More power to the vaccine arsenal

India has made huge strides as far as public health achievements are concerned, made possible by the use of safe and effective vaccines delivered through quality programmes. For example, small pox was eliminated in 1975, polio in 2014 and maternal and neonatal tetanus (MNT) in August 2015.

While India has shown its ability to undertake massive campaigns to improve vaccination coverage, routine immunisation coverage, which stands at 65 per cent when last measured, remains low. Moreover, the immunisation schedule lacks important vaccines that are already in use in most countries. All that is set to change.

In 2014, the Prime Minister’s Office announced the decision to introduce four new vaccines as part of India’s Universal Immunization Programme (UIP). These are vaccines against rotavirus, rubella and polio (injectable) and an adult vaccine against Japanese encephalitis introduced in districts with high levels of the disease. Earlier in 2011, a vaccine against Haemophilus influenza type B (Hib) was introduced as part of the pentavalent vaccine to contain diphtheria, pertussis, tetanus, hepatitis B and Hib. Thus the government has introduced or committed to introduce more vaccines than it has in the last 30 years of the UIP.

These vaccines could collectively prevent at least one lakh infant deaths, deaths of adults in the working age group and up to 10 lakh cases of hospitalisation each year. India’s UIP will now be able to provide free vaccines against 13 life-threatening diseases to 27 million children annually, the largest birth cohort in the world.

The India Newborn Action Plan (INAP) was launched in September 2014 with the aim of reducing preventable newborn deaths and stillbirths and the goal to attain single digit neonatal mortality and stillbirth rate by 2030. The current rate is 38/1,000 live births. To reach this goal, four additional vaccines are being thought of as priority vaccines for introduction in India.

Priority vaccines

The first of them is the Pneumococcal conjugate vaccine. Singularly, bacterial pneumonias kill more children under the age of five than any other disease. India has the world’s highest number of deaths caused by Streptococcus pneumoniae, the bacteria most commonly associated with pneumonias. There are an estimated 5-6 lakh cases of severe episodes of pneumococcal pneumonia and 95,000-1,05,000 deaths in India annually. An effective and safe vaccine for pneumococcus pneumonia is available.

The Human Papillomavirus (HPV) vaccine is next. Cervical cancer is one of the top three cancers affecting women in the world. Worldwide, every fourth new case is an Indian. It is estimated that in India, there are 1.32 lakh new cases every year and about 75,000 deaths reported. Two strains of HPV-16 and -18 are responsible for almost 80 to 85 per cent of cervical cancers. Preventive vaccines are available and are given to adolescents (9-13 years).

The third is the influenza vaccine. Immunising mothers during pregnancy against vaccine-preventable diseases has the potential to improve health outcomes in mothers and their children. This is likely to emerge as a key strategy to address neonatal mortality in particular which accounts for almost half of the under-five mortality. This strategy has been successfully used to eliminate MNT. Clinical trials have shown that influenza vaccination during pregnancy can prevent influenza disease in pregnant women and their newborn children for the first six months of life with no indication of harm to the recipients or their children .

Given the potential impact of maternal influenza immunisation programmes on maternal and child health worldwide, the World Health Organisation Strategic Advisory Group of Experts on Immunization (SAGE) has recommended that pregnant women having influenza vaccine receipt in countries initiating or expanding their influenza vaccine programmes be made a priority. In India, a large number of deaths were reported during the H1N1 outbreak from 2009 onwards. Infection in pregnant women led to deaths in their third trimester. The Maharashtra government has introduced seasonal flu vaccine for high-risk groups including pregnant women. Season flu vaccine, which includes the pandemic H1N1 strain, is a priority vaccine for use in high-risk groups in India including pregnant women.

The last is the cholera vaccine. Though interventions for the prevention and control of cholera (including an oral vaccine produced and licensed in India) are available, cholera remains an important cause of morbidity and mortality. It is estimated that there are about 7-8 lakh cases every year resulting in about 20,000-24,000 deaths. About 400-500 million people are at risk. Outbreaks occur after the monsoon. Though the oral vaccine is available in India, there has been limited use.

