Care home delivered

M Suchitra/ Kochi

The palliative movement, Neighbourhood Network in Palliative Care, and started in 2001, has proved a tremendous success in Kerala's primary healthcare sector

unique home-based palliative and chronic care movement is sweeping through Kerala. Thousands of trained citizens are volunteering two hours a week to take care of the chronically ill in villages and cities. Funding for this community-based scheme that has won WHO recognition comes in cash and kind from citizens, including schoolchildren, bus drivers, labourers and others.

The windowless room is dark and dingy, and smells of urine and medicines. For a few moments nothing is discernible. Then, the frail skinny form of 35-year-old Velayudhan lying on a cot becomes faintly visible. Velayudhan is paralysed from the waist down after a fall from a coconut tree five years ago. His twig-like arms and legs stick out from under the sheet covering him. There are sores all over his body. He is all alone in his hut, and looks depressed and gloomy.

"How do you feel today," asks Nishita, a trained nurse working with the Koilandy Palliative Care Society in Kerala's Kozhikode district, with a gentle smile. She and another volunteer, Anitha, start emptying the bedpan, dressing the sores, changing the condom catheter that allows Velayudhan to pass urine, checking the medicines on a nearby table, and dusting the bed -- all the while chatting with him affectionately.

"I can't even imagine what would have happened to me without these volunteers," says Velayudhan in a weak voice. "I would have died long ago." He says the volunteers even help feed him when his wife, a domestic helper, is away on work. According to Nishita, Velayudhan suffered from acute depression and even displayed suicidal tendencies. He recovered only after prolonged counselling by the volunteers.

The palliative movement, called the Neighbourhood Network in Palliative Care (NNPC), and started in 2001, has proved a tremendous success in Kerala's primary healthcare sector. It is a silent social revolution that's spreading fast from village to village, city to city. Participants include schoolchildren, senior citizens, labourers, doctors, farmers, housewives, and even the police.

Under this new initiative, thousands of trained volunteers from different backgrounds spend at least two hours a week on homecare visits, running out-patient clinics, organising family help, and raising funds. Besides dressing wounds and sores, they sit with patients and listen to their problems and fears. They also listen to the concerns of family members and train them in simple nursing tasks like catheterisation. All NNPC volunteer groups are supported by trained doctors and nurses.

The community-based palliative movement was an outcome of the realisation that patients with chronic and incurable diseases need long-term psychological, social and emotional attention alongside medical and nursing care. Each district is estimated to have over 20,000 bedridden patients. The existing hospital-centred services are designed mainly to look after people with acute illnesses; medical institutions alone cannot take up the responsibility of looking after chronically ill patients for very long. Moreover, even the limited services available are not accessible to most, especially the poor.

"The NNPC is an attempt to develop a sustainable, community-led service focusing on the long-term home-based total care of patients with chronic and incurable diseases," says Dr K Sureshkumar, director of the Kozhikode-based Institute of Palliative Medicine (IPM), which spearheads the movement. "The NNPC is a volunteer-driven movement that tries to empower local communities to take care of their own chronically ill patients." Doctors play only a secondary role in the movement.

Born in the early-1990s, the palliative care movement was clinic-based and served only terminally ill cancer patients until it took a major turn, in 1998, with the establishment of a palliative society at Nilambur, in Malappuram district. K M Basheer, a farmer with formal education only up to Class X, and two years experience as a volunteer in another clinic, took up the leadership. Basheer was perhaps the first non-medical person in the world to head a pain and palliative care unit.

He, along with a few friends, went around the locality identifying terminally ill patients. "There were many chronically ill people with all sorts of diseases, apart from cancer," he says. "Most of them were very poor. Prolonged treatment and huge medical bills had broken their families. We had to address the social and financial needs of the families too." Basheer and his team approached as many people as possible for assistance. Everybody was willing to help in one way or another. In just one year he had 60 trained volunteers; the following years he had many more.

With the success of the Nilambur initiative other units were opened in the district; within two years they had achieved 70% home-based palliative care.

Slowly, the movement spread to the neighbouring districts of Kozhikode and Wayanad, and further. Thousands of people volunteered their services. Following the massive community support, a network of palliative societies (the NNPC) was formally launched in 2001.

"It was a spontaneous evolution, not planned by any single individual," says Dr Mathews Numpeli, programme executive of the NNPC. "Many volunteers have much better administrative and organisational skills than the average healthcare professional."

The NNPC has now grown into a huge network of 150 palliative clinics, supported by 10,000 active trained volunteers, 85 doctors and 270 nurses who look after around 25,000 patients at any point of time. Malappuram district alone has 29 palliative care societies, 25 of which have their own clinics with paid part-time doctors, auxiliary nurses and their own homecare vehicles.

Each unit serves four to five village panchayats. Though, initially, the programme focused on patients with advanced cancer, it now includes geriatric problems, degenerative neurological disorders, chronic infectious diseases and chronic psychiatric illnesses.

Thanks to the initiative, the districts of Malappuram, Kozhikode and Wayanad all enjoy around 70% coverage in palliative care; palliative care coverage in Kerala is 20%, in the rest of the country it is just 1-2%, says Dr Anil Kumar Paleri, honorary secretary of the India Association of Palliative Care. He adds: "Under the watchful eyes of the community, the quality of palliative care has also improved." The NNPC's main problem is non-availability of full-time doctors trained in palliative care.

Since most patients are extremely poor, volunteers often have to financially support their families and provide rice, provisions, clothes, books and fees for schoolchildren. "We divide the patients into very poor, poor, middle class and well-to-do groups," says V M Ramla, who has been working as a volunteer in Malappuram district for 15 years. "The first two groups are given all sorts of support. The other two groups are usually provided only medicines, nursing care and emotional support." All services -- including doctors' consultations and medicines like morphine -- are free of cost for all sections of people.

Easy funding

Funding has never been a problem for the NNPC. Most funds come from the community itself through small donations. These may be Re 1 a day, or even less. Tens of thousands of ordinary people -- labourers, headload workers, autorickshaw drivers, government employees, teachers, even schoolchildren -- make small donations to keep the movement going. In Nilambur, for example, the four-person crew of each bus that enters the bus stand donates 50 paise a day. Each day, roughly Rs 500 is collected from this source alone. Employees contribute Rs 10 on salary day, students save Re 1 a month, headload workers leave whatever small change they can spare at the end of the day; even toddy shops have donation boxes!

