Monday 3 December 2012
Saturday 24 November 2012
Monday 12 November 2012
Thursday 25 October 2012
Tuesday 23 October 2012
Monday 15 October 2012
For adolescents under 15 years
The younger the mother is, the greater the risk to her and her baby. The risk of maternal death related to pregnancy and childbirth for adolescent girls between 15 and 19 years of age accounts for some 70,000 deaths each year. For adolescents under 15 years of age these risks increase substantially. Girls who give birth before age 15 are five times more likely to die in childbirth than women in their twenties. Adolescent girls and young women, married or unmarried, need special help to delay pregnancy. All who might be involved with an early pregnancy – adolescent girls and young women and adolescent boys and men as
well as their families – should be aware of the risks involved and how to avoid them. This should include information on how to prevent sexually transmitted infections (STIs), including HIV. After the age of 35, the health risks associated with pregnancy and childbirth begin to increase again. The risks may include
hypertension (high blood pressure), haemorrhage (loss of blood), miscarriage and gestational diabetes (diabetes during pregnancy) for the woman and congenital anomalies (birth defects) for the child.
Sunday 12 August 2012
Public Health Crisis
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  COVER STORY Public health crisis
At the children's ward of the King George Hospital in Visakhapatnam on June 21, a scene typical of most government hospitals in the country. However, while the reorientation of the approach and the overall premise suggested by the HLEG in its report of November 2011 are sound and many of its recommendations are worthy of implementation, setting a tight deadline of a decade to achieve UHC may be infeasible given the many ills of the public health care system and the largely unregulated market-driven situation in which it functions. The Steering Committee has incorporated some elements of the HLEG report within an altered framework that differs on key aspects from the HLEG’s perspective. It is the Steering Committee that will have a definitive influence on the decision-making process. But before the government begins to implement the Steering Committee’s recommendations, there is the need for a wider public debate on them because at least some of the recommendations would let the private sector continue to play a prominent role in health care and make the objective of UHC difficult to achieve. More pertinently, in many key components of the health care system the regulatory framework is either lacking or ineffective and hence a complete failure. Appropriate policy instruments and regulatory and institutional frameworks should be put in place in the immediate term to correct the serious maladies that plague the health care system so that measures for UHC are easily implemented. This edition of Frontline discusses some of the areas requiring urgent regulatory reforms. Issues highlighted in the reports of the HLEG and the Steering Committee will be taken up in later editions of the magazine. The unrestricted growth of all facets of the health care industry has to be regulated. K.M. Shyamprasad points out in his overview on the regulatory deficiencies that public health has to do with the health of populations, while health care has to do with the curative aspect and focuses on the health of individuals. Thus, medicine and public health have contradictory interests. The implementation of health policies has always been by medical professionals, people from the curative medicine background. This has led to the absence of a public health approach in our health care, points out Shyamprasad. He also emphasises the need for a public health law similar to what most developed countries have. A National Health Bill has been in the draft stage since 2009. Clearly, there is no political will to take it forward and enact it into law. The reports of the HLEG and the Steering Committee have emphasised the need for a National Public Health Act and State Public Health Acts on the lines of the Tamil Nadu Public Health Act, which has demonstrated its effectiveness. The Clinical Establishments (Registration and Regulation) Bill, 2010, was passed by Parliament nearly two years ago but it could be notified as an Act only on February 28 this year as it was being repeatedly challenged by the medical fraternity in courts. The Bill seeks to register and regulate clinical establishments (including hospitals and clinics in all recognised forms of medicine) and any laboratory offering pathological, chemical and other diagnostic services, so as to ensure that they meet the minimum standards of space and infrastructure (equipment and paramedical staff) as laid down by the government. Two writ petitions filed by the Indian Medical Association (IMA) are currently pending in courts. The opposition to the Act is driven largely by the interests of the large number of private practitioners who function out of places that do not meet the standards. Among the demands of the IMA, for which it has called a nationwide strike on June 25, is exemption from some of the provisions of the Clinical Establishments Act, which it feels are draconian. One particular concern with regard to this Act – that it does not provide for any compensation to doctors who are statutorily mandated to provide emergency medical services – seems to be valid, as Shyamprasad has pointed out in his article. The IMA generally opposes any kind of regulation and, as Shyamprasad says, as an organisation of health professionals it has failed the society by not observing effective self-regulation. It is also a fact that unethical practices abound in the medical profession resulting in crass commercialisation of health care. The IMA’s recent endorsement of commercial advertisements making claims of medical value in non-medical products is just one example. In a recent open letter to the IMA, the Medico Friends Circle (MFC) and the Forum for Medical Ethics Society (FMES) wrote: “The IMA should seriously try to reverse the current widespread unregulated commercialisation of health care in India, and should contribute to the process of health system reforms for eliminating the distortions in medical practice. This would be immensely beneficial to patients and would also raise the dignity of the medical profession manifold… [C]ut practice and commissions, irrationality in investigations and surgical practices, distorting influence of pharma industry on prescribing by doctors, and inflation of patient bills consequent to all of these, are extremely widespread. This has resulted in massive problems relating to both cost and quality of medical care for the people. Besides the evidence from various studies on caesarean section rates, injection practices, prevalence of hysterectomies and sex selective abortions, most practising doctors admit in private that malpractices are a pervasive trend, not limited to a few isolated individuals. In fact, distortions in medical practice induced by unregulated commercialisation have become systemic problems.” Unethical practices in the form of a nexus between the regulators and the pharma industry were highlighted in a recent report of the Parliamentary Standing Committee on Health. The assurance of access to