Why we need community health providers

They fill the vast gaps of access and quality. There’s a way to reconcile the views of the government and doctors

Are community healthcare providers needed, but unwanted? The controversy over the provision to provide limited licence to practice allopathic medicine, in the National Medical Commission (NMC) bill, unleashed an outcry of “quackery” from the medical professionals. It is essential that we consider who these healthcare providers are, and what role they can play in strengthening our health services. A look at global experience and the chequered history of mid-level health care providers in India will help.

An ideal health workforce is multilayered and multi-skilled, with complementary roles delivering competent, comprehensive, continuous and compassionate care. Doctors and nurses are most identifiable, but a variety of allied health professionals and community health workers are also integral. Among doctors, there are basic and specialist doctors. Among nurses, there are basic nurses, midwives and advanced nurses. A wide array of allied health professionals exist, from radiographers and optometrists, to lab technicians to physiotherapists and so on. Two other categories have been added across different countries, to meet growing but unmet healthcare needs. These are the community health workers (CHWs) and the mid-level healthcare providers.

Several developing countries have deployed CHWs, under different names but with the same intent — providing basic health services at home or close to home. CHWs also act as community mobilisers and trusted links to the organised health services. Ethiopia employed “health extension workers” to provide better antenatal care and reduce maternal mortality. Rwanda has recorded the sharpest fall in maternal mortality in the past 25 years, by deploying CHWs to link communities to nurse-run primary healthcare facilities. Swasthya Sebikas and Swasthya Kormis have strengthened primary healthcare in Bangladesh. Thailand has CHWs designated as village health volunteers and village health communicators. Brazil’s family health teams, too, have CHWs as an important component. India started deploying CHWs initially as mitanins in Chhattisgarh, and later built a nationwide army of accredited social health activists (ASHAs) as part of the National Rural Health Mission.

Mid-level health workers are a category of care providers who are more skilled and qualified than CHWs. This is a concept that emerged when even high income countries recognised that some of the functions that a doctor is traditionally expected to perform can be delivered by skilled persons with a lower level of training. Categories such as nurse practitioners, nurse anaesthetists and physician assistants grew in the United States. These drew on the experience of the Civil War and the Second World War when a shortage of doctors led nurses and paramedics to step in and perform. Formal training programmes, accreditation and role definition followed. Presently, nurse practitioners are a well-defined category in the US, New Zealand and Australia. Apart from shortages of doctors in some regions, the rising costs of healthcare also catalysed the emergence of mid-level healthcare providers.

The Indian experience of creating these categories has been fraught with hesitation and hurdles. Even the National Health Policy (NHP) of 2017 recognises this need, but progress has been slow and contentious. Chhattisgarh initiated a three-year graduate training programme (Diploma in Modern and Holistic Medicine) for creating a cadre of rural medical assistants. They were shown to be as capable as doctors in delivering some of the primary care services. Despite several name changes, the conflict between medical professionals and the aspirations of the new graduates resulted in an identity crisis that finally led to closure of the programme. Assam is the only state where such a course is presently run (Diploma in Medicine and Rural Health Course). On the other hand, the category of Physician Assistants (PAs) has taken root in some southern states and West Bengal, through a 4-year graduate course run by universities. They mostly perform duties under the supervision of doctors in hospitals but have the potential for delivering preventive and promotive services in primary care settings.

Seven years ago, the Union health ministry initiated a proposal to train and employ mid-level healthcare providers through a three-year programme modelled on the Chhattisgarh course, to meet the needs of primary care. The Medical Council of India (MCI) developed a curriculum which was a compressed MBBS programme (“MBBS Bonzai”) more suited to hospitals than to primary care. The MCI, however, balked at regulating this course because it violated its mandate to deal only with medical education.

So, the health secretary of the time, PK Pradhan came up with an unorthodox solution. The course was labelled as B Sc(Public Health), and the National Board of Examinations (NBE) was asked to deliver it through its affiliated hospitals and colleges. The NBE, which was hitherto mandated to deliver only postgraduate medical education, accordingly modified its articles of association to include undergraduate and postgraduate courses in public health. A group of experts, which included VK Paul (presently a member, NITI Aayog) prepared the curriculum for the course. However, the proposal lost steam after Pradhan’s tenure ended.

The proposal resurfaced after NHP 2017 called for a BSc in community health and “bridge courses” for developing mid-level healthcare providers. The proposal to provided bridge courses to AYUSH practitioners of the Indian systems of medicine seems to have retreated in the face of fierce opposition from the Indian Medical Association (IMA). However, the inclusion of community health providers (CHPs) in Section 32 of the recently passed National Medical Commission (NMC) Bill has reignited the debates on the qualifications, competencies and functions of these mid-level providers.

The concerns about this provision in the NMC arise because it was an abrupt insertion into the original bill that went before the Parliamentary Standing Committee on Health in early 2019. The courses prescribed, the institutions which will deliver them, the competencies that will be promoted and the nature of functions they are expected to perform are not clear at this stage. Only the role of the NMC in issuing a limited license is described, with ambiguity on when, where and how much medical supervision is required or autonomy is permitted. The blurred lines between NMC (which regulates undergraduate and postgraduate medical education through medical colleges) and this new cadre are agitating the organised medical profession.

India needs mid-level healthcare providers in several forms — nurse practitioners, physician assistants and community health providers — to fill the vast gaps of access and quality in our health services. They are especially required for primary care. Perhaps it is best to diffuse the controversy over CHPs by bringing them under the purview of the Allied Health Professionals Bill which is due to go before Parliament. The CHPs may not fit well into the NMC but surely they can be accommodated as allied health professionals. That may bring accord between the government and the medical profession.

