Plenary Session:3��Topic: Sustainable Development Goals and Tamil Nadu Health Systems, 2030�

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Dr. Darez Ahamed IAS

Commissioner

"Department of Rural Development and Panchayat Raj”

Government of Tamil Nadu

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• M.B.B.S, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Mangalore, Karnataka, India: 1994 – 2000

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• MSc HPPF (Health Policy, Planning and Financing), London School of Hygiene and Tropical Medicine (LSHTM), United Kingdom: 2019 Sep – 2020 Sep as Chevening Scholar

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• Started his career as a Sub-Collector in Devakottai, Sivagangai district and also served as Additional Collector in Madurai and Krishnagiri districts.

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• District Collector and District Magistrate, Perambalur (June 2011 – January 2016)

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• Implemented ‘Save the Girl Child’ project, to tackle female foeticide.

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• For this work, Sir was awarded the Prime Minister’s Award for Excellence in Public Administration, 2012-13.

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• Commissioner of Maternal and Child Health; Mission Director, National Health Mission; Commissioner of Trauma Care: Tamil Nadu

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• State has achieved the Sustainable Development Goals for reduction of Maternal Mortality Rate, Infant Mortality rate 12 years ahead of target (2030).

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• Implemented Universal Health Coverage (UHC) strategy for the state by strengthening Health Sub-Centres with a mid-level health care provider, diagnostics and drug dispensing. This model has been adopted throughout the country now. Independent evaluation studies have proved the efficacy of the intervention in reducing out of pocket expenditure (OOPE) and improving access to quality care.

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• Initiated new programmes based on analyses of DALYs lost

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• Tamilnadu Accident and Emergency Initiative (TAEI), a Trauma systems approach in the state linking pre-hospital, in-hospital, and rehabilitation care.

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• Incident Commander - Over all co-ordination of Unified Command Center (UCC) a Single Nodal Point for COVID-19 control activities

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• Executive Director of GUIDANCE Bureau, Tamil Nadu November 2020 – April 2021

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• Commissioner of Rural Development and Panchayat Raj (June 2022 to Till Date)

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• Officer on Special Duty (OSD), 44th Chess Olympiad In the office of Sports Development Authority of Tamil Nadu (April 2022 to August 2022)

• Nammai Kakkum 48 – Innuir Kappom Thittam . Free emergency care for accident victims for the first 48 hours.

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Professional and Academic Awards/Achievements/Scholarships

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• Prime Minister’s Award for Excellence in Public Administration for the year 2012-13

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• Best Practices Award for Good Governance by Chief Minister of Tamilnadu in 2018

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• Best Practices Award for Good Governance by Chief Minister of Tamilnadu in 2013

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• Best District Collector in Health Sector award by Chief Minister of Tamilnadu for two consecutive years 2011-12, 2012-13.

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• Best Collector in implementing schemes for differently abled sector award by Chief Minister of Tamilnadu in 2012-13.

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• Best Collector in implementing e-governance initiatives by Chief Minister of Tamilnadu in 2012-13 for e-District project.

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• Chief minister’s award for excellent work in Environment protection, 2013.

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• Award by Government of India, Ministry of Health and Family Welfare for achieving SDG goal of MMR in 2018.

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DPHICON 2022

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Dr Darez Ahamed

SDG and Tamil Nadu Health Systems 2030

06.12.22

Health in other SDGs

�SDG: 3 -‘Ensure healthy lives and promote well-being for all at all ages’�

• SDG- 17 Goals and 169 targets
• Lays a Holistic framework to the development of the nation
• Ensures balance among the 3 Pillars - social/economical/environmental dimension of sustainable development
• Goal 3- ‘Ensure healthy lives and promote well-being for all at all ages’
• Emphasizes on universal health coverage (UHC) and access to quality health care.
• Principle of Equity / inclusiveness- ‘No one must be left behind’.

Health Central to the SDG Agenda

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Percent of Deaths in 2016 from disease categories in Tamil Nadu

Health System Challenges to achieve SDG Targets

RESOURCE ALLOCATION

• The highest proportion of the 2019-20 budget was spent on maternal, neonatal and nutritional diseases which constitute a much lower burden i.e., DALYs like NCDs and Injuries.
• This paucity of funds is a limitation which needs to be addressed.
• The financing mechanism needs to be re-structured by taking into account the epidemiological context of the State and healthcare utilisation patterns.

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INVESTMENT IN PRIMARY HEALTHCARE

• Public health strengthening through a comprehensive primary health care approach is the key to achieve UHC in the State.
• However, the current scenario is that tertiary care has diverted the attention and resources away from primary and preventive care in recent years.
• The current allocation in the State to primary care is less than half of the total health budget, despite expert opinion and the National Health Policy suggesting that it needs to increase to at least 67%.
• Upon analysis of the current health context and 100 years of TN’s Public Health Department, it is time to re-design the TN public health code/Act to meet the current health needs and epidemiological context.

