The following is a synopsis of 12 articles published by ‘The Hindu’ under “Malady nation series” between 8th – 13th August, 2016
Personal and public choices eroding health
As per lancet journal:
- Non-communicable diseases cause for 60% premature death in India; clearly surpassing the communicable diseases (NCD)
- Cardiovascular diseases, cancer, TB and other diseases related to tobacco consumption are the most common NCD
- National Action Plan and Monitoring Framework for Prevention and Control of NCDs.
- Primarily focuses on population-level screening
- These diseases mere mostly linked to lifestyle risk factors-sedentary work culture/office policies; alcohol abuse; tobacco consumption etc.
- Proper urban planning – cities expanding at the expense of pedestrian facilities, public parks etc. should be done away with.
- Adopting healthy lifestyles- Incorporation of exercises; Stress management ; Abstaning from tobacco/alcohol
- Government should create awareness regarding health deteoriation among the masses.
When a sedentary lifestyle turns deadly
Lifestyle related diseases and India
- According to research by the WHO an Indian today has over twice the odds of dying of a non-communicable disease than a communicable disease.
- We are a victim not of lifestyle choices but of lifestyle compromises. To earn our livelihood and that extra income, we often outstretch ourselves, ignoring the important dietary/physical routine.
- Among younger professionals, long hours spent indoors lead to problems like demineralisation and osteoporosis. Besides this, work pressure also leads to insomnia, depression and anxiety disorders.
- There are more cases of fatty liver and fatty acid, which are both lifestyle related.
- Increased cases of obesity, endocrinology disorders and even some cases of juvenile diabetes
- Following good dietary habits. Avoiding calorie-dense foods
- A countrywide tax on calorie-dense foods, such as the ‘fat tax’ recently implemented by Kerala, could be one possible approach.
- Incorporating a more active routine to ensure physiological well-being. Yoga and meditation should be practised to reduce stress.
Remedying India’s healthcare colossus
Recent trends and issues:
- More than 75% people opt to visit private clinics as compared to public hospitals
- Entire healthcare system from tertiary in large cities to Primary Health Centre (PHCs) in rural areas is riddled with manpower shortage and inadequate supply of drugs and blood.
- Between 1995 and 2014 India’s public expenditure on healthcare rose only from 1.1 per cent of GDP to 1.4 per cent. High income countries spend 7.3%, while the low income group average around 2.2%
- Quandary is widespread- more than 70% people in tertiary care do not need to be there
- High out of pocket expenditure on medicines~60%
- Public expenditure on health should be increased
- India could learn from the experience of Thailand, where health outcomes such as life expectancy have far outperformed India’s based on a universal healthcare coverage scheme that, since 2002, was built on a successful social insurance model.
- Need of more manpower- Trained doctors, ANMs, Ayush Doctors
- PHCs should play more functional role. Get the patients to use PHCs and other primary treatment options optimally, and avoid rushing to tertiary care units which are overwhelmed and struggle to treat priority cases.
- Expenditure on degree education for medical students is too high. Reduction in this front would definitely provide a respite both to doctors(less investment) and to patients(doctor’s may charge less fees)
- Healthcare service is a social good. Public sector should play a major role in this, this would not only push Universal health coverage but also check the profit motive.
Labour pain: Sitapur’s maternity racket
Why in news?
- Recently a maternity racket exposed in Sitapur ,UP -the struggle to access to quality, affordable care for pregnant women.
- The “baksheesh” and “Chaff-pani” problem faced in getting institutional deliveries. Expecting parents are often harassed by the medical staff- outright from ambulance driver to nurses, everybody receives a cut.
Importance of institutional deliveries
- Millennium Development Goals (MDG) targets of bringing down Infant Mortality Rate (IMR) to 29 have not been achieved yet, still loitering @ 40
- MDG target of Maternal Mortality Rate (MMR) -109 is also far below the national average of178
- Both of these targets would be taken care of besides spreading sense of general well-being and security viz. health among the masses.
Government schemes and issues:
- Janini suraksha yojana: a conditional cash transfer scheme (under the National Rural Health Mission) to benefit expecting mothers. Under the scheme pregnant women are entitled to free medicines, hospitalisation, and free food during hospital stay, free transport (after the delivery) and an incentive of Rs. 1400 for choosing to deliver the baby at a government or private hospital.
- Several states have their own schemes proving pre-natal to post- natal care.