Targeting seven diseases

The UIP is now a much strengthened programme, supported by a transparent system of taking decisions to introduce new vaccines, being sensitive to adverse events following immunisation and with the capacity to add additional vaccines. Through Mission Indradhanush [to cover, by 2020, children who are either unvaccinated, or are partially vaccinated against diphtheria, whooping cough, tetanus, polio, tuberculosis, measles and hepatitis B], India aims to be on track to increase routine immunisation coverage to 90 per cent within a few years. The years to come may well be the golden years of immunisation in India.

(Prof. Ramanan Laxminarayan is Distinguished Professor and

Dr. Lalit Kant is Senior Adviser, Infectious Diseases, Public Health Foundation of India, New Delhi.

The views expressed are personal.)

It is said that rising antimicrobial resistance is a serious threat to economic growth. Examine why. 

Increasing resistance of anti-microbial is a concern for health sector for countries. But another major of concern is it's project adverse impact on economy in following way-

a) Economic productivity of demographic dividend- It will hamper the quality and quantity of workforce. especially, in case of India, where demographic dividend is an advantages, increasing anti- microbial resistance is a major source of concern.e.g Tuberculosis can affect Indian youth severely.

b) Increasing health burden on Public- Resistance to anti-microbial will severely affect the health and budget of poor and vulnerable people, it will not only decrease their wage hours but also increase the unproductive expenditure on health. This may be a set back for poverty alleviation programs by govt.

c) Govt and Institutional expenditure- R&D has to be increased on development of new medicines, hospital costs will be increased and whole medical infrastructure and network has to be strengthen to deal with coming crisis, it will demand lot of resources, which could be used for more productive purpose like education.

Anti-microbial were like a revolution in health and economy sector, but their resistance can proved to be catastrophic also, Govt should take every possible step to deal with it from R&D in new drugs to awareness among people about anti-microbial usages.

Band-aid solutions for health problems

The Draft National Health Policy of 2015 released by the Ministry of Health and Family Welfare, Government of India, is a comprehensive document. So comprehensive, in fact, that it says too little by saying too much. A National Heath Policy is commonly read as a political statement which is meant to provide a vision to the long-term health strategy for the country. The latest health policy speaks about a wide variety of issues that plague our health-care system — low public health expenditure, inequity in access, and poor quality of care. It also suggests a variety of ways to address them, mainly focussed around increasing government spending on health and expanding the public delivery system. However, the health policy fails to tackle head-on the core problem of the Indian health system — its management, administration and overall governance structure, without which the measures it suggests are merely symptomatic treatments, akin to putting a “Band-aid on a corpse.”

The policy draft itself provides evidence for this malaise. Russia and South Africa both spend a significantly higher amount on public health than India. In fact their spending is even higher than the target set by the draft health policy, yet they have life expectancies that are worse, as in the case of South Africa, or only marginally better, as in the case of Russia. On the contrary, Sri Lanka and Bangladesh are both countries that actually spend less on their healthcare (as a percentage of GDP) than India, yet both have better outcomes. Within India too, the draft policy notes that States with better capacity have utilised the National Rural Health Mission (NRHM) funds more effectively, while States with poorer initial conditions have been left with worse outcomes. The fundamental difference lies in management and governance structures.

Criticality of administration

The evidence from the draft policy does not stand alone, and is, in fact, supported by a rich literature. Globally, research findings have highlighted the criticality of administration in improving health outcomes. Rajkumar and Swaroop in a 2008 study find that the effectiveness of public health spending in reducing child mortality depends on the level of perceived corruption. It is found that higher integrity is associated with reduced child mortality. Gupta et al in a 2000 paper show that corruption indicators (using Kaufman, Kraay and Zoido-Lobatón, 1999) are negatively correlated with child and infant survival, attended births, immunisation coverage and birth weight. These results are robust even after accounting for spending on public health, education, and urbanisation. In a study looking at the United Nations’s Millennium Development Goals, Wagstaff and Claeson in 2004 conducted an analysis which showed that across-the-board additions to government health spending have no significant effect on underweight children, maternal mortality, or tuberculosis mortality in poorly governed countries. They defined poorly governed countries as being one standard deviation below the mean score on the World Bank Country Policy and Institutional Assessment (CPIA) index. They estimated that for across-the-board spending to have a significant effect on outcomes such as malnutrition and tuberculosis mortality, the CPIA score for a country has to get above the population-weighted average of 3.5. India’s score in 2011 and 2012 was slightly below that threshold. Bannerjee and others in 2008 provided evidence from an experiment within India. They find that an incentive programme designed to increase nurse attendance in Rajasthan was initially successful but was eventually undermined by the local health administration and workers. They concluded that piecemeal attempts to improve health delivery would be ineffective until health system reform becomes a top priority for the stakeholders.