quality, safe and efficacious drugs at affordable prices is the minimum prerequisite for an effective health care system before one can think in terms of cashless treatment under a UHC system. Non-essential and unsafe drugs have flooded the market because of an ineffective and corrupt regulatory system on the one hand and the doctor-pharma business on the other. Hundreds, if not thousands, of unlawful and undesirable drugs, including drugs banned elsewhere in the world, have entered the supply chain because corrupt functionaries in the Central Drugs Standard Control Organisation (CDSCO) under the Ministry of Health and Family Welfare have allowed them to without applying mandatory regulations such as appropriate clinical trials and without safety and efficacy data of these drugs (story on page 8). With India increasingly becoming a hub for clinical trials for institutions and companies abroad, even where drug trials are done they are not regulated properly in terms of the recruitment of subjects and the protocols followed. India is witnessing an unprecedented growth in its drug trials market – from Rs.423 crore in 2005, it is expected to cross Rs.2,721 crore, according to Sama, a non-governmental organisation. It recently brought out a report on ‘Regulation of Drug Trials’ following a National Consultation workshop. The report says, “India has a huge ‘treatment naive’ patient base, low-cost advantage and ‘efficient’ conduction of trials, ‘improving infrastructure’ and strong state support for outsourcing and privatisation.” At present, as elaborated in the story by T.K. Rajalakshmi (page 26), the infrastructure for regulation, ethics review and monitoring of clinical trials is insufficient and ineffective. “In this situation,” says the Sama report, “the government’s push to encourage clinical trials must be viewed with concern. There is an urgent need for a policy that truly engages with, and respects, the public by according the highest priority to transparency in clinical trial procedures, as well as protection of the rights of the participants…. India… requires a more stringent regulation, and effective implementation, in order to ensure the highest standards of independent inquiry, good clinical practice, enforcement of protocols, monitoring and follow-up, so that a strong and pro-people policy can be put in place.” It is high time the government enacted an appropriate umbrella Act for clinical trials and linked it to the existing guidelines on biomedical research of the Indian Council of Medical Research. The reports of the HLEG and the Steering Committee have highlighted the critical issue of Human Resourcefor Health (HRH). In fact, one of the terms of reference of the HLEG was to prepare a blueprint for HRH. One of the serious problems facing medical education in the country is that it has become highly commercialised, with entry into a medical course depending on one’s capacity to pay (from several lakhs of rupees up to a crore and more) rather than a transparent examination-based merit assessment. This is the result of unregulated growth of the private sector in the field of higher education, with the statutory body entrusted with evaluating, assessing and monitoring medical colleges and institutions, the Medical Council of India (MCI), itself becoming an active collaborator in promoting such dubious degree-churning grounds. The legislation aimed at replacing the MCI with an overarching statutory body covering medical, dental, pharmaceutical and nursing courses, called the National Commission for Human Resource in Health (NCHRH), introduced in 2010, is currently being examined by the Parliamentary Committee. If it had been enacted in time, there would have been no need to grant two extensions to the MCI, which, following charges of corruption, is in suspended animation, propped up by an ad hoc Board of Governors (BOG) since May 2010. More pertinently, there is evidence to suggest that corruption within the MCI continues in the matter of setting up new medical colleges. However, the proposed NCHRH Bill, too, is not without problems, a major one being concentration of power at the Centre while health remains a State subject. This would only result in continuing corruption in medical education (story on page 17). Another important deficiency in respect of HRH is the huge gap in demand and supply for rural health services, particularly at the primary health care level. A well-conceptualised short-duration (3½-year) degree course called the Bachelor in Rural Health Care (BRHC) is yet to become a reality though it was recommended by an expert body of the Ministry in 2007. Such initiatives proactively put in place by States such as Assam and Chhattisgarh have been successful. But the Centre is seen to be dithering and there are signs of a stand-off with the MCI (now BOG/MCI), which is required to develop the curriculum and syllabus for the course. The largely urban-centric medical fraternity of doctors, who mostly are unwilling to serve in rural areas, is opposed to such a course. In fact, calling the course “substandard”, the IMA has objected to its introduction. Following petitions in the Delhi High Court by public health professionals, there seems to be light at the end of the tunnel with the MCI assuring the court in March that the course will be ready by April. But the matter will not be resolved fully as the Parliamentary Standing Committee is not through with examining the issue ( story on page 21). The above are only some of the deficient regulatory frameworks in the area of health. There are many more which the Frontline Cover Story has not covered. All these have to be put in order – with new pieces of legislation where none exists or rectifying existing deficient ones – before policy makers even begin to think in terms of implementing a UHC programme |
Monday 6 August 2012
CHC -Executive Summary
Executive Summary
The Scheme
Our health policy envisages a three tier structure comprising the primary, secondary and tertiary
health care facilities to bring health care services within the reach of the people. The primary tier is
designed to have three types of health care institutions, namely, a Sub-Centre (SC) for a population
of 3000-5000, a Primary Health Centre (PHC) for 20000 to 30000 people and a Community Health
Centre (CHC) as referral centre for every four PHCs covering a population of 80,000 to 1.2 lakh. The
district hospitals were to function as the secondary tier for the rural health care, and as the primary
tier for the urban population. The tertiary health care was to be provided by health care institutions in
urban areas which are well equipped with sophisticated diagnostic and investigative facilities.
In pursuance of this policy, a vast network of health care institutions has been created, both in rural
and urban areas, and substantial resources, though inadequate vis-a-vis requirement, have gone
into planning and implementing the health and family welfare programmes. Increased availability and
utilisation of health care services have resulted in a general improvement of the health status of our
population, as is reflected in the increased life expectancy and marked decline in birth and mortality
rates over the last fifty years. However, these achievements are uneven, with marked disparities
across states and districts, and between urban and rural people.