- However until a strong vigilance system is not operationalised to curb the harassment of patients by medical staffs at these healthcare centres, no material improvement would be attained
- Also in absence of bank accounts the monetary benefits are not transferred.
- As per some surveys, many families are reluctant for going to hospitals for institutional deliveries due to various reasons like- poverty, disillusionment, large distance and non-availability of good transport. In such a scenario a different approach of bringing the institution to the needy could be a game changer.
- We can look for training more ANMs , ASHA workers so that children are at least delivered by safe-trained hands, if not in a hospital
Not all are equal: Where health coverage lags behind
Key facts: Major issues faced by health sector
Sharp contrast in quality and quantity- Both inter-regional and intra-regional is clearly visible. Rural-urban divide is very high.
Health-sector is faced by 2 great challenges
- Affordability: cost of medicine and treatment very high. A single stressed event often leads to impoverishment of various households in the vicinity of poverty line. Even the middle-income households many a times run out of their savings
- Accesssibility: Large sections of hilly and rural areas are underserved. Even in big cities we find ratio of no. of beds : population at 1000, far below the optimum of 1700-as per WHO. Shortage of manpower and drugs further aggravates the situation.
Institutional deliveries have definitely increased in recent years, and with schemes under NHM, it is further expected to go north
- Expand access to Primary healthcare in rural areas
- PHCs should be viewed as last mile connective link to deliver healthcare services. They must be revamped and be on high priority.
- Additionally, rational appointment of medical and nursing staff in the PHCs is vital. It is hoped that the Centre’s Universal Health Care project, launched in 2010, will be able to serve the goal of providing easily accessible and affordable healthcare to all Indians irrespective of caste, location or income.
Losing ground in the war on Superbugs
Why in NEWS?
- Recent reports show Drug resistant infections are increasing in hospitals. Patients in ICU in particular are at more risk.
- In many cases even the last resort-COLISTIN (having serious side effects) is failing. Hence Ceftazidime, a third generation antibiotic is administered
- Fear of spread of these Multi Drug Resistant (MDR) Suberbugs
- Years of antibiotic abuse
- low compliance with prescribed dosage
- Poor sanitation levels
- Heavy use of antibiotics in poultry is a concern
- Unaccounted over the counter sale of these drugs. This has also led to decline in effectiveness of antifungal drugs and creams
- Add to treatment cost
- Prolonged stay of patient in hospitals
- No new antibiotics on the horizon and the stronger antibiotics being used have toxic side effects.
- Antibiotics have been worked overtime, without prioritizing sanitations both in community and hospitals.
- Swachh Bharat Mission is definitely a welcome step- sanitary and hygienic conditions would lead to decline in incidence of infectious diseases thus also checking the overuse of antibiotics.
- R&D to develop more antibiotics
- Traditional way of treating infectious disease may hold the key. For e.g. Youyou Tu discovered Artemisinin, a drug that has significantly reduced the mortality rates for patients suffering from Malaria with help of traditional Chinese methods.
Antimicrobial resistance: clear and present danger
Keys facts and figures
- Antibiotic resistance is a global public health threat, but nowhere is it as stark as in India.
- The crude infectious disease mortality rate in India today is 416.75 per 100,000 persons… twice the rate in the U.S. (200) when antibiotics were introduced.”
- India was the largest consumer of antibiotics till 2010
- India awoke late to risks of antibiotic overuse and is scrambling to contain the surge in drug resistance.
- Only after the detection of the New Delhi Metallo-beta-lactamase-1 super bug, India sat up to the danger of anti-microbial resistance within its boundaries, and is beginning to understand the disastrous societal consequences of rendering certain life-saving drugs impotent.
- In 2011 that the Union government came up with a National Policy for Containment of Antimicrobial Resistance in India.
- Stop indiscriminate use of antibiotics both in medical and poultry use.
- Over the counter sale of drugs should be monitored. Revision of Schedule H drugs viz. antibiotics is a welcome step.
- Encouraging people to adopt traditional methods of treatment for minor ailments.
Regulating India’s regressive health insurance
Current status of health insurance in India
- Despite Several schemes, only about 24% of population having some form of medical insurance
- India primarily relies on commercial health insurance now.
- Rather than pool financial resources across social groupings for risk protection, and move towards tax-funded health care, government policy has created fragments with low insurance.
- In urban areas >90 % of the population are not covered, compared to 66% of the richest
- It almost entirely covers only catastrophic expenditure, such as the cost of highly restricted hospital treatments, which are offered without cost and quality regulation and external audits. Outpatient treatment and prescription medicines are not covered.
