Contents

Diabetes......................................................................................................................................4 Malaria........................................................................................................................................4 AIDS/HIV...............................................................................................................................4 Janani Suraksha Yojana 2005.....................................................................................................5 Accredited Social Health Activist (ASHA)................................................................................7 Integrated Child Development Scheme......................................................................................8 Child Under-nutrition.................................................................................................................8 National Family Heath Survey.................................................................................................10 National Rural Health Mission.................................................................................................11 Clinical Establishments Act......................................................................................................13 Compulsory Licensing.............................................................................................................14 Road Safety..............................................................................................................................15

1. Heath Issues in India: A note

Decadal growth of population during 1991-2001 had been 21.5 pc National Population Policy (2000) has two important demographic goals o Achieving the population replacement level (TFR: 2.1) by 2010 o Stable population by 2045 IMR is higher in rural areas (64) than urban areas (40) Neo-natal mortality constitutes nearly 60-75 pc of the IMR in various states. There is huge inter-regional divide and disparity. Kerala has life expectancy at birth about 10 years more than MP and Assam The large disparity across India places the burden poor, especially women, SC and STs

Urban Health Services Increase in the number of urban poor As per 2001 census, 4.26 crore people live in urban slums Lack of water and sanitation and the high population density in slums leads to rapid spread of infections. Eleventh FYP Reduce MMR to 1 per 1000 live births (Current: 3) Reduce TFR to 2.1 IMR to 28 per 1000 (current: 58) Reduce malnutrition among children in age group 0-3 to half its present level Reduce anaemia among females by 50 pc Improving the sex ratio

AIDS 2-3 million people in the country are living with HIV/AIDS AIDS is acquiring a female face and increasingly affecting pregnant women NACO working closely with Revised National Tuberculosis Control Programme (RNTCP) TB India accounts for one-fifth of the world incidence Every year 1.8 mn people in India develop TB Emergence of HIV-TB co-infection and multi-drug resistant TB has increased the problem Directly Observable Treatment, Short Course (DOTS)

Vector Borne Diseases National Vector Borne Disease Control Programme was initiated during the 10th plan Enhanced Malaria control project provided 100 pc support to 100 districts in 8 states

Lymphatic Filarisis remains endemic in about 250 districts in 20 states and UTs

Sanitation India accounts for 58 pc of those practicing open defecation globally: UNICEF o 54 pc of countrys population practices open defecation o

Diabetes
ICMR- India Diabetes Survey in 2011 (ICMR-INDIAB) o First truly national study done in India in the last 40 years after the last ICMR study in early 70s. o The study began in late 2008 and completed in 2010 Study in Maharashtra, TN, Jharkhand and Chandigarh o In these states and UT 14.73 mn people are classified as pre-diabetic and 11.88 mn are confirmed to be diabetic Extrapolation shows that 62.4 million people live with diabetes in India and 77.2 million people are on the threshold, with pre-diabetes What should be done? o Identify those at risk through established protocols, initiate prevention strategies, and offer good health care to diabetics

Malaria
In 1953 a national eradication campaign against malaria was launched. By 196566 malaria deaths were completely eliminated. However, the disease has made a comeback in recent years. Reasons for comeback: insecticide resistance, changes in mosquito behaviour, drug resistance in malarial parasites and lack of adequate resources to fight malaria. In its World Malaria Report 2008, the WHO estimated that there had been 10.6 million case of malaria and 15000 deaths from the disease in India during 2006. Malaria Atlas Project: The data on India is very volatile. <MAP is UK based organization founded in 2005 to develop a spatial database on malaria>

Views: India needs to get a good estimate of geographic prevalence of malaria and adopt a targeted approach.