These disparities in the health outcome could be attributed to a large extent, to the
differential access to health services by different segments of the population. While the demand side
factors do play a role in exercising the choice of the modes of delivery of health care services, for the
vast majority of our people, the access to health care services is determined primarily by the
availability (and the quality of delivery) of public health institutions. This is especially true of the
majority of the rural people, for whom alternatives to the public health services hardly exist.
In fact, the Fifth Five Year Plan document noted with concern the disparities in access to
health services between urban and rural areas and the tardy implementation of the schemes in the
health sector. The primary rural health care services were brought under the Minimum Needs
Programme (MNP) during the Fifth Plan (1974-79). It was decided to integrate and strengthen the
rural health care institutions through suitable organic and functional linkages between the different
tiers of the primary health care system.
In this framework, the Community Health Centre (CHC), the third tier of the network of rural health
care units, was required to act primarily as a referral centre (for the neighbouring PHCs, usually 4 in
number) for the patients requiring specialised treatment in the areas of medicine, surgery, paediatrics
and gynaecology. The objective was two-fold; to make modern health care services accessible to the
rural people and to ease the overcrowding of the district hospitals. To enable the CHCs to contribute
towards meeting the intended objectives, these were designed to be equipped with: four specialists
in the areas of medicine, surgery, paediatrics and gynaecology; 30 beds for indoor patients;
operation theatre, labour room, X-ray machine, pathological laboratory, standby generator etc. along
with the complementary medical and para medical staff.
Evaluation Study
At the instance of Planning Commission, the Programme Evaluation Organisation undertook the
study to evaluate the functioning of the Community Health Centres (CHCs) and their effectiveness in
bringing specialised health care within the reach of rural people.
CHC's
PEO Evaluation Studies
Functioning of Community
Health Centres (CHCs)
i Preface
ii Executive Summary
1 Introduction
2 The Evaluation Study- Objectives and Methodology
3 Coverage and Location of CHCs
4 Infrastructure in CHC – Availability and Adequacy
5 Utilisation of Medical Services
6 Family Welfare and National Health Programmes - Role of CHCs..
7 The Utility of CHCs- Beneficiaries’ Views
iii Appendix Tables
iv Project TeamPreface
The Community Health Centre (CHC), the third tier of the network of rural health care
institutions, was required to act primarily as a referral centre (for the neighbouring PHCs, usually 4 in
number) for the patients requiring specialised health care services. The objective of having a referral
centre for the primary health care institutions was two-fold; to make modern health care services
accessible to the rural people and to ease the overcrowding in the district hospitals.The CHCs were
accordingly designed to be equipped with : four specialists in the areas of medicine, surgery,
paediatrics and gynaecology; 30 beds for indoor patients; operation theatre, labour room, X-ray
machine, pathological laboratory, standby generator , etc., along with the complementary medical and
para medical staff.
At the instance of Planning Commission, the Programme Evaluation Organisation undertook
the study to evaluate the functioning of the Community Health Centres (CHCs) and their effectiveness
in bringing specialised health care services within the reach of rural people.
Both secondary and primary data were required to be analysed to test the various
hypotheses relating to the above mentioned objectives of the study. While the information available in
published sources was obtained and used wherever necessary, the major part of the data, required
for the study, was generated through a sample survey of 62 PHCs and 31 CHCs spread over the 16
sample districts of eight states selected for the study.
The findings of the Study are as follows:
(a) Given the other relevant factors, the services of a CHC are likely to be used less intensively, if:
(i) its geographical coverage is very large;
(ii) it has inadequate medical staff, particularly the specialists; and
(iii) the mean distance of the PHCs from the CHC is longer.
(b) Some CHCs have been approved without sanctioning all the posts of specialists. Only 30 per cent
of the required posts of the specialists were found to be in position. More than 70 per cent of
the sample CHCs are running either with one specialist or without any specialist.
(c) There is a mis-match between medical specialists vis-a-vis equipments/facilities/ staff, leading to
sub-optimal utilisation of resources. The over- all productivity of the public health services can
substantially be improved if this mis-match as well as thin spread of resources is avoided.
(d) Only two out of 31 CHCs were found to have been used as referral centres to some extent. As
many as 11 CHCs have not attended any referral case, while the remaining 18 have been
used sub-optimally with an average of 206 cases per year. The constraints to utilisation of the
services of CHCs relate to inadequacies of infrastructure, medical and paramedical staff, and
more importantly, the mis-match of various inputs.
(e) Notwithstanding the existing limitations in the services delivery system, a large majority of the
households expressed their strong preference for public health care system as against the private
facilities.
The findings tend to suggest that CHCs have not made any significant contributions towards
realisation of the intended objectives even after about two decades of their establishment. The study has been able to identify a set of key factors that has contributed to the poor performance of CHCs. It
is hoped that the findings of the study will be useful to the planning/ implementing agencies in
introducing the necessary corrective steps for improving the services delivery system.
The study received constant support and encouragement from the Deputy Chairman,
Secretary and Chairman (EAC) of Planning Commission. Dr. (Mrs.) Manjula Chakraborty, the then
Deputy Adviser (PEO) initiated the study, but it was designed and conducted under the direction of
Shri Amar Singh, Deputy Adviser (PEO). The efforts put in by the officers of PEO (Hqrs.) and
Regional/Project Evaluation Offices under the guidance of Shri V.K. Bhatia, Joint Adviser (PEO) in
completing the study deserve special mention.
The help and cooperation extended by the officers of Union Ministry of Health and Family
Welfare as also the Health and Family Welfare Division of Planning Commission at different stages of
study is gratefully acknowledged.
(S.P. Pal)
Adviser (Evaluation)
New Delhi.
Dated : September, 1999
Haryana lacks in nutrition of its children
Haryana lacks in nutrition of its children
The food surplus status of Haryana conjures up the image of green fields and formidable young men and women, many of whom have made the country proud by winning medals in various sports fields. Ironically, the food surplus state has been found lacking in nutrition of its children.
