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

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“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

Non-communicable diseases killed more Indians in 2015

 

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Cardiovascular diseases were the leading cause of deaths in males and females in India in 2015. And high systolic blood pressure was the number one risk factor.

In 2015, India, like other developed countries, had more number of deaths caused by non-communicable diseases. In the case of males, deaths due to non-communicable diseases (3.6 million) were more than double that caused by communicable diseases (1.5 million), while it was nearly double in females (2.7 million due to non-communicable diseases and nearly 1.4 million deaths due to communicable diseases, neonatal, and nutritional diseases). Globally, 70 per cent (40 million) of deaths in 2015 were due to non-communicable diseases.

Cardiovascular diseases were the leading cause of death in both sexes in India — 1.6 million in males and 1.1 million in females. The next biggest cause of deaths was chronic respiratory diseases — 0.68 million in males and 0.5 million in females.

These are some of the Global Burden of Diseases results (here, here, here, here, here, here,  and here) published in seven papers in The Lancet on October 6.

Injuries killed 0.6 million males and 0.3 million females in 2015 alone. India had the highest number of suicide deaths in the world last year, with nearly 132,000 deaths in men and over 76,000 deaths in women. At 0.36 and 0.31 million, neonatal disorders killed nearly equal number of males and females. The other leading causes of deaths last year in both sexes were ischemic stroke, haemorrhagic stroke, TB, lower respiratory infections and diarrhoea.

India had the highest number of suicide deaths in the world in 2015.

Slower reduction in MMR

Along with Nepal and Bhutan, India has registered a slower reduction in maternal mortality rate (MMR). The MMR was reduced by a little over 50 per cent in 25 years (1990 to 2015), from over 130,000 deaths in 1990 to nearly 64,000 deaths in 2015.

In 2015 alone, the number of under-5 deaths in India was 1.26 million. The number of stillbirths alone was 0.53 million. “India recorded the largest number of under-5 deaths in 2015, at 1.3 million (1.2–1.3 million), followed by Nigeria (726,600) and Pakistan (341,700),” says a paper in The Lancet. Neonatal pre-term birth complications, lower respiratory infections, diarrhoeal diseases and measles were some of the leading causes of under-5 mortality.

The rate of under-5 deaths was 48.9 deaths per 1,000 live births. For every 1,000, live births there were 29.06 neonatal deaths (0-27 days after birth), 20.25 stillbirths, 11.74 post-neonatal (28 days to 1 year) deaths, and 8.80 deaths during the 1-4 years.

The Janani Suraksha Yojana conditional cash transfer programme was established when increasing number of women sought reproductive health services. “[The programme] has been successful at increasing reproductive health-care services, but even despite its popularity this programme has not been as effective at reaching poor rural women, the sociodemographic group that is already at highest risk of adverse pregnancy outcomes,” a paper notes.

Leading risk factors

For both sexes, the leading risk factors are high systolic blood pressure, fasting plasma glucose, ambient particulate matter, household air pollution, and unsafe water. According to The Lancet, smoking is a bigger risk factor for Indians than even cholesterol and iron deficiency. Childhood under-nutrition and lack of whole grains figure in the list.

Iron-deficiency anaemia is the leading cause for years lived with disability in the case of India, followed by lower back and neck pain, sense organ diseases, and depression.

Published in The Hindu on October 6, 2016

Quacks treat a majority of rural India

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In rural Madhya Pradesh, 49 per cent of health-care providers had no formal medical training. yet, they accounted for a majority of services provided to people.

The compulsion to improve the level of competence of private health-care providers with no formal training in rural areas has once again been highlighted by a survey of over 23,000 households in 100 villages in Madhya Pradesh

On average, people had access to 11 health-care providers in a village. Seventy-one per cent of these providers were in the private sector but only 51 per cent had any formal medical training. In terms of primary care visits, the private sector accounted for 89 per cent, of which 77 per cent visits were to the providers who had no formal training. In contrast, only 11 per cent of all primary care visits were to the public health sector and only 4 per cent were to providers with an MBBS degree.

Despite the fact that availability of primary care centre in the public sector and the competence of doctors in the public sector improved with village size and socioeconomic status of households in a village, doctors in the public sector spent only 2.1 hours a day seeing patients as there were fewer patients per provider. This is despite the fact that doctors with formal training were relatively more competent as they exhibited higher correct diagnosis and correct treatment rates than health-care providers who were trained in alternative medicine and those without any training whatsoever.

The results of a study were published on October 5 in the journal Health Affairs.

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Only 30 villages had a doctor with an MBBS degree (private or public sector) and only 31 villages had access to a public primary care centre. In contrast, quacks were present in all but one village. Eighty-eight of the hundred villages had access to at least three quacks.