REIMAGINING SECONDARY AND TERTIARY CARE IN TAMIL NADU�

• Secondary care receives the lowest share of the health budget, highlighting a dire need to increase investment in facilities like Taluk Hospitals, District Headquarters Hospitals, which will help in reducing the burden on tertiary care institutions.
• Further, regarding tertiary care institutions, there is also an administrative need to de-link medical colleges from hospitals to improve the quality and efficiency of care at this level as well as to further improve medical education
• Medical Colleges should also be more strongly attached with academic institutions to serve as centres of public health, medical and health science research.

Lack of adequate decentralisation

• Decentralisation in healthcare is one area which remains largely unexplored in Tamil Nadu despite evidence of success in other States like Kerala.
• The devolution of funds to Local Self Governments (LSGs) and granting them financial autonomy will be a critical measure to enhance their engagement with the health system and to empower localised health innovations in the State.
• A greater role for LSGs by sensitising them about their role in improving public health should also be advocated for and all necessary capacity building so they can monitor health activities must be ensured by the Health Department.
• This will also help increase community engagement and ownership of schemes like MTM and Community Action for Health.
• As a first step, around INR 800 crores from the health grants under the Fifteenth Finance Commission (FC-XV) will be released annually to LSGs over a period of five years for defined activities.

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ENSURING EQUITY IN ACCESS AND REDUCING FINANCIAL BURDEN

• The foot print in public facilities in Tamil nadu has significantly increased over the past twenty years
• Public Facilities have become progressively more pro-poor
• The Financial burden on those accessing public system has reduced
• Public Facilities exert competitive pressure on private facilities
• Yet among the poor who seek care from private facilities, financial Burden remains high resulting in high impoverishment rates.

Global evidence from countries like Germany and the US indicate that generally, around 10% of patients account for 65% of health costs. This suggests the need to focus on patients with higher costs – a strategy which TN should also adopt in its journey towards providing equitable healthcare. The way to do so will be a three part strategy:

1. Primary Health Care Reform
2. Payment Reform
3. Health Technology Assessment

Health System Priorities Post-COVID-19�

• Non Covid essential health systems needs to be fully brought back to normal to achieve desired SDG Targets for TN
• Even in Covid years, mortality due to NCDs contributed to major proportion of deaths
• Strategies for prevention and control for HT, Diabetes, Cancer, Mental health issues, trauma care needs to be Govt’s top most health systems priorities

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Major Bills/ Policies being drafted

• Right to Health Act/Bill
• State Health Policy (Planning Commission)
• Selective highly toxic chemicals ban bill (Artificial Cow dung, Rat killer paste, etc).
• Urban Healthcare Revamping Bill
• EMS Act
• Road Safety Authority Bill
• HR Policy (NHM)

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Strategic Area 1:��Cancer and Palliative Care Services in Tamil Nadu

Together we can “Close the Care Gap”

Incidence of cancer Globally

• India has high incidence of Oral Cancer Compared to the other parts of the world.
• Perambalur district in Tamil Nadu was ranked the highest in India with a CIR of 42.4 which is also the fourth highest in the world.
• Tamil Nadu has higher Incidence of cervical Cancer, Breast Cancer and Oral Cancer Compared to the Other neighbouring countries with similar population setting

Source: Globocan 2020, Map Production : IARC, World Health Organization/ TNCRP

• Globally India has high Mortality due to Oral Cancer among Men and among Women Breast Cancer is the leading cause of death
• There were 7,266 deaths reported in Tamil Nadu due to Cancer

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Mortality due to cancer Globally

Source: Globocan 2020, Map Production : IARC, World Health Organization / TNCRP

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Tamil Nadu-Cancer Facts

In India, NCDs' are responsible for 63% of the deaths, among which cancers account for 9% of deaths. It is predicted that by 2030 the deaths due to cancer will Surpass the deaths due to other Non-Communicable Diseases

Source: NCDIR & TNCRP

* TNCRP 2016, in 2022 number of deaths is expected to be increased

Cumulative Risk Of Developing Cancer of Any Site in 0-74 years of Age in 28 PBCRs under NCRP -2021

The cumulative Risk of Developing Cancer in TN during 2016 was

• 1 in 12 among Males
• 1 in 11 among Females

Current Status

Status in 2016

Source: NCDIR

Currently it is 1 in 8 among Males and 1 in 7 among Females

Tamil Nadu State New cancer cases for the Year 2012-2017 and Projection for 2018-2021