"On an average, Malappuram district raises Rs 10 lakh every month," says Dr Mathews. "After the initiation of the NNPC there has been a ten-fold increase in funds available for palliative care."

Besides money, support comes in other forms too. Panchayats, municipalities and corporations contribute to the initiative. Individuals and shopkeepers donate rice, provisions, clothes, books and uniforms. Many families keep aside a handful of rice every day. "The Omni we use was donated by a well-wisher," says 27-year-old T K Muhammed Younus, a marketing manager by profession who heads the Koilandy Palliative Society in Kozhikode district.

"People are willing to support us because they know they are the beneficiaries," says Basheer. "They know where the money comes from and where it goes. Everything is transparent." These small donations are not only a stable and sustainable source of support, they are also feedback from the community on the functioning of the NNPC.

Policy matters

Recognising the importance of palliative care, the Kerala government -- in a first for any government in Asia -- came out with a palliative care policy in April 2008. The policy emphasises a community-based approach to palliative care and considers home-based care the cornerstone of palliative care services. It also highlights the need to integrate palliative care with primary healthcare.

"The government has formulated a detailed action plan," points out state health secretary Dr Viswas Mehta. "The emphasis is on training professionals and non-professionals, including volunteers, in setting up palliative care services both in the public sector and in the community, integrating palliative care into the activities of panchayats, and making essential drugs, including morphine, available."

In tune with the state policy, National Rural Health Mission (NRHM) Kerala has started a project for the development of community-based healthcare services for bedridden, elderly, and terminally ill patients. "The Rs 4 crore project is the largest palliative care project in India," explains Mohammed Saif, state manager of the palliative care component of the NRHM. "Also, this is the only palliative project under the NRHM in India." The project aims at awareness and capacity-building among local self-government officials, healthcare professionals, local politicians and students.

Kerala has already integrated the services of around 26,000 ASHAs (accredited social health activists) with the community-based palliative care units. No other state has done this so far, Viswas Mehta points out.

The success of the NNPC has motivated local self-government institutes to come forward with new initiatives. The Malappuram district panchayat has formulated a joint homecare programme with NNPC groups, called Pariraksha (protection), for all chronic and terminally ill patients in the district. The programme, implemented through primary healthcare centres (PHCs), will support 20,000 chronically ill patients, according to Salim Karuvambalam, health standing committee chairman of the district. Gram sabhas too have become more active now, and local bodies consult the NNPC whilst formulating health projects. A stage has been reached where no political party can ignore the people's health movement.

The Kerala model of palliative care has won global recognition, with the World Health Organisation (WHO) promoting it as model for developing countries.

But can the model be replicated in other parts of the country? "Adopting the same model might not work," says Dr Paleri. He points out that Kerala has achieved total literacy and has a high level of social and political consciousness. Caste-class-religious differences are minimal, compared to other states in India. But, Paleri points out, such community-based efforts could be taken as examples and new models developed for other places.

Making healthcare affordable

Sopan Correpondent

Rural India deserves better as many residents can now afford better facilities

There is a huge gap between demand and supply in rural healthcare in India. Although at present rural healthcare needs are met limited government facilities and private nursing homes, there has been no further enhancement of health care infrastructure in the rural areas. People by and large depend on quacks. The quality of infrastructure is usually poor and people end up having to go to nearby large cities if they need high-quality care.

Rural India deserves better, since the ability to pay has gone up over the last few years, driven by growth in income and penetration of government healthcare programmes like the Rashtriya Swasthya Bima Yojana (RSBY). Increasing demand, combined with the failure of existing infrastructure to scale, has resulted in rural healthcare being a large under-served market.

Absence of a viable business model prevents conversion of the huge rural expenditure on health into an economic activity that generates incomes and serves the poor. It is this gap that entrepreneurs such as Sabahat Azim are looking to plug.

He founded Glocal Hospitals with M Damodaran, the former chairman of market regulator Sebi, to take quality healthcare deep into rural areas through a large network of hospitals. Sequoia Capital invested in Glocal early last year and we have learnt the opportunities and challenges in healthcare delivery in rural areas.

Many times the talk of rural healthcare centres around "affordability". Rural India is in fact not looking for "affordable" healthcare; it is looking for "high-quality" healthcare provided in a costefficient manner.

Whether they live in urban or rural areas, people value health and are willing to spend within their stretch budgets to get the best healthcare service possible. This was our first significant learning at Glocal: to succeed in rural India, one needs to provide high-quality healthcare that is as good as what is available in urban India.

The real challenge of rural healthcare is in being able to provide high-quality care at a price point that provides maximum access to the rural population. That is, a price-point that can work towards expanding the market opportunity. This is critical for the model to be financially self-sustaining. At Glocal, we believe this is possible but not unless there is a radical change in how you design the healthcare delivery model. Taking the urban model and cutting it down to suit rural areas is not the right approach.

The Glocal team has followed three critical design principles that we believe are essential ingredients to creating a scalable and sustainable healthcare model: Glocal decided to focus on a zerobased approach to design and costing. Glocal started designing its delivery model with a clean sheet of paper. We studied the common disease types across the country and tried to design a solution that catered to more than 90% of the disease occurrences.

Our focus was on reducing capital expenditure per bed by focussing on a smaller subset of disease types and providing high clinical excellence in those versus servicing all disease types.

Our two hospitals today have been constructed for under `8 lakhs per bed, including land, building, equipment and doctor residences.

Instead of being a doctor-driven model, Glocal aims to be a protocol-driven model facilitated by doctors. While good doctors are the core of any healthcare service, protocols allow for ensuring good quality care that is independent of the skills of the doctor and reduces errors.

Glocal's model uses technology extensively to ensure operations can be lean across both the clinical and administrative aspects of healthcare delivery.

This improves both accuracy and efficiency of healthcare services at their hospitals. Technology is also being used to access highquality specialists who may not be physically located at the hospitals.

Most private sector health businesses have to learn how to create long-term viable models; they are still stuck with cost-plus models which increase patient expenditure without commensurate benefit.

From a category perspective, all of us should fervently hope that the Glocal team succeeds.

Glocal's success will hopefully inspire other entrepreneurs to step in; the eco-system clearly needs more such sustainable and longterm models.

