Build a network to share knowledge about health

Government partnership is becoming a buzz word in the social sector, but often lacks substance. In my experience, evidence generated at the grassroots, backed by community voice, is what makes for powerful policy change

The best part of my job is that I get to visit remote villages in many states. So often, I get a sense of déjà vu on these journeys, when I see frail pregnant women and new mothers, and malnourished children with listless eyes. But occasionally, there is a ray of hope. Inevitably it comes from groups of village women, working together to save and improve lives. These programmes, by both NGOs and government departments, should be sharing their best practices. That doesn’t happen.

Business knowledge for the most part is not shared, because it is the source of precious competitive advantage. When I left McKinsey and stepped into the public health world, I was dismayed because I saw something similar happening. NGOs were doing similar work, rarely exchanging knowledge. The only difference was that lives, instead of market share, were being lost. Couldn’t NGOs across India systematically capture and share grassroots knowledge?

Over the last two years, I led a small team that travelled across 53 districts in 18 states, to see if this knowledge network idea made sense. We visited 50 outstanding initiatives primarily in public health delivery. Indeed, many agencies were working on similar issues, and had many innovations they could share. There were five thematic areas — data use by front-line workers; community health workers; community mobilisation; data-based advocacy; and organisation building. Let’s consider each.

Health delivery programmes often fail to pinpoint the cases most at risk. It is not enough to know how many pregnant women and newborns there are in a village; programmes need to quickly find the few most at risk. In every village health services are provided by three women government staff — a nurse-midwife, community mobiliser and crèche worker. In Rajasthan, our Akshada programme developed a system of village mapping. These three regularly meet to share information, placing bindis of different colours on houses with the most urgent medical cases. This has been converted into an app. This data sharing and joint problem solving by front line workers is being implemented across the state, saving lives. We are eager to share our methods.

But what happens when government front-line workers are missing? This was the case in remote tribal locations we visited in Chhattisgarh, Maharashtra and Andhra Pradesh. We found ingenious methods to create community health workers and fill the gap, in different places. These local wMomen are trained to identify high-risk cases, and connect to the nearest health care provider.

We found that NGO programmes often take the beneficiary for granted. However, barriers like a lack of awareness, and social and cultural norms get in the way.

Government partnership is becoming a buzz word in the social sector, but often lacks substance. In my experience, evidence generated at the grassroots, backed by community voice, is what makes for powerful policy change. Sex workers from the Ashodaya community based organisation in Mysore work with government departments. They come equipped with hard data, such as access denied to government entitlements, and incidents of violence against sex workers. Their voice, backed by media coverage, and legal support, has led to a reduction in HIV cases. This principle of data-to-voice advocacy can be applied in other health programmes.

Sometimes entire vital functions are missing in NGOs such as for knowledge capture. Culturally, staff are not encouraged to express dissent and to treat it as an obligation. There are plenty of best practices to learn, including from companies.

The two-year Bharat darshan across 18 states has reaffirmed our belief: That vibrant solutions to most public health problems already exist. We only need a pan-Indian real-time knowledge network, ever expanding driven by mutual interest. That’s another story!

Ashok Alexander is founder-director of the Antara Foundation

Source: Hindustan Times, 19/10/2019

Empowering primary care practitioners

It is important to reclaim health care from ivory tower structures called ‘hospitals’ and incentivise general practitioners

What is special about Japan in the context of health-care services is that it managed to contain the clout of specialists in its health-care system and accorded a prominent voice to its primary care practitioners (PCP) in its decision-making processes.

Hospitals, for the early part of Japan’s history with modern medicine, catered only to an affluent few. The government limited the funding of hospitals, restricting them to functions like training of medical students and isolation of infectious cases. Reciprocal connections between doctors in private clinics and hospitals were forbidden, thwarting the possibility of the two groups creating a strong nexus; on the other hand, a sturdy lobby of clinic-based PCPs evolved to tip the balance in favour of primary health care. The Japanese Social Health Insurance was implemented in 1927, and the Japanese Medical Association (JMA), then dominated by PCPs, was the main player in negotiating the fee schedule.

