Epidemic proportions

S Remadevi /Kochi

Spread of viral and other infectious diseases in the wake of monsoon every year has triggered health care crisis in Kerala. The government's efforts to curb the menace have fallen flat.

Inflation, Every year as the monsoon lashes Kerala, there is a surge in cases of infectious diseases, especially dengue fever. Hospitals and healthcare facilities have been grappling with the recent phenomenon for some time.

The health department's efforts to curb the spread of diseases have fallen flat as every year the number of cases shows a steady increase. Viral fever patients swell hospital wards and observation rooms in almost all Government hospitals across the State. While much of the fever cases crowding the hospitals have been seasonal viral fever, often accompanied by a secondary bacterial infection affecting the chest, there is no denying the fact that dengue fever numbers are growing larger every year.

"Dengue has become so well-established in the State now that in every outbreak, at least three panchayats are involved. This is a recent phenomenon that we have had to reckon with and quite worrying because it indicates fast local transmission of the infection," a senior public health personnel said.

Official figures cite that there have been 1,021 confirmed cases of dengue fever in the State this year (till June 27), with five confirmed deaths. But these are the cases which have been confirmed in laboratories and reported to the Health department.

Which means that clinically dengue-suspected and unconfirmed cases could be even double or treble this figure. Also, the figure quoted by the department does not reflect the dengue cases which are attended to by private hospitals as reportage from the private sector continues to be very poor.

Reports from the districts suggest that after an upsurge of viral fever cases in June, with the monsoon remaining erratic, cases have been showing a downward trend. However, with the monsoon becoming active again, it is possible that the fever cases, including dengue could go up too.

The State has been bearing the brunt of Chikungunya outbreaks consecutively for the past four years during which time almost all districts were affected. This year, though there are scattered cases from all districts, outbreaks should be expected from Wayanad and Malappuram, which have so far remained relatively unaffected, Health officials said.

This year, the huge burden of mortality related to the Influenza A (H1N1 ) infection is something else that the State had to deal with. The H1N1 virus, in its second spell since May this year, has claimed 58 lives so far and nearly 1,100 cases of the infection have been confirmed

Dengue cases are currently showing an upward trend in Thiruvananthapuram, Pathanamthitta, Idukki, Kottayam, Wayanad, Kannur and Kasargode districts . Over 600 cases are from Thiruvananthapuram, Kottayam has 300-odd cases, about 144 cases have been confirmed from Idukki. Wayanad has fewer dengue cases - about 14 - and more of Chikungunya cases this year (44 confirmed). Leptospirosis continues to be a major problem in all districts, with high mortality rate also. Thiruvananthapuram has around 180 cases, Wayanad, 25 cases and seven deaths, Idukki has also reported some 20 cases. In 2009, official figures state that the State had 1,156 cases with 126 deaths.

"The actual figures from districts will never tally with the official figure. There is gross under-reporting and often, data from the OP clinics in the periphery are collected only till 1 p.m. to avoid showing the actual number of cases, a doctor working in the periphery said.

"All plantation districts and the rubber belt have loads of dengue cases. Ernakulam is another district, where increasing urbanisation and environmental degradation has led to an explosion in dengue cases. But with most people approaching the private hospitals for treatment, the official figures do not reflect the actual situation there at all," he added.

The high number of dengue cases in the plantation districts never reflect in the official figures because all dengue testing facilities are concentrated in urban areas, a public health expert pointed out. Thiruvananthapuram has more testing facilities, better surveillance and documentation, which naturally reflects in the high figures also.

"We are getting complacent about the annual dengue outbreak and seek comfort in the fact that our dengue mortality is still low. But this is no reflection of our better control measures; it just indicates that the doctors in the State are old hands at managing dengue now!", he pointed out.

Dengue and the vector primarily responsible for transmitting this disease, the Aedes species of mosquitoes, have become well-established in the State in the past decade and as soon as the rains begin, there is a surge in dengue cases also. Cases which start to trickle in by May-end with pre-monsoon showers peaks during July-August and ebbs around September-October.

Though this year, the Health department did try to plan ahead and had launched a comprehensive pre-monsoon, pre-epidemic disease-control programme -- the Four Plus Strategy-to tackle all mosquito-borne diseases and leptospirosis, the mosquitoes seem to have had the winning edge in this battle.

An explosion in the mosquito population and the manner in which the Aedes species seem to have adapted its breeding habits to the State's climatic and geographic conditions are playing havoc with the vector management strategies adopted by the State, which has been focussing mostly on source-reduction or destruction of mosquito-breeding sites.

Vector management is a problem rid with much difficulty in the plantation districts, where control strategies are limited because more than man-made breeding sources, it is Nature which plays host to the vector.

If in the urban areas, it is the Aedes aegypti which is the primary vector which transmits dengue, in the hilly terrains, it is the tiger mosquito or the A. albopictus which is the incriminating vector. A.albopictus is a less efficient vector, but it makes up for this by its huge numbers.

Entomologists pointed out that there can be no blanket strategy for controlling the Aedes species and that strategies would have to be devised depending on the geographical terrain, climatic patterns and the nature of human and mosquito contact. In plantations, source reduction alone does not work because the mosquitoes are found breeding in tree hollows, on the wet, leafy mass on ground and even inside the tiny rubber fruit pods scattered on the ground.

