‘We are making Kerala future ready’

Print edition : September 29, 2017

Rajeev Sadanandan.

Excerpts from an interview with Rajeev Sadanandan, Additional Chief Secretary (Health), on Kerala’s new initiatives in public health.

How do you see the tasks ahead now that the Aardram mission and the eHealth project have been launched?

In Aardram, we seek to improve the patient experience at government hospitals. We also seek the transformation of primary care. If you look at the National Health Service [NHS] of Britain, they have this family physician concept, or GP concept. One person handles 4,000 cases. In our primary care system, one unit handles 10,000 to 30,000 cases. There is no way we can meet the demand with the existing structure. Our other challenge will be non-communicable diseases [NCDs], all of which lead to severe complications. And unless we act now, and we are not acting too well, and start tracking people on an individual basis, tomorrow Kerala’s healthcare will go for a toss. It is a gigantic task. But if Kerala fails to do it, it is going to be in deep, deep trouble. The most important aspect is to ensure that we have a proactive personal care plan for every person and to track the person continuously. Whether Kerala will do well or not [in healthcare] will depend on how well we do this.

Doctors alone will not be able to handle all of it. So the challenge is how to train the nurses and other health workers and how to create a system that makes it possible for you to track a person, identify people in the target groups, say, people with diabetes or high BP. We would like to rework the family health centre to ensure that people become proactive and every person is screened and accounted for. But doctors and nurses today are not trained for it. There is such a huge training load. There is a huge referral network that we need to build. That is what we are engaged in right now. Once training modules are ready, the eHealth programme also comes in.

Government facilities account for only about 35 per cent of the patients visiting hospitals; the rest of the patients depend on the private sector. That is a big gap. In the context of Aardram, do you expect the government sector to handle the entire population of Kerala?

We also have a major programme to improve speciality health services in taluk and district hospitals. When we increase the working hours, and offer speciality services in taluk and district hospitals—I do not know if it is a good thing or a bad thing—we believe that a lot of people will shift from the private sector to the government sector. As you improve the availability of diagnostic services and drugs, people who value money above the convenience offered by the private sector will tend to shift. Is it good [for Kerala]? That is a question we cannot answer now. Because when the middle class shifts to the government sector, the poor may get pushed out.

So who are you targeting the new facilities for? Do you want the richer sections too to come in to the government sector?

We do not want that. But everybody pays their taxes. We cannot say we want to keep one section out. We have a clientele now, the poorest of the poor. We want to ensure that they get an experience that is technically as good as anywhere else. That is what we would like to happen. But then, the question that you are not asking is, will the discerning middle-class patients too not come to the government sector? We cannot exclude such a possibility. If that happens… I will try to explain with an example. We have taken a decision that in medical college hospitals, we will avoid prescribing out as much as possible. We know that anti-microbial resistance for antibiotics is very high in Kerala. So, a patient who has resistance necessarily has to pay more. Such resistance in patients is often a creation of the private corporate hospitals; after fleecing these patients, they will say, now go to the government medical college, there you will get the same drug free of cost. In such cases, for instance, we will try to restrict it to BPL [below poverty line]; but you cannot prevent people from coming in.

However, when it comes to long-term care, it is not profitable for the private hospitals. So, after they make their money in the first few days, then there is often only a question of ICU charges—such patients, too, are sent to the medical colleges. That may also happen. What I mean is, we are still ambivalent about whether it is a good thing or a bad thing. For instance, the government sector is handling 66 per cent of the cancer cases. Our aim is to take it to 80 per cent. The Kochi Cancer Centre will come up in two years. The Malabar Cancer Centre will also get upgraded to the level of the premier Regional Cancer Centre (RCC) in Thiruvananthapuram in two years. When that happens, you have the equivalent of three RCCs across Kerala. Moreover, five medical college hospitals are going to have comprehensive cancer care units. That is going to be a huge leap. Which means that 80 per cent of the cancer patients will come to the government sector. I have no hesitation in saying that is a good thing, because cancer treatment is so costly that even the middle class cannot afford it. Regarding cancer care, our aim is to identify them in advance and put them on treatment in advance. That will be a good thing for managing our scary cancer scene. So, the problem in all such interventions is that you proceed on certain assumptions. We have to wait and see what works out and what does not.

What is your timetable like for all this?

It is a good question. The real challenge with regard to Aardram is making the doctors and other health professionals own the programme. Will the doctors do that? Many of them will. But it requires a huge transformation. Will they acquire the knowledge? Will they start tracking patients? Will they track people who are not coming to the family health centres [FHCs]? Will they send their ASHA workers to their homes and bring them for treatment? That is the question. Even for TB treatment, will they ensure any person who has cough for three weeks is sent for a TB examination? If they put him on treatment, will they ensure that the treatment is completed? A lot depends on the sincerity and energy shown by the health personnel.

How are the local bodies reacting to the programme?

The local bodies are a major factor. But in each FHC, if the doctors take special care to explain the idea to the panchayat president, I do not think any panchayat president will say no to the programme. Because he or she is the one who will become popular if the programme runs smoothly. And wherever that has happened, they are doing a good job. There is enthusiasm among panchayat presidents for the eHealth programme because they also get mileage. eHealth is not the problem; it is Aardram that is going to be the challenge. But it is a big gamble. And, time frame? We have said three years but expect it to be some more.

What about urban primary health centres, or PHCs? It is a big chunk of people in the urban areas that the Aardram Mission is trying to ignore.