The study found that the socioeconomic status of a village and not household determines the quality of care that people receive. Households with low socioeconomic status located in villages with high socioeconomic status were able to access more competent health care providers. But households with low socioeconomic status located in villages with low socioeconomic status access low quality care. “Poor people living in poor communities are especially deprived of high-quality health services,” the authors write.

“Providing public care in scattered rural outposts is a very costly option. Even if the government were to staff these posts, the number of patients would be so low that doctors may effectively provide care to only five-six patients a day,” says Jishnu Das, a senior visiting fellow at the Centre for Policy Research, New Delhi and the first author of the paper. Imparting training to improve the competence of providers in the informal sector and providing villagers transport to seek care from health care providers located in larger towns are viable alternatives, the authors say.

Published in The Hindu on October 5, 2016

Gender bias: fewer girls get cardiac care in Punjab

male-OptimizedA retrospective study involving 519 school-children from various areas of Punjab has revealed that gender bias exists with parents favouring boys over girls when it comes to getting their children’s heart problems corrected, even when treatment is provided completely free of charge.

The children were diagnosed with either congenital or rheumatic heart disease. Of those who were referred for cardiac intervention, only 195 (37.6 per cent) were girls, while the remaining 324 (62.4 per cent) were boys.

Gender bias was apparent for all ages of children and seen in parents from both rural and urban communities. In fact, the discrimination was greater in the case of urban communities with the ratio of male to female patients being 1.71:1 for urban setting compared with 1.64:1 in the rural setting.

The results have been published today (May 26) in the journal Heart Asia.

Children were diagnosed with heart problems during a screening programme carried out under the National Rural Health Mission between 2009 and 2014. Since the prevalence of congenital heart disease is nearly the same in both the sexes, relatively fewer girls being brought to tertiary care centres and even fewer of them undergoing corrective procedures reflected a strong gender bias, the study said. Also, the average enrolment of girls (46 per cent) in schools was slightly lower than for boys (54 pr cent).

“The data suggests that economic and financial reasons are not the only factors leading to gender discrimination and inequity in healthcare,” writes  Dr. Shibba Takkar Chhabra, the corresponding author from the Dayanand Medical College & Hospital. And this discrimination existed in both urban and rural communities.

Gender bias
While economic reasons were cited for gender-based differences in accessing healthcare among the adult population, this study revealed that “gender bias affects the health-seeking behaviour of parents for their female children even when the medical services are provided free of cost.”

“The deep-rooted social issues (beyond just the economic causes) need to be addressed by medical professionals as well as policymakers to ensure equal access to healthcare for both genders,” the authors write.

Published in The Hindu on May 26

Editorial: Shoring up public healthcare

Published in The Hindu on January 1, 2011

The world’s growing riches seem to make little difference to over 100 million people globally as they slide into poverty every year because of healthcare costs. One of the unsolved conundrums in many countries is the inability to provide for universal healthcare coverage, despite economic growth and development. While the financial consequences of illness are severe for many in poorer countries that do not have appropriate systems in place, those in richer nations are by no means immune from this malady. Researchers at Harvard have made the point that illness or medical bills were behind 62 per cent of personal bankruptcies in the United States in 2007. In India, high spending on health is a major reason for people sliding into poverty. Inadequate state delivery systems mean India’s private expenditure on health accounts for 72 per cent of the total health expenditure. Moreover, with poor re-financing options, a staggering 89.5 per cent of this private health expenditure is met out of pocket, from the immediately available funds of individuals. Coming up with viable financing methods, therefore, is an urgent requirement for many countries, including India. The World Health Organisation makes a timely intervention by calling for reforms in the way nations finance healthcare in its World Health Report — Health systems financing: the path to universal coverage.

Any policy that aims at reducing personal financial burden related to healthcare should focus on bringing down the direct payments by the individual. This means a change in who pays for healthcare, now borne overwhelmingly by individuals in countries that have weak government-paid healthcare systems. The question of ‘who-else-should-pay’ gives itself two choices globally: integration of provision and payment, which calls for a lead role by governments; and an institutionally separate agency, say, an insurer or a government body that pays for healthcare on behalf of individuals. In India, there has been an increase in the share of private insurance to meet private health expenditure, up from 1.1 per cent in 1995 to 2.2 per cent in 2008. But this is no substitute for the state’s role in providing basic, affordable healthcare. The report’s suggested domestic options for innovative financing — for instance, diaspora bonds, and a minimal tax on foreign exchange transactions in currency markets (0.005 per cent in the case of India) — are timely as they could help governments fund better state-provided healthcare. Revenues raised from such measures should be used for putting in place strong and affordable delivery systems, particularly in the two important areas of primary and preventive healthcare.