जनता का स्वास्थ्य : 2015

Friday 20 November 2015

Health in India

It is an established and accepted fact that the health of the people in a country depends on the access to a network of basic needs that includes nutritious food and health care. A conducive physical and biological environment at the place of living and work, egalitarian social relationships, emotional well being as and a peaceful social environment are all recognised determinants of health of any population. To those of us working in the field of health, it is clear that there is a significant deterioration in the conditions needed for people’s health. Vital for health are not only the number of doctors, drugs and hospitals but also the distribution of these resources and the access to these by all groups within the community. The functioning of the state and the orientation provided by the political leadership of the nation are crucial to the administration of health care and all the resources needed to lead a healthy life with dignity and freedom. Also critical is a varied and balanced diet according to availability.

Friday 17 July 2015

Can McDonald';s reach a health facility? Jul 13, 2015

Shiv Charan Mathur

Vibrancy in the practice of a discipline draws curiosity of its practitioners, more so in a field like Public Health where stakeholders are many and multiplying fast!

It is to understand the dynamics of public-private-partnership (P-P-P) in primary health care, I attended the "Health Summit 2015" organized in a five-star hotel of state';s capital last week. Executives from well known brands like Philips and Vodafone discoursed on ';access and affordability';. Chains like Fortis and Manipal in the open market-place displayed glossy posters and distributed pamphlets of services provided by them. Honorable Minister was taken around the displays like a laboratory-on-a-mobike providing more than 70 investigations at any stop!

We were informed that out of more than 2,000 Primary Health Centers of Rajasthan, around 90 (overheard that in first instance 30 only!), have been handed over to WISH which seems to be a new private partner with Government of Rajasthan. Many in the audience were expecting from the private players - who solely controlled the dais throughout the day - to provide transparency to the transactions transpired so far. But they seem to be adding excitement to the game!

Going in the history of P-P-P, private player have joined the health field only when they could elicit the cost from the government. How far these new giants arriving on the carpet of Health sector would dole out from their corporate social responsibility is a matter which health activist might be vigilant to watch. Speculation is rife that budget allocated to health facility will be transferred to private players who in turn would add to the quality and effectiveness of the service delivery from the public facilities. How these facilities would be driven will be the matter to be included in the memorandum of understanding between public and private systems. Since the entrepreneurship of private players has a great potential, with increasing infra-structure of the state, no wonder if we can find something like a drive-in outlet of McDonald in a public health facility within a couple of years. Let it happen and accept it only if it is preceded by universalizing the access to affordable primary health care in a state where so far human development is a matter of concern.

Sunday 14 June 2015

JAN SWASTHAY ABHIYAAN FREE HEALTH CHECK UP CAMP AT SAMAIN VILLAGE ON 14.6.2015

Sunday 7 June 2015

जन स्वास्थ्य अभियान
अखिल भारतीय जनवादी समिति एवम
हरयाणा स्टेट मेडिकल एंड सेल्ज रिप्रेंजेंटेटिवज यूनियन (H.S.M.S.R.U)
के तत्वाधान में सूरत नगर फेज -२ गुडगाँव में स्वास्थ्य जांच शिविर का आयोजन किया गया जिसमें
शल्य चिकित्सा विशेषज्ञ Dr R.S.Dahiya,
सामान्य रोग विशेषज्ञ Dr O. P.Lathwal,
स्त्री रोग विशेषज्ञ Dr Sonia Dahiya,
शिशु रोग विशेषज्ञ Dr Narender Monga,
दन्त चिकित्सक Dr Raj Kumar व Dr Batra ने मरीजों का निरिक्षण किया । 180 से अधिक मरीज कैंप में आये । इसमें शुगर टेस्ट , B.P check up,ECG आदि टेस्ट भी मरीजों के किये गये. सभी डाक्टरों
को आयोजको द्वारा मोमेंटो देकर सम्मानित किया गया । दिनेश अवस्थी जी ने सबका धन्यवाद किया ।

Saturday 9 May 2015

Rural health inequities: data and decisions

The Lancet

DOI: http://dx.doi.org/10.1016/S0140-6736(15)60910-2

Article Info

70% of the world's 1·4 billion people who are extremely poor live in rural areas. A new report released on April 27 by the UN International Labour Organisation (ILO), Global evidence on inequities in rural health protection: new data on rural deficits in health coverage for 174 countries, presents the first global, regional, and national data on the extent and major causes of rural–urban inequities in coverage, and access to health care. 56% of rural residents worldwide are without legal health coverage (defined as protected by legislation or affiliation with a health insurance scheme)—compared with 22% of the urban population. 83% of Africa's rural population have no entitlements to health care, yet the most extreme rural–urban inequities in legal coverage occur in Asia and the Pacific. Reflected in the context of equity and universal health coverage (UHC), the report abruptly reminds us that the global community, despite all good intentions, are still doing too little too late for the health of rural populations.