Source :TNCRP-2016

State: Tamil Nadu, Year 2017

Common cancers incidence

Cancer Statistics by sex – All sites

Source :TNCRP-2016

Districts with high Incidence of cancer

Source :TNCRP-2016

Screening for Cancer

Cervical Cancer Screening

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Breast Cancer Screening

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Oral Cancer Screening

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• WHO recommends at least 70% of the Women to be screened for Early Detection of Cervical cancer.
• TN has screened only 10% of women for cervical cancer

• Though among Women, Breast cancer is of high incidence and Mortality the screening rates are only 5.6%

• Though Oral Cancer is among the top 5 cancers leading to mortality screening rates are only 1.1%

Current Cancer and Palliative Care Services in Tamil Nadu

• Screening for 3 Major Types of cancer (Breast, Cervical and Oral Cancer) in the community (MTM), PHCs, District Hospitals and Medical College Hospitals
• Provision of Surgical, Radiological and medical Oncological Services in the 40 Medical College Hospitals in Tamil Nadu
• Day Care Chemotherapy units established in 32 Facilities in Tamil Nadu
• Palliative care units (including Morphine tablet supply) in 34 facilities and home based Palliative care services are provided under the MTM scheme in Tamil Nadu

Upcoming Services

• HPV vaccination for girls of age 12-14 years of Age in Chennai
• Establishment of HPV -DNA detection through Primary Screening Facility

New Schemes that can be Introduced to support cancer Patients in Tamil Nadu

• Incentives to Women with Cancer to financially support them.
• Transport and Accommodation facilities institution wise to tackle the indirect cost
• Vulnerable groups such as Single women, People living with HIV and Transgender can be provided free cancer services
• Honorarium to patients who follow-up the treatment (to minimise the loss to follow-up rate) and support the cancer patients
• To implement Cancer Notification across the state and ensure full fledged Cancer Registry System

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Strategic Area 2:��Mental Health

Mental Health Program

• 2 Components:
• National Mental Health Program (NMHP) –Implemented by Medical College Hospitals (DME)
• District Mental Health Program (DMHP) –Implemented by NHM (through DMS) @ Secondary & Primary care facilities
• DMHP:
• Based out of District HQ Hospital (38) – through District Psychiatrist & Satellite Psychiatrist
• Emergency Care & Recovery Centres (10) + NGO Linked (10)
• De-addiction Centres (3) – TASMAC fund linked
• Tele MANAS- through 104
• Other Services linkage
• MI, MR, Half Way homes
• TAEI and 104 Suicide Helpline
• Social Welfare, Differently abled &

Education Dept

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Nearly 50 people commit Suicide in Tamil Nadu every day.

Source: State Crime Records Bureau (SCRB)

Suicides in Tamil Nadu (2016 -2021)

Source: State Crime Records Bureau (SCRB)

Rat poison Ban

5749 suicidal deaths by poison in Tamil Nadu (SCRB 2020, 22.4% of India)

• Selective highly toxic chemicals ban bill (Artificial Cow dung, Rat killer paste, etc).
• Find alternative less toxic pesticides for pesticides like Monochrotofos, Paraquat, Chlorpyrifos and regulate their production and sale in collaboration with Dept of Agriculture, TNAU and Centre for Prevention of Suicide by Poisoning (CPSP).

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Kerala

Prospects: A comprehensive approach in prevention of Suicides in the State

Control Access to Common Means of Suicide such as Poison.

Enhance public resilience and awareness through Information, Education & Communication.

Foster convergence and multi-departmental coordination

Establishing a robust Suicide Registry

Continuum of Care and follow-up for those attempting suicides.

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Implement District-wise interventions for increased impact on mortality reduction.

Interventions targeted at High-risk groups like Adolescents

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One-stop Responsibility through Suicide Prevention Taskforce with multi-stakeholder representation.

Key messages for achieving SDG-3 targets

• Enhance public spending
• Build capacities to use data and evidence
• Invest in a robust and resilient primary healthcare system to improve access as well as manage health care costs – imperative foundation for achieving UHC - about 80% of all conditions can be managed at the primary care level (eg: MTM)
• Strengthening Sub-centres for delivering comprehensive primary healthcare
• Ensure access to essential drugs & diagnostics
• Strengthen District Hospitals – to provide multi specialty care and serve as a district knowledge & training hub
• Integrated District Health planning involving all key sectors & stakeholders
• Integration of SDG indicators in HMIS and health service at National & State levels

Key messages for achieving SDG-3 targets

• Strengthening health facilities for integrated delivery of services as per footfalls and level of facility
• Quality of care in Public & Private facilities
• Responsive allocation to the facilities & group based incentives to influence provider behaviour
• Systematic approach to Health Technology Assessment for priority setting
• Well motivated, appropriately skilled, high quality HR in adequate numbers distributed equitably
• Improved availability of specialists, nurses and allied health professionals
• Create mechanisms to identify innovations & scale-up best practices
• Strengthening governance and accountability measures for efficiency and responsiveness

THANK YOU