The ministry of women and child development wants a shift in focus from female sterilization to male sterilization.

The Ministry of Women and Child development wants to shift the focus of family planning from female to male sterilization,in order to correct the patriarchal discourse present in society while also adopting the medical best practices.
The reasons for the move :
1) Men of a household push their wives for tubectomy as they think vasectomy will hurt their pride and masculinity.
2)Medically Vasectomy is preferable to Tubectomy as it is more safer and comparatively easier process. Their are no side effects and lesser chances of post operation complications like bladder problems.
3) Vasectomy is cheaper then Tubectomy
4)Tubectomy is more invasive then Vasectomy and recovery period is longer

India needs a combination of both surgical intervention as well as contraceptive interception to control population
1)Only a push for sterilization can get controversial as consent may not be there (like the 80's imbroglio),also threat of botched operations is there because of presence of targets by Ministry. And to add to it is the risk of quackery.
2)Incentivising the usages of contraceptives like condoms,copper-t ,mass awareness campaigns in rural areas,urban slums and even schools is required 
Both along with focus on women empowerment and gender sensitization can help in family planning. 

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.)

Public Health Policies

The Minister for Finance and Corporate Affairs and Information and Broadcasitng, Shri Arun Jaitley has announced a New Health Protection Scheme in the Budget 2016-17. In his Budget address in the Parliament today, the Finance Minister expressed concern that a serious illness of family member(s) causes severe stress on the financial condition of poor and economically weak families, shaking the foundation of their economic security. In order to help such families, the Government will launch a new health protection scheme which will provide health cover up-to rupees one lakh per family, the Finance Minister said. For Senior citizens of the age 60 years and above belonging to this category, an additional top-up package up to Rs.30,000 will be provided. 

The Finance Minister Shri Jaitley stated that making quality medicines available at affordable prices has been a key challenge. “We will reinvigorate the supply of generic drugs. 3,000 stores under Prime Minister’s Jan Aushadhi Yojana will be opened during 2016-17”, the Minister added. 

About 2.2 lakh new patients of End Stage Renal Disease get added in India every year resulting in additional demand for 3.4 Crore dialysis sessions. With approximately 4,950 dialysis centres in India, largely in the private sector and concentrated in the major towns, the demand is only half met. Every dialysis session costs about Rs.2,000 – an annual expenditure of more than Rs. 3 lakh. Besides, most families have to undertake frequent trips, often over long distances, to access dialysis services, incurring heavy travel costs and loss of wages. 

To address this situation, Shri Arun Jaitley proposed to start a ‘National Dialysis Services Programme’. Funds will be made available through PPP Mode under the National Health Mission, to provide dialysis services in all district hospitals. To reduce the cost, the Finance Minister proposed to exempt certain parts of dialysis equipment from basic customs duty, excise/CVD and SAD. 

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.

ZIKA VIRUS

The World Health Organization is convening an emergency committee on Monday to decide if the Zika virus outbreak should be declared an international health emergency.

At a special meeting on Thursday in Geneva, WHO Director-General Dr. Margaret Chan said the virus — which has been linked to birth defects and neurological problems — was “spreading explosively.”

Chan said although there was no definitive proof that the Zika virus was responsible for a spike in the number of babies being born with abnormally small heads in Brazil, “the level of alarm is extremely high.” She also noted a possible relationship between Zika infection and Guillain-Barre syndrome, which can cause temporary paralysis.

“The possible links, only recently suspected, have rapidly changed the risk profile of Zika from a mild threat to one of alarming proportions,” Chan said.

Zika virus was first detected in 1947 and for decades only caused mild disease. But Chan noted that “the situation today is dramatically different.” According to the US Centers for Disease Control, the Zika virus is now in more than 20 countries, mostly in Central and South America.

Chan cited four main reasons why WHO is “deeply concerned” about Zika: The possible link to birth defects and brain syndromes, the prospect of further spread, a lack of immunity in populations in the newly affected areas and the absence of vaccines, treatments or quick diagnostic tests for the virus.