Although inequities in health protection are recognised within UHC debates, data about the rural–urban divide are weak and fragmented, with a complete absence of disaggregated data within countries, regions, or globally. Policy makers tend to respond to what is presented to them. The absence of disaggregated data influences decisions on national resource allocation, and in turn perpetuates the neglect of systematic planning for rural populations in many countries. This report is the first step to rectify the gap in evidence by using five proxy indicators, measuring key dimensions of coverage and access to health care: legal coverage, staff access deficit, financial deficit, out-of-pocket spending, and the maternal mortality ratio (MMR).

The report highlights that virtually all rural–urban differences in health staffing, financing of services, and legal coverage occur in rural populations. Health worker shortages are unsurprisingly extreme in rural areas worldwide. Although half of the world's population live in rural areas, only 23% of health workers globally are deployed there, with an estimated seven million health workers missing globally in rural areas compared with 3 million in urban dwellings. 63% of the world's rural population do not access health care because of underfunding of global health financing, compared with 33% of the urban population. Out-of-pocket payments inequities are, at first glance, relatively smaller globally in rural populations, with lower out-of-pocket payments in rural than in urban populations in Africa, Latin America, and central and eastern Europe. Yet the lower out-of-pocket payments in many countries indicates an exclusion of rural populations from access to health care. The harsh reality in rural areas is that what does not exist (eg, health workers, clinics, transport) cannot be paid for, and therefore no cost accrued.

Across all regions except Europe and north America, rural MMR is at least double urban MMR, with Africa reporting the highest MMR regional level of 55 deaths per 10 000 livebirths. Country case studies from Cambodia, Mexico, Nigeria, and Zambia report using the same five indicators to highlight the main challenges to improve health coverage and access. In Nigeria, the country's rural population fares worse than the urban population on the indicators of staff access deficit, financial deficit, and maternal mortality. This situation exists despite rapid urbanisation and a high but inequitable supply of human resources for health relative to other countries. Zambia, with a largely rural population and an urban population reliant on private sector services, has higher out-of-pocket payments in urban than in rural areas. Mexico, with a mostly urbanised population, also reported higher out-of-pocket payments in urban areas—both illustrations of when services remain limited or completely inaccessible for rural populations. Cambodia performed better than the other countries on the MMR indicator, reflecting maternal health efforts.

The ILO report leaves no doubt that the urban–rural gap in access to health care exists. The question is more about the size of the deficit and what can be done. The conclusion that only a comprehensive and systematic approach can address these inequities cannot be overstated, and must be acted on. No single action focusing on one of the indicator areas is enough to achieve UHC. A country's approach must systematically and simultaneously address legal coverage and rights, health-worker shortages, extension of health-care protection, and quality of care. Only then can equitable access for all be fully achieved.

Thumbnail image of Figure. Opens large image

Sven Torfinn/Panos Pictures

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Wednesday 6 May 2015

Doctor - Patient Relationship, Rights And Responsibilities

Medico Legal

Votes(1) Comments(73) Viewed 3293 Times

Well....how many of us honestly practice this or how many of us have displayed the following in the waiting area of our clinics, Nursing Homes, Tertiary Care Specialty Hospitals, Medical Colleges, Charitable Trust hospitals, Polyclinics etc?. These are not rules and regulations but common sense practice which has to be incorporated in our behaviour and must be reinforced in the behaviour of our patients only then our society will be reconditioned towards respecting our, time, knowledge, skills, chargeability, etc and only then our long lost status of Demi Gods will be reinstated.

