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      The nuts and bolts of pediatric cardiac care for the economically challenged

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      Annals of Pediatric Cardiology
      Medknow Publications

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          Abstract

          A large number of people live in countries that are experiencing rapid economic transition. India and China along with many other countries in Asia are now classified as emerging economies. If current economic growth rates are sustained, the center of gravity of the world's economy is expected to shift to Asia by 2050.[1] However, human development in most of these countries has not matched economic development. The disparity between economic prosperity and most parameters that determine human development, such as infant and under-five mortality, literacy rate and life expectancy, is particularly striking in India.[2] This is largely the result of severely dysfunctional public health systems in the government sector and a completely unregulated private sector. This allows for a chaotic health infrastructure that is substantially divorced from national priorities and results in extraordinary contrasts. Most urban metros in India have become microcosms of the globalized world and showcase bizarre contradictions. Advanced high-tech health care that caters to overseas patients (medical tourism) and a relatively small (but growing) proportion of affluent Indians is available at a short distance from urban slums where a large number of people do not have access to basic health care. Comprehensive pediatric heart care is very resource intensive and requires a sophisticated infrastructure. It is challenging to develop a successful and effective program in the government sector. As a result, most pediatric heart programs in India are in the private sector and most procedures are expensive and largely out of reach of the average Indian.[3] The authors of the review (Cardiac care in the economically challenged: What are the options) have made an earnest effort to identify a number of potential sources (government as well as non-government organizations).[4] The information provided is of practical value and many readers of the journal will find this useful. The authors begin the review by touching upon the relevance of pediatric cardiac care from a public health perspective. They present an emotional defense to justify why pediatric heart programs are relevant in India when there are many other readily preventable causes of childhood mortality. In this context, it is important to understand that substantial reductions in infant and under-five mortalities to levels comparable to many developed nations are achievable without any facility for infant heart surgery. Cuba and Sri Lanka are examples of two countries that have achieved very low infant and under-five mortality without establishing a center with infant heart surgery.[5] When viewed purely from a public health perspective, government subsidies for pediatric cardiac programs would amount to seriously misplaced priorities in the face of readily preventable conditions. However, it is difficult to precisely regulate health care delivery in many situations. This is especially true for democratic nations. Perhaps as a result of this situation we do have a handful of institutions in India that have established good standards of pediatric heart care with rapidly increasing numbers. A growing number of new institutions are now looking to establish comprehensive pediatric cardiac services. The total number of infant open heart operations in India has almost doubled over the last 5 years. What are the most compelling factors that justify (or encourage) the establishment of centers with comprehensive and dedicated pediatric cardiac care in India? In absolute terms, there is a large disease burden simply because there is a large population of children with heart disease. With the rapid growth of the urban middle class, there are a number of families that can now afford pediatric heart care. The reduction in family size has resulted in greater willingness to allocate substantial resources for treatment of a child with heart disease. Many congenital heart conditions can be corrected early in infancy as “one-time fixes” with a near normal future. A single (although expensive) investment apparently translates into a lifelong benefit. Successful and safe infant heart surgery is often viewed as an important benchmark in quality for a number of hospital systems. A number of core hospital services will need to function at a very high level in order to make infant heart surgery safe. The spin offs from improved infrastructure and health systems in a hospital are substantial and can contribute to an overall improvement in the general level of care in a hospital. Health care is now developing as an industry. Apart from the growing middle class, there are opportunities for income generation through medical tourism for the developing world. There is a large pool of trained manpower available in India. A number of medical schools offer an excellent background in pediatrics and many pediatricians are looking to specialize. Pediatric cardiology is a new and exciting specialty that offers a great deal of intellectual challenge. Similarly, the human resources for paramedical, nursing and technical services are abundant and they can be readily trained through structured programs. Recognizing the economic transition that is happening in India, there is likely to be an enormous need for pediatric heart programs. If the average child in India were to have access to comprehensive heart care, we would need at least 200 large programs with an annual case load of 800-1000 open heart operations. Recognizing this long-term perspective, it may be justifiable to develop core expertise in selected large institutions and establish facilities for training manpower for the future. While recognizing the seemingly limitless opportunity, it is also important to understand that today there are a number of barriers to effective pediatric heart care in India. They include poor recognition and management of heart disease at the level of primary care facilities, district and medical college hospitals, logistic challenges resulting from concentration of pediatric heart centers in selected cities and cost of care. Dedicated pediatric cardiac surgeons are in short supply and little is being done to address the problem. There are no formal training programs for pediatric cardiac surgery and this will become a major bottleneck as new centers are established. These barriers need to be overcome. A number of initiatives have attempted to address some of these barriers. The pediatric cardiac society of India has been working on educating pediatricians and neonatologists on recognition of heart disease. Formal fellowship training programs have been established in pediatric cardiology. Many cost-effective strategies have been developed for catheter interventions and congenital heart surgery in Indian centers. Realistic guidelines for management of common congenital heart lesions are being developed. A number of challenges lie ahead. The most fundamental challenge however is in making comprehensive pediatric heart care available to the average child in the region. Obtaining a list of potential donors and insurance providers is a reasonable start. But, core issues will need to be addressed before government and non-government subsidies can be offered as a realistic solution for the average child in the country: How sustainable are many of the current insurance and donor programs? Will the governments continue to find resources to subsidize pediatric heart care for the years to come? How can they justify this expense from a public health perspective? Bottlenecks in the form of capacity to deliver care: Most pediatric heart programs in India are overloaded and have significant waiting lists. Potential for exploitation by those who can afford: Most systems that deliver subsidized care are flawed, in that most subsidies do not reach those who truly deserve them. Potential for inappropriate use by hospitals that cater to patients obtaining government subsidies through unwarranted procedures. The ethical dilemma of prioritizing pediatric heart care in India. Specific ethical questions include: Should multistaged palliations for single-ventricle physiology be performed? Should hypoplastic left heart syndrome be treated? Should we develop pediatric cardiac transplantation in selected centers? Etc. CONCLUSIONS There are perhaps enough reasons to justify the presence of pediatric heart care in India as we make the transition to the future. A number of issues will need to be deliberated upon and implemented as a national consensus. Practice guidelines recognizing our resource limitations will need to be developed. These guidelines will serve as useful references for insurance providers. Regulations and audits on how insurance and government subsidy is distributed are urgently needed to ensure equity. Simultaneously, a number of basic initiatives to reduce costs of care should be pursued. These include training manpower locally, continued efforts toward cost containment through appropriate treatment strategies and development of indigenous technology.