Srinath Reddy is president, Public Health Foundation of India, and author of Make Health in India: Reaching a Billion Plus

Source; Hindustan Times, 13/08/2019

A prescription for the future

While using cutting-edge technology, we need to find ways to continuously lower the cost of healthcare

The world as we know it is changing so fast and so much. Global mega-trends only reinforce this fact. The Internet has taken over our lives, smartphone penetration is growing rapidly, demographics are evolving. For the first time, in 2019, millennials (born between 1981 and 1996), who feel fully at home in a digital world, will overtake the population of baby boomers. There are dramatic lifestyle and behavioural changes occurring every day, with strong implications for the future of our planet and its inhabitants.

Impactful changes

Healthcare is no stranger to change — in fact, the most impactful transformations in human life have happened in healthcare. Time ’s cover three years ago showed the picture of a child with the headline, “This baby could live to be 142 years old”. That is the extent of the breakthrough in longevity that modern medicine has been able to achieve. Healthcare in India too has been transformed over the last three decades, and as members of this industry, we can be proud of how far we’ve come in terms of improved indices on life expectancy, infant mortality, maternal deaths and quality of outcomes.

But we cannot rest on these achievements now, because the pace of change is still scorching, and is fundamentally altering disease patterns, patient risk profiles and their expectations. Information technology and biotechnology are twin engines, with immense potential to transform the mechanics of care delivery, the outcomes we can achieve and, above all, the lives we can touch and save.

There are several examples of the kinds of impact technology and biotechnology can make on healthcare. Telemedicine has already brought healthcare to the remotest corners of the country. The use of artificial intelligence for preventive and predictive health analytics can strongly support clinical diagnosis with evidence-based guidance, and also prevent disease. From the virtual reality (VR) of 3D-printing, we are now moving towards augmented reality (AR), by which, for example, every piece of node in a malignant melanoma can be completely removed, thereby eliminating the risk of the cancer spreading to any other part of the body. Biotechnology, cell biology and genetics are opening up whole new paradigms of understanding of human life and disease, and have made personalised medicine a way of life.

Largest health scheme

So, the outlook is clear: those in healthcare who wish for status quo and for the comfort of the familiar run the risk of becoming irrelevant. And that goes for countries too. India needs to rapidly adapt to, embrace and drive change if it wishes to stay relevant in the global healthcare order.

India’s change imperative has become even more pronounced with the launch of the Pradhan Mantri Jan Arogya Yojana Abhiyan, or National Health Protection Mission (NHPM), under the ambit of Ayushman Bharat. This major shift in approach to public health addresses the healthcare needs of over 500 million Indians in the first stage through what is probably the world’s largest public health-for-all insurance scheme. The vast scale of the programme requires reimagining an innovative model which will transform healthcare delivery in the country. By leapfrogging through smart adoption of technology and using emerging platforms such as Blockchain, significant improvements are possible in healthcare operations and costs.

The private health sector is committed to support this programme, and ensure its success, because we are beneficiaries of society’s social licence to operate, and it is our responsibility to make sure this programme reaches the most vulnerable and the under-privileged, for whom it is intended. At the same time, we have a solemn responsibility to ensure that the sector is sustainable in the long term. For India to grow, healthcare as an engine of the economy needs to flourish. And the private sector, which has contributed over 80% of the bed additions in the last decade, needs to earn healthy rates of return on investment to continue capital investment in infrastructure, technology upgrades, and to have the ability to acquire top clinical talent, which can lead to differentiated outcomes. In our quest to achieve low-cost healthcare, we must not inhibit our potential for growth, nor isolate ourselves from exciting global developments.

The way forward

The prescription is clear. We need to achieve a balance between staying at the cutting edge of clinical protocols, technology and innovation and continue to deliver world-class care, while finding increasingly efficient ways of operating to continuously lower the cost of care and bring it within the reach of those who cannot afford it. This is a difficult balance to achieve, but not impossible. And when accomplished, India would have found an answer that can be an example for the rest of the world to emulate.

With clarity and focus, we can create a blueprint for the legacy we wish to build and set the trajectory for Indian healthcare for the next several decades. The decisions we make today are decisions we make for our children, a future we will create for them. Will they lead healthier lives than we do? Will they approve of our choices and actions? Are we building an inclusive and sustainable world for them? We have it in our hands to shape the winds of change we face today into the aero-dynamics that will definitively propel our collective destinies forward.

Suneeta Reddy is Managing Director, Apollo Hospitals Group

Source: The Hindu, 28/11/2018

Partnerships and alliances are the new mechanisms for savings lives

While donors and governments with the capacity to provide resources at a global scale can replenish these ‘Global Health Funds’, domestic donors can partner with their respective governments to set up similar mechanisms to multiply the impact that they can have working alone. These partnerships are essential if we want to create a world in which where you live does not determine whether you live.

The world’s progress in improving health and development related outcomes for people everywhere is one of the greatest success stories of the past 20 years. Two decades ago, the infectious diseases that killed or harmed millions often went unchecked. Children born in poor countries were only vaccinated against a handful of the same diseases as children born in wealthier countries. There was no access to life-saving drugs such as antiretrovirals to treat HIV. But if we look closely at the trajectory of healthcare, we realise that since the 1990s, we have nearly halved the number of women who die in childbirth and halved the number of children who die before the age of five.

There are many reasons for these gains. As countries have grown wealthier, they have increasingly invested in their own healthcare systems, helping more of their citizens to live longer and better lives. Aid programmes from donor countries channelled either through their own agencies or UN organisations such as the WHO and UNICEF, have helped fill critical gaps. Large global charities such as CARE and Save the Children have raised funds from government and individual donors and with those funds have run large programmes in many poorer regions of the world.