Still, convening an emergency committee does not guarantee that a global emergency will be declared — WHO has held 10 such meetings to assess the Middle Eastern respiratory syndrome coronavirus and no emergency has been announced.

Declaring a global emergency is akin to an international SOS signal and usually brings more money and action to address an outbreak. The last such emergency was announced over the 2014 devastating Ebola outbreak in West Africa; polio was declared a similar emergency the year before.

Marcos Espinal, WHO’s director of infectious diseases in the Americas region, said Brazil is conducting studies to determine if there is scientific evidence that Zika virus causes birth defects and neurological problems. He said they are hopeful Brazil may have data to share in a couple of months.

Brazil’s Zika outbreak and the spike in microcephaly have been concentrated in the poor and underdeveloped northeast of the country, though the prosperous southeast, where Sao Paulo and Rio de Janeiro are located, are the second hardest-hit region. Rio de Janeiro will host the Aug. 5-21 Olympic games.

Earlier this week officials in Rio ramped up their fight against the mosquitoes that spread Zika, dispatching a team of fumigators to the Sambadrome, where the city’s Carnival parades will take place next month.

There is no specific treatment or vaccine for Zika, which is related to dengue — scientists have struggled for years to develop a dengue vaccine but have failed to create an effective shot so far.

- See more at: http://indianexpress.com/article/world/world-news/un-to-decide-if-zika-virus-is-a-global-health-emergency/#sthash.bqr9bgom.dpuf

National Family Health Survey-4

After 11 years, the much-awaited data on India’s health indicators were released by the Health Ministry on Tuesday night. The Phase 1 results from the National Family Health Survey-4 for 2015-16, which covered 13 States and two Union Territories (UTs), are a reason to smile.

In nearly every State, fewer children are dying in infancy, and across all States, more mothers are getting access to skilled ante-natal care. The last round of NFHS data was released in 2005-06.

Other findings are that while anaemia is widespread, rates have declined. Currently, over half the children in 10 States and over half the mothers in 11 States continue to be anaemic. Consistent with the burden of non-communicable diseases in India, over-nutrition or obesity among adults has emerged as a major concern. At least three in 10 women are overweight or obese in the Andaman and Nicobar Islands, Andhra Pradesh, Goa, Puducherry, and Tamil Nadu.

A promising trend in the data shows that women are having fewer children.

Fertility rates

The report states, “The total fertility rates or the average number of children per woman, range from 1.2 in Sikkim to 3.4 in Bihar. All first phase States/UTs except Bihar, Madhya Pradesh and Meghalaya have either achieved or maintained replacement level of fertility — a major achievement in the past decade.”

Findings for the 13 States — Andhra Pradesh, Bihar, Goa, Haryana, Karnataka, Madhya Pradesh, Meghalaya, Sikkim, Tamil Nadu, Telangana, Tripura, Uttarakhand and West Bengal — and two Union Territories of Andaman and Nicobar Islands and Puducherry show that all have rates below 51 deaths per 1,000 live births, although there is considerable variation among the States/Union Territories.

MERS

Geneva: Disease trackers are accustomed to hunting deadly new pathogens in Africa’s jungles and Asia’s megacities. The sand dunes of the Middle East? Not so much. But that’s the birthplace of the latest previously unknown virus to spread globally: Middle East Respiratory Syndrome coronavirus, or MERS-CoV. Exactly where the virus comes from remains a mystery, but camels are thought to be the source of many human infections. It’s most dangerous for people with underlying health conditions and is often lethal.

The Situation

Three years after MERS emerged in Saudi Arabia, the first major outbreak of the disease outside the kingdom, in South Korea in May 2015, reignited concerns of a global health emergency akin to the Severe Acute Respiratory Syndrome (SARS) epidemic of 2003. Also for the first time, the disease was exported to a third country when an infected South Korean man went to China after ignoring instructions not to travel. Globally, the virus has sickened more than 1,200 people and killed more than 440, the vast majority in Saudi Arabia. MERS was first identified in the desert kingdom in 2012, when a 60-year-old Saudi man died with severe pneumonia and kidney failure, though a subsequent analysis found two earlier cases in Jordan. The virus appeared to be on the wane until April 2014, when the case count exploded. Contact with camels during the spring, when females wean their young, may have contributed to the surge in new cases, which was amplified by poor infection control in hospitals. Despite concerns that the annual pilgrimage of Muslims to Mecca and Medina in mid-October would spread MERS, not a single case was attributable to the pilgrimage, according to the World Health Organization. The virus does not appear to pass easily from person to person. While cases have been reported in the US, Europe, Asia and Africa, all have been in people who live in or travelled to the Middle East, or who were exposed to someone who did.