DOCTORS’ Rights

To equal treatment and equal benefit of the law in all applications by and dealings with government, the private sector and others. Substantive equality means that family responsibility, rural areas, historic disadvantage, etc. are relevant factors.
Not to be unfairly discriminated against by any patient, medical scheme, medical faculty or school, government, employer or any other person or institution on the basis of their race, gender, origin or any other ground. Doctors have the right not to be harassed.
To have his/her life protected which includes the right not to be placed in disproportional life-threatening situations.
To freedom and security of the person which includes the right to physical autonomy and the right to be free from violence.
Doctors have the right to reasonable accommodation of their religious beliefs, short of undue hardship to others. Doctors also have the right to clinical independence.
To fair labor practices including fair dispensations of overtime, leave and working conditions and the right to have their grievances taken up at appropriate forums. Doctors have the right to be assisted in disciplinary enquiries, to state their side of the case and to an impartial chairperson. Doctors have the right to work in an environment that is not hostile in terms of sex, gender, sexual orientation or (presumed) race or ethnicity

Doctors’ Duties and Responsibilities

Code of Ethics

Principles of Ethical Behaviour are applicable to all physicians including those who may not be engaged directly in clinical practice.

Consider the health and well-being of your patient to be your first priority.
Strive to improve your knowledge and skill so that the best possible advice and treatment can be afforded to your patient.
Honor your profession and its traditions.
Recognize both your own limitations and the special skills of others in the prevention and treatment of disease.
Protect the patient's secrets even after his or her death.
Let integrity and professional ability be your chief advertisement.

Standard of Care

Practice the science and art of medicine to the best of one's ability in full technical and moral independence and with compassion and respect for human dignity.
Continue self education to improve one's personal standards of medical care.
Ensure that every patient receives a complete and thorough examination into their complaint or condition
Ensure that accurate records of fact are kept.

Respect for Patient

Ensure that all conduct in the practice of the profession is above reproach, and that neither physical, emotional nor financial advantage is taken of any patient.
Recognise a responsibility to render medical service to any person regardless of colour, religion, political belief, and regardless of the nature of the illness so long as it lies within the limits of expertise as a practitioner.
Accepts the right of all patients to know the nature of any illness from which they are known to suffer, its probable cause, and the available treatments together with their likely benefits and risks.
Allow all patients the right to choose their doctors freely.
Recognize one's professional limitations and, when indicated, recommend to the patient that additional opinions and services be obtained.
Keep in confidence information derived from a patient, or from a colleague regarding a patient, and divulge it only with the permission of the patient except when the law requires otherwise.
Recommend only those diagnostic procedures which seem necessary to assist in the care of the patient and only that therapy which seems necessary for the well-being of the patient. Exchange such information with patients as is necessary for them to make informed choices where alternatives exist.
When requested, assist any patient by supplying the information required to enable the patient to receive any benefits to which he or she may be entitled.
Render all assistance possible to any patient where an urgent need for medical care exists.

Continuity of Care

Ensure that medical care is available to one's patients when one is personally absent, when professional responsibility for an acutely ill patient has been accepted, continue to provide services until they are no longer required, or until the services of another suitable physician have been obtained.

Personal Morality

When a personal moral judgment or religious conscience alone prevents the recommendation of some form of therapy, the patient must be so acquainted and an opportunity afforded the patient to seek alternative care.

Patients’ Rights

Right to be treated with respect and recognition of personal dignity irrespective of cultural, Spiritual or religious beliefs.
Right to request any information about your condition.
Right to ask for and obtain copies of records pertaining to your medical care in the hospital. (You may need to pay copying fee, fill the approval form and get it signed by the hospital).
Right to ask for a second opinion or consult with any doctor or doctors in our panel without prejudice and interference.
Right to be informed about relief of pain which is an important part of care and to receive information about options to reduce, control and relive pain.
Right to refuse treatment. (However this decision will have to be taken by you at your own risk).
Right to complain against your treatment plan, Doctors, Hospital or any other health care personnel to the Nurse in Charge, Administrative Medical Officer (AMO) or Medical Director (MD)
Right to ask for information and clarity doubts about the particulars of your bill. You will be provided with a statement on scheduled basis which will detail the hospital charges as they occur. These may not include the Doctor’s fees.
Right to privacy and confidentiality.
Right to personal safety and security.
Right to know the identity of individuals providing service to you.