2. AIDS/HIV
<refer Shankar notes> According to National AIDS Control Organization 2007 estimates ,out of an estimated 2.31 million people with HIV and AIDS in India, women constitutes 39% and children below 15 years stands at 7.8% Out of the 70,000 children below 15 years with HIV in India, 21,000 are infected every year through parent to child transmission. There are an increasing number of children dying with AIDS is a major concern in India. In April 2004 ART programme was launched in 6 high prevalence states of India for HIV infected people. Realising the need for extending free ART to increasing number of Children living with HIV, the paediatric AIDS initiative was launched in 2006 .The main focus was to reduce the disparity between the number of children living with HIV and AIDS and the number of children receiving treatment. However despite all the efforts by the government and civil society, sustainable access of CLHIV and families to ART centres is often limited due to several socio-economic and institutional barriers. Stigma and the resultant discrimination permeating the social milieu at various levels : within the family, community ,institutions and the society at large. Economic constraints caused by inadequate availability of financial resources in poor and child headed families resulting in ART taking a back seat. Infrastructural issues related to location of the ART centres at a long distance, insufficient number of ART centres to cater a large population. Unsatisfactory support from parents and care givers owing to procedural difficulties at ART centres. Lack of awareness about Paediatric ART and HIV/AIDS since ART was primarily adult focussed and there has been lack of child focused information, education and communication on HIV/AIDS. Lack of coordination, collaboration and convergence between agencies, depts and related programmes. Improved access to ART centres is key to fight against HIV/AIDS.It is important to design and implement intensive child-focused IEC separately targeting rural and urban population through an appropriate mix of media.It is also important to disseminate appropriate information on HIV and AIDS ,paediatric diagnosis and ART through mass media and other communication campaigns to impart correct knowledge and generate awareness across rural and urban areas. It is also imperative to expand the treatment by decentralising ART services by increasing the number of ART centres close to small and medium towns with services like HIV testing, CD4 count and prognostic support. These should be set up at strategic locations to reduce the time taken and also the expenses involved in travelling long distances to reach these centres. There should be direct referral of children from the counselling section to ART section to save them from the hassles of waiting at different counters. To further improve access, flexible timings should be introduced at ART centres to help parents and children avoid frequent absence from work and schools. There is a need for improved coordination between AIDS control societies and district health depts. There is a need to strengthen operational facilities and comprehensive package of services under one roof. All key facilities should be

brought under one roof to enhance accessibility and accountability.

Janani Suraksha Yojana 2005

The Janani Suraksha Yojana (JSY) is a centrally sponsored scheme aimed at reducing maternal and infant mortality rates and increasing institutional deliveries in below poverty line (BPL) families. The JSY, which falls under the overall umbrella of National Rural Health Mission, covers all pregnant women belonging to households below the poverty line, above 19 years of age and up to two live births. Features:

Budget of Rs 1540 crore and 9.5 million beneficiaries. It is the worlds largest conditional cash transfer scheme. Impact: Study published in Lancet shows that the programme has reduced about 4 prenatal deaths per 1000 pregnancies and 2 neonatal deaths per 1000 live births. However, antenatal care compliance is not good.

1. States/UTs classified into Low Performing States (J&K and Assam) and High Performing States. 2. Disbursement of cash incentive linked to conditions of accessing prenatal, neonatal and antenatal care and delivery in health centres/hospitals 3. Rs 600 and 700 in rural and urban areas respectively in non-high-focus states. Rs 1000 and 1400 in rural and urban areas respectively in high focus states. 4. Incentive to the ASHA (not less than Rs 200 per delivery case) 5. Assistance for Caesarean Section. Rs 1500 if government specialists not available and surgery done in private hospital 6. Payment to be made after delivery in one instalment

Accredited Social Health Activist (ASHA)

Integrated Child Development Services

43 percent of Indian children are malnourished Op-Ed: Sept 8 ICDS anganwadis are poorly managed and lack adequate facilities. In order to lay more stress on removing malnutrition following is suggested:

1. Develop new surveillance techniques using mobile technologies to allow the govt and civil society to react in real time to the changing nutrition situation 2. Creative campaigns 3. Feedback system

Child Under-nutrition
Under-nutrition causes 35pc of under-5 child deaths, impairs learning outcomes, increases the likelihood of being poor and is linked to illness or death during pregnancy India is estimated to reach its MDG nutrition indicator by 2043 o China has already met its goal, halving its 1990 rate of underweight a few years ago

Problems in government intervention

Nutrition data are collected every five to six years. This is too infrequent to track changes and respond to events Because there are so many moving parts in any nutrition strategy, the government needs to use nutrition diagnostic tools to prioritise and sequence action to improve child growth, in the way it does for economic growth This lack of data and strategic analysis also diminishes the effectiveness of Indian civil society to mobilise around nutrition.

Some suggestions

Make agriculture more pro-nutrition by focussing it more on what people living in poverty grow, eat and need nutritionally Experiment with cash based alternatives to TPDS (?) Promote community led approaches to sanitation Increase coverage of essential nutrition interventions in the context of a stronger public health system Focus ICDS resources more on children under two, on severe under-nutrition and locate centres where most needed Continue the fight against gender and social exclusion India needs national nutrition strategy with a senior leader within the government who

is empowered to implement that strategy o Successful implementation needs civil society to play its part

