We are in conversation with Dr. Raj Shankar Ghosh, an accomplished public healthcare expert in India, who shares his experience of working in the public healthcare sector in India and explains the unique features of the Indian public healthcare ecosystem.

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You’ve tuned in to Badlav for Better. A podcast by B Medical Systems -Saving lives through reliable and innovative technology hosted by Jesal Doshi.

Jesal Doshi

Dear listeners, it gives me great pleasure to welcome you all to our second episode of Badlav for Better. As you know, Badlav means change. And Badlav for better is our humble attempt to bring changes in the Indian health system through simple conversations with some of the leading health experts in our country. We focus on the challenges, the blind spots. What was the past? What is the future, and most importantly, how we change for the better? Today, we continue our fascinating conversation with Doctor Raj Shankar Ghosh, one of the Legends in India’s highly successful immunization story. Dear Doctor Ghosh, thank you for joining us once again. Our last discussion was indeed extremely insightful. And moving ahead, let’s really do a deep dive into the Indian public health delivery system. Some of the challenges that you mentioned. But what our listeners would be very interested to learn from you is to really to take those challenges not at the macro level as you mentioned, but at a micro level. So how does a person in a village in one of the remotest corners of India feel about health care? What are some of the things that are working, but also some things that are not working?

Dr. Raj Shankar Ghosh

Right. So I you know, some philosophers somewhere had said that in case of public health delivery, it is always a sad affair. The sad actually stands for an acronym, which means supply  access and demand. Now the first important thing that we need to understand is that if there is no supply, we cannot talk about access. If we don’t have good access, we cannot expect people to start demanding. So suppose someone say in a remote village in Saint Gumla district of Jharkhand falls sick today. What will happen? There are three options for the person. One option is that the person, kind of spends you know the money which the person does not have the capacity to money to spend, which means the person takes a loan or the person kind of sells something and you know gets referred to a  higher center at the district level or somewhere else, that is a huge expenditure. The second option is that the person actually goes to the nearby government Health Center by whatever means the nearest one, because almost every village is now connected to some kind of a center, and if not a center, at least a person, say Nash goes there. Finds that there is a lack of supply. There’s a lack of human resource. There’s a lack of, you know, availability gets treated by or managed by people who have half knowledge of doing all of that. And the third thing that would happen is that the person might actually get treated by a local, You know, a kind of practitioner, maybe a rural medical practitioner or a kind of a village quack or or a faith healer, Whoever it is, they get treated. So all of these three options are open. In the first instance, that is the biggest problem that India faces, and this is acknowledged by our Prime Minister, that out of pocket expenses, though we have reduced it, it remains one of the most critical problems because ultimately people do spend and go and I have heard so many people that tell me about those very sad stories. The second option that happens is that. We do not have a good health HR policy, which means that, you know, we are not able to incentivize people to really stay in the positions that they are, we are not able to ensure that they are well-trained to perform their services. And the third thing that happens is that there are still, recruitment gaps in, particularly in some of the states like, you know, I mentioned about UP Bihar, Jharkhand though we are improving, I’m not saying that you know we haven’t improved, we are improving but there are miles to go there still. So therefore all these issues about HR availability, HR, efficiency, HR sufficiency, all of these things are actually a major problem when it comes to the common man to seek health care. For example, if it would have been a Japanese encephalitis in which a child has suddenly a very high fever, goes to, you know, kind of mental, you know, delirium kind of thing and becomes unconscious. The mothers know the parents know that the only destination, if it was happening in eastern Uttar Pradesh and I’m talking about say. Five years out, not five years, 10 years back. The only destination was Gorakhpur Medical College PD Medical College in Gorakhpur. They would sell everything in order to save the life of the child and go. Then what happened is that it became unsustainable. The political leaders and the masters understood that this is something that cannot be continued. So therefore they converted the Primary Health centers into something called encephalitis Treatment Center. Then they understood that the encephalitis treatment center cannot be sustained throughout the year. And does not need to be sustained. It is already during that period of monsoon when the encephalitis happen that it needs to be done there. So today we have good access in several every Primary Health center has an encephalitis treatment center so earlier, about 90% would end up going to the BD Medical College from a very remote village saying, you know, good upper district or in basti or somewhere. But today only 10% would go the rest of them would go to the Primary Health center.

