may not be Nayakhanga's fault that I got carried away and wrote a poem here. 

Day 5: Kyanjin Gompa to Lama hotel
Wednesday, 30 May - The climb down in this stretch is easier than the climb up, and views are as lovely. It was fun to say hello again to the tea houses we had stopped at two days previously. 

Day 6: Lama hotel to Syafrubesi
Thursday, 31 May - Spoke too soon, this downhill walk nearly succeeded in murdering all of my toes. It was such joy to get back to our dear old Syafrubesi, which as it turned out, has a natural hot spring where you can soak your feet and coax them back to life. 
Sometime on day 5

Day 7: Bus ride from Syafrubesi to Kathmandu
Friday, 01 June - I spent the seven hours alternating between napping and saying "wow, how pretty is that mountain!"

Day 8: Recovering and exploring Thamel 
Saturday, 02 June - I have two highlights from this day of recovery at Kathmandu. One, the hotel we chose this time, the Nepal Cottage Resort, felt like absolute luxury with the unlimited hot water and warm beds. It also has a beautiful garden. Two, we watched a fabulous Nepali band perform at the Purple Haze rock bar. I want to come back in live in Thamel for a week sometime, walking and eating and listening to music. In spite of the dust clouds. About that, Kathmandu - what is it with being global #5 in the most polluted cities in the world?! 

Day 9: Flight back home
Sunday, 03 June - My journal entry from this morning says: "So when can I go next to the Himalayas?"

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