In India, on the contrary, a hospital-oriented, technocentric model of health care took early roots. Building urban hospitals through public investment enjoyed primacy over strengthening community-based, primary health care. Alongside this, a private sector with rampant, unregulated dual-practice system (doctors practising in both public and private sectors simultaneously) flourished. This allowed doctors to constitute a powerful group held together by coherent interests. This influential doctors’ community, which saw a lucrative future in super-specialty medicine, buttressed the technocentric approach, which also happened to concur with the tastes of the affluent and the middle class. This trajectory of events has had an enormous impact on the present-day Indian health care.

Focus on hospitalisation

While the well-to-do section has always rooted for ‘high-tech’ medical care, this preference has now trickled down to even the subaltern section, which lacks the wherewithal to pay for such interventions. Colossal health insurance schemes like Ayushman Bharat that harp on providing insurance to the poor largely for private hospitalisation — when the most impoverishing expenses are incurred on basic medical care — are at least partly influenced by the passionate popular demand for the so-called high-quality medical care and bespeak the deformity in the health-care system today.

The way this has affected medical manpower and its dynamics also warrants attention. It took 37 years after the landmark Bhore Committee report (1946), which highlighted the need for a ‘social physician’ as a key player in India’s health system, to finally recognise family medicine as a separate speciality — and another decade and a half to actuate a postgraduate residency in family medicine.

The highest professional body representing doctors in this country, the Medical Council of India (MCI), itself came to be dominated by specialists with no representation from primary care. There is a proposal to replace the MCI with a National Medical Commission (NMC) but the situation is unlikely to be much different with the new organisation.

The current opposition to training mid-level providers under the NMC Act 2019 is another example of how the present power structure is inimical to primary health care. Despite the presence of evidence proving that practitioners of modern medicine (say medical assistants) trained through short-term courses, like those of a 2-3 year duration, can greatly help in providing primary health care to the rural population, any such proposal in India gets robustly opposed by the orthodox allopathic community. Proposals to train practitioners of indigenous systems of medicine, like Ayurveda, in modern medicine are also met with similar opposition.

Such medical assistants, and non-allopathic practitioners, have time and again been written-off as ‘half-baked quacks’ who would only endanger the health of the rural masses. Such criticism ignores the fact that nations like the U.K. and the U.S. are consistently training paramedics and nurses to become physician assistants or associates through two-year courses in modern medicine.

Examples of U.K., Japan

Many countries, including the U.K. and Japan, have found a way around this by generously incentivising general practitioners (GPs) in both pecuniary and non-pecuniary terms, and scrupulously designing a system that strongly favours primary health care. What this careful nurturing has meant is that while a community of professionals in our part of the world has thwarted positive change, professionals of the same community in these countries have helped defend that very positive change.

Three broad takeaways emerge. One, it is imperative to actively begin reclaiming health from the ivory towers called ‘hospitals’. This could help in gradually changing the expectations of the layman and reversing the aspirations of medical professionals from being unduly oriented towards high-tech, super-specialty care. Given the current trends, however, this looks like a far-fetched possibility.

Two, we need to find a way to adequately empower and ennoble PCPs and give them a prominent voice in our decision-making processes pertaining to health care. This can create a bastion of primary health care professionals who can then fight to keep their enclave unscathed. Three, a gate-keeping system is needed, and no one should be allowed to bypass the primary doctor to directly reach the specialist, unless situations such as emergencies so warrant. It is only because of such a system that general practitioners and primary health care have been able to thrive in U.K.’s health system. In view of the current resurgence of interest in comprehensive primary health care in India, one earnestly hopes that these key lessons will be remembered.

Dr. Soham D. Bhaduri is a Mumbai-based doctor and Editor of the journal ‘The Indian Practitioner’

India’s menstrual health: End the crisis of shame

There are five areas that need attention to take up ‘safe-periods’ as a public health issue. We must look into them

Madhu (13) lives in a remote village in Northern India, and belongs to a low-income household with no toilet, and limited access to water. When she got her first period, Madhu’s mother gave her a piece of rag to manage her menses. She told Madhu, in whispers, that she was unclean, and what norms she should follow to avoid polluting the kitchen and puja (prayer) space. Following her mother’s well-meant advice, Manju began the process of endangering her health for five days, every month. She started accepting a natural body cycle as a matter of shame.