Hospitals fleecing poor patients

Sangita Jha/ Hisar

Health care has become very expensive with mushrooming private and corporate hospitals indulge in unethical practices to rob the gullible people of their money and peace. Insensitive doctors stoop down to any extend and indulge in unethical practices to make moolah.

Two years ago 66-year-old Bhateri Devi of Hisar in Haryana proudly showed triplets that she had given birth to at a controversial infertility centre. Foreign scribes scrambled to speak to her, who struggled even to understand Hindi, as Bhateri Devi was declared the oldest woman in the world to give birth. Amid the euphoria, an information officer of the Haryana state government in New Delhi took pains to convince Delhi-based journalists headed to Hisar to take a detour to check the fate of another old woman, after giving birth to a baby girl, was on her death bed.

A trip from New Delhi to Hisser will easily surprise anyone at the score of infertility centres dotting on the roadside. Bhateri Devi was also told by one such infertility centre, that she no longer needs to bear the taunts of being infertile. After being cajoled for over three months, she and her land-owning husband opted for the services and became proud parents a year later. But the information office wanted scribes to check the fate of Rajo Devi Lohan in Hisser only, who was dying after giving birth to a baby girl. Lohan had accused her infertility centre for not explaining the risks associated with such exercise.

Medical services in the last two decades have emerged as top business in India. Not only infertility but scores of ailments afflicting people in the hinterland of the country have made the superspeciality hospitals dotting the metropolis cities to rope in executives to bring the patients for treatment. Superspeciality hospitals having been established by corporates in metropolitan cities need supply of patients in big number too to keep them in the business.

In a country where the government had been negligent to focus on the primary health sector, it surprises to see mushrooming of so many superspeciality hospitals.

"Initially the superspeciality hospitals were confined to four metropolitan cities but they have branched out in state capitals. These hospitals are luring patients who should ideally have been going to primary health centres of the state governments. However, the governments in state or at the Centre have been callous in attending to the needs of primary health centres, which could be gauged from the fact that not only doctors and paramedics are most often found missing from them, they even do not have the basic facilities," said a senior doctor of the RML hospital in New Delhi.

A senior medical practioner confided that the recent spurts in super speciality hospitals setting up health camp in the rural areas is in reality the very modus operandi to enlist patients for them. "Once in a month these hospitals put up health camp in rural areas within a distance that the patients could make if they were suspected to be suffering from any ailments for further treatment. These health camps are without any high-end medical equipment to conduct most of the medical tests. Suppose they examine 100 patients in one day, they will ask 20 of them to come to their hospitals for further tests after telling them that they had symptoms which needed close examinations and tests. This is the real motive of setting up of health camps by superspeciality hospitals," he explained.

However, it must be stated that there are some genuine NGOs too which in true spirit of the social service also sets up health camps in rural areas for free heath check ups. One of such NGO associate said that they not only take doctors along with them but move most of the medical equipment to conduct on the spot tests so that the patients need not go anywhere after the check up. "Our experience tells us that if we examine 100 people we fined 20 suffering from minor ailments for which we give medicine right there, while there are only one or two cases, which would require further examination for which we recommend them to go the nearest government hospitals," said an associate of one NGO active in setting health camps in rural areas.

He, however, further explained that it's tough to stick to pure social service. "It's tough to get doctors to accompany for such health camps. Since we do not serve the purpose of the big private superspeciality hospitals, the monetary incentive for the doctors to undertake such a health cap is not there. Hence, even doctors from among the friends make excuses after one such trip," said the NGO associate in Hisser.

What should ideally have been the case? There should have been a good network of primary health care owned by the government and equipped by good young doctors, whose rural posting for a couple of years in the beginning of their career should be compulsory, in the rural and semi-urban areas. These centres in turn should refer patients to hospitals higher in their hierarchy for complicated cases. But such a chain does not exist, which is clearly exploited by agents of the privately owned superspeciality hospitals.

If putting up health camp is one way of luring customers to the business of the superspeciality hospitals, the foreigners in India constitute another lucrative business with the help of students pursuing various courses from such countries.

"There is a well oiled network of foreign students who have access to the medical history of the foreigners staying in India who are tricked into consulting doctors for any ailments, which in fact is the beginning of their exploitation by such hospitals with students-turned-agents making huge commission big enough to keep the business going," stated a doctor based in New Delhi.

Doctors do take pledge for the services to the humanity but they too have been clearly corrupted due to the allures of the huge money which could be made through some tweaking with their ethics. The corporate culture with a network of agents surviving on the commission has heralded a new wave of enlisting patients, who, otherwise, would have happily been treated at their own places had the services been in place.

As one medical practioner explained, that the healthy network of primary health centres in rural and blocks followed by secondary health centre at the district centres backed with tertiary health centres at state capitals should have kept the system and society healthy. But, he added, the link is broken, and people's trust in the government run centres being low, there is a whole world for the greedy people to exploit, which flourish with non-existent cheks as well.

It's true, fake drugs flooding markets

Sangita Jha/New Delhi

You can contest the figures rolled out by pharma lobby, but that doesn't mean the scare is baseless. Spurt in crackdown shows spurious drug industry is growing.

While the government is of the view that the spurious drug size is as low as 0.04 per cent, spate of arrests made by police in various parts of the country tell a different story. Also, there is a section which is of the view that spurious drug scare is being exaggerated by the lobby of the multi-national companies.

Notwithstanding difference of opinion in the government and the pharma community, there appears a clear case that a large number of patients across the country are being taken for a ride. What is worse is that someone having bought a counterfeit electronic product may just rue the fact that he has been fleeced of his hard earned money, the victims of spurious drugs in some instances may pay with his life as well. So, there is no difference of opinion that spurious drugs can kill.

The Central government on the basis of a study conducted by the Ministry of health which had a sample size of 6000 chemists across the country maintains that the spurious drug size in the country is as low as 0.04 per cent. However, the industry experts peg it to be anywhere between 10 per cent to 30 per cent. Clearly, the range is quite wide and one can take liberty to come to his conclusion, that the actual spurious drug size could be anywhere between the government and industry's estimates.

Critics of the health ministry's findings question if the chemists would keep the spurious drugs on the shelf at their shops to invite the censure. The sample of the study conducted by the ministry of health was on the basis of random shopping of medicines done at 6,000 chemists. The critics do have a point that an organised racket of spurious drugs could have a modus operandi to escape the ambit of the study of the health ministry.