Jesal Doshi

Thank you, Doctor Ghosh and I think the example you mentioned about Japanese and the encephalitis is a prime example of badlav for better, right? It’s exactly what we would like to educate our listeners about, which is how can we change and how that change improves the lives. And in this case, right as you said, you know, people were selling everything that they had to save the life of their child. And here we are creating a transformation. Not just for the child, but for the entire family and for generations to come.

Dr. Raj Shankar Ghosh

So just I’ll. I’ll just interrupt you to emphasize on one point that I had also said in my earlier kind of response is that it’s not only about having the infrastructure, but it’s about also the behavior change in the community. So, you know, the chief Minister Yogi from Uttar Pradesh, being the very smart person who understands people psyche . We not only build that infrastructure of in other Primary Health centres turning into encephalitis treatment centers, but you also understood that they must be utilized. So what he did was that there is a program called Dastak program where, you know, they go the health workers go and they are, you know knocking at the door of the person and saying that if you have a problem, this is where you go. They educate them, they kind of change their behavior. They kind of monitor as to where they are going, so this project was started by path with the government of Uttar Pradesh. And also supported by the Bill and Melinda Gates Foundation. So, when they did it, you know, initially it was like still 70% were going to the Medical College, then it reduced to 50%. Then it came to the notice of the Chief minister and he said, oh, this is not working at the speed I want. Immediately kind of put in the Dastak campaign and overnight everything turned and immediately you know 70 percent, 75%. 80% were going to the Primary Health Center for the treatment and he ensured that all of the other, you know, things are fulfilled. There is a supply of essential medicine lists. All the medicines, diagnostics, anything that is required is available. The doctors and trained officials are there. There is a good referral mechanism because without that the next part doesn’t work. The behavioural change doesn’t work, so there came the experience. Wow, such a wonderful setup here. Why was I going to the Medical College? So therefore they started coming there. And the new spread. The second thing that they ensured is that the access, which means that you know the referral system through the ambulance, through the local, you know, transport mechanism. That was set up so that they can have access to those centers well. So it’s not just about, you know, doing some kind of 1 aspect of the program. It has to address the entire issue about supply, access and demand, then only, you know, miracles happen.

Jesal Doshi

Absolutely. And I think your example again illustrates the supply access demand of the sa principle, but also the importance of having visionaries who can implement it. I think in this case, Chief Minister Yogi and the example that you gave is a is a great example.

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You’ve tuned in to the second episode of Badlav for Better, an Indian healthcare story.

Jesal Doshi

Talking back about the lack of financing, you know and  how technology is also playing a role here and this is maybe my only value added contribution to this podcast, but I recently came across a very innovative startup called Arogya Finance, which uses a pension based financing to provide healthcare to patients who really need it, but at a fraction of the cost. So, if you think about treatment for cancer, which can easily cost up to a few lakhs, they can bring the cost down by as much as 70%. And this is really as a result of technology of partnerships. So again, going back to some of the examples that you mentioned and the principles you mentioned, so we bonded to spend some time talking about technology.

Dr. Raj Shankar Ghosh

See, you know, in all the revolutions in public health that have happened, technology has played a role. For example, you know, if we are just talking about vaccines. A vaccine vial monitor has been a game changer. You know its people just think that it’s about understanding whether the vaccine is good or. It’s not just about that. Earlier when parents came with their children to get, they get the vaccine, they used to think that, you know, should I go and check the expired date? Is the vaccine good? Ensure that you know it has been maintained. Well, now everyone and such a simple technology to see the color change. Everybody can understand. They are so confident. OK, this vaccine I see, which is being given such a good one. Vaccine vial monitor built the confidence within the community about vaccines such great game changer. Electronic Vaccine Intelligence network when it was initially started, people said that it’s a very costly kind of technology to come in, but see, you know, the kind of change it has made, the kind of you know cost effectiveness it has brought to the program, talk about, you know, auto disabled syringes has tackled so many diseases which were earlier happening because of shock breaks and all of those, you know the, you know, hazards that come with the injections and all of that. So, technology in itself has been one driver. This is one example that I gave you. Now we come to another program which is the CoWin. With CoWin you know it is probably one of the first time that I saw that people felt that they owned their entire health intervention. For example, what happened ,A person could choose the vaccination center that the person wants to go. The person could choose the time that they want to go. The person could choose the vaccine that they want to take. Somebody would have thought that, OK, fine, I’m going to choose for Covaxin. It’s India made,ICMR support, I’m going to go and do that. Somebody would say that no, I want the Covidshield vaccine. They could choose that such ownership of the program could only happen because of technology. Now with that, what happened is that. Technology, you know, not everybody is technology friendly, so there needs to be assisted technology, which means that there’s a lot of capacity building that we really need to do if we are to introduce new technologies into  the programs and that calls for. Resource that calls for a technical expertise because without that things are going to fail initially. You know, people were so nervous with CoWin, but then the government got the feedback from the community. They kind of changed. So, technology has been a driver, technology will be a driver of the  public health programs but technology we need to understand, is not something that will be introduced without the right amount of investments that we need to make the right kind of capacity building that we need to make and the right kind of confidence that needs to be built in the Community about the technology because people are skeptical about my data going away, my kind of privacy going away, so we need to build that confidence within the community and that, you know, lot of ownership lies on our community leaders and our political leaders in order to really build that confidence within the Community.