Patients’ Responsibilities

Responsibility for providing accurate and complete information about medical problems, Past illnesses, hospitalizations, medications, pain and other matters relating to their health.
Responsibility for following the treatment plan recommended by those responsible for their care.
Responsibility for their actions if they refuse treatment or do not follow the health care team’s instructions.
Responsibility for seeing that their bills are paid as promptly as possible and following hospital rules and regulations.

Tuesday 10 March 2015

HUMAYOON PUR

Sunday 1 March 2015

Comments on Health Budget

Dear Sundar,

Why don';t you draft it? Let us send out a JSA critique as most papers have not reported this cut in health budget. I have copy-pasted below the key budget figures

As per budget paper 2015-16 : Expenditure on Health in Rs. crores
	Actual 2013-14	Budget 2014-15	Budget 2015-16	reduction
AYUSH	642	1272	1214
Pharmaceuticals	107	248	259
AIDS control	1473	1785	1395
Health research	874	1017	1018
NHM	18633	24490	18295	6195 (25.3%)	Page 168
	27145	35163	29653	5510 (15.7%)	Page 169 vol II
Plan outlay	22476	30645	24549	6096 (19.9%)	Page 169 vol II

Anant

On 1 March 2015 at 07:45, Sundar <sundararaman.t@gmail.com> wrote:

There are two important things about health sector in the 2014-15 budget speech. The first is the almost complete absence of mention of it- not even one full paragraph on it. Just a bland budget allocation line in one para, and then in another para as part of setting up different central institutions in all states a mention of AIIMS in a few states, then in another paragraph a proposal to give persons a choice to shift over from ESI to private insurance and finally in the tax proposals mention of increased limit for tax exemption for health insurance. All in different sites as part of different agendas- where health is very incidental

Secondly - there is a reduction in health expenditure even in nominal terms- let alone adjusting for inflation in budget allocation. The overall budget allocation reduces from 39237 crores to a 33152 crores. As related to expenditure of the last year- it stagnates in nominal terms but declines in real terms. Within this budget the decrease of NHM budget is much more. Also the addition of CGHS into this budget amount which was earlier placed elsewhere means that the decrease may be even more steep. Thus the central govt employees would have care at Rs 7000 per capita and the rest of the population at only about 900 per capita- about one tenth of the same, of which the central govt share is in the range of Rs 270 !!

One argument that is raised is that the health expenditure is being transferred to states through the 14th finance commission recommendations that have been accepted as part of moving away from centrally sponsored schemes. This claim has to be examined further. But even if it were so, the central committment both in line with 12th Plan and the govt';s own draft national health policy is to raise the central share also and this was urgently required in many areas of health systems strengthening. The complete disconnect with the National Health Policy 2015 draft is total- where specific central committment is stated as "this policy proposes a potentially achievable target of raising public health expenditure to 2.5% of the GDP. It also notes that 40% of this would need to come from Central expenditures. At current prices, a target of 2.5% of GDP translates to Rs. 3800 per capita,"

In other words though states would have to increase their expenditure, the central expenditure on health has to increase also to reach Rs 1520 per capita in three years ( at current prices). This budget puts the central expenditure at about Rs 276 per capita, which is less than one fifth of the target. The direction also is not of increase. Clearly the draft policy and all its proposal are reduced to just empty words.

The provision for AIIMS hospitals is also insubstantial and in 5 years only buildings will come up- and anyway it is not really the solution at all. None of the new AIIMS are operating at the level of AIIMS- they have just about begun outpatient care and a few admissions and have less services than the usual state medical college. It took them all of ten years to reach this stage. And a series of AIIMS are anyway no answer to the dismal situation in health.

Another aspect of the exemption in tax for those paying for medical insurance. The limit has been raised to Rs 25,000 per year. That is costly even by private medical insurance standards. And obviously this is trying to get the upper middle class and the rich to buy even costlier insurance. It has nothing to do with publicly financed insurance where the premium is only Rs 750 per year. By mentioning only insurance for the rich, yet another signal is being sent.

Nothing in nutrition or education or any other social sector.

All in all a terrible day for public health.

Equally dangerous was the way the TV media went on about the budget with no space for any views except that for industry representatives and their view point.

I think the contributions of Ravi Duggal, Anant, Amit etc have been useful and I only reiterate much of what is already stated. We must work on a quick statement - perhaps within the next couple of days. is that possible? Would be willing to help.