The background

MERS-CoV belongs to the same family of pathogens as the SARS virus, which killed about 800 people worldwide after first appearing in China in 2003. MERS-CoV turned up in three-quarters of samples taken from camels across Saudi Arabia, according to a study published in early 2014. Camel herders and people who visited a camel farm or consumed unpasteurized camel milk have been among those infected. The virus has also been found in bats, suggesting that they may be a natural reservoir. MERS causes fever, cough and shortness of breath, leading in severe cases to respiratory failure, organ failure and death. People with weakened immune systems are more at risk. There’s no vaccine and no specific treatment. Despite the spread of the virus to South Korea and China, there’s no evidence that it has mutated into a more transmissible form, according to the WHO. Most of the cases in which people passed along the disease involve family members or health-care workers who were exposed.

The argument

The World Health Organization has declared global public health emergencies only three times. In 2009 for the H1N1 influenza (swine flu) pandemic, in May 2014 when it announced that polio had rebounded after almost being eradicated, and in August 2014 when Ebola ravaged west Africa. The WHO’s emergency committee has met to discuss MERS eight times since July 2013 and each time decided against labeling it an emergency, in large part because of its limited transmission between humans. Rather than suggest travel bans or other global measures that could raise anxieties, the agency said health-care workers should take standard infection-control measures, such as washing their hands between patients, and wear protective equipment when treating those with symptoms of acute respiratory infection. Amid criticism that South Korea missed opportunities to contain MERS early, WHO convened a team of specialists to study the country’s response and recommend measures for ending the epidemic.

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 Right of Persons with Disabilities Bill, 2014

The Rights of Persons with Disabilities Bill, 2014 was introduced in the Rajya Sabha on February 7, 2013 by the Minister of Social Justice and Empowerment, Mr. Mallikarjun Kharge.  The Bill repeals the Persons with Disabilities (Equal Opportunities Protection of Rights and Full Participation) Act, 1995. Definition of disability: Disability is defined to include 19 conditions such as: autism; low vision and blindness; cerebral palsy; deaf blindness; haemophilia; hearing impairment; leprosy; intellectual disability; mental illness; muscular dystrophy; multiple sclerosis; learning disability; speech and language disability; sickle cell disease; thalassemia; chronic neurological conditions; and multiple disability.  Persons with benchmark disabilities are defined as those with at least 40 per cent of any of the above specified disabilities.   Rights of persons with disabilities: The Bill states that persons with disabilities shall have the right to equality and shall not be discriminated against on grounds of their disability.  Rights of disabled persons include protection from inhuman treatment and equal protection and safety in situations of risk, armed conflict, humanitarian emergencies and natural disasters. All existing public buildings shall be made accessible for disabled persons within five years of the regulations being formulated by the National Commission for Persons with Disabilities.  No establishment will be granted permission to build any structure, issued a completion certification or allowed to occupy a building, if the building does not adhere to the regulations formulated by the Commission. Education, skill development and employment:  The Bill provides for the access to inclusive education, vocational training and self-employment of disabled persons. All government institutions of higher education and those getting aid from the government are required to reserve at least five percent of seats for persons with benchmark disabilities. The central and state governments have to identify posts in establishments under them to be reserved for persons with benchmark disabilities.  At least five percent of the vacancies are to be filled by persons or class of persons with at least 40 percent of any of the disabilities.  Of this, one per cent shall be reserved for persons with (i) blindness and low vision; (ii) hearing and speech impairment; (iii) locomotor disability; (iv) autism, intellectual disability and mental illness; and (v) multiple disabilities.  The Bill provides that the reservation has to be computed on the basis of total number of vacancies in the strength of a cadre.  The government may exempt any establishment from this provision.  Legal Capacity: Disabled persons have the right, equally with others, to own and inherit movable and immovable property, as well as control their financial affairs.  Guardianship: The Bill provides that if a district court finds that a mentally ill person is not capable of taking care of himself or of taking legally binding decisions, it may order guardianship to the person.  The nature of such guardianship is also specified. National and State Commissions for persons with disabilities: The central and state governments are required to establish a National and State Commissions for Persons with Disabilities, respectively.  The Commissions will be composed of experts and be required to (i) identify any laws, policies or programmes that are inconsistent with the Act; (ii) inquire into matters relating to deprivation of rights and safeguards available to disabled persons, (iv) monitor implementation of the Act and utilisation of funds disbursed by governments for the benefit of disabled persons. Central and state advisory boards: The central government and state governments shall constitute Central and State Advisory Boards on Disability.  The boards shall advise governments on policies and programmes on disability and review the activities of organisations dealing with disabled persons.

