Can health spending of 2.5% of GDP only by 2025 help achieve the goals set by India’s National Health Policy?

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The National Health Policy wants to reduce infant mortality rate to 28 per 1,000 live births by 2019.

The long awaited National Health Policy announced a few days ago proposes to raise public health expenditure as a percentage of GDP from the current 1.15% to 2.5% by 2025. The resource allocation to individual States will be linked with their development indicators, absorptive capacity and financial indicators. “There will be higher weightage given to States with poor health indicators and they will receive more resources. The Policy aims to end inequity between States. But at the same time, States will be incentivised to increase public health expenditure,” says Manoj Jhalani, Joint Secretary — Policy, Ministry of Health and Family Welfare.

The catch

While public health expenditure as a percentage of GDP will reach 2.5% only by 2025, many of the goals listed in the Policy have a deadline of 2025 and some of them even earlier.

The Policy stresses on preventive healthcare by engaging with the private sector to offer healthcare services and drugs that are affordable by all. It wants to reduce out-of-pocket “catastrophic” health expenditure by households by 25% from current levels by 2025.

The focus is on providing free, comprehensive care in primary care for the most prevalent communicable and non-communicable diseases, and increased affordability of care at secondary and tertiary care services by a combination of public and not-for-profit private providers wherever necessary. It wants to increase the utilisation of public health facilities by 50% from the current levels by 2025.

Health card roll out

The Centre is working on introducing a health card — an electronic health record of individuals. “The health card will be for retrieving and sharing health data by lower [PHC] and higher [secondary and tertiary] healthcare facilities. It will be helpful when patients move from primary to secondary or tertiary healthcare facilities,” says Mr. Jhalani. “It will be launched in six months to one year’s time. It will be launched in those States that show interest to roll it out in certain districts or across the State.”

Disease control and elimination

Like the Health Ministry’s National strategic plan for tuberculosis elimination 2017-2025 report, the Policy wants to reduce incidence of new TB cases to reach elimination by 2025. In a similar vein, the policy has set 2017 as the deadline to eliminate kala-azar and lymphatic filariasis in endemic pockets, and 2018 in the case of leprosy. In the case of chronic diseases such as diabetes, cancer, cardiovascular diseases, it envisages a 25% reduction in premature mortality by 2025.

The Policy “aspires” to provide secondary care right at the district level and reduce the number of patients reaching tertiary hospitals. For the first time, there is any mention of public hospitals and facilities being periodically measured and certified for quality.

Pipe dream

The Policy has sharpened its war on tobacco by indicating a 15% relative reduction in tobacco use prevalence by 2020 and 30% by 2025. But the most ambitious target is providing access to safe water and sanitation by all by 2020. As per January 2016 Ministry of Drinking Water and Sanitation country paper, sanitation coverage was only 48%.

Reducing IMR and MMR

Other challenging targets set by the Policy include reducing infant mortality rate to 28 per 1,000 live births by 2019 and under five mortality to 23 per 1,000 live births by 2025. According to the National family Health Survey 4, IMR was 41 in 2015-16; it took 10 years to reduce IMR from 57 to 41. Similarly, under five mortality was 50 in 2015-16 and it took 10 years to reduce it from 74. Over 38% children under five years were stunted according to the NFHS-4 report. The Health Policy wants to reduce this by 40% by 2025.

Increasing immunisation coverage

As against 62% children 12-23 months old who were fully immunised in 2015-16 according to the NFHS-4 data, the Policy has set a target of 90% by 2025. “Going up to 70% coverage is hugely a challenge of reaching the community. But beyond 70% coverage, other factors come in and it becomes a very big challenge,” says Dr. Pradeep Haldar, Deputy Commissioner — Immunisation, Ministry of Health. According to J.P. Nadda, the Union Health Minister, the Mission Indradhanush has increased the annual increase in full immunisation from 1% to 5-7%.

Published in The Hindu on March 19, 2017

Now, ‘qualified’ quacks will treat rural folks in West Bengal

quack1-optimized

“The endeavor to train quacks is not to produce doctors of sub-optimal quality for rural people but to make them as assistants to doctors,” says Dr. Abhijit Chowdhury.

If everything works to plan, health care in rural West Bengal may soon see a change for the better. Nearly 3,000 quacks — informal health-care providers with no formal medical education — are to be trained for six months. The crash course in medicine, and to be conducted by 130 trained nurses, is to begin from December 1.

The objective is to provide these informal providers with a minimum scientific understanding of human health and the dos and don’ts when those who are sick approach them. (Listen to the podcast).

