Take Home Messages for Rural Surgeons from Indian Health Policy 2017

The National Health Policy 2017 comes 15 years after the previous national health policy [http://www.mohfw.nic.in/]. It spells out the Sustainable Development Goals. There are several areas that are of interest to the rural surgeons.

THE KEY PRINCIPLES

1. THE PRO – POOR POLICIES: The key policy principles talk about the poor and the marginalized and talks of:
   1. Equity to reach the poorest
   2. Affordability to keep the costs below the catastrophic expenses
   3. Universality to cover the entire population
   4. Inclusive partnerships with Academic institutions and NGOs

...

The following are the various sections of the Policy that are relevant to the rural surgical community.

1. ALIGN GROWTH OF PRIVATE HEALTH CARE SECTOR WITH PUBLIC HEALTH GOALS [2.3.3]
2. USE OF DALY [Disability Adjusted Life Years] as index of disease burden [2.4.1]
3. INCREASE THE UTILIZATION OF PUBLIC HEALTH FACILITIES [2.4.2]
4. INCREASE COMMUNITY HEALTH VOLUNTEERS [2.4.3]
5. OUTPUT BASED STRATEGIC PURCHASE OF SECONDARY AND TERTIARY CARE [3.3]
6. MOBILE MEDICAL UNITS ESPECIALLY FOR TRIBAL AREAS [3.3]
7. TWO BEDS PER 1000 POPULATION FOR SECONDARY CARE [PURCHASE AFTER DUE DILIGENCE FROM NGOS [3.3.2]
8. ACCESS TO BLOOD AND SPECIALTY SERVICES [3.3]
9. CLOSING HR / SKILLS GAP [3.3.4]
10. NON COMMUNICABLE DISEASES [4.6]
11. ATTRACTING & RETAINING DOCTORS IN REMOTE ARES [11.2] AND RURAL MEDICAL COLLEGES
12. PERFORMANCE LINKED SALARIES FOR SPECIALIST SERVICES [11.3]
13. SUPER SPECIALTY PARAMEDICAL TRAINING AND CARE [11.7]
14. COST BENEFIT AND COST EFFECTIVENESS STUDIES [12]
15. COLLABORATION WITH NGO FOR RURAL AREAS [13]
16. OUTSOURCING TRAINING OF TEACHERS AND SCHOOL HEALTH CARE [13.1]
17. OUTSOURCING SKILL DEVELOPMENT PROGRAMS [13.2]
18. REFERRALS TO CHARITABLE HOSPITALS [13.7]
19. MAKE IN INDIA FOR INDIGENOUS MEDICAL DEVISES [13.11]
20. SKILL UP GRADATION FOR PRIVATE SECTORS [13.13]
21. RESEARCH COLLABORATION FOR COST EFFECTIVE MEDICAL DEVICES [25.4]

The Association of Rural Surgeons of India [ARSI] and the implementing Lancet commission on Global Surgery India – Secretariat [iLCoGS – India] can make use the items from the Indian Health Policy in the following ways. Presenting to Health ministry and discussing during the National Surgical Forum can help with making use of the Government initiatives.

1. SPONSORING AND FUNDING RESEARCH SPECIFIC FOR RURAL SURGERY
   The Health Policy items 25.4 talks about research collaboration for cost effective medical devises. Item 13.11 encourages Make in India initiative for medical devises. The Lancet India [iLCoGS – India] Center of Excellence in innovation for rural surgery already works on several projects that are specific for rural surgery.
   1. Gas less Laparoscopic surgeries: This would dramatically reduce the cost of Minimally Invasive surgeries and make them available in rural areas where regular laparoscopic surgeries are not possible.
   2. Low cost vacuum therapy unit and dressing materials for non – healing ulcers especially diabetic ulcers. This also would address item 4.6 relevant to Non communicable chronic disease management like Diabetes
   3. Noninvasive and low cost vital signs and blood sugar and hemoglobin monitoring devises can help equip rural health care facilities with Indian made low cost devises
      The PGSSC of Harvard University [http://www.pgssc.org/] is already involved with the center of Excellence at Karunya University and is a great value addition to the research work for rural surgery.
2. TASK SPECIFIC TRAINING & COMPETENCY BASED CREDENTIALING
   The ARSI and Lancet India [iLCoGS – India] already had the Center of Excellence in Surgical training at Gudalur and involved with Spinal anesthesia training for rural surgical workforce. The Karunya University and the Harvard University Dubai campus is involved in this program along with PGSSC.
   Health Policy items 13.2 talks about Government outsourcing such training programs. Item 11.7 also talks about training for specialty services for paramedical personnel. The ARSI and Lancet India [iLCoGS – India] can talk to Government for them to outsource these activities to them. This also would help to close the HR / SKILLS Gap that item no. 3.3.4 of Health Policy talks about.
3. MOBILE MEDICAL UNITS OF ARSI
   Item no. 3.3 of Indian Health Policy talks about Mobile Medical Units especially in tribal areas. The ARSI and Lancet India [iLCoGS – India] can host Mobile Medical Units for 100,000 population around the areas where the members work. They can choose four health care facilities including Government ones to offer the specialist services at a cost effective way. This will also benefit the government doctors who will benefit by the performance linked salaries mentioned in item no. 11.3. This would also be in line with item no. 13 that talks about collaboration with NGOs for rural areas. The Mobile units can have the equipment and personnel for Minimally Invasive Surgeries like gas less laparoscopic surgeries, endoscopic Urology surgeries, etc., and they can dramatically increase the surgical coverage per 100,000 population. This also would increase the utilization of public health facilities as envisaged in item 2.4.2
4. THE SURVEY AND STUDY CELL OF ARSI
   The Health Policy encourages several studies like use of DALY as disease burden [2.4.1], cost benefit and effectiveness studies [12], utilization of facilities [2.4.2] and increasing community health care volunteers [2.4.3]. The ARSI and Lancet India [iLCoGS – India] can help with these surveys and studies and coordinate the use of volunteers in areas of need.
5. STANDARDIZATION AND ACCREDITATION SERVICES OF ARSI
   The Health Policy advocated having 2 beds per 1,000 population [3.3.2] and this can include private beds bought after due diligence. This would translate to about 200 beds per 100,000 populations and as mentioned earlier four facilities per 100,000 population sharing the human resource and equipment can take care of most of the secondary level needs. With standardization accreditation voluntary surgical workforce can help with surgical care in these areas [2.4.3]. The model of NABH using voluntary assessors could be used by ARSI for the accreditation and standardization process and also the training programs.
6. RURAL MEDICAL COLLEGE AND UNIVERSITY
   The Health care policy 11.2, 11.7 talk about rural Medical colleges especially for tribal areas. The ARSI and Lancet India [iLCoGS – India] can promote the rural medical university model practiced in Canada [http://www.bcmj.org/article/training-physicians-rural-and-northern-british-columbia], where the students are trained at rural hospitals with a flexible curriculum that teaches about patients that they see rather than regular class room lectures.
7. ARSI CONSULTANCY SERVICES
   The Health care policy encourages referrals from government hospitals to charitable institutions [13.7]. The ARSI and Lancet India [iLCoGS – India] can set up tele–medicine based consultancy services for rural hospitals and use the existing upgraded facilities for referrals from government primary health centers to provide low cost, efficient health care.

Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.