Midwifing Efficient Healthcare

Anand Krishnan





Establish regulatory mechanisms to monitor the cost and quality of India's health system

Devi Shetty has recently argued in these columns (September 10) how red tape is strang ling the health system in India and is not allowing simple interventions which can transform healthcare to happen. Without belittling his argument, and while acknowledging his achievement as a cardiac surgeon and in running Narayana Hrudayala, let me offer a different viewpoint. I work with community health and my experience is in looking at the health care pyramid from the bottom.He starts by saying that maternal and infant mortality rates in India will not come down because we do not have skilled manpower; he recommends creation of more skilled and specialist manpower like obstetricians. However, today more than 80% of all deliveries occur in health facilities due to the government creating an enabling environment and infrastructure. There is no need for obstetricians to conduct normal delivery . Nurses and auxiliaries can conduct them with supervision of a MBBS doctor.
He makes a case for two lakh anaesthetists and gynaecologists to do 5.2 million caesarean sections out of about 26 million births annually (or about 20%).Caesarean rates should ideally be around 10% of all deliveries. As per WHO norms any rate more than 15% indicates an overuse of caesarean sections by obstetricians. Even if we assume one caesarean a day by an obstetrician working 250 days a year, for 2.5 million surgeries (10%) we will need only 10,000 obstetricians.
We do not need more obstetricians.Caesarean rates in private sector are about twice that in public sector. Having more obstetricians would result in increased competition, and more caesareans would be done.
Devi Shetty advocates equalisation of undergraduate and postgraduate seats (14,000 versus 50,000) to cover the shortfall of specialists. Any health system is built as a pyramid with a large base, which gets narrower as you reach the top. The top is of the super-specialists (cardiologists, neurosurgeons, etc). Therefore, there has to be more MBBS seats than MD seats and still lower number of DM seats.
One could argue for some increase (say 50%) but the pyramid cannot be converted into a square, as by that logic all MD physicians should super-specialise into cardiology , gastroenterology , endocrinology , etc. We could, however, proportionately increase the seats for all levels, if it is desired after factoring in India's high population.
He advocates making it easy to start a medical college and allow training in non-medical college settings. The quality of medical education, especially at undergraduate level, is an issue of grave concern to all health professionals in India. Just focussing on increasing quantity will be extremely detrimental to patients. The way medical college recognition occurs due to collusion between private medical colleges and Medical Council of India is to be seen to be believed. If at all, there is a case for stricter monitoring of quality of teaching.
To compensate for lack of doctors in the rural areas, he suggests creation of cadres of nurse practitioners or physician assistants and involving Ayush doctors by conducting bridge courses. I support this; it can be done.
Finally, he suggests micro-insurance schemes in the mould of `Yeshaswini' started by him to address high cost of care. There has been strong advocacy for India to start a national health insurance scheme. While health insurance is something that needs to happen, we need more debate around this and design better schemes.
There are three major concerns with respect to health system in India ­ access, cost and quality of care. The `five-star' hospitals have been cited as examples of excellent low cost (compared to international standards) and good quality care.Yet, there is no doubt in my mind as a doctor hailing from a middle-income group, that i would be very hesitant to get my near and dear ones treated in these `centres of excellence' precisely because of cost and quality of care considerations.
While government needs to substantially increase the allocation to health to strengthen its health facilities in quantitative and qualitative terms, the private health sector is a major player which needs to be `reined' in. In the private sector the need of the hour is accountability; both at the professional level as well as to patients.
Government has to establish regulatory mechanisms, set up benchmarks and monitor the cost and quality of care. It needs to define standard treatment guidelines or packages for different types of facilities. Consumers need to have a say in the monitoring of these facilities. We cannot depend on the charitable nature of the private sector because it does not exist. There is also great scope for professional self-regulation before government steps in.
Finally , all discourse in India on public health is restricted to health care provision. There is an enormous world outside it on which urgent actions are needed to improve health of Indians.This includes, to name a few, regulation of marketing of foods and beverages to children, working with food industry to reduce fat and salt content of processed foods and so on. Strengthening of disease surveillance systems linked to action is essential if we do not want to have our regular annual tamasha over swine flu or dengue related deaths.
The writer is Professor of Community Medicine at the All India Institute of Medical Sciences, New Delhi

Source: Times of India, 22, -09-2015

Economic and Political Weekly: Table of Contents

Politicising the Military

Vol - L No. 38, September 19, 2015 

• Editorials

Political missteps and administrative mismanagement have opened a Pandora's box.