There are millions of girls like Madhu, especially across rural India. According to the National Family Health Survey 4 (NFHS-4), sanitary napkin usage in rural India is only 48.2%. In the absence of sanitary methods, women take recourse to dirty rags, ash, newspapers, and hay when they menstruate.

The health and social implications of poor menstrual hygiene are not widely appreciated. Reproductive tract infections are 70% more common among women who use unhygienic materials to manage their menses. These infections can also be passed on from pregnant woman to unborn child. Cervical cancer incidence in India is almost twice the global average and is associated with inadequate menstrual hygiene. The drop-out rate of girls in school is 23% when they start menstruating, and absenteeism is over 20% of the school year. (all data, ‘Spot On!’ report --Dasra, et al).

There are five areas that need attention to take up ‘safe-periods’ as a public health issue.

The first is to create awareness. Women’s self-help groups are widespread in many states, and often focus on savings. Health, including menstrual hygiene, needs to be part of their agenda. Menstrual health is supposed to be part of the rural school education programme — but it has to be taught to girls, and also to boys. Mothers-in-law must be counselled by the three government health workers who operate in every village.

Second, stigma must be tackled relentlessly. The cultural norm that menstruating women are in some way “unclean” and cannot enter places of worship, or kitchens must end. Until 1990, sanitary napkin advertisements were not allowed on TV — today’s media has a big role to play in fighting menstrual taboos. The movie Padman demonstrated the power of film to destigmatise the issue. TV shows like Veera incorporated the issue into their content.So far, no woman Bollywood star has championed the issue.

Third, there must be easy access to sanitary methods, and this is best done by involving the community. Locally produced napkins through women’s’ self-help groups was pioneered in Tamil Nadu. At Barefoot College, an NGO in Rajasthan, four women make enough high-quality sanitary napkins, to serve the entire village, at a cost of only Rs 11 per piece. Quality alternatives to the sanitary napkin are also needed – UNICEF has promoted the use of local, sanitised cloth.

Fourth, availability of water, sanitation and hygiene and disposal facilities are essential. Making sanitary napkins available is not adequate. Toilets are needed at home. The government’s Swachh Bharat scheme is a big step in this context. Tamil Nadu, in 2004, was the first state to address menstrual health management as part of its sanitation policies and programmes.

Fifth, school infrastructure must be made more comfortable for menstruating girls. Tamil Nadu provides separate toilets, incinerators and sanitary napkin vending machines for girls in school. Menstrual hygiene clubs increase awareness among students and teachers in government schools.

Sixth, governments must regard menstrual hygiene as much more than just a health issue. Himachal Pradesh has demonstrated how relevant and effective interdepartmental coordination can be in this context. Three government departments — health, education and rural development — have collaborated for the state-wide implementation of a menstrual hygiene programme.

The problems of menstrual health range from ignorance to infrastructure, sanitation to stigma — and more. Today, there is a much-needed national mission in nutrition. Swachh Bharat plays a pioneering mission role in sanitation. Surely, the time has come for India to also launch a national menstrual health management mission.

India’s women are enduring a crisis of menstrual health. Let’s put an end to this crisis of shame.

Ashok Alexander is founder-director of the Antara Foundation

Source: Hindustan Times, 4/08/2019

Pursuing a degree in public health after MBBS

Amongst the most plum of health-related avenues is that of Public Health, which entails all aspects of promoting and maintaining the standards of people’s health. There are specialized courses that empower and guide students for this role, the most important being MPH or Master of Public health.

Remember the simpler days when our dreams were restricted amongst core jobs such as doctor and engineer? When one’s medical journey led to either being a doctor or a medical practitioner. When opportunities post MBBS remained in restrictive categories? Apparently, the diaspora education has evolved to such an extent that life after MBBS is enriching, as various verticals of health and welfare expand to create newer positions and avenues to contribute towards the benefit of a robust future.This is a world envisioned based on demands and hence, the educational world evolving to meet these circumstances.

Amongst the most plum of health-related avenues is that of Public Health, which entails all aspects of promoting and maintaining the standards of people’s health. There are specialized courses that empower and guide students for this role, the most important being MPH or Master of Public health.

What is Master of Public Health?