According to a recent National Family Health Survey III (NFHS III), 46 per cent of children suffer from stunting (height according to age), 43 per cent suffer from underweight (weight according to age) and 19 per cent suffer from wasting (weight according to height) in Haryana.
The anomaly has come to light when it was found that the situation in Haryana on child nutrition front is even worse then 100 backward districts of six states — Bihar, Jharkhand, MP, Orissa, Rajasthan and UP. This was in sharp contrast to Kerela, where only 24 per cent children suffer from stunting, 22 per cent from underweight and 15 per cent from wasting.
The fact has been corroborated by another independent study by the Kuruksherta University. Associate professor Dr Rajeswari, in his study “spatial pattern of child nutrition in rural Haryana: A socio-economic analysis,” says that it was surprising to find a shocking proportion of child malnutrition.
The study is based on the primary data collected from 1,440 households spread over 16 villages in eight districts of the state. “Child malnutrition was measured in terms of long-term nutritional intake i.e. height for age and a comprehensive indicator of long and short-term dietary and illness episodes i.e. weight for age,” she said.
The analysis revealed that child malnutrition was pervasive, irrespective of spatial and social status. The study also pointed towards some serious and urgent need to take short and long-term measures to achieve nutritional security in the state.
Among short-term measures, it suggested the need for an awareness campaign for healthy dietary practices as well as special attention towards maternal health as more than 60 per cent of expectant mothers were found anaemic, who gave birth to low-weight babies.
According to a recent National Family Health Survey III (NFHS III), 46 per cent of children suffer from stunting (height according to age), 43 per cent suffer from underweight (weight according to age) and 19 per cent suffer from wasting (weight according to height) in Haryana.
The anomaly has come to light when it was found that the situation in Haryana on child nutrition front is even worse then 100 backward districts of six states — Bihar, Jharkhand, MP, Orissa, Rajasthan and UP. This was in sharp contrast to Kerela, where only 24 per cent children suffer from stunting, 22 per cent from underweight and 15 per cent from wasting.
The fact has been corroborated by another independent study by the Kuruksherta University. Associate professor Dr Rajeswari, in his study “spatial pattern of child nutrition in rural Haryana: A socio-economic analysis,” says that it was surprising to find a shocking proportion of child malnutrition.
The study is based on the primary data collected from 1,440 households spread over 16 villages in eight districts of the state. “Child malnutrition was measured in terms of long-term nutritional intake i.e. height for age and a comprehensive indicator of long and short-term dietary and illness episodes i.e. weight for age,” she said.
The analysis revealed that child malnutrition was pervasive, irrespective of spatial and social status. The study also pointed towards some serious and urgent need to take short and long-term measures to achieve nutritional security in the state.
Among short-term measures, it suggested the need for an awareness campaign for healthy dietary practices as well as special attention towards maternal health as more than 60 per cent of expectant mothers were found anaemic, who gave birth to low-weight babies.
Child malnutrition rises in India despite economic boom
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60650-3/fulltext
Child malnutrition rises in India despite economic boom
The growth of India's economy during the past decade has had little effect on the nutritional status of its youngest citizens. Even in affluent states, the percentage of underweight children younger than 3 years has risen over the past 10 years. Patralekha Chatterjee reports.
Chandigarh, the joint capital of Haryana and Punjab—two of India's richest states—is an elegant city, with the highest yearly per head income in the country. The signs of affluence are everywhere: glitzy malls, luxury cars, and a high-spending middle class. But on the outskirts of this town, the underbelly of India's booming economy is clearly visible.
In the Azadpur slum, crouched on the floor of her one-room shack, Krishna Devi, twenty-something and 8 months pregnant with her second child, looks listlessly out the door. Her husband, Hriday Ram, a migrant, works as a gardener in middle-class homes. Theirs is a hand-to-mouth existence. But the future holds more promise than in their native village in the under-resourced, over populated state of Uttar Pradesh.
Krishna is anaemic. Kiran, her 2 year-old son, is severely malnourished. Although anaemia can be tackled with iron and folic acid tablets, Krishna is unaware of their importance. A tin of protein supplements and packs of iron and folic acid tablets lie on a shelf in the corner of the room, unconsumed. “I did not like the taste”, she says.
Krishna has had no antenatal check ups to date. A private doctor prescribed expensive protein supplements but did not explain the need for an iron-rich diet during pregnancy. Every morning, Krishna gives her son a cup of milk diluted with water along with a few biscuits. Like most people in the Azadpur slum, Krishna's contact with the public-health system is negligible.
Despite having an economy growing at nearly 10% a year, widespread malnutrition, and its associated health problems, such as anaemia, remain one of India's formidable challenges.
In February this year, UNICEF officials created a stir by telling a gathering of national and international journalists in Delhi that an Indian child is more likely to be malnourished than a child in Ethiopia, the Horn of Africa nation known for its periodic droughts, famines, and long civil conflict and border war with Eritrea.
The comment stemmed from India's 2005-06 National Family Health Survey (NFHS), which reveals that almost half of Indian children younger than 3 years are underweight. The results show that the malnutrition crisis is not confined to migrants huddled in urban shanties like Krishna and her family. Anaemia and undernutrition in small children and pregnant women in their prime is growing, even in India's prosperous states like Haryana.
Life in Dundahera village in the Gurgaon district of Haryana, offers a glimpse of perhaps why economic boom is not translating into better maternal and child health in India. In recent years, Gurgaon has emerged as one of India's hottest outsourcing hubs. Shopping centres, multinational companies, and industrial complexes dot the cityscape. Eager to tap the emerging commercial opportunities, Dunadhera's farmers are selling their land to builders. New houses have been built to accommodate the growing number of migrant families streaming into the area to fuel the economic boom. Many families who have sold their land have suddenly become rich. But within the family and this highly patriarchal society, the status of women has scarcely improved.