Governance structures

The weight of evidence clearly suggests that if we want our health outcomes to improve, the Indian health policy needs to focus on how its health system is governed and managed. While our people are among the best and brightest, long years of neglect and misgovernment have vitiated our public management systems with perverse incentives. It is easier and more sensible for people within the system to subvert their jobs — through chronic absenteeism, endemic corruption and private practice — than to actually do them. The draft policy mentions band-aids for a few of these problems, but it needs to prioritise and lay far greater focus on the critical issue of governance and management of the Indian health system.

Governance structures need to balance responsibility, flexibility and accountability (Feldman and Khademian, 2001) in order to carry out their functions. It is clear that our systems today, at best, fix responsibility, but do not provide flexibility and accountability — managers/bureaucrats need to do their jobs. A useful, and not entirely radical, model to consider would be the one pioneered in India by the Tamil Nadu Medical Services Corporation. It is a registered corporation set up by the Tamil Nadu government to procure drugs for the public health system. It is accountable to an independent board of directors which includes the health secretary. The corporation has an IAS officer as its managing director, and professionals and academics are hired or taken on deputation as deemed necessary. The model has proved so successful in improving drug supply in Tamil Nadu that several other States, including Kerala, have adopted it as the basis of their own governance structure.

A similar governance structure at the State level, albeit at a much larger scale, could be a suitable vehicle for the coming expansion of public delivery in primary and preventive healthcare in India. Present health workers and doctors who are employees of the government can be absorbed on deputation, while new hiring and capacity building can be carried out by the corporation. Thus, they will not be hampered by either restrictive government rules for employees, or the negative image that is associated with short-term contracts which became the favoured capacity building instrument for the NRHM. Internationally, this model is in fact already quite well established in the healthcare delivery space. The National Health Service of the U.K., one of the largest organisations in the world, already operates on a very similar model, with an executive board that is accountable to the secretary of health. Its mandate and targets are set by the government, but it operates as a largely independent entity. Finances are devolved to local health boards, which ‘purchase’ or contract NHS primary care providers and hospitals on a services rendered basis, ensuring accountability at the local as well as the highest levels.

Whether or not this specific type of model is adopted for healthcare delivery in India, the more fundamental point is that governance and management of any health system is a core determinant of its effectiveness. The National Health Policy of the Narendra Modi government should make it a prominent focus of reforms, thereby announcing a tectonic shift in India’s healthcare system.

(Shamika Ravi is Economist, Brookings Institution, India Center, and Rahul Ahluwalia is Research Associate, Institute for Financial Management and Research, Chennai.)

http://www.thehindu.com/todays-paper/tp-opinion/bandaid-solutions-for-health-problems/article6914567.ece

The draft National Health Policy 2015 needs to pay more attention to the basics of healthcare.

Over 63 million persons in India face poverty every year due to healthcare costs alone with the share of out-of-pocket (OOP) expenditure on healthcare as a proportion of total household monthly per capita expenditure being 6.9% in rural areas and 5.5% in urban areas in 2011-12. In view of this, the central government’s draft National Health Policy (NHP) 2015, which is in the public domain and open to suggestions and comments until 28 February, is particularly significant. The draft NHP intends to make health a fundamental right and therefore its denial a justiciable matter. It hopes that this will “give a push for more public health expenditure as well as for the recognition of health as a basic human right”.