The Master of Public Health (MPH) degree entails on nuances of public health practices, on both grass root and government levels. Here, students are encouraged to develop strong competencies over a set of integrated interdisciplinary domains such as Epidemiology and Biostatistics, Health Policy and Systems, Public Health Leadership and Management, Evidence-Based Policy and Health Care, Health Communication, Diversity and Culture, Program Management and Planning, Public Health Biology, Systems Thinking and Environmental Health Sciences. This degree often supplements the skill sets achieved by an MBBS course, making it the perfect post-MBBS program.

Why is Public Health important?

While the health status of the population has improved to the great extent globally in this century, a lot more needs to be done. With the evolution of the public health comes the enormity of diseases that manage to withstand the test of advancement. The public health initiatives taken by such public health officers affect mankind on a global scale. Public health professionals address broad issues that can affect the health and well-being of individuals, families, communities, societies, and countries —taking proactive measures to proceed towards a better future. Here are a few achievements that public health officers have made a reality:

Increase in life expectancies.

Reduction in infant and child mortality, at a global scale.

Eradication/reduction of deadly communicable diseases.

Career options for the future

Physicians-MPH covers preventive care and patient education- two of the most crucial aspects that every physician needs to master over. This degree provides its bearers with expertise to conduct awareness

programs among their patients, lowering the risk of chronic illnesses and infectious diseases.

Nurses-MPH program has newly inculcatedthe branch of Occupational Health Nursing, catering to this segment. Now, degree holders can oversee various community outreach programs at their facilities, while gaining a chance to work with educational institutions and nonprofit organizations in the field of public health.

Occupational and Environmental Health Specialists- MPH program changes the focus from individual specific issues to population-based problems. This makes it easier for individuals to understand the impact of the environment on the health of the community, grooming enthusiast into being the catalyst of change.

Epidemiologists and biostatisticians gain great knowledge from undertaking an MPH course. It helps them harness an understanding of diverse social, economic, cultural and religious factors that impact community health, bringing in a broader perspective into the table.

Policy analysts-Public health forms an integral aspect of public policy and programs, based on which the betterment of the world is considered. Analysts with a Masters in Public Health tend to have an in- depth understanding of health issues affecting the community, noting their impact on the political mark up.

The demand and supply

The demand of individuals holding this degree has risen, owing to the upward state of health and sanitation that contributes greatly to the well-being of the nation. To supplement this demand, eminent institutions s are uplifting the educational framework of the health domain, through its Master of Public Health (MPH) degree.

(The author is President, IIHMR University, Jaipur)

Source: Hindustan Times, 17/07/2019

We need a leap in healthcare spending

India needs to focus on long-term investment, not only episodes of care

The Central and State governments have introduced several innovations in the healthcare sector in recent times, in line with India’s relentless pursuit of reforms. However, while the government’s goal is to increase public health spending to 2.5% of GDP, health spending is only 1.15-1.5% of GDP. To reach its target, the government should increase funding for health by 20-25% every year for the next five years or more.

While the Interim Budget is responsive to the needs of farmers and the middle class, it does not adequately respond to the needs of the health sector. The total allocation to healthcare is Rs. 61,398 crore. While this is an increase of Rs. 7,000 crore from the previous Budget, there is no net increase since the total amount is 2.2% of the Budget, the same as the previous Budget. The increase roughly equates the Rs. 6,400 crore allocated for implementation of the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY).

Per capita spending on health

According to the National Health Profile of 2018, public per capita expenditure on health increased from Rs. 621 in 2009-10 to Rs. 1,112 in 2015-16. These are the latest official numbers available, although in 2018 the amount may have risen to about Rs. 1,500. This amounts to about $20, or about $100 when adjusted for purchasing power parity. Despite the doubling of per capita expenditure on health over six years, the figure is still abysmal.

To understand why, let’s compare this with other countries. The U.S. spends $10,224 per capita on healthcare per year (2017 data). A comparison between two large democracies is telling: the U.S.’s health expenditure is 18% of GDP, while India’s is still under 1.5%. In Budget terms, of the U.S. Federal Budget of $4.4 trillion, spending on Medicare and Medicaid amount to $1.04 trillion, which is 23.5% of the Budget. Federal Budget spending per capita on health in the U.S. is therefore $3,150 ($1.04 trillion/ 330 million, the population).