Full-size image (50K) Patralekha Chatterjee
A charity worker talks to a family in the Azadpur slum about the basics of a nutritious diet
“Alcoholism is on the rise in Dundahera. The new rich spend their extra cash on beautifying their house, on clothes, and gadgets. The health of the woman is not a top priority for most families. Even if the family owns cattle, they will prefer to sell most of the milk. There is no one really to ensure that an expecting mother eats well. More money in hand does not mean healthy mothers and children”, says Sharda, a village-level anganwadi (child development and nutrition) worker.
The latest NFHS data are preliminary findings. Detailed analyses are awaited, but nevertheless, the current findings have sparked justifiable concern: 41·9% of children under 3 years in Haryana were clinically underweight (too thin for their age) in 2005—06 compared with 34·4% in 1998—99. During the same period, the number of children younger than 3 years who are too thin for their height rose from 5·3% to 16·7%. Disturbingly, the new data also reveal that 69·7% of pregnant women in the 15—49 year age group in Haryana are anaemic compared with 55·7% 7 years ago.
Full-size image (63K) Patralekha Chatterjee
Life on the outskirts of Chandigarh is very different from its bustling financial centre
The discrimination against girls and women in affluent Haryana might explain some of the increase in anaemia. Girls continue to be worse fed than boys in most families, especially in rural areas.
The latest NFHS data also support other recent sample surveys in the state. A community-based study in ten villages in Haryana in 2004—05 found that 25 out of every 100 newborn babies in rural Haryana are low birthweight (less than 2500g at the time of birth). The prevalence of low birthweight babies in rural Haryana has remained nearly constant for the past two decades, despite the state's rapid economic progress.
“The problem of low birthweight is due to inadequate food intake and maternal anaemia. There is little awareness among mothers about what food to eat, how much to eat, and an inability to co-relate the food intake with the outcomes. If this is showing up as low birthweight and child malnutrition, failure to identify maternal anaemia is to blame”, says Arun Aggarwal, one of the researchers on the study based at The Postgraduate Institute of Medical Education and Research in Chandigarh.
“Pregnant women take tetanus toxoid injections. So, there is a contact with the health-care system but this is not translating into awareness about anaemia. Health workers in the villages rarely conduct haemoglobin tests on pregnant women.”
“Other problems on the ground include irregular supplies of the reagent required to conduct haemoglobin tests. Tetanus toxoid has been flagged, anaemia has not. The community health worker is supposed to identify anaemic women on laboratory and other clinical parameters and provide double dose of iron folic tablets but such tablets also are often in short supply. There is an urgent need to make the monitoring and evaluation system for maternal anaemia more rigorous”, Aggarwal told The Lancet. By the time, the anaemia is diagnosed in a pregnant woman, it is often too late.
However, there are signs of change. The Government of Haryana and UNICEF have signed a Memorandum of Understanding to work together to improve social indicators for women and children in the state. Recently, the Haryana Government has set up a state-level steering committee on nutrition. Attempts are finally being made to address the root causes affecting child nutrition. And following the advice of community doctors, health and nutrition workers have begun focusing on the health of the adolescent girl.
“If we want to fight under-nutrition among small children, we have to target mothers before they become pregnant. Today, we are targeting young girls—those who are in the 11 to 18 year age group, who are likely to become young mothers in a few years, through ‘balika mandals’ (support groups of young girls). We counsel them about health and hygiene, about deworming, prepare them for motherhood, sensitise them about the need to take iron tablets. This goes hand-in-hand with our continuing work with expecting mothers”, says Chanchal Dhalwal, who is in-charge of Gurgaon district's Integrated Child Development Services—a nation-wide nutrition and health programme that serves millions of women and children.
The Haryana Government has also decentralised the supplementary nutrition scheme to improve efficiency. Now, self-help groups of women are given cash to procure raw materials locally and make local preparations.
Other attempts to improve maternal health and nutrition include “best mother contests”. Best mothers are those with the best scores in a health education quiz.
“The contests, which began 3 years ago, are intended to get mothers hooked to the health-care system. The initiative is now being taken to other districts in Haryana. It is slow process but women are becoming more nutritionally literate in [the] Gurgaon district and severe malnutrition among children under 6 [years] is going down”, adds Dhalwal.
Sunday 17 June 2012
Doctors, Nurses and Public Health System
Doctors, Nurses and Public Health System
----Ravi Duggal
Getting Doctors and Nurses to Work for the Public Health System
One major concern with the functioning of the public health system is availability of key functionaries, especially doctors and nurses. The question is not one of lack of production because that happens adequately with about 25000 each of doctors (allopathic alone, in addition about 20000 AYUSH doctors) and nurses being produced annually. Infact we produce enough to cater to the world and Indian doctors and nurses are in great demand all over the world – over 5000 doctors and 7000 nurses go abroad each year. But the public health system, both in rural and urban areas, is unable to attract the requisite human resources needed for running the public health system. This despite the fact that over 80% of such production happens with public resources.
It is time that the legislators of this country give serious attention to this shortage of human resources for the public health system if the National Rural Health Mission has to achieve any significant success. Apart from doctors and nurses the public health system also needs managers under the architectural corrections mandated by the NRHM.
Over the years various mechanisms have been tried but they have failed because there was no legal backing for them. Whatever was done was done on good faith which is in fact the corner stone of the medical profession. But we all know that ethics in medical practice is getting even more distant with gross commercialization of healthcare and good faith is no longer a value cherished by this profession. This makes the role of the lawmakers of the country even more critical.