Undoubtedly, this is a welcome proposal but the right to education, which was declared a fundamental right in 2009, comes immediately to mind. The parallels with healthcare are many: the quality of education in government schools and the quality of services in public hospitals and primary health centres; the insistence, as a result, of even poor parents on their children attending private schools, however badly run; the beeline to private hospitals even by poor patients; and the small and large glitches in the implementation of the law. The lesson is obvious: what looks excellent on paper becomes a different proposition when it has to be put into practice.

The draft policy proposes increasing the expenditure on healthcare from its present level of 1.04% to 2.5% of grossdomestic product (GDP) in the next five years. This increase is, however, way below the requirement but what is not convincing is the explanation for keeping it at 2.5%: the healthcare system’s low absorption capacity and inefficient utilisation of funding. Incidentally, the government got a lot of flak for the temporary cut of 20% in the 2014-15 healthcare budget. The draft policy hopes to create a health cess (similar to the education cess) on liquor and tobacco products. One will definitely need to examine whether such a cess will be even close to adequate. Nevertheless, the draft policy promises that there will be universal access to free drugs and diagnostics in hospitals even as it notes the fact that the national health programmes leave out 75% of the non-communicable diseases and not all communicable diseases are covered either.

However, it does seek to broaden the definition of primary healthcare to accommodate reproductive and child health as well as some non-communicable diseases. The draft also seeks to involve panchayati raj institutions in a big way and lists seven “priority” areas to get the community and media to participate. Among these are the Swasth Nagrik Abhiyan (of which the Swachh Bharat Abhiyan is a part), the Nasha Mukti Abhiyan (anti-tobacco and alcohol measures), Yatri Suraksha (prevention of accidents) and Nirbhaya Nari (against gender violence, sex determination tests, etc).

According to the draft policy, the private sector provides nearly 80% of outpatient care and 60% of inpatient care. However, while noting the many concessions by the government to build a “positive economic climate for the healthcare industry” and hoping to “intervene and to actively shape the growth of this sector for ensuring that it is aligned to its overall health policy goals”, the draft does not go anywhere near spelling out the forms of intervention, whether institutional or regulatory. Whether it is the National Accreditation Board for Hospitals and Healthcare Providers or the Clinical Establishments (Registration and Regulation) Act of 2010, the response of the private players has been far from enthusiastic.

The draft has just one paragraph on mental health noting that it needs urgent attention since the gap between service availability and needs is widest here with 43 facilities in the nation and 0.47 psychologists per million people. It includes the Mental Health Bill (there are a few others too) among those that need to be reviewed. Considering the state of the mentally ill in this country, this section needed to be much more comprehensive and well thought out.

Ultimately, the devil is in the detail. India’s public health services need so much more basic infrastructure, medical and paramedical personnel, ironing out of the implementation wrinkles in the health insurance schemes like the Rashtriya Swasthya Bima Yojana, promoting computer-enabled systems to reach out to patients (like Tamil Nadu has done), straightening out of the corruption-ridden system of procurement and distribution of drugs, these among a long litany of requirements. The private sector needs a massive dose of regulation and monitoring in almost all aspects, from pricing to crooked third-party administrators to patient-care standards. At the government level, there has to be a deep commitment to make health-for-all a deliverable right, starting with plugging the leaks and poor utilisation of funds under various schemes. All this must come before the claim to make the right to health a justiciable right.

source: http://www.epw.in/editorials/long-eloquence-short-detail.html

A year of man-made health crises

Over the past year, several significant public health crises have unfolded in India and globally. As this year hurtles to an end, it becomes important to examine these events, if only momentarily, to understand the lessons they hold.

On closer examination, it becomes apparent that many of these crises were man-made — either because of continued neglect, a lack of focus on prevention and insufficient investment in health, or a focus on addressing diseases but not their root causes, i.e., the social determinants of health.

Early in the year, the war in Gaza and the blockade exacerbated a health crisis caused by continued international neglect of the people of Gaza. At the last count, the four-week conflict left 10,000 homes annihilated and displaced 4,50,000 people. The real public health crisis was the lack of electricity, clean drinking water and safe homes. Overcrowding and the lack of water and sanitation facilities led to a rise in the incidence of water-related diseases. As time passes, this destruction will expectedly result in multiple health crises that will affect the physical and mental well-being of hundreds of thousands of people.