In India, allocation for healthcare is merely 2.2% of the Budget. Per capita spending on health in the Budget in India is Rs. 458 (Rs. 61,398 crore/ 134 crore, which is the population). (Medicare and Medicaid come under ‘mandatory spending’ along with social security.) Adjusting for purchasing power parity, this is about $30 — one-hundredth of the U.S.

Admittedly, this runaway healthcare cost in the U.S. is not to be emulated, since comparable developed countries spend half as much per capita as the U.S. Yet, the $4,000-$5,000 per capita spending in other OECD countries is not comparable with India’s dismal per capita health expenditure. The rate of growth in U.S. expenditure has slowed in the last decade, in line with other comparable nations.

The Rs. 6,400 crore allocation to Ayushman Bharat-PMJAY in the Interim Budget will help reduce out-of-pocket expenditure on health, which is at a massive 67%. This notwithstanding, per capita Budget expenditure on health in India is among the lowest in the world. This requires immediate attention.

Health and wellness centres

Last year, it was announced that nearly 1.5 lakh health and wellness centres would be set up under Ayushman Bharat. The mandate of these centres is preventive health, screening, and community-based management of basic health problems. The mandate should include health education and holistic wellness integrating modern medicine with traditional Indian medicine. Both communicable disease containment as well as non-communicable disease programmes should be included. An estimated Rs. 250 crore has been allocated for setting up health and wellness centres under the National Urban Health Mission. Under the National Rural Health Mission, Rs. 1,350 crore has been allocated for the same. The non-communicable diseases programme of the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke has been allocated Rs. 175 crore, from Rs. 275 crore. Allocation to the National Tobacco Control Programme and Drug De-addiction Programme is only Rs. 65 crore, a decrease of Rs. 2 crore. The allocation for each of the wellness centres is less than Rs. 1 lakh per year. This is a meagre amount.

History shows that where there is long-term commitment and resource allocation, rich return on investment is possible. For instance, AIIMS, New Delhi is the premier health institute in India with a brand value because of resource allocation over decades. AIIMS Delhi alone has been allocated nearly Rs. 3,600 crore in the Interim Budget, which is a 20% increase from last year. Similar allocation over the long term is needed in priority areas.

Prevention and its link to GDP

NITI Aayog has proposed higher taxes on tobacco, alcohol and unhealthy food in order to revamp the public and preventive health system. This has not found its way into the Interim Budget. A focused approach in adding tax on tobacco and alcohol, to fund non-communicable disease prevention strategies at health and wellness centres, should be considered. Cancer screening and prevention are not covered. There is no resource allocation for preventive oncology, diabetes and hypertension. Prevention of chronic kidney disease, which affects 15-17% of the population, is not appropriately addressed. The progressive nature of asymptomatic chronic kidney disease leads to enormous social and economic burden for the community at large, in terms of burgeoning dialysis and transplant costs which will only see an exponential rise in the next decade and will not be sustainable unless we reduce chronic kidney disease incidence and prevalence through screening and prevention.

Due to lack of focus in preventive oncology in India, over 70% of cancers are diagnosed in stages III or IV. The reverse is true in developed countries. Consequently, the cure rate is low, the death rate is high, and treatment of advanced cancer costs three-four times more than treatment of early cancer. The standard health insurance policies cover cancer but only part of the treatment cost. As a consequence, either out-of-pocket expenditure goes up or patients drop out of treatment.

Increase of GDP alone does not guarantee health, since there is no direct correlation between GDP and health outcomes. However, improvement in health does relate positively to GDP, since a healthy workforce contributes to productivity. We don’t mean to say that funding must be redirected from current allocations to preventive care. The 1,354 packages for various procedures in PMJAY must be linked to quality. For various diseases, allocation should be realigned for disease management over a defined time period, not merely for episodes of care. Further, the health sector must be made a priority area, like defence. Since a major innovation in universal healthcare is being rolled out, it must be matched with a quantum leap in funding. Only if we invest more for the long-term health of the nation will there be a similar rise in GDP.