Delhi and the National Capital Territory Region (NCR) are considered the conduit for the distribution of the spurious drugs across the country. A number of arrests by the police in the national capital have revealed that the manufacturing base of spurious drugs is spread from the western Uttar Pradesh to the neighbouring areas of Haryana, Punjab and Himachal Pradesh. In fact, the Minister of state for home affairs Mullappally Ramachandran had informed the Parliament in a written answer that 10 people were arrested in 2011 for involvement in the production and distribution of spurious drugs in Delhi, while two cases of spurious drugs production and distribution racket were registered in the national capital last year. He had stated that there were five such cases in 2010 and six cases in 2009, while in 2008 there was just one case.

Mr Ramachandran's statement in the Lok Sabha does point to one clear indicator, that cases of spurious drugs being registered by the police are on the rise. And also that there could be a bigger network of those involved in the manufacture and distribution of spurious drugs evading the eyes of the police.

The industry on the other hand is of the view that the low estimate of the government of spurious drugs could also be due to the definition of counterfeit. In fact, Tapan Ray, director general, Organization of Pharmaceutical Producers of India (OPPI), had earlier stated "anything that is not genuine is counterfeit". Section 17 of Drugs and Cosmetics act 1940 specifies that spurious, adulterated and misbranded are counterfeits. Regulators do not agree on definition of counterfeits.

Many pharmaceutical companies manufacture drugs at third party facilities. When the pharma companies squeeze margins, third party manufacturers resorts to diverting additional production to market without original manufacturer name and selling at lower price because of lack of marketing costs. These are called legal counterfeits by the pharma experts.

However, Mr Ray had suggested three-pronged approach to fight against spurious drugs by way of legal enforcement, consumer awareness and deterrent to seller, and technology to differentiate between genuine and fake.

India has put in place a strong legal safeguard against menace of spurious drugs. The ministry of health and family welfare has notified and implemented the "Drugs and Cosmetics (Amendment) Act, 2008", significantly increasing the penalty for manufacture of spurious or adulterated drugs. The amended Act enhances the penalty for manufacture of spurious drugs to a minimum imprisonment of 10 years, which may extend to a life term, and a minimum fine of Rs 10 lakh or three times the value of the drugs confiscated, whichever is higher. And it makes the offence non-bailable in some cases.

While the legal mechanism has been put in place, the industry is of the view that the government should encourage whistleblowers along with enough safeguards to ensure that those indulging the trade of manufacture of spurious drugs are apprehended with no loss of time.

A glance at the number of arrests made by Delhi police in the last year may alarm of the people at large of the extent of the spurious drugs' reach. For example, police raids carried out at central Delhi's medical wholesale market, Bhagirath Place, and subsequently also in Agra on June 3 and June 6 respectively yielded spurious drugs worth Rs 8 lakh drugs worth Rs 34 lakh. The police later said that a total of 115 different kinds of drugs were being sold without any licence by this gang. Racketeers may have stamped the spurious medicines with the names of different government agencies to authenticate them so that people will assume that these medicines are genuine and purchase them, DCP (crime) Ashok Chand, who had led the raiding team, had said.

Worst part was that almost the entire lot recovered from Agra turned out to be expired drugs. They were pushed into north Indian markets after recycling. Worse, a senior official of a pharmaceutical company, who accompanied the raiding party, told the police that 45 ampoules of seized 'Susten 100' injections, used by pregnant women, were also spurious. Other medicines included those meant to cure heart ailment and diabetes.

In another catch, the police busted a spurious drugs manufacturing unit in Uttar Pradesh and stumbled upon fake drugs worth more than Rs 1 crore. Following interrogation of those arrested, the police seized huge quantity of reputed antibiotics and pain-killers worth more than Rs 1.37 crores. The police later said that following tip-off they nabbed 92 boxes of Voveran. Among the seized items were 26 lakh spurious tablets of diclofenac sodium, 14,000 spurious Voveran tablets, 600 empty boxes of Voveran, 25 empty boxes of Nor TZ, one strip packing machine, a tablet printing machine, two dye rollers, 11 rubber stamps and 4,500 Novartis stickers among other things. Delhi police officials maintain that there exists network of racketeers which ship the spurious drugs from the northern parts to as far as West Bengal, Orissa and Bihar.

The spurious drugs not only threaten the prospects of an industry worth Rs 75,000 crore by revenue but at the same time put the lives of a large number of patients at risk. Therefore, the government and the industry need to join hands in finding a solution to the menace by giving top priority to the safety of the patients.

मृत्यु का सालाना महोत्सव

मनोज कुमार सिंह/ गोरखपुर

नवम्बर की 24 तारीख को संतकबीर नगर जनपद के चार वर्षीय सौरभ ने गोरखपुर के बीआरडी मेडिकल कालेज के एपीडेमिक हास्पिटल में दम तोड़ा तो आंकड़ों के लिहाज से वह 590 वां व्यक्ति था जिसकी मौत इस वर्ष इंसफेलाइटिस से हुई है। यह आंकड़े सिर्फ बीआरडी मेडिकल कालेज गोरखपुर के हैं। अक्टूबर के आखिर तारीख तक भारत सरकार के स्वास्थ्य मत्रालय के अधीन काम करने वाले नेशनल वेक्टर बार्न डिजीज कन्टोल प्रोग्राम ने पूरे देश से एईएस व जेई से होने वाली मौतों के जो आंकड़े जुटाए हैं उसके अनुसार अब तक देश में इस बीमारी से 844 मौतों हो चुकी हैं। इसमें यूपी में सर्वाधिक 462 मौतें हुई हैं। इसमें भी सबसे अधिक पूर्वी उत्तर प्रदेश यानि कि गोरखपुर, महराजगंज, सिद्धार्थनगर, बस्ती, संतकबीरनगर, देवरिया, कुशीनगर आदि जिलों में लोग इस बीमारी के शिकार हुए हैं। आंकड़े बताते हैं कि देश के 16 राज्यों में एईएस और जेई का प्रकोप है जिसमें से चार राज्य सबसे ज्यादा प्रभावित हैं। इनमें यूपी, आसम, बिहार और तमिलनाडू हैं।