Jesal Doshi

So, Doctor Ghosh, I have two follow up questions. The first one you mentioned vaccine vial monitors, yes, just for our listeners, some of whom may not be aware of what this is.

Dr. Raj Shankar Ghosh

Sure, sure, sure.

Jesal Doshi

Can you explain what what?

Dr. Raj Shankar Ghosh

So, this vaccine vail monitor started during the polio program.So, what happens is on every vial ,there is a circle and a square in which the colors change based on the exposure of the vaccine to heat and light. And after a certain time, you know of exposure to heat and light, the time, heat and light, all of these are important factors. The vaccine may not be it doesn’t get bad. What it becomes is that it may not be as efficacious as it would have been with the proper kind of exposure to light. The proper cold chain maintained and all of that. So, people can see that color change in the circle and the square and they can understand whether the vaccine is very potent or whether the vaccine vaccine is potent or, you know, the vaccine will not be as efficacious as it should be. And it’s for the layman to understand, because it’s just a comparison of the color between the square and the circle.

Jesal Doshi

So for any person getting a vaccine or for their child, they should look at this and determine if the vaccine is good or bad.

Dr. Raj Shankar Ghosh

And it’s very simple. So, it is even, it doesn’t require one to be literate, it doesn’t require one to be technical. They just need to understand the two colors, Gray and the dark Gray and all that.

Jesal Doshi

And that’s a great example of how technology can be also got down to the level of the common man where he or she can simply understand it and talking. The other question was related to technology. And people’ distrust in it you mentioned about the fact that you need to convince people, especially when you think about many platforms and globally, not just in India. There’s a huge push towards privacy towards individual data. So how do you? How do you see this in  context of an application like CoWin where there is a lot of skepticism amongst people may not be justified, but just to you know, for our listeners, again yes. How can they get comfort with something like this?

Dr. Raj Shankar Ghosh

So, one of the things that I aim to make very clear is that in most cases I’m not saying in all cases, in Most the distrust happens because of lack of awareness and knowledge, so something new is introduced. Now you know, when we used to go for the polio vaccination in the in the community. The first question that they used to ask us is that the Community is that my child has fifty other problems. Our house has so many problems, why suddenly you are coming with this vaccine to feed my child? You have never cared for my child. When my child was dying from diarrhea or from pneumonia. What is your interest in saving my child? So we had to explain the whole context of why we know we are doing the Polio drives and all of that. So one of the things that first we need to understand the community is not kind of, you know, hugely trusting of any new intervention that comes. So, what they need to it is the onus is on us. The onus is on the public sector. Owners in the private sector to explain to people about. What is the product that is being brought? How can they benefit from it? What are the risks because there is nothing without risks? What are the risks? Which means that they need to be taught how to use the product to well. For example, how to use the CoWin application? Well, it’s similar to you know the ATM card everybody uses ATM card. But then the bank also releases, you know, 10 things that they must not do. So I think for technology it is very, very important that there is a very transparent conversation around why the technology is being introduced. And that calls for education, the 2nd is there needs to be some hand holding in order to teach people to use that application well, because the more they use it, the more they become familiar, the more their confidence on the technology grows and they take it forward in terms of technology, what is very, very important is that we need to have a two way mechanism. It is not just about, you know, giving for example, in CoWin one of the things that people knew very well that if they register through CoWin and do it, that there was no other way to do it also, but they would get that certificate also digital, you know in my my house health who comes. She was so happy to show on the mobile that see my certificate that now it is a proof. Here I can show the guard at the entrance of this society that I’m vaccinated. So this kind of was convenient for that person. So therefore I think with technology, we need to first of all give them some flexibility in order to you know overcome their apprehensions. Second is on job training, and the third is give them some kind of incentives and benefits, which they. Kind of accept.