National Family Heath Survey

National Rural Health Mission

2005 Aims at o providing universal access to health care, which is affordable, equitable, and of good quality. o Make architectural corrections to basic health care systems o Reduce regional imbalances, pool resources, integrate organisational structures, optimise human resource, decentralise the management of district health programmes and integrate many vertical health programmes o Facilitate community participation, partnership and ownership of health and health care delivery

Challenges

Regional Variation o Regions with good health indices have shown marked improvements, while those with prior poor indices have recorded a much lesser change o Improving governance and stewardship within NRHM programmes mandates general improvement in the overall governance of States and regions Convergence of different programmes o Lack of synergy between complementary programmes focusing on rural poor like ICDS, NRHM and MNREGS o Eg. The NRHMs Village Health and Nutrition Days compete with the ICDSs well-established Anganwadi programme Parallel health systems o The idea that the States will take over the financing of NRHM after 2012 does not generate enthusiasm for long-term commitment from staff at the State and disctrict levels o Lack of integration with other programmes and systems Process and outcome indicators o NRHM currently employs process indicators to measure its implementation. The measures are mainly related to infrastructure and personnel o There is a need to shift to indicators of efficient functioning and hard data on health outcomes Need to focus on the social determinants of health such as clean water, sanitation and nutrition

Clinical Establishments Act

At a time when there is regulatory confusion and well-founded concern over the cost and quality of health care, the Clinical Establishments (Registration and Regulation) Bill, 2010 passed by both houses of Parliament is an important step forward. Provided its objective is pursued sincerely, the legislation can go a long way in empowering patients who are now forced to deal with a medical establishment that is opaque, unaccountable, and often unethical in its working. Among other things, the Bill provides for compulsory registration of all clinical establishments in recognised systems of medicine (allopathy, yoga, naturopathy, ayurveda, homoeopathy, siddha, and unani); the publication, within two years of its commencement, of a national register of establishments; and the laying down of minimum standards, also within a period of two years. By prescribing penalties for violations by private as well as public institutions, it promises to raise standards of accountability. It can also eliminate quackery. The Bill protects the regulatory role of the State administration, as the district registering authority will have the district collector and the district health officer as members. Moreover, there will be a State Council involving senior officials and medical authorities.

Compulsory Licensing
The Department of Industrial Policy and Promotion (DIPP) has draft paper on Compulsory Licensing (CL) in the Pharmaceutical sector. Through CL the government can permit a third party to produce and market patented products without the consent of the patent holder. This is required in India because:

1. Many Indian pharma companies have been acquired by multinationals. This may make the drugs more expensive. 2. Many pharma companies are export oriented. Hence the domestic prices are high.
DIPP suggests four ways of using CL to make drugs affordable in the country:

1. Invoking the provisions at the time of a public health emergency 2. Invoking the Competition Act 2002 to find out if the price or the availability of a drug is a result of an anti-competitive agreement or a combination which has an adverse effect on competition 3. A review of the foreign investment policy for pharmaceutical companies 4. Expanding the ambit of the drug pricing authority to regulate prices of a larger number of drugs than the present 74.

Road Safety
Every year, road traffic crashes kill an estimated 1.2 million people. The figure for the injured is over 50 million. The poor and the vulnerable (pedestrians and cyclists) bear the brunt. Death of breadwinners can often push the family into poverty. Highways: The highways constructed did not take into account the local reality. Most of the highways were built on existing roads connecting small towns. These highways hence go through towns, bisecting villages. Pedestrian crossings, near towns and villages, make for killing fields. The absence of overbridges and alternative roads for village traffic means that speeding vehicles compete with slow-moving farm and rural traffic (cycles, tractors, animal-drawn carts etc). Alcohol outlets along the highways encourage drunken driving. Cities: Most cities employ ad-hoc and non-uniform solutions to local road situation. Routing heavy vehicular traffic through densely populated areas, and poor and non-standardized road signs and marking also compound the problem. Lackadaisical enforcement: There is a basic lack of knowledge of road safety rules among users. Driving tests in India never examine the actual driving skills on regular roads. Seat belts in cars and crash helmets for pedal and motorbikes are not used regularly, increasing the risk of serious and fatal injury. Vehicles overloaded with people, produce and products go unchecked (or after greasing the palm of the policeman). Little respect for pedestrians rights. Road safety must be seen as a public health challenge. There is a need to seriously examine and correct lapses and inadequacies in road design and planning. Periodic fitness certification of all motorised vehicles, universalisation of road signs and enforcement of law and safety regulations are crucial. Cumulative penalties for recurrent infringements should result in temporary withdrawal of licences or a permanent ban on driving. A combination of legislation, enforcement of laws and education of road-users can significantly improve compliance with key safety rules, thereby reducing injuries.