इस वर्ष बिहार और असोम में बड़ी संख्या में इंसेफेलाइटिस से मौते हुईं हैं। बिहार में मगध क्षेत्र में अखबारी रिपोर्ट के मुताबिक 200 से अधिक मौतें हुई हैं हालांकि सरकारी आंकड़ा अभी 64 की संख्या बता रहा है। इसी प्रकार असोम में अक्टूबर माह तक इंसेफेलाइटिस से 250 लोगों की मौत हुई है। इस तरह हम देखते हैं कि इंसेफेलाइटिस का प्रकोप और प्रसार और ज्यादा है और इसका मुकाबला करने की सरकारी तैयारी उतनी ही कमजोर है। यहां बताना जरूरी है कि डब्ल्यूएचओ के गाइड लाइन के अनुसार दिमागी बुखार से मिलते-जुलते लक्षणों वाली सभी बीमारियों को अब एक्यूट इंसेफेलाइटिस सिन्डोम यानि एईएस की श्रेणी में रखा जाता है। जापानी इंसेफेलाइटिस यानि जेई क्यूलेक्स विश्नोई प्रजाति के मच्छर के काटने से होता है और इसके वायरस की पहचान हो चुकी है और इसको रोकने के लिए टीकाकरण बहुत प्रभावी उपाय है। केन्द्र सरकार पिछले पांच वर्ष से प्रभावित राज्यों में जापानी इंसेफेलाइटिस का टीका लगा रही है। यह टीका 1-15 वर्ष के बच्चों को लगाया गया है। चीन से आयात किए गए इस ठीके को लगाने से जापानी इंसेफेलाइटिस की रोकथाम हुई है। गोरखपुर के बीआरडी मेडिकल कालेज में इस वर्ष इंसेफेलाइटिस के 3489 मामलों में से 183 में जापानी इंसेफेलाइटिस की पुष्टि हुई है। शेष मामले इंसेफेलाइटिस के अज्ञात वायरसों के हैं जिनकी पहचान नहीं हो पाई है। अभी सिर्फ दो वायरसों इन्टेरोवायरस 76 और काक्सेकी की ही पहचान हो पाई है। विशेषज्ञों के मुताबिक इनमे से अधिकतर वायरस गंदे पानी में पाए जाते हैं। देश के ग्रामीण क्षेत्रों में लोगों को पीने के पानी की जो स्थिति है, उसके देखते हुए इस बीमारी की रोकथाम में बहुत मुश्किले हैं।

अक्टूबर माह के अंत में केन्द्रीय स्वास्थ्य मंत्री गुलाम नबी आजाद ने गोरखपुर के बीआरडी मेडिकल कालेज का दौरा किया और यहां भर्ती मरीजों को देखने के बाद कहा कि केन्द्र सरकार इस बीमारी से निपटने के लिए मंत्री समूह गठित करेगी। उनकी घोषणा के मुताबिक मंत्री समूह गठित हो गया है। साथ ही उन्होंने यूपी सरकार पर आरोप लगाया कि वह इंसेफेलाइटिस से प्रभावित इलाकों में लोगों को पीने का शुद्ध पानी मुहैया नहीं करा रही है।

इंसेफेलाइटिस के इलाज को लेकर केन्द्र और प्रदेश सरकार में आरोप-प्रत्यारोप का यह दौर नया नहीं है। यदि सरकारों ने आरोप-प्रत्यारोप में अपनी जितनी उर्जा खर्च की है, उसका इस्तेमाल इस बीमारी से निपटने मे लगाया होता तो कुछ हद तक कामयाबी मिल सकती है। लोगों को याद होगा कि मुलायम सरकार के समय राहुल गांधी ने गोरखपुर का दौरा करने के बाद मच्छरों पर अंकुश लगाने के इरादे से छिड़काव के लिए हेलीकाप्टर भेजने की बात कही थी। हेलीकाप्टर आ भी गया लेकिन राज्य सरकार ने उसका इस्तेमाल करने से इंकार कर दिया। इसको लेकर ,खूब बयानबाजी हुई। दो वर्ष पहले यूपी में टीकाकरण के लिए आए वैक्सीन रखे-रखे खराब हो गए और उसका इस्तेमाल नहीं किया गया। इसको लेकर मायावती सरकार और केन्द्र सरकार में खूब आरोप-प्रत्यारोप हुए; राज्य सरकार ने एक्सपायरी डेट के टीके भेजने का आरोप लगाया तो केन्द्र सरकार ने कहा कि यूपी सरकार ने टीकों का इस्तेमाल करने में देरी की। यह स्थिति आज भी बनी हुई है जबकि स्थिति दिन ब दिन खराब होती जा रही है। मुलायम सरकार ने इंसेफेलाइटिस से मरने वालों और विकलाग होने वाले लोगों को मुआवजा देने की घोषणा की थी। एक वर्ष यह मुाअवजा बंटा भी लेकिन मायावती सरकार ने इस मुआवजे पर रोक लगा दी जबकि यह एक बहुत राहत देने वाला फैसला था क्योंकि इस बीमारी से अधिकतर ग्रामीण क्षेत्र के गरीबों के बच्चे शिकार होते हैं। उनके पास इलाज के लिए पैसे नहीं होते।

वर्ष 2005 में गोरखपुर में इंसेफेलाइटिस से 1500 से अधिक मोते हुईं तब जेई के रोकथाम के लिए टीकाकारण का काम शुरू हुआ। उसी समय यह बात सामने आने लगी थी कि जापानी इंसेफेलाइटिस के अलावा जलजनित इंसेफेलाइटिस के मामले अब ज्यादा आ रहे हैं लेकिन सरकार अब जाकर इस बीमारी के प्रति थोड़ी सचेत हुई है। जापानी इंसेफेलाइटिस पर रोकथाम आसान था कि क्योंकि इसके वायरस की पहचान हो चुकी थी और यह भी पता था कि टीकाकरण कर इस बीमारी पर बहुत हद तक अंकुश लगाया जा सकता है लेकिन टीकाकरण का निर्णय 2006 में लिया गया। जापानी इंसेफेलाइटिस का प्रकोप पूर्वी उत्तर प्रदेश में 1978 से था। जब इसके टीकाकरण का निर्णय लिया गया तब तक सरकारी आंकड़ों के अनुसार 12 हजार से अधिक बच्चे इस बीमारी से जान गंवा चुके थै। इस तरह की घातक लापरवाही अब यदि जलजनित इंसेफेलाइटिस में की गई तो पूर्वी उत्तर प्रदेश में तबाही आ सकती है।