An additional important reason the world has made such large gains in improving global health in the last two decades is the emergence of the ‘Global Health Funds’. These new and powerful mechanisms have made it possible for donor governments and United Nations agencies to partner with large private donors and civil society organisations (CSOs) to create very large pools of funds and technical capability to tackle some of the most pressing issues that poor countries face. In these funds, organisations like the Bill & Melinda Gates Foundation have contributed significantly, by way of money, deep expertise, and as catalysts, alongside other private and sovereign donors, allowing each one to multiply the impact they could have had if they had acted alone.

The ‘Global Health Funds’ currently comprise the Global Polio Eradication Initiative (GPEI); the Vaccine Alliance (Gavi); the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); and the Global Financing Facility (GFF) and have had a remarkable impact:

In 1988, there were an estimated 350,000 cases of wild polio every year, killing or paralysing its victims. In 2017, there were just 22, with a large and complex country such as India having entirely eradicated the disease, due to the joint efforts of domestic governments, CSOs, and GPEI.

In 2000, 30 million children in poor countries were not being immunised, leading to millions of unnecessary deaths. Since then, Gavi has supported the introduction of 380 routine vaccines into the health systems of vulnerable countries and helped to immunise 690 million children, preventing 10 million future deaths.

Since the creation of the Global Fund, deaths related to AIDS and TB have fallen by a third, and malaria by half.GFF’s ‘In Support of Every Woman Every Child’ is today tackling the more than five million maternal, newborn, and child deaths that still occur among the world’s poorest people each year.These spectacular gains made in human health need to be sustained and accelerated. Polio is only endemic in three countries, but until we get to zero, all countries will be at risk of polio re-emerging. Following the historic progress of reductions in malaria cases and deaths, we are on the verge of a resurgence that could see millions more at risk. And, despite more children being immunised worldwide than ever before with the highest level of routine coverage in history, increasing coverage rates with children in the world’s poorest countries continues to be a challenge.

To address these ongoing concerns, a massive replenishment effort for these funds is under way. As large philanthropists emerge both at global and domestic levels, these new forms of partnerships and alliances offer a powerful way forward. While donors and governments with the capacity to provide resources at a global scale can replenish these ‘Global Health Funds’, domestic donors can partner with their respective governments to set up similar mechanisms to multiply the impact that they can have working alone. These partnerships are essential if we want to create a world in which where you live does not determine whether you live.

Joe Cerrell and Nachiket Mor are both employees of the Gates Foundation. Joe Cerrell is Managing Director of the Gates Foundation’s Donor Government Relations team working across Europe, the Middle East and South Asia and Nachiket Mor is Country Director for India.

Source: Hindustan Times, 1/11/2018

The community’s health can drive great economic and social progress

The Global Conference on Primary Health Care approaches health care in a fresh manner

The Alma Alta Declaration put “health for all” centre stage as a fundamental right in 1978, with 134 countries committed to making primary health care the mainstay to achieve universal health coverage. In a tectonic shift from the existing disease-focused hospital-based treatment approach, it redefined health as physical and mental well-being of the community and essential for social and economic progress.

Over the next three decades, the declaration was dismissed as idealistic and unrealistic and the focus shifted to selective, targeted deliverables that offered low-cost and quantifiable solutions to the most common causes of death. Instead of strengthening primary healthcare, policies and public health budgets went almost exclusively to controlling communicable diseases and programmes on ‘GOBI’ (growth monitoring, oral rehydration, breastfeeding, and immunisation), and later, ‘GOBI-FFF’ (GOBI plus food supplementation, female literacy, and family planning). India, too, got on the targeted programmes bandwagon with the major chunk of its health budget going to reproductive and child health and family planning.

There is now a steady and growing support among public health experts to end this approach to health care. The Sustainable Development Goals on good health and well-being also call for making modern health care equitable and accessible to all by investing in community-based care, health centres, hospitals, and population-based interventions for prevention, early diagnosis, treatment and management.

Though people in most parts of the world enjoy better health than ever before, most countries still struggle to provide primary health care. Disease-specific policies, an unregulated private sector, overinvestment in specialised hospitals for curative treatment, and an acute workforce shortage has widened the gap in access to quality health care between the rich and the poor. Epidemics and outbreaks caused by new emerging infectious diseases, such as HIV, Ebola and influenza, further burdened the public health infrastructure in many countries already struggling to meet the growing load of non-communicable diseases, such as heart disease, diabetes, cancers and mental health diseases.

Half the world’s population still has no access to essential health services, even though 80-90% of their health needs across a lifetime can be provided by primary health care services, which range from maternity and child care, to disease prevention through vaccination, management of chronic diseases such as diabetes and hypertension, and supporting care of ageing populations, who live longer but often less healthy lives because they have more than one disease.

This week, 1,200 decision-makers and influencers, including heads of state, ministers of health, finance, education, and social welfare, not-for-profits and health professionals will meet at the Global Conference on Primary Health Care in Astana, Kazakhstan, which is co-hosting the meet with the World Health Organisation and Unicef. As in the rest of the world, much has changed in Kazakhstan since 1978. Kazakhstan is independent of the Soviet Union, Alma Ata has been renamed Almaty, and the country’s capital has shifted to Astana, best known for its glittering, sci-fi skyline that appears to have magically sprung up in Steppe wilderness. What is now being resurrected in this futuristic city is the need to rejuvenate and revitalise people-centric primary health care using newer tools, such as technology.

India, which was one of the participants in the Alma Ata conference, has made a start with the launch of health and wellness centres under Ayushman Bharat that offer health promotion, disease prevention and management, treatment of simple fever, infections and pain, and early diagnosis and timely referrals to hospitals at the community level. These will be staffed by a new cadre of technologically enabled community health officers (CHOs) trained as mid-level providers, who will work with support from auxiliary nurse midwives, community workers (Asha), and male health workers to ensure everybody in a population of around 5,000 people gets free basic medicine, diagnosis and treatment.

