Social Justice- Health Sector

Issues related to the provision of Social Sector Services

Privatization of Health Sector

NITI Aayog and Health Ministry has mooted the ideas of incorporating a PPP model into the provision of health services by allowing private hospitals to run select services within district hospitals by leasing out portions
The select services included are treatments for cardiac disease, pulmonary disease and cancer care
PPP model would improve accessibility to specialized health care
PPP model would provide a mechanism for private sector to engage with the public utilising government facilities and infrastructure of district hospitals. A viability gap funding by the state government needs to be set up for this.
Private parties would share ambulance services, mortuary services and blood banks with the district hospitals while public hospitals benefit from superior quality of human resources as well as increased capital of private players
It would ensure timely diagnosis and detection of diseases reducing regional disparity in provision of such services

Concerns

Health being a state subject, NITI Aayog has limited advisory powers and hence a top-down approach may not be suitable for a subject in the state list
Increased privatization may lead to further commercialization of the health sector- only BPL and insured patients would be provided access to free health care thus ignoring the majority of the population.
Private parties would be able to cherry-pick districts with individuals who have high paying capacity thus widening the existing regional disparity in the provision of quality health services
Handing over public healthcare services to private sector reflects the inefficiency of public health care services and abdication of governments duty from providing free healthcare to all citizens

HIV AIDS UNAIDS REPORT

India has a high percentage of HIV patients in the world and HIV cases have been reported in new areas of the country
India is a vital supplier of generic antiretroviral drugs to world pharmacies and hence a coordinated approach on innovation, intellectual property rights and public health is required to tackle AIDS at the global level particular in low and middle-income countries
UNAIDS focuses on achieving the 90-90-90 target: 90% diagnosed, out of them 90% provided ART and out of those provided treatment 90% are virally suppressed

HIV AIDS Response by the Govt through AIDS (Prevention and Control Bill)

Prohibition of discrimination towards HIV patients in provision of education, health facilities, employment, housing and other such services. Any violation of this right due to unfair treatment vetted out to HIV patients will amount to punishment.
All HIV patients under the state are guaranteed access to preventive, testing, medical and counselling care including ART which is the key feature of the bill aiming to attain 90-90-90 target.
The state government is required to employ an ombudsman to address grievances relating to the violation of the act
The status of HIV patients shall not be disclosed unless by a court order

HIV and Hepatitis C Twins

Similar to HIV, HCV can be transmitted through needles, inadequate sterilisation of needles and by sexual interaction
Call for integrating HCV into National HIV Control Programme
Health experts argue that twin testing facilities should be made available for HIV and Hepatitis C as cases of Hepatitis C have been commonly observed mainly in HIV patients
Early detection of the disease can enable easier treatment with the availability of drugs
A common infrastructure facility would be a win-win for both the government as well as the public in terms of cost and accessibility

Built-up Drug resistance

Overuse of antibiotics – Bacteria evolves to resist antibiotics – Government currently addressing the overuse by introducing red line medicines to discourage sale and consumption of antibiotics
Unnecessary antibiotic usage among livestock
Discharge of effluents from pharmaceutical industries
Improper control on infection
Lack of hygiene: A government report Scoping Report on Anti-microbial resistance in India have proved that mass bathing in the Ganga has caused anti-microbial resistance to build-up
India faces a challenge of MDR TB and its resolution as a part of the Revised National TB Control Programme
Currently concerns regarding resistance to antiviral drugs used for treatment of swine flu
Similar to antibiotic resistance these drugs are antiviral in nature and their uncontrolled usage will build up resistance
Government has decided to take off 2 drugs used or treatment of Swine flu from the restrictive Schedule X of the Drugs and Cosmetics Rules meaning that they are easily available rendering them vulnerable to misuse
Antibiotic resistance is also cited as a roadblock in the treatment of the sexually transmitted disease Gonnorhea by WHO

India’s fight against MDR TB

According to WHO, India has 1.7 million new TB cases reported in 2016 and so a decline of 12% TB deaths from last year although there was a 5% increase in new cases (Improved diagnosis?) reported.

India also has a 90-90-90 target in TB ( 90% reduction in disease incidence, mortality and catastrophic expenditure)

India’s policy aimed at achieving this target is centred around improved diagnostics (using GenXpert devices), short term treatment courses (shifting to daily regime from thrice weekly),improved availability of bedaquiline and delamanid and comprehensive preventive strategies (improved nutrition, sanitation and hygiene)

India follow the DOTS (Directly Observed Treatment Short Course) strategy recommended by WHO

Prevention

Mutual cause effect relationship between TB and malnutrition. People with malnutrition are predisposed to contracting TB and TB itself can result in under nourishment
Need for provision of nutritional assistance for economically vulnerable TB patients through markets and other alternatives like CSOs facilitating access to low cost fortified foods
National Strategic Plan (NSP) brought out by the government with an aim to eliminate TB by 2025 focuses on addressing nutritional insecurity of TB patients
Under nutrition contribute to 55% of TB incidence in India

Diagnosis

Detection of the disease is key with regard to TB
India lags behind in detection as most of the public and private sector still make use of smear microscopy which is an ineffective method as it can detect only 50% of TB cases.
Xpert machines which are better equipped to diagnose TB are not proficiently available within the country; India’s procurement of GeneXpert (a multi-disease detection device) however, is a welcome step to address the same.