Yet nothing made more news than the Ebola crisis in West Africa, where over 7,000 people have died. In the poorest and perhaps most politically unstable part of the continent where this crisis unfolded, the biggest areas of neglect were health systems, infrastructure, funding, trained human resources and little community education. Ebola has been endemic to the West Africa region for almost two decades. Yet, the ability of this region to address this disease, or any other, remains severely limited. Ebola wasn’t a global priority either, because it was centred in a poor region. International agencies bickered and took their time to respond while people died. When the first case emerged in the U.S., Ebola finally qualified as an important disease, and new experimental drugs, vaccines and preparedness soon followed. As always, it seemed too little, too late.

Health care in India

Let’s turn homeward. As India marched towards acche din , it also marched towards global leadership in many diseases. This year witnessed repetitive crises in malaria and dengue. Diabetes and heart disease continued to confound us. Earlier this year, we had a shocking stock-out of HIV testing kits and later of HIV drugs that, ironically, we produce and supply globally. Even as thousands were deprived of drugs in the public health sector, the government defended itself saying the situation was not “too bad.” India’s drug-resistant TB crisis too came out of the closet with over a 1,00,000 cases. We also finally admitted on national television that TB is the country’s time bomb.

However, the highlight was the sterilisation tragedy in Chhattisgarh. Over 10 of the 83 women who underwent sterilisation surgeries in the State died, while many others were hospitalised in a critical condition. The incident revealed the patriarchal mindset of successive governments who focus on female surgical sterilisation as a cornerstone of family planning. It also revealed the ongoing nexus between government officials and petty manufacturers, as the antibiotics given to patients were suspected of containing rat poison. Unfortunately, no politician or government official has been tried for culpable homicide. These deaths remain unpunished.

On a broader level, the quality of health services in urban and rural India, in both the public and private sectors, continued to be abysmal, as millions of patients travelled to access health services elsewhere. Over 60 per cent of all Indians continued to access healthcare in the private sector (many from quacks) at exorbitant costs and were often exploited with inappropriate tests and treatment. India’s epidemic of micro bacterial resistance also continued unabated as pharmacies sold antibiotics over the counter without sufficient control from the government. The biggest blow came at the end of the year as news leaked that the new government would cut health spending by around 20 per cent. For a country whose spending on health is among the lowest in the world, this was a terrible way to wrap up the year.

Lessons for the next year

What can we learn for 2015? Governments in India and elsewhere that promise development, growth and human well-being must recognise this: all this is not possible without investments in health and health systems. We need to invest in improving preventive and primary health care, sanitation, waste management and health education. Finally, if our long history of continuing disease and recent crises teach us anything, it is that the fundamentals of health remain critically important in disease control — sufficient nutrition, safe habitation, better air quality, sanitation, health-seeking behaviours, safety, and reduced conflict. All of these are deeply linked, not just to health but social and economic policy. Reducing spending on health will make things worse, not better, in India and elsewhere. Acche din will not arrive either next year or the decade after unless India integrates these lessons with its public policy.

Healthcare in India

 “The quality of health services in urban and rural India, in both the public and private sectors, continues to be abysmal, as millions of patients travel to access health services elsewhere.” Critically comment.

Healthcare in India is a major issue as basic health is not reaching rural areas and villages and 60% of Indians are depend on private sector which is too costly for common man. The quality of health is an issue in India as rural areas are filled with jholachhap doctors, AYUSH doctors practising  allopathic medicines and in cities everyday we are receive several complains over mis-conducts of private hospitals.

Recently the deaths in Chhattisgarh, Multidrug resistance TB cases and shortage of AIDS test kits are few examples of failure quality of health services in country.

For the major deceases, there is few centres in the country and we are unable to provide facilities to every part. Even specialised private hospitals are limited.

Although medical tourism is increasing in the country and 100% FDI is lucrative, on ground level the quality of health services in urban and rural India, in both the public and private sectors, continues to be abysmal and we need better plans more efforts, awareness and dedicated people to improve the healthcare facilities in India.