It is very clear that the only way of meeting the shortages of human resources for public healthcare and other public services is by instituting legislation that mandates compulsory national/state public service of 3 to 5 years. Thus all medical and nursing graduates as well as management, engineering, accounting, general stream etc.. graduates must put in compulsory public service as a social return for the investment in them by the public exchequer. This will not only provide the public system with human resources but it will also instill social responsibility and ethics in the professionals.
A number of countries have national public service, either military and/or non-military, and it is time India put in place such a mechanism. We need a legislation on national public service for anyone attaining age 21 with immediate effect otherwise the economic growth and development will have little meaning as we will increasingly lose skills and resources to the developed world one way or another.
We can learn from different countries, some have general compulsory public service and some target specific professionals like doctors and nurses. Since there is already a historical debate on the health professionals doing some compulsory service like in rural areas we can begin with this profession through a national ordinance making public health service compulsory with immediate effect and gradually bring in the broader legislation for a national public service.
We urge Parliamentarians to consider this with urgency and bring this into effect in the winter session of Parliament. Since 25000 each doctors and nurses graduate each year and over 10000 specialists also, we can immediately fulfill all shortages faced by the public health system with one stroke of the pen. Doctors and nurses will agitate and resist but the State must show strong political will to realize the critical objectives of our Constitution of social justice and equity. Similarly management graduates, especially from the IIMs should be targeted as for them it would be a great opportunity to prove their skills in efficiently managing public systems before they learn to manipulate markets. The NRHM needs these management graduates as much as they need doctors and nurses. Let the public health system become the experimental ground for a national public service because with healthcare needs addressed, a healthy population is the best guarantee for economic and social development.
(Published in IMPF Newsletter Vol. 2 No. 3, Winter Session, 2007)
India Budget 2011-12 – A Brief Comment---RAVI DUGGAL
India Budget 2011-12 – A Brief Comment
The 2011-12 budget overall shows that there is further compression in public spending. There is a southward trend in the budget with the estimates indicating only a 13% nominal increase over the previous year and a decline in the budget estimate as a proportion of the GDP by more than 1% point to14% of GDP. This is happening despite the real growth rate being over 8%. Similarly tax revenues of the Central budget have stagnated around 10% of GDP. The Centre has failed to net in increased revenues from the growing national income. And the present budget does not give any indication that the Tax:GDP ratio will move northwards. Unless the latter happens we cannot expect public spending, especially for the development and social sectors like rural development, health, education, welfare, housing etc.. to grow significantly. Today public spending on health is a mere 1% of GDP when WHO recommends that it should be atleast 5%. The government over the last six years has not been able to move towards its own target of 3% of GDP for health. The share of the Central government in public spending for health is a mere 0.25% of GDP when as per the UPA target it should be 40% of 3% of GDP that is 1.2% of GDP or Rs. 86,400 crores at today’s prices.
In contrast to that the Central Ministry of Health allocation is only Rs. 30456 crores (including grants to states), short by Rs. 55944 crores as per commitment of UPA government. Of the Rs 30456 crores, Rs. 1700 crores or 5.5% of the Health Ministry's budget goes to HIV AIDS, which has been accorded a status of a separate Dept in this year’s budget; Rs 771 crores goes to Health Research, mainly ICMR and its institutions and Rs. 1088 crores to AYUSH. The Health and Family Welfare department gets Rs 26897 crores of which Rs. 16140 crores goes to NRHM and Rs. 5435 crores goes to the Central Government Hospitals and Medical Colleges and further Rs. 653 crores goes for healthcare of Central government employees under CGHS - a whopping Rs. 3628 per Central government employee in sharp contrast to about Rs. 500 per capita which all state and the Central governments together spend on healthcare for its citizens
Under NRHM some of the key allocations are Rs. 1238 crores for the various National Disease Control Programs like TB, Vector borne diseases, blindness. leprosy etc., Rs 3378 crores for Family Welfare, Rs. 240 crores for RCH, Rs 511 crores for routine immunisation and Rs. 664 crores for polio, and the Mission and RCH Flexipool gets Rs. 8776 crores. In addition NRHM also gets funds of Rs. 1784 crores under the NE special program and Rs. 247 crores under AYUSH.
So what does the above tell us. The overall spending on healthcare by government is certainly very low when we consider global standards. As a consequence the out of pocket burden for citizens, especially so of the bottom two quintiles is huge - about Rs. 3000 per capita. While within the Central budget the allocation to health ministry has increased by 21% over the previous year and gives the impression that health and other social sector programs are an important priority for the government. This is largely due to the political push under the flagship programs and is a good sign but when we look at actual expenditures then this optimism is belied. Actual spending in the social sectors like health and education are invariably 10-15% less than the budget estimates and often in the key programs like NRHM and Sarva Shiksha Abhiyan as also pointed out in the audits conducted by the CAG. This year for the first time the Central budget has included actual expenditure for 2009-10 and we see that for the Health Ministry the overall shortfall in expenditure as per the budget estimate was 8%, and 10% for the plan component of the budget, most of which goes as grants to state governments. However the surprise is (actual expenditures are still provisional) that NRHM shows an actual expenditure in excess of 17% (7% excess in plan expenditures), largely due to the RCH and immunisation programs and pumping in of non-plan resources (whopping increase from the Rs.72 crores in budget estimates to Rs. 1397 crores in actual expenditure) which certainly shows an increased commitment on part of the Central ministry of Health. Perhaps 2009-10 was the year for the consolidation of the NRHM program but this came as a cost to the medical care sector under the Ministry of Health, which means that public hospitals and teaching hospitals were neglected, their shortfall in expenditure being as much as 20%
To conclude, while the UPA government seems to be inclined towards strengthening the public health system by giving a larger weightage to the health sector in budgetary allocations, overall this is not enough because there is significant compression of overall public spending. The consequence is that this impacts public health spending and the neglect of the public health system continues.