Treatment

When it comes to treatment, India follows the thrice weekly treatment regimen contradictory to WHO’s recommendation of all day treatment; the thrice weekly treatment regime helps build up drug resistant TB.
Lack of availability of bedaquiline and delamanid which are currently WHO recommended drugs to fight MDR TB. Currently these drugs are available only in select cities of the country.

National Strategy Plan to Eliminate TB by 2025

Detect-Treat-Prevent-Build Approach

Achieve zero deaths by 2025

Detection

Focus on early detection of TB cases, both drug-sensitive and drug-resistant in patients without waiting for them to voluntarily get tested
Using highly sensitive diagnostic tests to ensure that all cases are identified and ensure universal testing for drug-resistant TB

Treatment

Reaching out to patients seeking care from private doctors and target high-risk populations
Seeks to make daily regimen universal which is currently followed only in 5 states; elsewhere the thrice weekly treatment regime continues
Provide anti-TB treatment to all patients seeking the same and put in place soical support systems for patients
Rapidly upscale availability of bedaquiline and delamanid
Facilitating nutritional support to TB patients
Incentivize private sector doctors to notify cases
Sending customized SMSes to improve drug compliance

Prevention

Prevent emergence of TB in susceptible populations

Paediatric TB

Rise in MDR TB in children
Early diagnosis and detection is important to provide treatment
Drug susceptible TB can be resisted with Fixed dose Combination drugs(FDCs) hence their availability and children’s accessibility to them should be ensured with special focus on targeted areas where TB cases are high
Use of expert machines to detect TB is a welcome step as it is more efficient compared to the spear microscopy method used earlier
All household contacts of a TB patient, including children needs to be monitored, tested and put on treatment if required

Actions of Regulatory Authorities

National Pharmaceutical Pricing Authority (NPPA) had recently regulated the price of cardiac stents
NPPA now aims to define an upper limit on orthopaedic implants as they constitute huge margins with many opting to stay away from surgery due its expensive nature for patients and insurers
Regulation of prices by NPPA can have the negative effect on research activities in areas associated with the medical product
Price capping will improve affordability for patients and will initiate a competition as demand for implants rise
Different body parts will have implants priced at different rates and hence arriving at a price cap would be a challenge

Telemedicine Project

Central government has adopted Odisha’s successful telemedicine project model
Has enabled to eliminate regional disparity and provides access to treatment for patients particularly in rural and underserved communities
E-medicine platforms are set up in government run Primary Healthcare Centres(PHCs), community health centres and sub-divisional hospitals
Telemedicine projects have created employment opportunities for local youth as they are trained in e-health assistance after which they receive loans to start e-health centres in PHCs
These centres have electronic database storing records of patients for future use

Generic Drug Prices Deflation

Price reduction improves affordability of medicines for patients
Effect of increased competition among drug manufacturers to improve efficiency of production and cut prices of their drugs
Concurrent to decreasing demand for drugs hence can be interpreted as a sign of a society that is becoming more healthy
Reduces profitability of generic drug manufacturing companies
Can be discouraging for researchers in the field of drug production

Kala-Azar

Vector-borne disease that India has not been successful in reduction (only 30% reduction)
India accounts for half the global burden of Kala-Azar
Endemic to Bihar, Jharkhand, U.P and West Bengal
Parasitic disease transmitted by carrier called Sand Fly
Being a disease of the poor, adequate sanitation facilities need to be provided to eradicate Kala-Azar
Use of malarial insecticide DDT was found to be efficient in controlling the disease
Built up drug resistance to SSb injection meant that fatality rates increased and stopped India’s efforts at eliminating the disease
NVBDCP has issued directives to ASHA workers for local surveillance in endemic regions to look for patients with visible symptoms of Kala-Azar for identification and early treatment
A rapid diagnostic test called rK39can and new drugs have aided the fight against Kala-Azar
PKDL refers to dormant parasite within patients even after cure of the disease that can be a future source for transmission of the disease

Mental Health Sector Challenges

India adopted a National Mental Health policy in 2014 and passed the National Mental health Act in 2017. Although these acts and policies are forward looking and progressive, the challenges in mental health sector remain reflective of the main challenge in the rest of the health sector – financing