 As part of medical ecosystem

“The aim is to turn the self-proclaimed, untrained village doctors into a group of skilled health workers who can deliver primary health care in villages and detect life-threatening conditions and refer patients to qualified doctors or medical facilities,” says Dr. Abhijit Chowdhury from the Institute of Post Graduate Medical Education and Research, Seth Sukhlal Karnani Memorial Hospital, Kolkata. “Uttar Pradesh has shown interest in undertaking similar work and we are doing pilot studies in Bihar and Jharkhand.”

“The endeavour is not to produce doctors of sub-optimal quality for rural people. It is an attempt to use the available health-care human resources to become assistants to doctors by providing them with some understanding of life-saving measures,” he says. “They are not as good as qualified doctors and we will teach them not to call themselves doctors but as health-care workers.”

Fully trained informal providers were found to be on a par with qualified doctors in handling cases.

West Bengal has taken the lead in providing some essential and basic training to informal providers after a novel experiment that trained quacks to correctly handle cases and compile basic checklists. The results have put to rest the long-held concerns of the Indian Medical Association (IMA) that trained informal health-care providers would violate rules with greater impunity and frequency or worsen their clinical practice. The programme was undertaken in 2013 in 203 villages in the State’s Birbhum district by the Liver Foundation in West Bengal.

Key findings

Spread over 150 hours over nine months, the programme for 152 randomly recruited informal providers led to 14.2 per cent improvement in their ability to correctly handle cases and compile basic checklists. Where the attendance was 56 per cent, it was found that the gap between qualified doctors and quacks to correctly manage cases was reduced by half. Those who had attended all the training sessions were found to be on a par with qualified doctors in handling cases. The results were published on October 7 in the journal Science; Dr. Chowdhury is one of the authors of the paper.

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An informal health provider examining a patient

“We take two definitions of correct case management — did the patient get what was needed to make them better irrespective of anything else that they may or may not get. And, what was the overall rating (taking into account necessary and unnecessary care) by a panel of three physicians, blinded from the identity of the providers. We find improvements in both; because public sector MBBS doctors give more unnecessary medicines and antibiotics, we find slightly stronger effects for the latter,” says Dr. Jishnu Das from the Centre for Policy Research, New Delhi and the lead author of the paper.

The trained providers were able to correctly manage cases in 52 per cent of interactions, while the control group that did not undergo any training could offer only over 11 per cent of “average quality or higher” treatment. Though the training had little effect on the use of unnecessary medicines and antibiotics, quacks prescribed about 28 per cent fewer unnecessary antibiotics than qualified doctors.

The trained providers would have been able to correctly manage cases nearly 26 per cent better than the control group had all the 152 providers attended all the sessions, says Dr. Das. Standardised patients who posed as patients suffering from chest pain (angina), breathing problem (asthma) or dysentery were used to evaluate how well the providers handled cases. A day-long clinical observation to evaluate clinical practice of genuine patients was also conducted.

“These three conditions cover situations where the provider must refer (angina); diagnose and possibly manage (asthma) and treat in the primary care (diarrhea). We gave the simplest possible, non-complicated case without any co-morbidities. The reason for this is that even with this very simple depictions of the cases, there are significant deficits in the quality of care, even among MBBS providers. For instance, in the public sector, 35 per cent diagnose and treat such cases wrong,” says Dr. Das in an email.

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Dr. Jishnu Das (right) with an informal health provider.

Role in primary care

The training was not restricted to these three conditions but covered a range of topics to improve their diagnostic medical skills. Since the trainers were unaware of the conditions that would be used for evaluation, the authors say that there is “some evidence” that training increased the correct management of cases for more number of conditions that quacks encounter in their daily practice.

The increased case load of trained informal providers is again proof that overall quality of care offered by them had improved. The increase in quacks’ case loads was witnessed only in those villages where qualified doctors were not available. Since 90 per cent of patients said they would seek care only from informal providers, the increased case loads of trained quacks must have been from patients switching from untrained providers to trained providers than from qualified doctors to trained quacks, the authors say.

Nearly 75 per cent of primary care visits in rural areas, especially in States such as Rajasthan, Madhya Pradesh, Andhra Pradesh and Uttarakhand are to informal providers. Since all steps to increase the number of qualified doctors in rural areas and change the health-seeking behaviour of patients have not been successful, training informal providers might be an “effective short-term strategy to improve health care in rural areas”.