Greetings

Sundararaman

T. Sundararaman

Saturday 28 February 2015

COMMENTS ON HEALTH BUDGET

Dear All

Maybe I have not understood the full budget but to me it appears that "health" has been given a go by in this budget. Establishing AIIMS in different states is a faulty way to provide health to the people. For one Govt does not allocate adequate resources to establish a functional AIIMS like institute which alone would require substantial funds and then to provide AIIMS like faculty on salaries given is a quixotic idea. Good faculty remains in AIIMS because of the excellent academic environment, intellectual oppurtunity and overall lifestyle of the staff. These so called AIIMS become a caricature of the premier institute with no purpose except to fool the public as a political vote gathering tool. The only thing I could find was relief provided to Ambulance services from the purview of service Tax. If Taxing the Ambulance services was on the radar of the Government then I must thank the Finance Minister for the "Acche Din" indeed.Yoga has been included in list of charitable activities and hence can be expected to have tax benefits.

There has been mention of "diagnostics" becoming expensive due to increased service tax on some talk shows but I still need to see the concrete details before commenting on this. All in all no special mention of any increase in health budget. No tax benefits to small and medium healthcare establishments. No plan to increase the tax base so professionals like doctors who anyway are tax payers can expect to be squeezed. Increase in exemption to health insurance will benefit corporate hospitals with increased business more than the SMHCE. The budget is blind to the role the SMHCEs who play a crucial role in health care delivery to the nation and their needs have been left unfulfilled.

Dr Neeraj Nagpal
Convenor, Medicos Legal Action Group
Ex President IMA Chandigarh

In the current year’s health budget, there is a reduction of Rs. 5100 crores, i.e. by about 17% compared to last year’s budget. This is unprecedented and shameless. The health care budget for central government pensioners (about Rs. 2000 crores) was included all these years in the budget of the Secretariat, the Mantralaya. But this time it has been shown in the general Health Budget. This has misleadingly increased the health budget by 2000 crores. This item should be removed when comparing this year’s health budget with last year’s. If this is done, the reduction is about Rs. 7000 crores! The announcement of National Health Assurance Mission was a mere slogan.

It was felt that at least AYURVEDA would get an increase. But – No ! The provision for Ayurveda has decreased from 265 to 248 crores. The National Health Policy Draft has stated that the vaccine producing public sector units need support. But this budget has not been increased! The provision for special loan to public sector pharma units like Hindustan Antibiotics, IDPL has been slashed to zero! When in India medicines worth 87000 crores are sold annually, to have a budget of a mere 35 crores for Janaushadhee Scheme for generic medicines is a cruel joke. Increase in the deductible amount spent for health insurance and such concessions would benefit some middle class people. But the ordinary people will now be exposed to the full blown effect of policy of privatization.

Anant

On 28 February 2015 at 22:46, Dr MIRA SHIVA <mirashiva@gmail.com> wrote:

If Primary health care is asphyxiated , morbidy & mortality of the vulnerable sec20%
Corporate tax decreased from 30% to 25% . Removal of Health Tax ,
Increase in Service tax , which includes Medical Services.
Cut in ICDS This will be terrible for children 46 % of whom are already malnourished .
We must respond .
I have seen the AIIMS in Rishikesh , the building is up but are unable to get faculty .
PM in his speech had spoken about Sickle Cell Anaemia being worse than Cancer and New technology Stem cell being in a position to contribute . Wanted to respond to this & Australian Researcher adding Nutrition to Banana .
Golden Rice will be brought in in the name of Health of Children . Already GM Golden Rice pushers are here .

Regards,

Mira

Highlights of health budget:

Reduction in per capita allocation even compared to previous year, especially if you account for inflation and population increase. Completely flies in the face of all kinds of rhetoric in Party manifestos and planning documents of increasing public expenditure to 2 - 2.5% of GDP
Token allegiance to healthcare shown by announcing a few more ';AIIMS like'; institutions. Its like mopping the floor while the tap is open full throttle. Reduce allocation for health and starve primary care and then believe that a few tertiary hospitals will do the trick. Betrays a fundamental bankrupcy in the vision towards health.
Tax breaks for those buying private health insurance. This is the real vision -- encourage the middle class and the elite to migrate to the private sector, and forego taxes that could be used to strengthen public services. Thus accelerate the creation of dual systems -- a poorly funded public for the poor and helpless and a strengthened private sector with guaranteed clientele, supported by tax breaks for insurance. Even ESI beneficiaries to be now given a choice to opt for insurance rather than seek care in ESI facilities.