- Risk pool size is low, largely due to:
- Non- participation of younger age group. Hence the burden of high premium falls on the much middle –to –old aged group.
- Even less participation by the affluent section
- Moral hazard: patients and care providers like hospitals build up claims without cost concerns. If there is any attempt to regulate providers, they respond with cost-cutting measures that harm patients.
- Behavioural changes are to be induced into masses for taking health insurance
- The vulnerable sections need to be provided with sufficient health cover. Schemes like RSBY are a welcome step
- A specialised regulatory body should be appointed to cater to the needs of this overlooked sector.
- Higher premium charges act as a deterrent. Larger risk pool size along with government intervention are needed to bring down the higher premium rates.
Gaping holes in the safety net
Insurance, both state-sponsored and private, does not cover everything and certain segments of the population have neither.
- Lack of awareness about insurance coverage, government schemes among the masses.
- People with disabilities, especially intellectual and psychosocial disabilities, also generally fall through the gaps of mainstream insurance coverage
- Denial of coverage by private companies to those above 75, having diabetes, or those who have had cancer
- Cost of treatment is very high and uneven which leads to exhaustion of the corpus much before treatment is complete.
- In Tamil Nadu, the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS), for those below an annual income of Rs. 72,000, provides Rs. 1 lakh per family per year with a provision to pay up to Rs. 1.5 lakh for specified procedures.
- CMCHIS covers only the first of the cancer treatments. “Since cancer requires follow-ups and sometimes, additional treatment, the cover may fall short and many patients do not have adequate money for follow up care,”
- Moving towards Universal Health coverage
- Bringing down out-of-pocket expenditure
When the last resort is the best
- According to medical journal The Lancet, outpatient care by private general practitioners and pharmacists as a proportion of all doctor visits in 2014 was 71.4 per cent in rural areas and 78.8 per cent in urban areas.
- Meanwhile private inpatient care rose sharply from 40 per cent in rural areas and 39.6 per cent in urban areas in 1986–87 to 58.1 per cent in rural areas and 68.0 per cent in urban areas in 2014.
- The experience of many patients leave little doubt that Tamil Nadu’s public healthcare system is a lifeline to vast numbers among the poorer sections of its population.
Rajiv Gandhi Government General Hospital (GH) in Chennai treats almost entirely free of cost approximately 12,000 outpatients per day. It has at least 3,000 beds. Though it admits patients from backgrounds and criticality, only genuine medical need is a factor in deploying state-the-art testing equipment such as the Fully Automated Immunoassay Analyser.
- Such hospitals are definitely a respite for all patients who are in dire need of speciality healthcare
When policy attention is the best remedy
- The World Health Organisation (WHO) categorises certain parasitic and bacterial diseases as Neglected Tropical Diseases, or NTDs, that cause substantial illness but affect only the world’s poorest populations, affecting over a billion people, primarily poor populations living in tropical and subtropical climates.
- Skewed presence of Neglected Tropical Diseases in poorer sections leads to under-investment in research.
Diseases affecting poor get proportionately less funding. Except for communicable diseases like HIV or Ebola that are scary to people because they cross boundaries
- Governments of the high burden countries need to step up research and development funding for NTDs
- The role of BRICS in particular would be of high importance
- In May this year, WHO certified India yaws-free becoming the first country under the 2012 WHO NTD roadmap to eliminate yaws.
Battling the poverty-parasite menace
- Belongs to the Neglected Tropical Disease (NTD) family of diseases
- Parasitic disease transmitted by the sand fly and characterised by irregular bouts of high fever, substantial weight loss, and enlargement of the spleen and liver.
- Families living in close proximity to livestock and the humid conditions along the southern banks of the Ganga (instance – Bihar) is a perfect hunting ground for the sand fly, and indeed Bihar is the global epicentre of kala-azar.
MSF and its role in containing Kala-Azar
- MSF(Médecins Sans Frontières) – Doctors without Borders
- They started a project in Bihar and Standardized Kala-azar treatment-single day single dose.
- But still results varied significantly, and after a while realized that the patients were suffering from HIV too.
- Scarce amount of statistical data
- The vulnerable community has to be made aware about the HIV-KalaAzar co-infection. But this can cause a panic.
- Only one in eight kala-azar cases gets caught in official surveillance data, according to a study conducted in 2006.
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