Around 80% of India’s 1.04 million registered doctors of modern medicine (allopathy) work is in cities, which is home to 31% of the country’s population. The rural population is heavily dependent on the public health sector, where the allopathic doctor-patient ratio is 1:11,082, against the WHO-recommended ratio of 1:1,000. These CHOs will help meet the shortfall of doctors in rural and underserved areas and strengthen health sub-centres at the village level to free up doctors for tertiary care and substantially reduce people’s out-of-pocket health spending.

Strong primary health care, rooted in community participation, builds resilience against new and existing diseases and helps governments to respond to evolving health needs, demographics, environmental challenges, and emergencies to improve outcomes and well-being at lower costs.

sanchitasharma@htlive.com

Source: Hindustan Times, 24/10/2018

The health transition

Progress on non-communicable diseases should not be benchmarked against sustainable development goals.

In the last week of September, India’s health ministry received the prestigious UN Inter-Agency Task Force Award for “outstanding contribution to the achievement of NCD (Non-Communicable Diseases) related SDG targets”. At the same time, a Lancet paper by the monitoring group, NCD Countdown 2030, contended that India will fall short of the NCD targets pertaining to SDGS. NCDs are the leading cause of mortality, globally and in India, and are dominated by cardiovascular diseases, cancers, diabetes and chronic respiratory diseases. So what is true?

The target set for all countries is to achieve one-third reduction in NCD related mortality between the ages of 30 and 70 by 2030, relative to 2015. The Lancet study reports that high income countries and several upper middle income countries are on course to achieve this target. Lower middle income countries, like India, will need to accelerate the rate of decline to reach the target. Many low income countries are unlikely to reach the target by 2030.

The Lancet paper examines global trends in NCD mortality, using three rates: Mortality between 30-70 years, mortality under 70 years and mortality under 80 years. The first is the indicator linked to the SDGs. The second also measures NCD mortality below 30 years of age, which represents a considerable burden in regions like sub-Saharan Africa. The third regards most NCD deaths before 80 as preventable and premature. The authors rightly argue that the arbitrary selection of the 30-70 year age range limits consideration of, and action against, NCD deaths in the younger and older age groups outside that age band.

These arguments make perfect sense when pleading for broader multi-sectoral policy commitment and extended health system action against NCDs, whose challenge demands a life course perspective — one that is not limited to middle age. Further, the challenge of NCDs will not cease in 2030. As the epidemics mature, the 70-80 age group will pose challenges in many parts of the world. Therefore, the current response should not be a short-term staccato response but one which anticipates and mitigates preventable NCD mortality across the entire 0-80 age range even after 2030.

Use of the three indicators simultaneously to judge progress towards 2030 ignores the varying stages of developmental and epidemiological transition that different countries are traversing. As countries advance along this path, life expectancy progressively rises and the median age of NCD-related mortality will move to a higher age at each subsequent stage. Even within countries, groups with relatively lower NCD mortality in the 30-70 age group (most often women and persons in underdeveloped regions) are likely to move to higher levels of mortality in that age group.

As countries in early health transition (such as sub-Saharan Africa) advance to the next stage by 2030, they will see reduced levels of NCD mortality under 30 but will see NCD mortality rising in the 30-70 age group. A substantial reduction in NCD mortality in the 30-70 age group, by 2030, is not an appropriate performance measure of progress in such populations. Similarly, countries like India which have advanced to the next stage of transition will experience the gender effect of more women facing the risk of dying from NCDs between 30-70 years, even as men will see some NCD deaths shift to the 70-80 year age group. The under-developed states of India will behave like sub-Saharan Africa, transferring under-30 NCD deaths to the 30-70 age group. Inability of these countries to fully meet the 30-70 age SDG target, or reduce the under-80 NCD mortality by a third by 2030, should not be projected as a failure. Much of the impact of current efforts, on reducing the under-80 NCD mortality in India, will come after 2030 even though substantial progress would have been achieved in reducing deaths under 70 by that year. Reducing the 30-70 or under-70 or under-80 NCD mortality should not, therefore, be regarded as an acid test of performance in all countries.

However, age limits should not become a barrier to the provision of NCD care under a Universal Health Coverage (UHC) programme — another major SDG target. Countries keen on achieving the specified 30-70 age related mortality target may tend to focus their resources on preferential care for that group, especially in the provision of life saving clinical services, neglecting other age groups. This militates against equity and undermines the principle of universality. For this reason, reduction of under-80 mortality would be a better measure to judge the overall health impact of UHC.

Therefore, reduction in 0-70 mortality would be a reasonable indicator for tracking India’s progress on NCDs while progress in under-80 mortality would be a good indicator for assessing progress on UHC. It is essential that the government, civil society, academia and media recognise these nuances of health transition which shape the sweep of NCD epidemics as they evolve.

Actions to curb tobacco and alcohol consumption will help reduce future risk of NCD in the under-30 age group, while reducing mortality at all ages, and help create a healthier society which will yield inter-generational benefits well beyond 2030. Actions related to reduction of blood pressure, control of diabetes and provision of competent primary care supplemented by cost-effective specialist clinical care for treatable NCDs will benefit all age groups, with the highest benefits in the 30-80 age group. Energetic implementation of public health policies and NCD-inclusive health services under UHC are what the country needs. India’s efforts in these areas certainly merit the UN commendation. The indicators used to track progress are helpful to further stimulate these actions even if they are not perfect for measuring progress across the broad spectrum of health transition in the relatively short run up to 2030.

Source: Indian Express, 12/10/2018

Survey: India ranks 158th among 195 countries in health care investment

A study by Seattle-based Institute of Health Metrics and Evaluation published in The Lancet says that India’s ranking of 158th in 2016 represents an improvement from its 1990 ranking of 162nd.