एईएस और जेई की रोकथाम के लिए कुछ फौरी और कुछ दीर्घकालीन कार्यवाही किए जाने की जरूरत है। पहला यह कि बीआरडी मेडिकल कालेज गोरखपुर को इस बीमारी के इलाज के साथ-साथ शोध के केन्द्र के रूप में आवश्यक संसाधानों से लैस किया जाए क्योंकि पूरे देश में सबसे अधिक मरीज इलाज के लिए यहीं आते हैं। वर्तमान समय में यहां इलाज की ही मुकम्मल व्यवस्था नहीं है। जितनी बड़ी संख्या में यहां पर मरीज आते हैं, उनके लिए बेड व अन्य जरूरी संसाधनों की कमी पड़ जाती है। एक एपीडेमिक वार्ड बना जरूर है लेकिन वह भी पर्याप्त नहीं होता क्योंकि एक समय में यहां 400 से 500 मरीज यहां भर्ती रहते हैं। इतनी बड़ी संख्या में मरीजों के इलाज के डाक्टर व पैरामेडिकल स्टाफ की जरूरत भी पूरी नहीं है। दूसरे अस्पतालों से कुछ माह के लिए डाक्टर व पैरामेडिकल स्टाफ यहां भेजे जाते है। जरूरत पर्याप्त संख्या में डाक्टरों व पैरामेडिकल स्टाफ की तैनाती का है। इस बीमारी विकलांग हुए बच्चों के पुनर्वास व इलाज के लिए भी ठोस पहल करने की जरूरत है। तीसरा कदम इस बीमारी के प्रति लोगों केा जागरूक करने मे उठाना चाहिए। इस दिशा में एक छोटा कदम एक डाक्टर ने उठाया है। डा आरएन सिंह इंसेफेलाइटिस उन्मूल अभियान के चीफ कैम्पेनर हैं। उन्होंने कुशीनगर जनपद के एक गांव होलिया में लोगों को इंसेफेलाइटिस के प्रति जागरूक करने के लिए गोद लिया। यहां पर इंसेफेलाइटिस के कई मामले सामने आ चुके थे। उन्होंने लोगों को सूर्य की किरणों से पीने के पानी को विषाणु रहित बनाने का तरीका सिखाया। साफ सफाई के प्रति भी जागरूक किया जिसका नतीजा यह हुआ कि तीन वर्ष में इस गांव में इंसेफैलाइटिस को कोई दूसरा मामला नहीं आया है। अब गोरखपुर के जिला प्रशासन ने होलिया के तर्ज पर पांच और गांवों में यही माडल अपनाने की बात कही है। इसके आलावा गांवों में शुद्ध पानी के लिए देसी हैण्डपम्पों को या तो हटा दिया जाना चाहिए या उन्हें और अधिक गहरा किया जाना चाहिए। ऐसा करने के लिए एक बड़े अभियान की जरूरत होगी लेकिन अभी सरकार ने इसके लिए कोई पहल नहीं की है जबकि यह कोई मुश्किल काम नहीं है। स्वच्छ शौचालयों का निर्माण व उनका प्रयोग इस बीमारी से लड़ने के लिए बहुत जरूरी है।

ठस दिशा में कुछ प्रयास शुरू हुए है। नेशनल डिजास्टर मैनेजमेंट एथारिटी के उपाध्यक्ष एम शशिधर रेड्डी ने दो बार गोरखपुर का दौरा किया है। अभी हाल के दौरे में उन्होंने एक विशेष प्रशिक्षण कार्यक्रम शुरू किया। इसमें चार सौ मास्टर टेनरों को शुद्ध पेयजल, सफाई, मच्छरों पर नियंत्रण, खुले में शौच की प्रवृत्ति को समाप्त करने का जागरूकता का प्रशिक्षण दिया गया। ये मास्टर टेनर बाद में आशा, आगनबाड़ी कार्यकत्रियों, एएनएम आदि को प्रशिक्षित करेंगे। ये सभी बाद में गांव-गांव जाकर लोगों को जागरूक करेंगे।

जहिर है कि कुछ प्रयास शुरू हुए हैं लेकिन अभी बहुत कुछ किया जाना बाकी है। जरूरत सभी प्रयासो को समन्वित कर प्रभावी तरीके से लागू करने की है ताकि पूर्वांचल के लिए शोक का बनी यह बीमारी को हमेशा के लिए खत्म किया जा सके।

Callous attitude

The West Bengal govt seems unconcerned even after scores of children died in state-run hospitals. It also shows the poor condition of health care system.

Sopan Correspondent/ Kolkata

Ten infants died at the B.C. Roy Children's Hospital in Kolkata, West Bengal's only paediatric referral hospital, on October 26. Twenty-one infants had earlier died in a span of 48 hours in the hospital between June 27 and 28. On October 31, a baby died after birth because carbolic acid was used instead of dettol to disinfect during delivery at the Lalbag sub-divisional Government Hospital in Murshidabad. On October 29, 12 babies died at the Burdwan Medical College and Hospital.

B.C. Roy Children's Hospital authorities maintained that there was nothing unusual about the deaths. Hospital head Mrinal Kanti Chattopadhyay said the crib deaths were due to the "critical condition of the babies when they are admitted". The 360-bed hospital, he added, is ill-equipped to handle the average 50 admissions a day. "At least half the babies admitted to our hospital are referred by district hospitals when little can be done to save them," he said. Explaining the Burdwan deaths, Tapas Kumar Ghosh, Deputy Superintendent of Burdwan Medical College and Hospital, said the infants that died were suffering from jaundice, encephalitis and septicemia and were severely underweight.

The spate of deaths shows that healthcare in state government hospitals continues to remain in a sorry shape. Chief Minister Mamata Banerjee had rushed to the B.C. Roy Children's Hospital soon after the June deaths and promptly promised new equipment and infrastructure. Apart from a state-of-the-art 40-bed Sick Neonatal Care Unit that is ready to function from November, nothing has materialised.

The National Commission for Protection of Child Rights (NCPCR) on October 31 sought details about the infant deaths from the state government. "It is a matter of grave concern that so many infants died," NCPCR member Luv Verma said. Quizzed about the tragedies, Banerjee, who is also the health minister, brusquely ticked off journalists, saying, "Do not irritate me."

Bihar surges ahead in health while UP lags behind

State shows improvement in a short period


Sopan Correspondent / Patna


Both Bihar and Uttar Pradesh suffered from myriad problems in the health sector for decades, plagued by issues ranging from high infant mortality rate, low immunization and poor reach of the state health care mechanism in the rural areas. However, Bihar has now surged ahead on several health parameters while UP has lagged behind.