• Read more
• 0 Comments

Munnar Upheaval

Vol - L No. 38, September 19, 2015 

• Editorials

Women workers pose questions to managements, trade unions, political parties--and men.

• Read more
• 0 Comments

Editorials Prosecution as Defence The Cobrapost expose of the Ranveer Sena calls for an overhaul of how such crimes are prosecuted in court. Read more	Commentary Andhra Pradesh's Master Plan for Its New Capital Speculation and Weak Foundations C Ramachandraiah Amaravati, the planned new capital of Andhra Pradesh, is to be set up in a highly fertile, multi-cropped area in the Guntur-Krishna belt where the water table is just 15 to 20 feet below the surface. The Government of Andhra Pradesh has been... Read more
Commentary Bank and Poverty Reduction A Critique of World Development Report 2015 M A Oommen A close reading of the World Bank's World Development Report 2015 shows that it works on the assumption that human beings generally think automatically, socially, and with mental models, and that future development policy, poverty alleviation... Read more	Commentary Child Labour Law Amendment Applying the Brakes on Social Mobility Alex George, Sameet Panda The proposed amendment to the Child Labour (Prohibition and Regulation) Act 1986 hopes to align it with the Right to Education Act, 2009. It prohibits child labour up to 14 years and regulates the employment of children between the ages of 15 and... Read more
Commentary Disentangling the Economics of Net Neutrality Vinod Kumar The debate around net neutrality in India has focused on safeguarding the rights and freedoms of using the internet, but little has been said about the economics of data transportation and pricing. This article argues that just like physical... Read more	Commentary Recalibrating Fiscal Deficit Numbers for India Siddhartha K Rastogi The fiscal deficit numbers are often managed in undesirable ways. This article recalibrates the fiscal deficit numbers for the combined finances of the centre and the states, and then for the centre in the last 10 years in which fiscal... Read more
Commentary Understanding Kalaburgi Sha Settar A tribute to M M Kalaburgi, the eminent scholar of the history of Karnataka and the language of Kannada, who was assassinated in Dharwad on 30 August. Read more	Book Reviews India's Environmental Past Meena Bhargava Shifting Ground: People, Animals, and Mobility in India’s Environmental History edited by Mahesh Rangarajan and K Sivaramakrishnan, New Delhi: Oxford University Press, 2014; pp 418, Rs 875. Read more
Book Reviews Rethinking the Bengal Partition Territories, Citizens, Identities Sudha Tiwari Partitioned Lives: Migrants, Refugees, Citizens in India and Pakistan, 1947–1965 by Haimanti Roy, New Delhi: Oxford University Press, 2012; pp xii+254, Rs 695. Read more	Perspectives Is Another Emergency Likely? K N Hari Kumar Through a discussion of the build-up to the 1975 Emergency, what happened then and thereafter, and of the run-up to the 2014 elections and the first year of the Narendra Modi government, it is argued that in spite of all its deficiencies, India... Read more
Special Articles Catastrophic Failure of Public Trust in Mining Case Study of Goa Rahul Basu Minerals are a commons, held by state governments in public trust for the people, especially for future generations. With mining, states dispose of minerals for money, and have so far lost more than half their value. As this study shows, over the... Read more	Special Articles Rural Credit Cooperatives in Maharashtra A Tale of Growing Divides Pallavi Chavan Examining the different phases of growth and distribution of cooperative credit in Maharashtra between the 1960s and 2000s, this paper tries to understand the multiple dimensions of the phenomenon in the state—across regions, crops,... Read more
Special Articles Between Daughter Deficit and Development Deficit Situation of Unmarried Men in a South Indian Community Sharada Srinivasan Drawing on research in Namakkal District in Tamil Nadu on the Kongu Vellala Gounder community, which has a history of daughter elimination, it can be seen that the effects of daughter deficit unfold, not in isolation, but amid changing economic... Read more	Notes 'Demerger' and Statehood Similarities between Gorkhaland and Telangana Bivek Tamang, Sangmu Thendup The Darjeeling Hills and surrounding areas were merged with West Bengal in 1947. This article argues that the formation of Telangana opens the door for accepting the century-old demand of the Indian Gorkhas for a separate homeland. It also argues... Read more
Discussion The Institutional Lives of Intersectionality Jennifer C Nash Continuing the debate on intersectionality (EPW, 25 April 2015 and 15 August 2015), this comment raises the issue of the institutional life of intersectionality as illustrated by women's studies in the United States.