India ranks 158th in the world for its investments in education and healthcare, a survey of 195 countries has revealed. It ranks below countries like Sudan, Azerbaijan, China and Bosnia Herzegovina. According to the survey, Finland tops the list of 195 countries in the two key sectors.

A study by Seattle-based Institute of Health Metrics and Evaluation published in The Lancet says that India’s ranking of 158th in 2016 represents an improvement from its 1990 ranking of 162nd. It comes from having seven years of expected human capital, measured as the number of years a person can be expected to work in the years of peak productivity, taking into account life expectancy, functional health, years of schooling and learning, the survey said.

“Our findings show the association between investments in education and health and improved human capital and GDP, which policymakers ignore… As the world economy grows dependent on digital technology, from agriculture to manufacturing to the service industry, human capital becomes important in stimulating local and national economies,” said Dr Christopher Murray, director of IHME.

Source: Indian Express, 25/09/2018

New health paradigm

Pradhan Mantri Jan Arogya Yojana will ease burden on poor, be a catalyst for more changes in health sector.

Ayushman Bharat is a far-reaching initiative aimed at ensuring holistic healthcare services. Its first component of expansion of services with elements of promotive and preventive healthcare under comprehensive primary health through health and wellness centres was launched on April 14 from Chhattisgarh’s Bijapur district. Since then, 2,287 health and wellness centres have come up around the country.

Its second component, the health assurance mission addressing concerns of catastrophic expenditure by vulnerable families for secondary and tertiary care, the Pradhan Mantri Jan Arogya Yojana (PMJAY), will be unveiled on September 23.

It will provide a cover of Rs 5 lakh per family per year for inpatient care to 10.74 crore families at the bottom of the pyramid. This translates into more than 50 crore people, around 40 per cent of India’s population. The health conditions and surgical procedures, covered free, are encompassed in over 1,350 packages that include practically all secondary and tertiary conditions requiring hospitalisation, barring a few such as organ transplantation. The services will be provided by empanelled public and private hospitals.

Unlike private insurance schemes, PMJAY does not exclude a person on account of pre-existing illnesses. The size of the family is no bar. There is also no need for formal enrolment; families that are listed with defined deprivation criteria on the Socio Economic and Caste Census database are automatically enrolled. All that is required is a proof of identity, which could be Aadhaar or any other government-issued identity card.

All but a few states have agreed to be a part of the PMJAY. Most have chosen to run the scheme in the trust mode, which means that the state health agencies will directly implement the mission. A strong fraud control mechanism has been conceived. An audit system has been put in place. Thousands of Ayushman Mitras are being trained. At each facility, one of them will receive the beneficiary, check her eligibility and facilitate in-patient care. A system for patient feedback and grievance redressal is also in place. The system will be cashless and largely paperless.

The Yojana will be implemented in concord with state-level schemes, if they exist. An autonomous and empowered National Health Agency (NHA) has been established with corresponding state level health agencies (SHAs). A plethora of guidelines on every aspect of the scheme has been developed and pre-tested. A robust IT system has been put in place. An efficient claims management system is functional with payments to be made within two weeks.

One unique feature of the PMJAY is its national portability once fully operational. If a beneficiary from Jharkhand falls sick in Uttar Pradesh (UP), she is entitled to receive treatment in any of the empanelled hospitals in UP. Her home state will make the requisite payment for the services availed.

The service package rates are based on an extensive exercise to determine market-discovered estimates. The rates of all state schemes as well as the CGHS system were carefully studied. The cost of packages is modelled on quality care in a general ward. On the base rates, states can add upto 10 per cent as required. The base rates can further be augmented by 10 to 15 per cent each if the hospital is accredited, if it is located in one of the 115 aspirational districts or is running a specialty education course. If a state’s existing scheme has a higher rate for a specific package compared to the PMJAY, the former will apply.

PMJAY will herald a new era in healthcare for four reasons. First, it will dramatically improve provision of healthcare for the poor. It is now possible for a construction worker with an injured knee to have an implant for free, a rickshaw-puller with a heart attack to undergo a stent procedure and a farmer’s wife to receive full treatment for breast cancer.

Second, the PMAJAY will be a catalyst for transformation. It will be an enabler of quality, affordability and accountability in the health system. The empanelled hospitals have been tasked to follow the treatment guidelines. Patient outcomes will be monitored. Another impact of the PMJAY will be rationalisation of the cost of care in the private sector. With an increase in demand created, it is expected that private sector will move from a low volume-high return paradigm to a high volume-fair return (and higher net profit) model.

The earnings of public hospitals under PMJAY will be available for their upgradation and also for incentivising the provider teams as these funds will be deposited with the Rogi Kalyan Samitis. Up to 30 per cent of the overall public spending on the scheme may return to public sector institutions.

Third, the PMJAY is a poverty-reducing measure. Each year, six to seven crore people, above the poverty line, fall below it because of health-related expenses. PMJAY would reduce this number significantly. More than a third of the out-of-pocket expenditure (around Rs 5,000 per household) is due to inpatient hospitalisations. One out of eight families have to incur health expenditure of more than 25 per cent of the usual household expenditure each year. PMJAY will ease this burden on the poor.

Fourth, the scheme will create lakhs of jobs for professionals and non-professionals — especially women. It will give a boost to the health technology industry.

The implementation of a mission of this size, ambition and complexity is hugely challenging. High uptake, quality care, beneficiary satisfaction, efficient operations and fraud-controlled systems are the key metrices of its success. With highly competent and dedicated teams at the NHA and SHAs, backed by the highest political will and the goodwill of the people, the PMJAY is poised to deliver on its promise. There is also willingness to learn, improve and reform.