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          Common wealth: Economics for a crowded planet

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            Cardiac care for the economically challenged: What are the options?

            The hardest part of being a pediatric cardiac medical person in India is having to tell a patient the cost of open heart surgery or device closure and watch the despair in their eyes. To produce the finances required can wipe out a family. We have all encountered families where they sold their last piece of jewelry or their only piece of land to be able to offer cardiac care for the child they love. For families such as these, there are now various government programs and charities available that can help in times of need. The aim of this article is to spread the information available so that more patients can access the resources now available in our country. One could argue philosophically that in a country that still has malnutrition and malaria, we should not even be attempting to repair hearts in children, an exercise that can be expensive and, at times, a palliative proposition. On the other hand, we just put Chandrayan on the moon. It is our opinion that as the world's largest democracy, our families have the right to be able to offer cardiac care to their children and it is our duty to provide high-quality cardiac intervention at an affordable cost to these families and their children. Nothing stops the government and pediatricians from working on the issues of malaria and diarrhea in parallel with advances in high-end medical services. It is a matter of pride that the pediatric cardiac community in India is offering such high-quality surgery and transcatheter interventions to children with heart disease that children from all over the world are coming here – Indian cardiac centers have become an oasis in a desert of poor cardiac care in this part of the world. Thus, as a nation, having developed expertise in treating children with heart disease, including complex ones, we need to ponder on the next issue – how do we make this care affordable and within the reach of the majority, irrespective of their financial status. How can a hospital manage to achieve high volumes without imploding or compromising on patient care. It is commonly believed that operating on children with heart disease is not “profitable” and is not sustainable. We will proceed to describe below some of the methods that can be used to provide high-quality, low-cost care to children with heart disease. The concept of a low-cost package system, i.e. the patient knows at admission the total cost of hospitalization with no extra charges imposed for extra days in the hospital. This immediately gives the patient a feeling of security that he will not enter with a full wallet and exit a pauper. This does mean that certain patients, who have long intensive care unit (ICU) stays, skew the cardiac surgical budget for the hospital. However, higher volume means that in the mix of cases will be patients who are discharged in 5 days so the outliers cost is made up by the “easier” cases. How does one create a low-cost package, i.e. how does one perform surgery for Rs. 80,000 when everything from the pump oxygenator to the staffs' salary costs money. A high-quality sterilization system can ensure longevity of use of operation theatre (OT)/ICU items, lower salary structure for medical personnel, a standardized system of workflow, including admission/anesthesia check/on call echo with surgeon and pediatric cardiologist can lead to rapid posting of patients and the ability to turnover the OT fast. In addition, hiring of fast and outstanding dedicated pediatric cardiac surgeons with a well-equipped and exclusive pediatric cardiac ICU with dedicated pediatric intensivists ensures a good surgical outcome. A low-mortality statistic spreads like no public relation exercise ever can. A higher volume ensures a proportion of patients will need off pump surgery or closed heart surgery and the balance sheet evens out. Despite a low-cost package, there are still patients who cannot afford this. Thus, the idea of a charitable wing makes sense in a country such as ours. A procedure package is given to the patients and they pay what they can afford. What they cannot afford is raised for them by the charitable wing fund raiser from kind-hearted souls and their donations. The hospital gets its package and so remains sustainable, the patient pays what he/she can afford and the donor's money is well used. However, charity is not always the best way to grow and be sustainable. Thus, other models have been conceived, one of the more successful of which has been the Yeshashwini insurance scheme – each member of a cooperative group pays a nominal amount and the corpus created is used to fund surgeries that are one-time expensive medical interventions. The Yeshashwini scheme has been adopted by the Karnataka Government and has become a highly successful model of cardiac care for the poor. Insurance is one way in new India that all patients will have access to high-quality medical care without burning a hole in their pockets. It is important to advise families to take insurance cover that starts at birth (so it covers neonatal cardiac lesions) as also to cover pre-existing illnesses. It is up to us, the medical community, to audit ourselves and ensure that the insurance cover is not misused, i.e. unnecessary procedures not be carried out on patients and the bills are not inflated for these patients. If hospitals get a bad