Dr. T.S. Ravikumar is Director of JIPMER, Puducherry, and Dr. Georgi Abraham is Professor of Medicine at Pondicherry Institute of Medical Sciences

Source: The Hindu, 7/02/2019

Think differently about healthcare

India’s public health system can no longer function within the shadows of its health services system

In India, public health and health services have been synonymous. This integration has dwarfed the growth of a comprehensive public health system, which is critical to overcome some of the systemic challenges in healthcare.

A stark increase in population growth, along with rising life expectancy, provides the burden of chronic diseases. Tackling this requires an interdisciplinary approach. An individual-centric approach within healthcare centres does little to promote well-being in the community. Seat belt laws, regulations around food and drug safety, and policies for tobacco and substance use as well as climate change and clean energy are all intrinsic to health, but they are not necessarily the responsibilities of healthcare services. As most nations realise the vitality of a robust public health system, India lacks a comprehensive model that isn’t subservient to healthcare services.

A different curriculum

India’s public health workforce come from an estimated 51 colleges that offer a graduate programme in public health. This number is lower at the undergraduate level. In stark contrast, 238 universities offer a Master of Public Health (MPH) degree in the U.S.

In addition to the quantitative problem, India also has a diversity problem. A diverse student population is necessary to create an interdisciplinary workforce. The 2017 Gorakhpur tragedy in Uttar Pradesh, the 2018 Majerhat bridge collapse in Kolkata, air pollution in Delhi and the Punjab narcotics crisis are all public health tragedies. In all these cases, the quality of healthcare services is critical to prevent morbidity and mortality. However, a well organised public health system with supporting infrastructure strives to prevent catastrophic events like this.

Public health tracks range from research, global health, health communication, urban planning, health policy, environmental science, behavioural sciences, healthcare management, financing, and behavioural economics. In the U.S., it is routine for public health graduates to come from engineering, social work, medicine, finance, law, architecture, and anthropology. This diversity is further enhanced by a curriculum that enables graduates to become key stakeholders in the health system. Hence, strong academic programmes are critical to harness the potential that students from various disciplines will prospectively bring to MPH training.

Investments in health and social services tend to take precedence over public health expenditure. While benefits from population-level investments are usually long term but sustained, they tend to accrue much later than the tenure of most politicians. This is often cited to be a reason for reluctance in investing in public health as opposed to other health and social services. This is not only specific to India; most national health systems struggle with this conundrum. A recent systematic review on Return on Investment (ROI) in public health looked at health promotion, legislation, social determinants, and health protection. They opine that a $1 investment in the taxation of sugary beverages can yield returns of $55 in the long term. Another study showed a $9 ROI for every dollar spent on early childhood health, while tobacco prevention programmes yield a 1,900% ROI for every dollar spent. The impact of saving valuable revenue through prevention is indispensable for growing economies like India.

Problem of health literacy

Legislation is often shaped by public perception. While it is ideal for legislation to be informed by research, it is rarely the case. It is health literacy through health communication that shapes this perception. Health communication, an integral arm of public health, aims to disseminate critical information to improve the health literacy of the population. The World Health Organisation calls for efforts to improve health literacy, which is an independent determinant of better health outcome. Data from the U.S. show that close to half of Americans lack the necessary knowledge to act on health information and one-third of Europeans have problems with health literacy. India certainly has a serious problem with health literacy and it is the responsibility of public health professionals to close this gap.

Equally important is a system of evaluating national programmes. While some fail due to the internal validity of the intervention itself, many fail from improper implementation. Programme planning, implementation and evaluation matrices will distinguish formative and outcome evaluation, so valuable time and money can be saved.

The public health system looks at the social ecology and determinants focusing on optimising wellness. Healthcare services, on the other hand, primarily focus on preventing morbidity and mortality. A comprehensive healthcare system will seamlessly bridge the two.

A council for public health

A central body along the lines of a council for public health may be envisaged to synergistically work with agencies such as the public works department, the narcotics bureau, water management, food safety, sanitation, urban and rural planning, housing and infrastructure to promote population-level health. In many ways, these agencies serve to bring in many facets of existing State and federal agencies and force them to see through the lens of public health. The proposed council for public health should also work closely with academic institutions to develop curriculum and provide license and accreditation to schools to promote interdisciplinary curriculum in public health.