Source: Indian Express, 22/09/2018

Restoring dignity

The time has come to end the stigma and discrimination against the leprosy-affected

It has long been a blot on Indian society that while leprosy is completely curable, there lingers a social stigma attached to it. Even more shocking is that colonial laws that predate leprosy eradication programmes and medical advancements remain on the statute book. These were unconscionably discriminatory from the beginning, but even in independent India, where the law has been an instrument for social change, the process of removing them has been bafflingly slow. The Lepers Act of 1898 was repealed only two years ago. It is time for concerted action to end the entrenched discrimination in law and society against those afflicted by it. Two recent developments hold out hope. One was the introduction of a Bill in Parliament to remove leprosy as a ground for seeking divorce or legal separation from one’s spouse, and the other was the Supreme Court asking the Centre whether it would bring in a positive law conferring rights and benefits on persons with leprosy and deeming as repealed all Acts and rules that perpetuated the stigma associated with it. The Personal Laws (Amendment) Bill, 2018, is only a small step. An affirmative action law that recognises the rights of those affected and promotes their social inclusion will serve a larger purpose. It may mark the beginning of the end to the culture of ostracisation that most of them face and help remove misconceptions about the disease and dispel the belief that physical segregation of patients is necessary. It is sad that it took so long to get such proposals on the legislative agenda.

Since last year, the Supreme Court has been hearing a writ petition by the Vidhi Centre for Legal Policy seeking to uphold the fundamental rights of people with leprosy and the repeal of discriminatory laws against them. The court has been approaching the issue with sensitivity and is seeking to find legal means to ensure a life of dignity for them. The 256th Report of the Law Commission came up with a number of suggestions, including the repeal of discriminatory legal provisions. It listed for abolition personal laws and Acts on beggary. The report cited the UN General Assembly resolution of 2010 on the elimination of discrimination against persons with leprosy. The resolution sought the abolition of laws, rules, regulations, customs and practices that amounted to discrimination, and wanted countries to promote the understanding that leprosy is not easily communicable and is curable. The campaign to end discrimination against those afflicted, and combating the stigma associated with it, is decades old. While governments may have to handle the legislative part, society has an even larger role to play. It is possible to end discrimination by law, but stigma tends to survive reform and may require more than legal efforts to eliminate.

Source: The Hindu, 28/08/18

The need for a strong UN declaration on TB

India must push back against US attempts to keep critical language on ‘access-to-affordable treatment’ out of the declaration

There is a concerted effort to eliminate tuberculosis (TB) from the world. The shift in the global threat perception of the disease was evident at the first ever Global Ministerial Conference on ending TB in Moscow late last year. There, 120 nations adopted the Moscow Declaration, which included commitments on universalizing access to TB care, ensuring adequate financing of TB programmes, investing in research and development (R&D) and building mechanisms to review progress.

The ministerial conference helped define the narrative for a forthcoming high-level meeting (HLM) on TB at the UN general assembly, perhaps the biggest window for global action on TB in the foreseeable future. At the HLM, it is widely expected that a political declaration will be adopted by member-states that will include unanimous commitments along the lines of the Moscow Declaration.

However, the collaborative and inclusive spirit of the declaration is now reportedly under threat, with the US putting profit before public health and employing arm-twisting tactics to keep critical language on “access to affordable treatment” out of the declaration.

Last month, several media organizations broke the story that due to extreme US pressure, the latest draft of the political declaration no longer included references to the flexibilities contained in the 1994 World Trade Organization Agreement on Trade-Related

Aspects of Intellectual Property

Rights (TRIPS) in the operative paragraphs. The global health community was justifiably alarmed. This part of the declaration would have affirmed the rights of developing countries to access affordable medicines via TRIPS flexibilities. On 26 July, South Africa pushed back and refused to approve the draft, thereby reopening the text of the declaration for negotiations.

South Africa’s bold stand has bought the developing world some time, but the battle is far from won.

The next few weeks will witness extremely tough rounds of negotiations to resist US efforts to remove all references to the TRIPS flexibilities from the declaration. Civil society groups in India and the US have taken up the fight, urging the Indian and American administrations to take concrete steps to strengthen the political declaration and ensure it is favourable to the needs of developing countries. It is now absolutely critical that these countries themselves, particularly India, come to the fore and persevere to retain the references.

When TRIPS was created in 1995, it introduced standards for protecting intellectual property rights to an extent previously unseen at the global level. It also incorporated important flexibilities, which included granting countries freedom to determine the grounds for issuing compulsory licences.

The right of countries to use these flexibilities to protect public health was confirmed in the 2001 Doha Declaration. Through compulsory licensing, countries can ensure that patents do not impede the protection of public health and that lifesaving drugs under a patent are made available to large populations at a cheaper and affordable price.

India used this provision when it issued its first compulsory licence in 2012 for the cancer drug Nexavar, driving down its cost to a tenth of the original. Similarly, South Africa, Rwanda and Brazil have been able to significantly lower the price of antiretroviral drugs, while Thailand has lowered the prices of drugs to treat heart disease and various forms of cancer.

The removal of the operative clause from the political declaration that refers to the commitments made in Doha to “protect public health and in particular, to promote access to medicines for all” is thus worrying. It endangers the rights of people in developing countries to access new lifesaving medicines. The TRIPS flexibilities were built in for the greater public good. Essential drugs are a matter of human rights; they must be made universally accessible to everyone who needs them.

This is especially true of TB drugs. TB is a curable disease. Yet, tragically, over 400,000 Indians die of it every year. The estimated 2.4 million patients who survive the disease have to bear the double burden of wage loss and productivity. Their families often have to take care of them; as a result, entire households can be pushed to the brink of poverty. This then affects children in the family, who are forced to drop out of school or seek employment. TB doesn’t merely ravage the body and mind of patients, it destroys the lives of their families too. Basic humanity and good conscience, therefore, demand that the concept of affordability take centre stage whenever we talk about the disease.