reputation and insurance stops covering cardiac care, it is the patients who suffer. Medical loans – another novel concept – wherein the State Bank of India (the largest state-owned bank) will now give interest-free loans to any patient for urgent surgery. This allows the family time to breath, get the intervention done without further delay and then return home to sort out the financial situation. Finally, it is our belief that greatest good can be done by governments with a will. Insurance schemes for the poor have been implemented in states such as Karnataka, Gujarat, Maharashtra and Andhra Pradesh and other states are following suit. Below is a list of different schemes applicable to different governments or states. This is not an exhaustive list and similar schemes are being implemented in other states and by the Central government in various degrees of public and private partnership. Any doctor/hospital willing to help these patients can access information on various government schemes and private-public partnerships by contacting the local health care department. KARNATAKA SCHEMES Yeshasvini scheme (www.yeshasvini.org) Considered a very impressive model in which the law of large numbers is effectively used to provide a high degree of health security to the poorest populations of the world. Yeshaswini scheme has the acclaim for providing health security to large sections of the population in a developing country, depending less on the resources but more on mobilizing capacity and organization. The Arogya Raksha Yojana was started in Anekal taluk of Karnataka in 2005, under which the insured is entitled to free outpatient treatment at 17 network hospitals, special discounts on outpatient diagnostics, hospitalization for medical conditions and 100% coverage for over 1600 surgeries, both complex and simple. The Suvarna Arogya Chaitanya Yojana-e is another novel idea executed by the Karnataka government. It involves free treatment of cardiac ailments to all school-going children. Unlike the Yeshaswini scheme, both surgical and non-surgical modalities are undertaken through this scheme. Each child is eligible for a maximum grant of 1.2 lakhs toward the treatment cost. Also, expenditures toward travel of patient and attendant to the referral hospital are covered, along with free outpatient investigations and consultation. The Hridaya Spandana scheme aims to support at least one surgery a day. It works by an understanding between the government, three private charitable trusts as well as a private hospital, respectively, to help poor patients undergo heart procedures. TAMIL NADU SCHEMES The Government of Tamil Nadu has constituted the Tamil Nadu State Illness Assistance Society with a revolving fund of Rs. 15 crores as an initial corpus fund. The funding pattern is in the ratio of 2:1 between the State Government and the Government of India. “Heart Surgery for School Children” is a special scheme for children aged between 5 and 15, wherein the government will meet the entire cost. The Department of Public Health, Medical Education and District Administration jointly implement the project. In order to facilitate heart surgery for children from poor families without any delay, the Young Children Heart Surgery Scheme is being implemented by this government in partnership with private hospitals. Under this scheme, the government provides grants-in-aid up to Rs.70,000/- to private hospitals. UTTAR PRADESH (UP) Rajiv Gandhi Arogya Yojana This is UP government's pilot project at Amethi for out patient care of cardiact problems. ANDHRA PRADESH (AP) In 2004, the government of AP announced financial aid for the treatment of children aged 0–12 years suffering from heart diseases by utilizing facilities in government and private hospitals. GUJARAT Replications and extensions of the Yeshaswini scheme have been tried in Gujarat. Children are also referred from Gujarat at the discretion of the state-run UN Mehta cardiac center to Bangalore for advanced and complex heart surgeries. The entire cost of the surgery is borne by the state government. CENTRAL AND STATE GOVERNMENTS The Offices of the Honorable Prime Minister and Chief Minister award grants toward heart surgery from relief funds. Poor patients availing general ward may benefit up to Rs. 30,000/- from the Prime Minister's relief fund and up to Rs. 25,000/- from the Chief Minister's relief fund.
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              Paediatric heart care in India

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                Author and article information

                Journal
                Ann Pediatr Cardiol
                APC
                Annals of Pediatric Cardiology
                Medknow Publications (India )
                0974-2069
                0974-5149
                Jan-Jun 2009
                : 2
                : 1
                : 99-101
                Affiliations
                Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India
                Author notes
                Address for correspondence: Dr. R. Krishna Kumar, Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India. E-mail: rkrishnakumar@ 123456aims.amrita.edu , kumar_rk@ 123456yahoo.com
                Article
                APC-02-99
                10.4103/0974-2069.52807
                2840766
                20300282
                ebbc36d6-a65b-4d27-9b0b-2bacdd8f4ab9
                © Annals of Pediatric Cardiology

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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