You were earlier referring to the private sector. If 70 per cent of the patients are outside, how do we cover them? What I hope will happen is that a market will develop in Kerala for the primary care provider—as it has developed in Lifecare centre in Bangalore, and so on. If the family health centre concept works in rural areas, an individual will realise it is better to consult a trained general physician and then get referred to speciality facilities only if needed, like it happens in many advanced countries. To make that possible, you need to have a decent course offering a PG degree in GP practice. Maybe the insurance companies can also work out a different model: that you first consult a GP and only with a GP’s reference should you go to a speciality hospital. Because treatment costs will come down and a lot of unnecessary procedures can be avoided. There will be other benefits too.

I believe an economic model is possible in the private sector with these people [small hospitals]. A large number of small hospitals are under threat today because of the spread of corporate hospitals. And we are thinking of having discussions with such small hospitals, encouraging them too to convert to family practice. But that requires a decent degree course to train doctors. We are negotiating with some universities abroad to see if they can conduct a twinned course for us for general practice. If that is the case, these doctors can be absorbed by the private sector. But given the present staff constraint in urban centres, the government will be able to cater only to, say, some slum areas, and some such places where there are at-risk populations. The rest of it we are not planning at this stage.

Is it because in urban areas these big private hospitals are already well established?

It is not because of that. We don’t have sufficient people. That is the main reason. But even in urban areas, they will benefit by having access to a GP. But at this point the government is not planning to provide that. Same question will apply to eHealth also. When a person consults a private hospital, we are not allowing eHealth access to private hospitals at this point. Only later, once it stabilises, will we think about how to include them in it.

Does the State have enough funds, say, for your timetable of three to five years?

The Finance Department is very supportive, the Finance Minister is sold on the idea. Major investments will happen during this period. We will have money coming in from the Budget, from KIIFB, and that will be huge. But whether the entire cost, which is mind-boggling, will be met is yet to be seen. For our current timetable, I think we can manage. And again, if we succeed it will be difficult to stop it. Before a new government comes this has to be put into place. Yes you are right, because every panchayat president will start demanding that an FHC should be established in their panchayat. The question is, can you make it a success?

You are planning to give everyone a unique health ID [UHID]. And you are trying to link it to Aadhaar? Have you thought of the privacy issues that would arise?

When we planned it initially, we only meant everyone to have a unique number. But then the UID authorities came to us. They were saying, why do you want to create yet another ID for this; Kerala has got 100 per cent Aadhaar coverage, and so why don’t you link it to Aadhaar? It was the easier option for us. Because data are already there and that makes it easier to tag people. It was later that privacy became such a serious issue.

So, earlier we were saying, the Aadhaar ID will be your identification number here too. But now we have decided that the Aadhaar ID will stay only in the background. Unless you hack our server, you cannot get the link. The front end will be on UHID, not on Aadhaar. That is the change we have made. Back-end linkage will still be through Aadhaar. That will be difficult to change. So your health records will be safe, unless our servers get hacked. We are trying to close all access to our servers, and the transactions will take place on the unique health ID numbers. But at the back end we are still retaining the Aadhaar linkage.

How are government doctors reacting to the eHealth programme’s requirements?

At the Peroorkada [Thiruvananthapuram] Government Model Hospital where the programme was launched, the general medicine doctor who handles 250 or more patients a day is finding it impossible to work on the system. But the respiratory medicine doctor who handles only 80 patients a day is able to do it. That is a challenge we have to deal with.

But there were protests by the Kerala Government Medical Officers Association (KGMO) as soon as Aardram was launched.

They have not said anything about eHealth. Aardram conceives of OP till 6 p.m. Then the doctors who were so far free and perhaps doing private practice from 4 p.m. will stop getting patients. Tomorrow, when the speciality services too are launched in the taluk hospitals, then who will seek them out in private clinics? Not only government doctors, but many private hospitals have now started working behind the scenes to foment trouble against Aardram. In Ernakulam, where the private sector controls the field, there is such a strong movement: because we are starting excellent cancer care facilities there and the corporates are rallying against government hospitals.

In all lower-level hospitals, facilities for specialist consultation will go up. The number of doctors and other staff will also go up. But not in the community health centres [CHCs]. They are not highly patronised in Kerala, as per our research. But taluk and district hospitals and medical college hospitals are. That is where we are focussing. There, funds are available, new posts are created, equipment, civil construction all are there.

Is eHealth not a difficult project to implement?

eHealth is a unique project. No other State is anywhere near us [in capability to implement it]. We made seven presentations in Delhi and we insisted that we must have this. We bid for this project, we fought for it, we made all sort of changes, finally the Union Secretary for IT said your project is so ambitious that I am sure it will fail. But even that failure is going to be such a learning experience that we think we will fund it. That is how we got the project.

They think that even Kerala will fail, but still gave it, because other States cannot even think of it, except perhaps Tamil Nadu. No other State has come forward for it. That is why nationally it is hot property. But there is a lot to be done.

Regarding both Aardram and eHealth, what does Kerala hope to achieve eventually, vis-a-vis other States?

Aardram’s focus is on primary care, and we are building it up to the taluk and district hospitals. And we are changing the orientation of primary care, from family planning, from mother-and-child care alone. We are changing the focus to communicable diseases, to NCDs.

eHealth is a big, ambitious thing. We are planning to create longitudinal data on individuals. Because the future of health is going to be AI big data and genomics. Genomics is also data-based. In genomics, research is all data mining, nothing else. So, what we hope to do is to create a database of the people in Kerala. Think of the research possibilities, of clinicians having so much data with them. That is why people are afraid that somebody might try to hack in and get the data. But then you cannot have one without the other. That is the real thing. We are making Kerala future ready.