Recently Bihar impressed the World Bank with its parameters in health and general development indices which resulted in an aid worth several hundred crores for development of the state. The state came out with schemes like appointment of doctors on contract in the rural areas and ending the practice of absentee doctors which had been going on for a long time.

Ironically, this is not the case of UP which has lagged behind Bihar even though it was ahead of the state in health parameters a few years ago.

Figures from the National Rural Health Mission (NRHM) are pointers to the surge of Bihar in the health sector. Number of institutional deliveries - the chief tool to curb infant, neonatal and maternal mortality rates - in Bihar stood at 2.37 lakh in 2005. Five years since, a five-fold increase has been recorded in the state with the help of several schemes to promote institutional delivery. In UP, however, the progress hasn't been much and is a cause for concern now for the health workers and experts in the field. Compared to the figure of 19.22 lakh in 2005, number of women delivering babies in recognised health care centres didn't even double by 2010.

Routine immunisation is another example of poor health infrastructure in UP. As of now, four out of five children in UP aren't fully immunized. In Bihar, the ratio of children is much better than its neighbour. Figures show that Bihar's rate of immunisation stood at merely 10% during the first National Family Health Survey which grew to 33% in NFHS-3. In UP, 19.8% were fully immunised during the time of NFHS-1 while the figure rose to 23% in NFHS-3.

In a new initiative, the Bihar government has chalked out a new agenda to streamline the health sector across the state in which the priorities include opening up of super-speciality hospital of every major disease, upgradation of primary health centres to 30-bed community health centres, setting up nine modern trauma centres, provision of treatment and medicines under ayush stream in every hospital, making functional all health centres 24x7 and bringing down infant mortality rate (IMR) and maternal mortality rate (MMR) rate below the national average.

Compared to 2008 figure, IMR in Bihar has come down to 52 percent from the previous 56 percent, which is just two percentage above the national average of 50 percent.

Similarly, efforts are on to bring at par the reproduction rate which, at present, stands at 3.9 compared to the national average of 2.7.

Every health centre at block level has been made functional 24x7 so that they can be upgraded to 30-bed community health centres. Similarly, additional primary health centres (APHCs) too are being upgraded and those which have got their own building and have doctors available, would be made functional 24x7.

Doctors shun rural responsibility

HEALTH

A new approach is needed to provided quality healthcare in the rural areas

Sangita Jha / New Delhi

Rural to Urban India is more often a one way street. Not only for thesake of employment but even for medical needs. Rural India appears tobe lagging behind when it comes to access to quality primaryhealth care.

A disturbing trend which is fast taking deep roots is in the approachof the governments – both Central and state - to give more attention tothe tertiary health sector. A number of super-speciality hospitals arecoming up in big cities. For the government the catch word is thePublic-Private-Partnership (PPP). There should be no complaint againstthe super-speciality hospitals but it becomes a matter of concern whenthe primary health finds itself completely off the radar.

To make the matter worse, doctors often develop cold feet when itcomes to serve in the rural areas. The matter gets further compoundedwhen the medical students make beeline to get into the MD course aftertheir MBBS. Everyone wants to be a specialist. This is not without anyreason as fat money is in the super speciality hospital.

Senior consultant with Sir Ganga Ram Hospital in New Delhi R. S. Tonkrues the fact that the medical students just want to do the MD. "Noone is just satisfied with the MBBS degree. I keep telling the juniordoctors if they all work in big cities for big hospitals what willhappen to the patients in the rural areas. But no one is ready tolisten to," Tonk says, regretting the medical system which is evolving.

Even the government data candidly admits the underlying problem in the rural areas which are getting neglected in health care. Government data reveal that rural India is short of over 16,000 doctors, including 12,000specialists. As many as 12,263 specialists are needed in communityhealth centres (CHCs) and 3,789 doctors in primary health centres(PHCs). These data belong to the Union health ministry.

The government data explains why the preventive aspect of health care is not being addressed in the manner it deserves. It alsoshows why top medical institutions like the All India Institute ofMedical Sciences (AIIMS) are crowded by patients from far-flung rural areas with their medical ailment in the advanced stages.

Tonk, who in his own capacity has brought together a team ofdoctors from Delhi to reach out medical services to the rural areas ofHaryana and Western UP, believes that timely medical intervention inthe villages could well take care of the problem of overcrowding inthe premier medical institutions in the metro cities.

The health ministry data show that the shortage of doctors isparticularly acute in villages of Uttar Pradesh and Madhya Pradesh.Health experts are of the opinion that the doctors are not being givenenough incentives to work in the rural areas. As per the officialfigure 1,087 specialists and 614 doctors are needed in Madhya Pradeshand 1,442 specialists and 1,689 doctors in Uttar Pradesh.

The other states that face an acute shortage of trained medicalpractitioners in PHCs are - Assam (500 doctors), Orissa (413), Bihar(211), Gujarat (65) and Punjab (45). Each PHC is targeted to cover apopulation of approximately 25,000. The PHCs act as referral centresfor Community Health Centres (CHCs), which are 30-bed hospitals at thedistrict level.

Though under the National Rural Health Mission (NRHM), the healthministry is trying to augment the human resource crunch, the doctorsare reluctant to serve in the rural hinterland due to a host ofreasons. The ministry is giving thrust on better accommodation formedical professionals in the rural areas after this having beenreported as one of the key reason for lack of interest on the part of medical professionals.

Health experts are of the opinion that mere remuneration is not enoughto attract doctors in the rural areas. Some even opine that there should be acompulsory five years stint for doctors to work in the rural areas. Itappears that the road leading to better health facilities in the ruralIndia has obstacles all the way.

The silver lining, however, is the huge corpus of funds at thedisposal of those who wish to take health care in the rural areas, asa number of corporate bodies are coming forward as part of thecorporate responsibility obligation. As has been the experience ofsome of the senior doctors who have been mobilising doctors to spendtime in the rural areas, the opportunity is aplenty, which cansupplement the government efforts.

Health cover for all Indians

Sopan Correspondent / New Delhi

Given the rising cost of health in the country and the inability of the poor to avail private and expensive health services, a health insurance scheme that will cover every Indian has been conceived.