Depressing and totally disappointing scenario.

Amit

Budget 2015-16 and the Health Sector – Continued Neglect--RAVI DUGGAL

SATURDAY, FEBRUARY 28, 2015

Budget 2015-16 and the Health Sector – Continued Neglect

The Finance Minister Mr. Arun Jaitely makes a statement in his opening remarks about

health, “Good health is a necessity for both quality of life, and a person’s productivity and

ability to support his or her family. Providing medical services in each village and city is

absolutely essential.”

This generic statement in good faith does not get reflected in budgetary commitments. Please note he says “providing medical services in each village and city” and does not say by whom.

The budget overall is very disappointing - it is a budget for Adanis and Ambanis. The corporate tax reduction to a rate of 25% is nearly 17% less burden on Corporates. So corporate hospitals, pharma and medical devices industry, apart from the general corporate world will benefit in a huge way.

Hike in service tax through a cess to fund Swacha Bharat is not a good move as it will hike up patient bills and increase further out of pocket expenditure burdens.

The increased rebate on health insurance premiums from Rs 15000 to 25000 must be creating euphoria in the insurance industry but it is bad for the health of the aam aadmi. This is a clear message from Modi Sarkar that arrange for your own healthcare through purchase of insurance - healthcare is your personal responsibility so we are reducing the budget allocations from Rs 39231 crores budgeted in 2014-15 to Rs. 33260 crores for 2015-16, a slashing of over 15%. This too will contribute to further increase in out of pocket spending. Further if we look at the flagship NHM program the cut in spending is even worse from Rs. 24491 crore in 2014-15 down to Rs. 18295 crore, a whopping decline of over 25%.

Further in the budget speech Jaitley is suggesting an option for ESIS covered workers to opt out and seek cover with health insurance. This will kill the ESIS and social security of workers. He should have instead asked ESIS to cover all organized sector employees by removing the income ceiling for ESIS membership so that not only the working class is covered but also the white collar and executive class. This would be a tremendous boost for not only workers health but also health for the general population as huge resources can be generated with such a move.

While more AIIMS type hospitals in different states is welcome the allocations for it are meagre. The Delhi AIIMS has a budgetary provision of Rs. 1470 crores and for the other AIIMS as of now about 10 the budget is a mere Rs. 1756 crores. That apart getting appropriate faculty and other staff remains a huge challenge for the AIIMS in other states which have already started operations.

The pharmaceuticals department has made a provision for the Jan Aushadi scheme to the tune of Rs. 35 crores up from Rs. 30 crores last year. However in the health budget there is no provision of the much talked about free medicines and diagnostics scheme for public healyth facilities.

One disturbing feature in the health budget is the allocation for CGHS. Why should the general health budget support what is essentially a social security package for its employees. So the real health budget should actually be reduced by the Rs. 915 crores for CGHS dispensaries and further Rs. 2249 crores for medical treatment of pensioners covered by CGHS. If we reduce this total of Rs 3164 then the net health budget is even lower at Rs. 30096 crores. This works out to a Central government allocation of a mere Rs. 240 per capita.

To conclude, the trajectory of public healthcare spending is quite dismal. The neglect of public healthcare continues. Infact the much touted NHM allocations for 2015-16 are even less than the actual expenditure two years ago as is the allocations for AIDS control. So certainly no aache din for peoples healthcare is on the horizon.

Table: Central Government Health Sector Allocations – Rs. crores

	2013-14 A/C	2014-15 BE	2015-16 BE
Health and Family Welfare	27145.29	35163	29653
of which Medical Institutions	2020.55	2004.7	2248
Medical Education and Training	4798.73	5110.8	5569.24
Public Health Programs	960.49	1929.94	1767.15
NHM	18633.81	24490.88	18295

AYUSH	642.41	1272.15	1214

Health Research	874.08	1017.67	1018.17

AIDS control	1473.15	1785	1397

Total Health Sector	30134.93	39231.01	33