It is vital for India to showcase its leadership and stand firm against efforts to deny its TB patients access to essential medicines—now and in the future. The outcome of the forthcoming negotiations will be crucial to our efforts to eliminate TB by 2025. The tug-of-war over the declaration is a clear indicator that while concerted efforts are being made to eliminate TB, walking the last mile to ensure that target is achieved will take substantial effort.

It is this opportunity that India must seize to ensure that the declaration is meaningful and delivers on the promise to rid the world of TB.

Source: Livemint epaper, 16/08/2018

Making NHPM work: On Ayushman Bharat

Extending health cover to the most needy is vital, and needs an infrastructure upgrade

Prime Minister Narendra Modi’s announcement on Independence Day that Ayushman Bharat, or the National Health Protection Mission, will be launched formally on September 25 sends out the signal that the government is finally recognising the linkages between health care and economic development. Political parties have not yet made the right to health a campaign issue, and the National Health Policy does not recommend such a right since it cannot be fulfilled. But there is increasing awareness that it is unsustainable for a country of 1.3 billion people to rely on household savings to pay for health care. The NHPM is an ambitious initiative, providing a coverage of ₹5 lakh per family a year to 10 crore families chosen through the Socio-Economic Caste Census, mainly rural poor and identified urban workers. State governments, which will administer it through their own agency, will have to purchase care from a variety of players, including in the private sector, at pre-determined rates. Reaching a consensus on treatment costs through a transparent consultative process is vital for a smooth and steady rollout. A large-scale Information Technology network for cashless treatment should be set up and validated. Since a majority of the families will be rural, and the secondary and tertiary public hospital infrastructure suffers from severe efficiency and accountability problems, State governments should upgrade the administrative systems.

National schemes on health provide an overarching framework, but the responsibility of executing them falls on the State governments. It is widely recognised that there are “nations with the nation” in India, given the population sizes, disease burdens and the development levels of different regions. Clearly, the NHPM has a problem with the distribution of hospitals, the capacity of human resources, and the finances available for cost-sharing. Addressing these through the planned increase in public health spending to touch 2.5% of GDP, and 8% of State budgets, is the immediate challenge. With steady economic growth, meeting that policy commitment through higher investments will be a test of political will. Yet, it is also an opportunity to tap into a large labour pool for the new jobs that will be created, and to raise skill levels. Reducing the cost of universal health coverage is imperative, and it requires parallel investments in the neglected public sector. Private insurance can only be a short-term option, and it clearly has limitations. Less ethical institutions have been found ordering unnecessary treatments to claim insurance compensation. An ombudsman to deal with complaints from NHPM users should, therefore, be a priority. The Centre should extend the scheme to all children and senior citizens, and cover out-patient consultation and essential drugs to sharply reduce out-of-pocket spending.

Source: The Hindu, 16/08/2017

India not on track to meet 2030 targets of reducing child mortality

The number of neonatal deaths remains around 2.4 times higher than the target

Almost half of the districts in India are not on track to reduce the mortality rates of newborns and meet the target set under the Sustainable Development Goals for 2030, a study has found.

India still has the world’s highest number of deaths among children under five and newborns, around 1.1 million per year.

The study, by Jayanta Bora and Nandita Saikia from Austria-based non-profit International Institute for Applied Systems Analysis, is the first to evaluate neonatal and under-five mortality at a district level in India, as well as a state level.

Under the World Health Organization’s Sustainable Development Goal 3 (SDG3), all countries should aim to reduce neonatal mortality to 12 deaths per 1,000 live births per year, and under-five mortality to a maximum of 25. Researchers used data from the National Family Health Survey, a survey of the full birth history of women aged 15-49, carried out most recently in 2015-16, and used the data from the previous round conducted in 2005-06 to model future trends.

Poverty and neonatal deaths

They found that the various measures employed in India have cut the number of deaths of under-fives by around half in in the past 23 years, from 109 deaths per 1,000 live births in 1990 to around 50 in 2013, but this is still double the target.

The number of neonatal deaths remains around 2.4 times higher than the target, at around 29 deaths per 1,000 live births. The picture, however, is very complex. For example, the under-five mortality rate for boys in the South West district of Delhi is 6.3 per 1,000 live births, well within SDG3 targets.

However, in Rayagada in Odisha, the mortality rate is 141.7. The researchers found that just nine per cent of districts in India overall have so far reached the SDG3 targets for neonatal mortality, with 14 per cent reaching the targets for under-five mortality.

The vast majority of the worst performing states on mortality rates are in the poorer states of north-central and eastern India, although there are some high-risk districts in richer, more developed states such as Andhra Pradesh and Gujarat.

Almost all districts in the most populous states of Uttar Pradesh, Bihar, Madhya Pradesh, and Chhattisgarh will fail to achieve the SDG3 goal on neonatal mortality. In Uttar Pradesh, the research showed that not a single district would meet the target for under-five mortality.

Socioeconomic and geographic disparities

There is also some variation between genders. The female neonatal mortality rate is below that of males, which is expected as this is the global trend. However, this is not the case with under-five mortality, indicating gender discrimination.

“The state-level mortality rate does not reflect the inter-district variation in neonatal or under-five mortality rates,” said Bora. “While some districts of a particular state may already have achieved the Sustainable Development Goal 3 (SDG3) target 15 years in advance, some districts will not achieve this even by the 2030 target time. Mortality rates vary enormously across the districts.”

Much of the variation is likely due to socioeconomic and geographic disparities. District-level female literacy rates vary from 24-89 per cent while urbanisation ranges from 0-100 per cent.

There are also large differences in the implementation of mortality reduction schemes and the accessibility and availability of healthcare. “It is important to note that India experienced the highest reduction in mortality rate in the period 2005-2016. Therefore, to achieve the SDG-related mortality goals at the district level, it needs to intervene more rigorously than ever,” said Saikia. “The majority of Indian districts need to make a giant leap to reduce their neonatal and under-five mortality rates.”