The Need To Express Heartfelt Gratitude

Gratitude is spontaneous thankfulness to someone who has benefitted us in any manner.It springs from the heart and is sometimes expressed in words and at other times through gestures and actions. It is much more than the usual expression of thanks uttered habitually as a matter of course in a casual manner in the course of our daily interactions. When we are grateful to someone we remain always keen to return the compliment in all possible ways. It is a basic human emotion rooted in ethics and values which make us better human beings. It is highly essential for conducive domestic, social, national and international relations.

September 21 has been designated as World Gratitude Day to call our special attention as we are too selfish, indifferent or plain forgetful to express our gratitude to others. We do not count the innumerable blessings of God showered on us. We do not exhibit due gratitude to parents, teachers and those who benefit us. Shakespeare composed a complex cosmic tragedy on human relationship in King Lear on the filial ingratitude of the two daughters of the old king.Innumerable scripts of films and fiction have been written on human ingratitude. But still we are no better than what we were before as human memory is short, particularly when it comes to remembering those who help us in time of need.

Why are we so ungrateful?
Heart of hearts, we are basically egoistic. We feel that by showing gratitude to those who benefit us we would somehow compromise ourselves. Hence we find an easy escape route to be ungrate ful with a fault-finding attitude. And any fool can find fault with others.

Once, Ishwar Chandra Vidyasagar, a great educationist and benefactor of the poor was told that someone had abused him. He was surprised and said, “I do not remember to have benefitted him in any way . Why should he speak ill of me?
Only those whom I help speak ill of me.“

He never expected gratitude from anybody and profusely helped those in need or anybody approaching him for help without expectation of any kind of return.

When Jesus acquired divine healing powers he cured 10 lepers. Leprosy was an incurable disease those days.

Nine of them instantly left the place to rejoice without even thanking him. Only one of them waited to thank him.After sometime Jesus turned back and asked him, “Why are you waiting?“ He replied, “To thank you for divine healing.“

most humility Jesus said, “Don't With utmost humility Jesus said, “Don't thank me. Thank God, because His healing power has worked through me.“

Like Jesus we must not expect gratitude from others in return. But when our turn comes, following the example of the 10th man, we must exhibit the same to others in words and deeds.

In India we have a rich tradition of expressing gratitude not only to our superiors through suitable gestures, we also pay due regard to animals and even inanimate objects from which we derive benefits. This has in many cases taken the form of nature and animal worship.We worship cows as Gomata and rivers as mothers, mountains as fathers, trees and plants as nurturing deities. These are all expressions of gratitude to something from which we derive benefit.

Let's reinforce our rich tradition of expressing gratitude whenever called for and be grateful for all that we have received. (September 21is World Gratitude Day.)

Here comes the UN's Sustainable Development Goals

The Headquarters of the United Nations (UN) is an impressive complex. Its buildings are not just the repository of the world’s post-World War II history but also home to a treasure trove of artworks, each of which has a connection with what the UN’s second secretary-general Dag Hammarskjold saw as the reason for the 193-member strong body’s existence: “The UN was not created to take mankind to heaven, but save humanity from hell”.

The 70th session of the UN General Assembly (GA) opened on September 15 and this week will be one of the most important in recent times because member-states will adopt one of the most ambitious and bold development agendas of our times: The Sustainable Development Goals (SDGs), replacing the Millennium Development Goals (MDGs), which expire this year.

The UN has its own share of sceptics and the headquarters is often mocked as ‘Turtle Bay’ (after the locality where it stands) for its bureaucratic ways. Many consider the GA as a stage for leaders to make grand promises from the famous green marble podium that are often forgotten once they reach their home soil. Naturally, many have questioned why the world needs another set of development goals.

