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

Low measles-rubella vaccination coverage may cause more cases of congenital rubella syndrome

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There is a great need to increase measles-rubella combination vaccine coverage in Tamil Nadu.

Only about 50 per cent of children aged nine months to 15 years in Tamil Nadu have been vaccinated by the measles-rubella combination vaccine since the campaign was launched. Unless and otherwise the vaccination coverage is increased to over 90%, there is a high possibility that the State would witness more rubella infections among older age groups. This would, in turn, lead to an increase in the number of newborns with congenital rubella syndrome (CRS) — hearing impairments, eye and heart defects and brain damage –  miscarriage and even infant deaths when  women get infected with rubella virus during the early stage of pregnancy.

Paradoxical increase in CRS

“When the rubella childhood immunisation coverage in communities is sub-optimal, there will more number of CRS cases than before as the infection shifts to an older age group. This is called the paradoxical increase in CRS,” says Dr. Jacob John who is co-chairman of the India Expert Advisory Group for measles and rubella. “There will be fewer CRS cases initially (one-three years) after immunisation. But in four-five years, as the infection shifts to an older age group, there will be more CRS cases than before.”

“In order to avoid this we need high coverage during both the campaign and the universal immunisation programme (UIP),” he says. There is a compulsion that the UIP becomes more efficient than before. “The national average for immunisation coverage is 72%. The country and the States have been stagnating. It’s a tall order that all States achieve above 95% coverage. This is an unprecedented requirement for UIP,” says Dr. John.

“The measles-rubella vaccination coverage in Goa is over 90%. In the case of Karnataka it is 87-88%. Tamil Nadu is struggling at 50%,” says Dr. Pradeep Haldar, Deputy Commissioner — Immunisation, Ministry of Health and Family Welfare, Government of India. “Karnataka has been able to handle the crisis of misinformation about the safety of the combination vaccine by adopting several strategies, while Tamil Nadu has been struggling.” As a result, the duration of the campaign in Tamil Nadu was extended by 15 days to cover more children in the nine months to 15 years age group.

“Of the 35 million children targeted in the five States [Karnataka, Tamil Nadu, Puducherry, Goa and Lakshadweep] we have already vaccinated 23 million children. If there were any concerns about vaccine safety we would have already seen it by now. But we have not seen any. So the vaccine is safe and the fear is unfounded,” stresses Dr. Haldar.

Problem with low coverage

Greece and Brazil witnessed the paradoxical increase in CRS due to shift of age distribution of rubella cases. In 1993, a “major rubella epidemic took place [in Greece] affecting women of child-bearing age at a rate higher than in previous years,” says a 1999 paper in the BMJ. Following the rubella epidemic, Greece saw the largest number of babies born with CRS.

In Greece, during the later 1970s and the 1980s, rubella vaccination coverage remained “consistently” below 50% and did not reach 50-60% before 1990. As a result, the proportion of pregnant women susceptible to rubella showed a steady increase — from 12% in 1971-75 to 24% in 1984-89 to 36% in 1990-91.“In 1993, the mean age of patients with rubella was 17 years and 64% were 15 years or older,” says the paper.

Published in The Hindu on March 4, 2017