Officials said a committee of experts appointed by Prime Minister Manmohan Singh and headed by prominent cardiologist K Srinath Reddy, also the chief of the Public Health Foundation of India (PHFI), is working on a public-funded scheme, likely to be introduced in the 12th Five Year Plan, starting in 2012-13. “We are looking at a scheme where people will pay premium depending on their income,” said Planning Commission member secretary Sudha Pillai.

A system which the government could be looking at is in Karnataka where Dr Devi Shetty has pioneered the business for democratizing heart care in India. He heads the world's largest and also the cheapest heart care institute called Narayana Hrudayalaya. He has proved that a low cost health care model can also be profitable. He has made possible the world’s largest heart and cancer hospitals, a specialty hospital for all the plastic reconstructive surgery, an institute for organ transplant, a hospital and also training and research institutes. Dr Shetty is also the pioneer in the field of health insurance in which a very low premium for the poor can help them avail the facilities at the world-class health system.

In the government model, the plan is that entire premium for those below the poverty line could be paid by the government itself. For the better off, the government’s contribution will diminish. This scheme is likely to cover not only hospitalisation expenses, but also treatment undergone at listed hospitals. Most private health insurance schemes cover only hospitalisation.

There is already a health insurance scheme under the Rashtriya Swasth Bima Yojana for BPL families. Close to half of 6 crore BPL families are covered under this scheme. In the next step, all those enrolled in the Mahatma Gandhi National Rural Employment Guarantee Scheme will be covered, followed by women enrolled in over 10 lakh angwanwadi centers around the country. According to the National Sample Survey Office, an Indian spends 80 % of his health expenses on buying medicine. The high cost of treatment makes health services unaffordable to many. Presently, over 90 % Indians are not covered by any public or private health insurance.

Insurance penetration in rural sector

Industry watchdog comes out with suggestions

Confederation of Indian Industry (CII) has said that rural and social sectors offer huge potential for improving insurance penetration for the uninsured sections of the population. It said that to achieve this, better risk management, innovations on product design and distribution, infusing technology and greater investments was required. It also called for greater engagement of foreign partners in bringing in better risk management practices, innovation in production & distribution, technology and specialized skills.

The industry watchdog was commenting on the Insurance Laws (Amendment) Bill, 2008 which is under consideration by the government.

CII said that insurance penetration to rural and social sectors is marked by high risk and hence more dynamic and efficient risk management systems are crucial while innovation is needed not just in terms of insurance products but also in ways of distributing them. In addition, use of better technologies right from issuance to servicing of Insurance services is also crucial for long term growth of Insurance sector in India.

Insurance industry is witnessing the transformation of insurance agents from mere intermediaries to financial advisors. Greater foreign investments would help in training and skills upgradation of the agents. Well trained agents would be better equipped to convince the customers about the benefits of insurance besides contributing to simplifying the procedure.

India has one of the lowest penetration of health insurance with a majority of people depending on government service which is often inadequate. With the penetration of private health care system in almost all parts of the country, the need is being felt of increasing the cover.

Taking care of healthcare

HEALTH

Govt plans to provide a comprehensive health scheme to 650 districts in 12th Plan

Sopan Correspondent / Hyderabad

The government plans to extend the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke to all the 650 districts of the country under the 12th Five Year Plan.

Health Minister Ghulam Nabi Azad has said the programme was already being implemented in 100 most-backward and remote districts spread across 21 states. The implementation in these districts will continue till 2012. "Depending on the success of the programme, all 650 districts in the country will be covered under the 12th Plan," Azad said in his inaugural address at the conference of health ministers of the states.

The two-day conference assessed the progress under various schemes and drew up an action plan for the rest of the 11th plan (2007-12) and road map for the 12th Plan. The conference focused on issues like education in maternal and infant mortality rates, population stabilisation, prevention and control of infectious diseases, national vector-borne disease control programme, revised national TB control programme and strengthening of disease surveillance systems. About 25 ministers of health, medical education and family welfare from all the states attended the conference.

Azad said despite the achievements made under the National Rural Health Mission (NRHM), there were still areas of concern. "The pace of decline in various key health indicators like maternal mortality ratio, infant mortality rate, total fertility rate, death and morbidity due to communicable diseases have not improved as compared to pre-NRHM period," the minister said.

Complimenting the southern and western states for their excellent performance, the health minister asked central, eastern, northeastern and north Indian states to identify the bottlenecks in the implementation of the schemes and improve the performance. "Only then we can press for continuation of the NRHM which is currently up to 11th plan only. We can also convince the planning commission for higher outlay during the 12th plan period so as to achieve the MDGs (Millennium Development Goals)," he said.

He pointed out that the Indian government has provided Rs 53,000 crore to the states under NRHM in the last six years.

"One of the success stories of the last year was progress of polio eradication after the introduction of bivalent polio vaccine. There have been only 42 cases in 2010 as compared to nearly 700 cases in 2009. In the case of TB, we have achieved more than 72 per cent detection rate and 87 per cent cure rate, which are more than the WHO (World Health Organization) recommended levels," Azad said.

Referring to HIV, he said the new annual infections have declined by more than 50 per cent over the past decade while most of the countries are showing increasing trend. Azad said the government was formulating the National Urban Health Mission which would take care of infrastructure needs at district and sub-divisional levels.

The meeting passed a comprehensive resolution for enhancement of the healthcare facilities in the country and also drew a roadmap to meet the same. To bring down maternal and child mortality, it was decided that it would be made mandatory for posting one doctor and one nurse at each PHC by 31st March 2012. In addition, full antenatal care of the pregnant mothers will be ensured, tracking system would also be in place to ensure, safe delivery, post natal care and immunization of children. Blood banks at all district hospitals and blood storage facilities at sub-divisional hospitals would be set up by December 2012 and there would be free delivery services to pregnant women in Government health facilities, so that they do not incur any out of pocket expenses

Recognising the dangers of tobacco misuse, a fact brought out by the latest Global Adult Tobacco Survey (GATS) that 26 per cent of all adults use smokeless forms of tobacco (gutkha, khaini, etc.) all state governments resolved to chalk out a plan for an awareness/education campaign aimed at that segment of the population which is most vulnerable.

The realisation of the problems of the elderly was an important outcome of the deliberations. In view of increased incidence of cases of illness and neglect of elderly persons, especially in towns and cities, state governments and municipal corporations will be asked to allot land for construction of Geriatric Homes and hospital for elderly.

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