Other than Gujarat and Kerala, no other states have a standalone mental health policy
Financing of mental health sector is very low in most states resigned to less than 1
Under National Health Mission, the states are entitled to receive funds for mental health sector under Non-Communicable Diseases- but states have largely refrained from making productive use of such a provision from a centrally sponsored scheme
Overall lack of state level action plans- defining activities for implementation, budgetary allocation, timelines, lack of monitoring agencies and indicators for gauging outcomes

Mental Healthcare Act, 2017

Aims to provide mental healthcare and services for persons with mental illness
Seeks to ensure that mental patients lead a life of dignity without being discriminated against or harassed

Definition of Mental illness

A substantial disorder of thinking, mood, perception and orientation of memory which impairs judgement, behaviour, capacity to recognize reality or ability to meet ordinary demands of life + Mental Conditions associated with alcohol or drug abuse.

It does not recognise mental conditions that are a result of underdevelopment of the brain or sub-normality of intelligence

Features of the Bill

Ensures that all individuals would have the right to treatment for mental illnesses in hospitals or clinics run or funded by the government
Guarantees free treatment to BPL and homeless even if they do not possess BPL card
Recognizes the right of the individual to live with dignity and to not be discriminated against
Right to confidentiality of the person with respect to mental health, mental healthcare and treatment vetted out to him
Photograph of the person cannot be released to the media without his consent

Treatment

The individual can choose his preferred mode of treatment and a nominal representative with the care giver given the option to deviate from the chosen mode of treatment after making an application to Mental Health Board to review/cancel the advance directive.
A medical practitioner following the advanced directive of the patient shall not be held liable on any unforeseen circumstance
Electro-convulsion shall not be done without administering anaesthesia or muscle relaxation. It shall strictly not be performed on minors
Patients shall not be chained and physical restraint may be used only if necessary

Mental Health Authority

The Bill empowers the government to set up Central and State Mental health Authorities. These bodies are responsible for:

Registration, Supervision and Maintenance of all mental healthcare establishments in the state
Registering all mental healthcare practitioners
Standardisation of quality norms for provision of mental health care services
Making the practitioners aware of the provisions of the Act
Receive complaints with respect to provision of services and appropriately take action after enquiry
Advice state governments on matters of mental health

Decriminalizing Suicide

A person who attempts suicide shall be considered to be a patient suffering from mental illness and shall not face punitive action under IPC
The state shall in such a case would be liable to provide care and treatment to such a person to reduce the risk of recurrence of attempt to suicide

Drawbacks of the Act

Definition of Mental Health Professional: The definition of a mental health professional does not include psychotherapists and psychoanalysts
Lack of clarity on Advance Directive: The Act fails to provide for full list of treatment options which enables individuals to take a decision without information asymmetry. The advance directive is not subject to approval by a competent authority
Expert Committee Clarity: Neither act or rules define constitution, procedure and terms of reference of the expert committee mandated to review and effective implementation of the Act. Greater transparency is required for such a body.

Swachch Bharat Abhiyan Gramin

Implementing individual household latrines to improve sanitation and achieve open defication free coverage – IHHL and ODF are pillars of the programme
Verification and implementation of SBM(G) parameters using geo-tagging and capturing Aadhar details

Swachh Bharat Gramin

Positive Outcomes of the Mission

Increased toilet construction within households (individual household latrines) and schools and its usage
It enhanced sanitation facilities for rural people thus reducing vulnerability to health hazards like diarrhoea, encephalitis and other water borne diseases by progressing towards the eventual aim of open defecation free villages
Emancipated dignity of women within households and also encouraged attendance of girl students in schools

QCI’S Empirical Evidence

QCI carried out Swachh Survekshan Gramin Survey, 2017 to monitor construction and usage of toilets in households with geo-tagging of households
QCI survey provided evidence to a dramatic improvement in construction and usage of toilets evidence of a discernible behavioral change among rural people
The survey found that toilet coverage has doubled and in comparison to 2011 census, households without toilets constitute only 32% down from 69%
9 in 10 rural households that have access to toilets are actually using it evidence for the behavioral turnaround

Swachh bharat has created a healthy competition between villages, states, cities and districts with public health and hygiene being the ultimate victor. A palpable change is visible in rural areas as evidence collected by QCI suggests. We should continue the combination of infrastructure readiness with impact measurement and people’s movements to achieve maximum potential of the mission.

The costs of public health crisises far outweigh the cost of fixing it and hence it is imperative that Swachh bharat powers on reducing vulnerabilities by enhancing public health and hygiene.

Possible Question

Swachh Bharat Gramin has been successful in overcoming the behavioral aversion among rural population in using sanitation facilities. Evaluate.

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