Wednesday 9 May 2012
Role of Private Providers in ‘Health Care for All’ by 2022
Role of Private
Providers in ‘Health Care for All’ by 2022
Draft Note
Anant Phadke
(Background : During the
JSA meeting on 21st-22nd March 2012 in Delhi, one of the
decisions was that as a step towards formulating the JSA position in the
current debate about UHC, I would write a draft of JSA’s position on Role of Private Providers in ‘Health Care for
All’. I had circulated the first draft of this note on 10th April amongst those
of us who were to meet in Delhi
As part of our vision
of Health for All, as JSA, we need to put forth a broad, realistic road map for
achieving the goal of Health Care for All (HCA) to be achieved within say coming10
years from now, i.e. by 2022,. We will
reiterate that in order to achieve the goal of HCA, the Public Health Services
would be the backbone of HCA; for this purpose there will have to be
substantial strengthening and expansion of Public Health Services as well as
it’s enhanced democratization internally and in relation to the people. Private
Providers would be in-sourced when and if necessary and under certain terms,
conditions. Within this basic framework, one of the exercises to be done is to
estimate the number of doctors needed for HCA; to see whether private providers
would have to be in-sourced into the HCA system and further if yes, then to
estimate how many private providers would have to be in-sourced and how.
This current note is
limited to in-sourcing of doctors for urban areas. Similar exercise needs to be
undertaken for doctors needed for HCA in rural areas. This will require taking
into account various specificities of rural health care including the role of
CHWs and other paramedics and of the proposed scheme of Bachelor of Rural Health
Care. [1]
Yes. Some back of the
envelop estimation of number of doctors required for HCA in urban areas will
show this. –
Currently our urban population is about 400
million (33% of the total population of 1200 million). As per the WHO norm of 1
doctor per 1000 population, the requirement for cities is 4 lac doctors. However,
in cities, currently about 10 to 15% of the required doctors are in Public
Health Facilities (PHFs).[3] Thus only
60,000 of the required 400,000 doctors for HCA are currently in urban PHFs.
It has been estimated that in 2020, urban
population would be, 532 million, i.e. estimated 40% of the total estimated
population of 1330 million. For this urban population, about 0.5 million
doctors would be needed for HCA. Ignoring premature deaths and retirement of
the existing about 60,000 doctors currently working in urban PHFs, about 0.44 million
additional doctors would be needed by 2020 if all urban health-care is to be
provided by PHFs. As per MCI, 34,595 students were admitted in the 300 colleges for the
academic year 2009-2010, a good number of them in private medical colleges. The
HLEG has recommended setting up of 187 new medical colleges in backward areas. If
these colleges are set up as per HLEG recommendations and are functional by
2022, these colleges would together produce 0.31 million doctors. However, currently
most of the medical graduates go into private practice. Given this background
and the experience of NRHM in recruiting doctors for PHFs, we can not hope to
increase the number of doctors in urban PHFs from the current about 60,000 as
estimated above, to more than say 120,000 to 150, 000 in coming 10 years.
It is thus not
realistic to expect more 25-30% of the required number of doctors to work in
PHFs in India
Progressive
socialization of in-sourced private providers in the HCA system
These in-sourced
doctors would act as an extension of the Public Health system
by following appropriate guidelines. But for this to occur, the terms
of engagement with the private providers should be so formulated.
Towards this end, guidelines formulated by in the JSA’s draft booklet ‘Towards
People’s Health Plan’ prepared during the National Health Assembly II in Bhopal
(1)
Clearly demarcate the commercial private
commercial sector from the not-for profit and voluntary sector in health care
provision and treat them differentially.
:
(2)
Quality and Cost Regulation of service
delivery and a transparent system of monitoring would have to be in place and
these should be structured such that it can be expanded into a system where all
private and public health facilities are eventually so monitored. The systems
of contracting have to be friendly to such monitoring and have the ability to prevent
inappropriate care and costs.
(3)
That the mechanisms of access to the poor are
clearly defined and there are mechanisms of enforcing its adherence.
(4)
PPPs should supplement and strengthen public
sector but not substitute or weaken existing public health care services.
(5)
Expanding/bringing in investment working for
the public health goals: Which would mean no transfer of assets and resources
from public ownership into private hands.
(6)
Prompt payment with dignity for the private
sector partners so that ethical low budget
proprietary services in smaller towns are favoured;
(7)
Ensuring that efficiency is based on better
management practices and not based on unfair wage structures and compromised
social security benefits, especially for women health care providers like ANMs
and nurses;
(8)
Exclusion of private nursing homes where
government servants are providing services from such a framework – to avoid a
conflict of interests.
Now in the 21st
century, various ingredients of health-care like medical education, production
of medicines, diagnostic equipments, machines, etc have already been
substantially socialized in the sense that nobody can deny that the content has
to be based on scientific norms and not on individual views and interests.
Secondly, private
Providers need to follow the same textbooks and guidelines that doctors in PHFs
have to follow. Under HCA, it can be mandated that private providers too would
have to follow the scientific, Evidence-Based Medicine (EBM) and that they will
have to tune in their clinical practice with the goal and logic of Public
Health. EBM has it’s own limitations and politics. For example, it will take a
long time make all practice of medicine strictly, rigorously scientific; medicine
would and should continue to be both art and science of healing; guidelines are
sought to be influenced by private interests; the framework of EBM can be
‘misused’ to push protocols which favour certain corporate interests ------. To
counter all this is another level of struggle. But in the 21st
century, ‘private interests’ have to progressively loose ground in this field
because of the very nature of modern, socialised clinical and social medicine.