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.

Action plan soon to prevent deaths from diarrhoea, pneumonia / AARTI DHAR

The Centre will soon launch an action plan against diarrhoea and pneumonia in four States, including Rajasthan. The aim is to end preventable child deaths from these two by 2025. As high as 36 per cent of all child deaths, below the age of 5, in India are caused by these two conditions.

India accounts for the highest number of diarrhoea and pneumonia deaths among children in the world with over 2 lakh children dying of diarrhoea and over 3.8 lakh children of pneumonia annually, accounting for the mortality of 4 in every 10 children under-five.

The highest burden is being borne by the poorest sections of society.

The four States where the India Action Plan for Diarrhoea and Pneumonia will be rolled out — Madhya Pradesh, Uttar Pradesh, Bihar and Rajasthan — account for half of under-five mortality in the country which stands at 62 deaths per 1,000 live births nationally. The under-five mortality rate of Rajasthan is 59 per 1,000 live births.

Launch next month

The action plan, likely to be launched next month, is a follow-up of the Global Action Plan for Diarrhoea and Pneumonia that was launched by WHO and UNICEF in April 2013 which aims to reduce pneumonia mortality to less than 3 per 1,000 live births, diarrhoea deaths to less than 1 per 1,000 live births, reduce incidence of severe pneumonia and diarrhoea by 75 per cent compared to 2010 levels and reduce by 40 per cent the global number who are stunted as compared to 2010 levels by 2025.

While India has taken several measures to reduce maternal and child mortality over the years, including launching of the National Rural Health Mission; Reproductive Maternal Neonatal Child Health plus Adolescent programme and the India Newborn Action Plan to end preventable newborn deaths, the success in reducing under-five mortality has not been uniform.

Seven States have achieved the MDG-4 target of U5MR of 38 per 1,000 live births and nine States are showing a decline of more than the national average.

While Delhi, Kerala, Karnataka, Maharashtra, Punjab, Tamil Nadu and West Bengal have achieved the MDG target, the rate of decline is 7.3 per cent in Rajasthan, 5.6 per cent in Madhya Pradesh, 7 per cent in Uttar Pradesh and 6 per cent in Bihar.

Twenty per cent districts in Rajasthan have shown an increase in U5MR between 2010-11 and 2012-13 in the annual health surveys.

Collaboration

The WHO and UNICEF have been entrusted to collaborate with the respective governments in implementing the action plan which is not a new project or a programme but a framework for strengthening coordination of existing interventions where the coverage remains low like in exclusive breastfeeding (39 per cent), vitamin A supplement (75 per cent), DTP3 immunisation (83 per cent), measles immunization (84 per cent), HiB 3 immunisation (43 per cent) and other interventions like access to antibiotics and ORS solutions, sanitation, better living condition, hand wash and clean drinking water.

Since diarrhoea and pneumonia are caused by multiple pathogens, no single intervention, including vaccine, will help in protecting children.

Source: http://www.thehindu.com/todays-paper/tp-national/action-plan-soon-to-prevent-deaths-from-diarrhoea-pneumonia/article6726609.ece