There is broad agreement among nations that while the MDGs provided governments a framework around which they could develop policies and aid programmes designed to improve the lives of the poor, they were narrow.  Second, the MDGs failed to consider the root causes of poverty and overlooked the holistic nature of development.

The MDGs made no mention of human rights and did not specifically address economic development. While the MDGs, in theory, applied to all countries, in reality they were considered targets for poor countries. On the flipside, even though the progress of MDGs has been uneven, they influenced development policy formulation and planning globally.

India has witnessed significant progress towards the MDGs, with some targets having been met ahead of the 2015 deadline. However, progress has been inconsistent. Despite an uneven MDG record, India has been in the forefront of the negotiations and the SDGs have a strong Indian fingerprint.

Many feel that the 17 SDGs are unwieldy but the general consensus is that it is better to have goals that tackle the issue of development holistically. The key question is of course, how to fund these goals.

With overseas development assistance coming down to a trickle, the nations will have to raise money from internal sources, from the private sector, through tax reforms, and through a crackdown on illicit financial flows and corruption.

It definitely won’t be an easy task but nations will have to give it their best shot for their own good.

Source: Hindustan Times, 2109-2015

40% of Indians exposed to second-hand smoke at home: WHO

Sushmi Dey

New Delhi:





Even as the government is still deliberating on larger pictorial warnings on packs of tobacco products, 40% of Indian adults are exposed to second-hand tobacco smoke at home.These are people who do not smoke themselves but are vulnerable to various diseases because someone smokes at home, showed a latest assessment by the World Health Organisation, highlighting risks of second-hand smoking and the need to warn people who smoke.
Despite India's regulation on public smoking, 30% of adults are found exposed to second-hand tobacco smoke at work, the study said.
Experts say second-hand smoking is as harmful as tobacco smoking and there is an urgent need for public awareness as well as enforcement of existing laws and regulations. In India, smoke-free public spaces cover health and educational facilities, public transport, government facilities and workplaces. However, designated smoking rooms in offices and restaurants not only create intense smoking environment but are also often attached to smoke-free spaces.
“There are architectural requirement that needs to be followed while creating even separate smoking rooms. For instance, there should be separate ventilation system,“ said K Srinath Reddy , president, Public Health Founda tion of India. He added, “There is conclusive evidence and there is no dispute that exposure to second-hand smoking is harmful for health and can lead to respiratory problems in children, cancer and heart diseases in adults.“
According to Dr Kewal Krishan, program in-charge, heart transplant and ventricular assist devices, Max Hospital, passive or second-hand smoking is particularly harmful to children and can significantly increase a non-smoker's risk of getting lung cancer.
“It can damage lungs as second-hand smoke contains over 4,000 chemicals, many of which are irritants and toxins and some of which are known to cause cancer,“ said Dr Krishan. He added that second-hand smoking may also cause fibrosis, which is a disease that causes scarring of lung tissue. As the scars thicken, lungs slowly lose their ability to move oxygen into the bloodstream and fail to deliver oxygen to vital organs.
Globally , second-hand smoke is killing over six lakh people annually , including 1.65 lakh children before they reach their fifth birthday . According to WHO assessment, 46% of adults are exposed to second-hand smoke at home in the South East Asia region.
India and other countries need to strengthen their tobacco control policies, said Dr Thaksaphon Thamarangsi, director at WHO's department of non-communicable diseases and environmental health.
Advocating smoke-free public spaces to protect those who do not smoke, Dr Thamarangsi said that joint government and public action is required to tackle the burden of diseases which can be otherwise prevented.
“Government policies and programs must focus on informing masses about the illeffects of tobacco use. Effective measures like pictorial health warnings on tobacco products must depict heart disease and stroke as real dangers of tobacco use,“ Dr Reddy said.
Tobacco kills over 6 million people every year. Besides, 22% of global cancer deaths and 10% of deaths due to cardiovascular diseases are because of tobacco.