Related story and link:

Quacks treat a majority of rural India

Published in The Hindu on October 9, 2016

Editorial: A model for the rest of India

Published in The Hindu on February 20, 2013

It comes as no surprise that Tamil Nadu has once again been applauded for its “excellent” maternal and child-care services by the Common Review Mission of the National Rural Health Mission (NRHM). Suffice it to say that at a time when 99 per cent of global maternal mortality occurs in developing regions of the world, Tamil Nadu, Kerala and Maharashtra have become pockets that have bucked the trend. Even as India has been reducing its maternal mortality ratio — defined as the number of maternal deaths per 100,000 live births — the rate of reduction, from 380 in 1993 to 97 during 2007-2009, has been rapid in the case of Tamil Nadu. So much so that Tamil Nadu, along with Kerala (81) and Maharashtra (104), has already achieved the Millennium Development Goal of 109 maternal deaths per 100,000 live births by 2015. Compare this with the national average — an MMR of 212 for 2007-2009, which is more than double the MDG target. The State has been able to accomplish this by taking up a multi-pronged approach. First, it has equipped all health-care settings, starting with the 1,612 primary health-care centres, with trained staff nurses available round the clock and all essentials required for safe deliveries. Second, it has through innovative and women-friendly initiatives ensured that most deliveries take place in health-care settings. According to a recent survey by the University of Delhi, institutional deliveries are as high as 99 per cent in Tamil Nadu. The national average is about 73 per cent.

More than the very high percentage of institutional deliveries, what is more significant is the percentage of deliveries taking place in government-run institutions. Nearly 67 per cent of deliveries take place in government institutions, compared to 33 per cent in the private sector. The PHCs alone account for 27 per cent; it was about seven per cent in 2005. In fact, today, PHCs face a demand-side pressure. Compare this with Kerala — where the private sector accounts for roughly 60 per cent of deliveries. The primary reason why women in Tamil Nadu are flocking to government facilities is the changed nature of health-care services being provided. As many as 105 PHCs in the State have the facilities to conduct C-sections and store blood, and their main focus is maternal and child heath care. Women-friendly services like screening and appropriate intervention for gestational diabetes, hypertension and anaemia have had a magnetic effect. But the most critical contributor has been the strong and continued importance accorded to health-care services by whichever political party is in power.

India: Appalling condition of primary healthcare services

Published in The Hindu on December 6, 2012

Suffering from unstable angina, asthma or dysentery? The chances of correct diagnosis and treatment in both rural and urban areas by private and public care providers are dismal.

The shocking state of primary healthcare services in both private and public clinics in urban (Delhi) and rural (villages in Madhya Pradesh) areas has been highlighted in a scientifically carried out study published a few days ago in Health Affairs .

What is all the more appalling is that the 305 healthcare providers tested in urban and rural India were presented with nearly uncomplicated conditions — unstable angina, asthma or dysentery — and for which there exist well established medical protocols with clear triage, management and treatment checklists developed by the government’s National Rural Health Mission. These conditions are also common in both urban and rural areas.

In rural Madhya Pradesh, correct treatment protocol was followed only about 30 per cent of the time, and unnecessary or even “harmful” treatment was prescribed about 42 per cent of the time.

That only 14 per cent of care providers “asked about pain radiation” in the case of unstable angina is indeed a cause for grave concern. Pain radiation is a typical and clear indication of unstable angina. Little wonder that some of the incorrect diagnosis for unstable angina included “gastrointestinal or weather-related problems.” Less than a third of other vital sign checks were completed in these “patients.” The results are almost similar in the case of asthma and dysentery.

Of the care providers who accounted for “80 per cent of all primary care visits from households,” only 11 per cent of rural care providers had any medical education and 67 per cent had no medical qualification whatsoever.

But it is no different in the case of Delhi. The rate of correct diagnosis was as low as 22 per cent, and at nearly 46 per cent, the rate of correct treatment was lower than the halfway mark. Even the adherence to the standard and essential care checklist was just about 34 per cent. Although private sector care providers followed the essential care checklist, the likelihood of their prescribing the correct treatment was “significantly lower.”

Dispel the notion that care providers in the private sector in Delhi are better qualified. Only 52 per cent of care providers studied in both private and public sectors had any medical degrees. 41 private providers and 23 public providers were studied.

The wrong diagnosis or failure to follow the essential care checklist does not come as a surprise as care providers in the 58 villages in Madhya Pradesh spent just about 3.6 minutes, while it was 5.4 minutes in the case of Delhi.

“In both the rural and urban setting, we found only small differences between trained and untrained doctors in adherence to the checklist and no differences in the likelihood of providers’ making a correct diagnosis or providing the correct treatment,” the paper states. “In fact, the evidence suggests that untrained private-sector providers were better in adhering to the checklist, and no worse in their treatment protocols, than their public-sector counterparts.”

What makes the study unique is that it used 22 standardised patients (recruited from local community) who interacted with 305 healthcare providers in urban and rural India.

These “patients” were trained for 150 hours to present their illness consistently to multiple care providers and to accurately recall interactions with the care providers.

The use of adult standardised patients is considered as the “gold standard in quality measurement.” The use of such “patients” avoids recall bias and does not in any way change the behaviour of doctors “treating” them. It also helps the authors to estimate the case detection rate and make comparisons between doctors.

In all likelihood, the results from the study may hold true for many other common conditions in most parts of the country — both urban and rural areas and private and public care providers.