As international health systems are combating rising healthcare costs, there is an impending need to systematically make healthcare inclusive to all. While the proposed, comprehensive insurance programme Ayushman Bharat caters to a subset of the population, systemic reforms in public health will shift the entire population to better health. Regulatory challenges force governments to deploy cost-effective solutions while ethical challenges to create equitable services concerns all of India. With the infusion of technology driving costs on the secondary and tertiary end, it is going to be paramount for India to reinvigorate its public health system to maximise prevention. India’s public health system can no longer function within the shadow of its health services.

Ravikumar Chockalingam is a public health scholar and psychiatrist at the Veterans Affairs Medical Center, Saint Louis, Missouri

Source: The Hindu, 29/01/2019

Vaccine refusal among top 10 threats to public health: WHO

Refusal or hesitation to get vaccination against deadly diseases despite availability of vaccines is seen as one of the top threats to public health, according to World Health Organisation (WHO). The UN agency recently released a list of what it considers the top 10 threats to global health for 2019, which include air pollution, obesity and antibiotic resistance. This is the first time that vaccine hesitancy has made it to the UN agency’s list of ten biggest threats to world health. “Vaccination is one of the most cost-effective ways of avoiding disease — it currently prevents 2-3 million deaths a year, and a further 1.5 million could be avoided if global coverage of vaccination improved,” it said. In India, lack of awareness and information coupled with apprehension of adverse event following immunisation are seen as the major reasons for children not getting vaccinated. The two factors together account for around 65% of the children not getting vaccine coverage, as per government estimates. Between 2014 and 2018, India’s annual immunisation growth rate has risen to 4% from 1% previously

Source: Times of India, 24/01/2019

A Matter of Dignity

As the number of its elderly increases, India needs strategies to deal with dementia.

The 2018 WHO dementia plan focuses on the urgent need for a multi-phased approach and a multi-sectoral policy response to address the needs of people with dementia, their carers and families. The rapid increase in ageing population across countries requires national strategies to deal with age-related diseases — dementia care is becoming a significant issue.

Data from many parts of the world reveals age as a risk factor for dementia — though the debilitating condition, is not an inevitable consequence of ageing. Dementia is a form of cognitive impairment that affects memory and other cognitive abilities and significantly interferes with a person’s ability to perform daily activities. According to the WHO, it affects 50 million people worldwide; a number that is projected to increase to 82 million by 2030 and 152 million by 2050. According to some estimates, one person gets affected by dementia every three seconds.

Studies have revealed how the stigma attached to the disease leads to the social isolation of patients, their families and careers. Research has thrown light on the deterioration in the quality of their lives. There is an urgent need to treat dementia as a public health concern by raising awareness on all aspects of the disease including risk reduction, diagnosis, treatment, research, care and support for patients and care givers. The efforts of the Alzheimer’s and Related Disorders Society of India (ARDSI) and the initiatives of the Ministry of Health, based on directives of the WHO’s Global Dementia Action Plan, are directed towards that end.

Studies that draw on interactions with people affected by dementia, their families, and caregivers indicate that several of the needs of such people — social, economic or those related to health — remain unfulfilled. For instance, leave concessions at work, adaptable housing environments, adequate diagnostic facilities, treatment options,

care provisions and risk reduction measures for people with dementia are not in place. Many require psychological support, biomedical facilities, appropriate medications, counselling services and end of life care. But these are not available. The complexity of needs cutting across health, economic and social sector requires attention and policy responses.

Over a year ago, the World Health Assembly in Geneva adopted the Global Action Plan on the Public Health Response to Dementia 2017-2025. India endorsed the plan, confirming its commitment to improving the lives of people with dementia, their carers and families. The country’s commitment to Sustainable Development Goals — especially with respect to Goal 3 that deals with good health and well being — and the UN Convention on the Rights of Persons with Disabilities should push it into formulating a strategy to deal with this debilitating condition. Such a plan should incorporate public awareness campaigns and research.

As the percentage of aged people in the country increases, improving the lives of people with dementia and their families and carers must become a national priority. These programmes could be aligned with existing policies and care models.

The writer is a sociologist, gerontologist and social scientist who specialises on health issues

Source: Indian Express, 2/11/2018