Jesal Doshi

What’s very interesting and thank you, Doctor Ghosh.

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Aap sun rahe hai Badlav for better. A podcast by B Medical Systems saving lives through reliable and innovative technology. Jesal Doshi Dwara hosted.

Jesal Doshi

Again for our listeners. One book I would highly recommend for you all to read if you’re interested in new innovations and technology is a book called Build by Tony Fadell, he is the creator of the iPod, and h he’s also built the nest, which was acquired by Google.Fascinating book and a lot of great insights and learning. For all of those interested in doing anything new. So, Doctor Ghosh, coming back to technology. What would you think are or what do you think are the most interesting? Two or three technologies that will likely come up? That will impact public healthcare at scale.

Dr. Raj Shankar Ghosh

So I think one of the things that we will have to understand and we were talking about climate and all of these before is around the use of resources like energy. You know we have long dependent on various kind of traditional sources of energy, particularly solar energy. In case of health is going to be a very important issue for  supply, not only of vaccines about, you know, blood products, about insulin, about some of the diagnostics medicines and all of that, the second thing that I think is going to be very, very important for us is. You know, using technology for data harmonization data actually, you know, there was a person who had first told me this data is about is an acronym that we can look at standing for digitalization. Accuracy, timeliness, and access. This is what comprises of data. If we do not have digitalized data, then that data is not the data for the future. If we cannot have. We cannot ensure that the data is accurate and we don’t have mechanisms to kind of ignore or shred off, you know, inaccurate data. That data is not valuable if it does not come in time. Data is useless, and if it is not accessible by all parties who need to access it, then that data is not going to be utilized for action.So I think it is very important for us to use technology to get data in its full meaning that I talked about. And the third thing that I think is very important is the. Again, I’ll come back to this digital money, which means that, you know the the incentives that we are talking about, the kind of payments that we need to make to our Ashas, to our beneficiaries, to our mothers who are accessing some of the great, you know, incentivized programs that the country has launched today all of those needs to be digitalized so that we don’t have those systems of, you know, cumbersome systems of, you know, paying money and all of that. So digital payment is a very, very important issue that. We need to focus on and technology will play a great role in that.

Jesal Doshi

Thank you, Doctor. Gosh, really interesting insights, dear listeners, as we round up our discussion and podcast on badlav for better, I would be amiss if I did not ask Doctor Ghosh’s last question. Doctor Ghosh at the very beginning you mentioned about the human emotions and about the smile on the face of a child and the mother that you saw. Now, having spent more than three decades in public health. What would your advice be to youngsters to our young listeners who are looking to enter public health?

Dr. Raj Shankar Ghosh

Right. So, I think that you know there are multiple things that I can talk about, but I will say just two things. One is that you know, if one decides to choose a career in public health or in any development sector. One needs to really be passionate about it. And one cannot overnight become passionate. One really needs to study about the field in which the person is getting into. The second thing that is very, very important is that public health theory is very important. One needs to know the theory of public health, otherwise one cannot act. But the excitement of public health lies in the field. So, if you are getting into public health, do negotiate with your. You know employer. As much as you would negotiate on you know. Remuneration and everything about you being able to actually go to the field and see the action, the faces that you will see, the houses that you will visit, the kind of beauty that you will see in the  in the rural heartlands of India. That is what is going to drive you next day to work, so please do two things. One read about public health where we have progressed from the times of, you know, India has a very rich history of public health starting from our malaria days and smallpox, polio and much prior to that everything is very rich history. You will feel proud that you are going to become a part of this public health journey of India and the second thing that I want is that you know Please ensure that you have opportunity to actually go and see where public health is in action. Otherwise, you will never be the get the motivation that you need in order to continue. In public health.

Jesal Doshi

And I think with that, with your two insights of being passionate being out there in the field, one can really be an agent for Badlav for Better. Thank you very much and stay tuned in for our next episode.

Dr. Raj Shankar Ghosh

Thank you so much.

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You were listening too, Badlav for Better. An Indian healthcare Story ,a podcast by B Medical Systems -Saving lives through reliable and innovative technology. Hosted by Jesal Doshi.