Source: The Hindu, 6/08/2018

India ranks 56th in early initiation of breastfeeding, say UNICEF, WHO

Only two in five newborns are breastfed within first hour of life across the world

A new report released by UNICEF and the World Health Organisation (WHO) has ranked Sri Lanka at the top of the list of countries with early initiation of breastfeeding.

India ranks 56th among the 76 countries that were analysed. The report, released ahead of World Breastfeeding Week (August 1 to 7), says that only two in five newborns are breastfed within the first hour of life across the world.

“Whether delivery takes place in a hut in a village or a hospital in a major city, putting newborns to the breast within the first hour after birth gives them the best chance to survive, grow and develop to their full potential,” says the report, which emphasises on exclusive breastfeeding.

Countries like Kazakhsthan, Rwanda, Bhutan and Uruguay have fared much better than India, making it into the top 10. Azerbaijan, Pakistan and Montenegro are at the bottom.

Speaking to The Hindu, Gayatri Singh, UNICEF’s childhood development specialist, said various aspects contribute to early initiation of breastfeeding. “Generally, the focus is only on the mothers. However, we have to target the mother-in-law, the husband and the service providers as well to ensure that early initiation does take place,” Ms. Singh said. She said the data for India was taken from the fourth National Family Health Survey (NFHS-4).

Though nearly 80% births are institutional deliveries in India, there are missed opportunities of early initiation of breastfeeding due to low awareness among healthcare staff. “The early initiation period has doubled as compared to NFHS 3. But more progress can be made by capitalising on opportunities and creating awareness at the community level,” Ms. Singh said.

Breastfeeding in the first hour of life is significantly important for survival. The first feed, or colostrum, is termed as the baby’s first vaccine and is extremely rich in nutrients and antibodies. Continuous and exclusive breastfeeding thereafter is also important.

Source: The Hindu, 2-08-18

The public-private gap in health care

Policymakers have shown no inclination to provide equitable medical care

The recent controversy about transparency in the working of the cadaver transplant programme in Tamil Nadu has provided an opportunity to revisit the vexed question of medical rationing in India.

It is a hard reality that not all medical interventions are available to every citizen who may need it. The gap between what is technologically possible and what government hospitals generally provide widened appreciably after the technological leaps in medical care began, starting in the 1980s.

Covert medical rationing

The NITI Aayog’s document, ‘Three Year Action Agenda, 2017-18 to 2019-20’, has a section on health care. One of the recommendations is for the government to prioritise preventive care rather than provide curative care. The document also advises the government to pay attention to stewardship of the health sector in its entirety rather than focussing on provision of health care. Therefore, the system of private health care for those who can afford it and government care for those who cannot will continue in the foreseeable future.

Every government since Independence has stated egalitarianism as its goal in health care. The policies, however, have not matched the statements. Many interventions, especially those which are very expensive, continue to be provided only to those who can pay for them. This is medical rationing of the covert kind. Token provision of these interventions in a few government hospitals is merely an attempt by governments to appear fair.

The new Ayushman Bharat health scheme to provide secondary and tertiary care to those who are socio-economically deprived has a cap of ₹5 lakh per family per year. It is quite obvious that many interventions cannot be accessed for this amount, certainly not human organ transplants.

Transplanting a human organ is not a single event, but a life-long process. The actual act of transplantation itself needs expensive infrastructure and trained human resources. For the continuing success of the transplanted organ, expensive medication is needed. It is a sad truth that in India, out-of-pocket expenses for medical care are about 70% of all medical expenditure, and this particular intervention is only going to be available to those who can pay.

Inequitable medical rationing

Health care in India is obviously not egalitarian, but is it at least equitable? The evidence suggests otherwise. Governments have been giving subsidies to private players, especially to corporate hospitals. The repeated boast that India can offer advanced interventions at a fraction of the costs in the West does not take into account the cost of the subsidies that makes this possible. Since it is all taxpayers’ money, it is a clear case of taking from the poor to give to the rich. In an illuminating article, “Investing in health”, in the Economic and Political Weekly (November 11, 2017), Indira Chakravarthi and others pointed out that private hospital chains in India have entered every segment of medical care, including primary and secondary care and diagnostics. Most have large investors from abroad and some are effectively controlled by foreign investors. In short, taxpayers’ money is being used to ensure profits for foreigners.

Successive governments have been increasingly dependent on the private sector to deliver health care. The Ayushman Bharat scheme is a further step in this process. The benefit to patients is questionable but private players will see a large jump in profits. It will further institutionalise medical rationing by explicitly denying certain interventions — a “negative list” presumably of procedures which will not be covered, which is not yet in the public domain.

The problem of distrust

Besides being inequitable, medical rationing has other detrimental effects. One is a distrust of the public in government hospitals. The poor expect to get from them what the rich get in private hospitals. With present policies, this is simply not possible. Without a clearly defined mandate, morale among medical personnel in public hospitals is low. The perception that doctors in the private sector are much better than those in the public sector has a severe debilitating effect on the professional image of medical personnel in public hospitals. Attempts by doctors to provide these high technology interventions in public hospitals is bound to fail without continuing commitment from policymakers; it is quite clear from policy documents, which doctors and the public do not read, that such commitment will not be forthcoming.

Our hearts tell us that every possible medical intervention should be available to every citizen. Our minds tell us that the government is not committed to this. The only pressure group which can ensure at least equitable medical care is the electorate. Until such time as it demands this from governments, we will continue to witness the tragic drama of two levels of medical care in India.

George Thomas is Chief Orthopaedic Surgeon at St. Isabel’s Hospital, Chennai

Source: The Hindu, 1/08/2018