Source: The Times of India, 21-09-2015

Maharashtra tops in number of women held for murders in 2014

V Narayan

Mumbai:





The Sheena Bora murder case, in which her mother Indrani Mukerjea is an accused, is not an isolated incident involving a woman in a serious crime. Last year, as many as 579 women were arrested for murder in Maharashtra. Although way below the number of men arrested for the same crime in the same period (5,187), it is the highest for any state.The crime report for 2014 released by the National Crime Records Bureau (NCRB) last month also places Maharashtra second and third among all states and UTs for the number of women arrested for attempt to murder and culpable homicide not amounting to murder, respectively . Maharashtra also tops 36 states and UTs for women arrested under all types of offences.
In the list of women arrested for murder, Maharashtra was followed by Uttar Pra desh (472), Karnataka (330), West Bengal (317) and Madhya Pradesh (316). The report said that the maximum number of crimes were committed by women in the 30-45 age group, followed by those between 18 and 30 years.
According to the report, 194,867 women were arrested across 36 states and UTs, of which 30,568 were from Maharashtra. The latter figure is nearly double that of UP (17,437). Rajasthan (16,187), Gujarat (14,152) and Bengal (12,181) follow.
In Maharashtra, 95,174 women were arrested in the 20122014 period. The charges covered a wide spectrum: murder, attempt to murder, culpable homicide not amounting to murder, rape, attempt to commit rape, kidnapping and abduction, dacoity, dacoity with murder, preparation for dacoity , robbery , burglary , theft, unlawful assembly , riots, breach of trust, cheating, forgery , co unterfeiting, arson, grievous hurt, dowry death, assault on woman with intent to outrage her modesty , cruelty by husband and relatives, importation of girls, causing death by negligence, offences promoting enmity between different groups, extortion, disclosure of identity of victims, rash driving or road rage, human trafficking and unnatural offences.
Mumbai police spokesperson DCP Dhananjay Kulkarni said, “Very few women manage to give up crime after release from prison; 99.9% of them turn into hardened criminals. Many form gangs specialising in pick-pocketing, theft and economic offences.“
A study done by S P Singh for the NCRB in 2004 on involvement of women in violent crimes stated that in the past too experts have concluded that the increasing incidence of violence by women shows that they have a natural capacity to be as violent as men.

Source: The Times of India, 21-09-2015

What is Dengue?

According to the World Health Organization, Dengue is a vector-borne disease transmitted by the bite of an infected female Aedes Aegypti mosquito. The mosquito becomes infected when it feeds on the blood of a person infected with the virus. After about one week, the mosquito can then transmit the virus while biting a healthy person.

How many strains of dengue are there?

There are 4 serotypes of the virus that causes dengue. These are known as DEN-1, DEN-2, DEN-3, DEN-4. Infection with one strain will provide life-time protection only against that particular strain. However, it is still possible to become infected by other strains and develop into severe dengue.

Can it spread from person to person?

Dengue cannot be spread directly from person to person. However, a person infected and suffering from dengue fever can infect other mosquitoes. Humans are known to carry the infection from one country to another or from one area to another during the stage when the virus circulates and reproduces in the blood system.

Where does dengue happen?

Most cases occur in tropical areas of the world, including the Indian subcontinent, Southeast Asia, Southern China, Taiwan, the Pacific Islands, the Caribbean,    Mexico, Africa, Central and South America.

What are the symptoms of dengue?

Dengue causes flu-like symptoms and lasts for 2-7 days. Dengue fever usually occurs after an incubation period of 4-10 days after the bite of the infected mosquito. High Fever (40°C/ 104°F) is usually accompanied by at least two of the following symptoms: headaches, pain behind eyes, nausea, vomiting, swollen glands, joint, bone or muscle pains and rash.

What happens in severe dengue?

Severe abdominal pain, persistent vomiting, bleeding gums, vomiting blood, rapid breathing, fatigue/ restlessness.

What is the treatment for dengue?

There is no vaccine or specific medication for dengue fever. Patients should seek medical advice, rest and drink plenty of fluids. Paracetamol can be taken to bring down fever and reduce joint pains. However, aspirin or ibuprofen should not be taken since they can increase the risk of bleeding.

Patients who are already infected with the dengue virus can transmit the infection via Aedes mosquitoes after the first symptoms appear. As a precautionary approach, patients can adopt measures to reduce transmission by sleeping under a treated net especially during the period of illness with fever.