To ensure that the
managerial and technical requirements of regulation are followed adequately and
properly, adequate law, rules, policy and regulatory structure should be in
place before any in-sourcing of private providers takes place. The
Clinical Establishment Act 2010 entails that the Director of Health Services
and the DHOs would be in charge of the regulatory work. However, they are
unable to give justice to their existing work responsibilities – do we expect
that they would be able to perform the additional regulatory responsibilities? Unless an effective, adequate regulatory
structure, like the one suggested by HLEG is mandated, the talk of regulation
would mean only empty words.
Differential
strategy for different sections of the private sector -
To win over the
people to our programme of HCA, apart from
the ordinary citizens who would be the main beneficiaries, we need to rally
round a section of the health care providers in the private sector around the
programme of HCA and to neutralize a section of these providers. For this
purpose we need to have some analysis of the different sections within the
private health care providers.
Private providers in India
1.
Traditional healers of various kinds by and
large are not part of the commodity market of health-care and are part of the
pre-modern relationships
2.
Unqualified providers using allopathic
medicines, AYUSH medicines
3.
Graduates and post-graduates of allopathic
and AYUSH disciplines working in their own clinics as general practitioners or
consultants and who are mostly akin to petty commodity producers
4.
Owners of small and medium hospitals who have
a crucial, role to play in providing health care due to their skills and
expertise in modern medicine. Most of them currently make excess money through
commercial exploitation of patients and also through exploitation of the staff
employed by them.
5.
Trust hospitals, mission hospitals which were
set up by socially motivated doctors, philanthropists, 30-50 years back and
which continue to be genuinely non-profit entities.
6.
Owners, managers of so called Trust Hospitals
especially those set up in last 10 years or so have no role to play in actual
delivery of health care.
7.
Owners of the corporate hospitals are
moneybags who have no role to play in actual delivery of health care.
The first two of
these sections would not be part of the HCA system. Out of all the other sections
of the private providers, those who opt to work for the HCA system and are
selected, would have to follow scientific clinical guidelines, protocols and
will also have to discharge the relevant public health functions. The
regulatory framework should be participatory and would have an element of
self-regulation.[4] (Experience of other countries shows that such
regulation of private providers can be achieved.) Secondly all of them will have to respect, observe
patients’ human rights and should have adequate, just grievance
redressal system. But at the same time we need to have different strategy for
these different layers -
In India UK
Similar is the case
with smaller, medium hospitals. Some of these can be in-sourced into the UHC
system under the condition that they follow overall the logic of the UHC
system. The state can then encourage co-operatives of these small hospitals and
can thereby further undermine their ‘private’ nature.
The ‘Trust
hospitals’ are legally registered as non-profit entities and hence if
sufficient public pressure can be generated, they will have to function as genuinely
non-profit entities, especially because they have generally received public
subsidies in some form or the other. This can be done by pinning them down on their
declared objective in the Trust Deed. Secondly more stringent laws, rules
will have to be formed so that all the aspects of their functioning follow the
overall the logic of the HCA system. The current practice of indulgence in money-making
and yet showing no profits in the balance sheet can not be continued! Secondly
their internal functioning would have to be further democratized- the
doctors and other staff working in these hospitals should have adequate say in
the functioning of these hospitals and their democratic rights should be
respected.
The strategy towards
the corporate
sector would depend upon balance of socio-political forces. Most
of the members of this section would be least amenable to serve social goals.
They are less likely to be part of a genuinely regulated UHC system. In any
case all corporate hospitals will have to be regulated even if all of them
remain outside the UHC system. An unregulated corporate sector would adversely
affect the overall culture in the health care even if it serves only
the rich. Progressive social control over the medico-industrial complex
with internal democratization should be the direction we should advocate.
Actual progress in this direction depends upon level of political pressure that
can be generated towards this end. Overall it is true that comparatively, the
Private health system by it’s very nature, is less amenable to internal
democratization because of the constitutional sanctity to private property. But
good unionization and furthering of democratic culture in the society at large
can curtail to some extent the arbitrary power of the owners vis a vis the
employees.
To summarise,
To achieve ‘Health
Care for All’ in India India
This in-sourcing will
have to be based on appropriate guidelines because of which these in-sourced
doctors would act more as an extension of the Public Health System. They would
be so regulated that they conform to scientific, ethical medicine in tune with
the logic of social medicine while they lead an honourable, comfortable living.
Adequate law, policy, regulatory structure and payment on observance of certain
norms – all this will be required to ensure regulation in practice. The
strategy for different layers amongst private providers would have to be
different.
*************
[1] For
example, the distribution of doctors is likely to continue to be uneven in
urban and rural areas to a certain extent for some years. At the risk of being
accused of employing double standards, we can use separate parameters for urban
and rural areas. This is because there is already substantial involvement of
ASHAs, ANMs and other paramedics in rural health care and we too want to
restrict the role of doctors where it is really needed. Hence for rural areas we can take the
Mudaliar Committee parameter of I doctor for 3500 population. But this can not
be done for urban areas
for which we will follow the WHO norm of 1 doctor per 1000 population.
[2] Though in
this note, by way of example, we have estimated the number doctors needed for
HCA in urban areas, it does not mean that other components of the human power
for HCA, i.e. nurses, technicians, Public Health Managers etc. are not
important.
[3] For example,
Dr. Shyam Ashtekar in his study of Nashik district reports that in Nashik city
with a population of about 1.8 million, in 2011, there were only 241 doctors in
various PHFs including Central and State govt. service, ESIS, municipality.
This is 13.3% of the requirement of1800 doctors for a population of 1.8
million.
[4] Towards
a Regulatory Framework for Private Providers in UHC. Anant Phadke, Abhay Shukla. MFC Bulletin,
February-July 2011. mfcindia.org
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