Last year, at Kanjirappally in Kottayam district, A. albopictus was the primary vector responsible for the outbreak there. Though this vector is believed to breed in natural environs, in Kanjiarappally, entomologists found that this species had adapted itself to indoor breeding and that it was breeding in flower vases and refrigerator trays. Multi-pronged strategies, including intensive fogging, use of pesticides etc would have to be adopted along with source reduction in plantation areas.

Vector management is thus rid with new challenges and this is one area where in the long-term, State would have to invest heavily in research and development, it is pointed out. More entomological research - the adaptability of mosquitoes, the local climatic and geographic conditions, environmental issues -- would be crucial for the State in evolving new vector control strategies.

In the 2008 March issue of Public Library of Science journal, in the article, `Defining Challenges and Proposing Solutions for Control of the Virus Vector Aedes Aegypti', scientists have pointed out that the universal reliance over the last 50 years on source reduction may appear logical given the vector's domestic habitat, but obviously, it has not been working in societies at risk.

Unless there is blanket coverage of source reduction activities, conscientious execution over a sustained period and a determined leadership to monitor the execution of the programme, source reduction cannot be successful, the article said. Unless all members of the community participate in the activities, one could still be at risk from a neighbour who does not bother about source reduction.

Which is why, the article suggested, that perhaps it is time that strategies for Aedes destruction were revised, to give more attention to adult mosquitoes as in malaria prevention programmes. More focussed surveillance and improved strategies for killing mosquitoes, use of improved and less toxic pesticides for indoor residual spraying should be tried, it says.

Geographic mapping of dengue or suspected cases of dengue are important for outbreak assessment as well as for launching control measures. Risk stratification is a strategy that the island nation of Singapore has been using successfully to tackle its huge dengue burden.

While the dengue situation in Singapore is quite different from the State's scenario, last year, the Health department despatched its entomologists to Singapore to assess if there were lessons from the island nation's war against mosquitoes that Kerala could adopt.

In Singapore, it is mandatory that doctors report all dengue cases to the Health Ministry, which in turn alerts the National Environment Agency. The NEA prepares a dengue spot map and any area where two cases of dengue occur within 14 days of each other in about 150 m radius is treated as a hot spot , because it indicates local transmission. Intensive source reduction and vector control measures like spraying and fogging are then launched in these hot spots.

This strategy could be adopted here too for checking outbreaks and for preventing flare-ups.

Even allowing for all the limitations that dengue management might pose for the State's health task force, public health experts are quite disappointed over the health system's poor response to the newer challenges that the State has to face year after year.

In the public health arena, it is the doctor in the local health care institution who should play a pivotal role in leading the health care activities in a locality. But the doctors here are focussing only on the curative aspect and none has any orientation in public health, it is pointed out. Doctors mostly handle the OP clinics and the paper work and leave and there are none to supervise and monitor public health activities in the field.

"What we need is a dedicated public health cadre, with adequate training, skills and experience in public health and epidemiology at the Centre and State-level. We need personnel who are experienced in case-based and real-time disease surveillance; detection of early signals of outbreaks and immediate interventional response and coordinated control and monitoring of trends of all endemic infectious diseases which will vary from region. Most of all we need a good infectious disease surveillance system, which closely interfaced with health care in the public and private sector," T. Jacob John, a prominent public health activist in the country and the former Head of the department of Clinical Virology, CMC Vellore, said.

This old age home is a hell, will make you sick

Gautami /Shimla

Although human rights activists had raked up the appalling conditions in state-run old age homes, the government is yet to shed its callousness

Situated in Basantpur, 55 km away from the Shimla, the government-run old age home is a veritable hell.

Mentally-ill and completely bed- ridden Kedar (55) cramped inside a dingy room spent his time by playing with his night soil, while Krishna Devi (40), another person with severe mental illness blabbers continuously without any pause.

Kedar died on June 18 in the same appalling conditions while government was showing its true indifferent nature even after the issue was raised up in the media by a public welfare trust, Umang Foundation and a congress MLA Sukhwinder Singh Sukhu raised a question in the state legislative assembly on 5th April. Another inmate Hari Ram physically disabled and hearing impaired, is missing fro the Home since 1st July. Krishna's mental sickness hasn't let her roommate Gandharku Devi sleep for nights together. Now Gandharku has also become mentally sick.

Now, Ajai Srivastava, a noted human rights activist and chairman of Umang Foundation who is determined to fight for their rights, has written a letter to the chief secretary of the state demanding a judicial probe in this matter otherwise he would file a PIL in the High Court. Mrs. Urmila Singh, Governor of Himachal Pradesh, after going through the media reports, showed her concern and has sought a report from the state and the government was forced to institute an inquiry which in progress.

A visit to the old age home at Basantpur, established in 1964 and run by Himachal Pradesh State Social Welfare Board was horrendous and shocking. Gross Human Rights violation and extreme negligence on the part of the state government was clearly visible in the home.

The old age home has become more of a torture home for those lonely people who don't have anyone to support them in their last days of life. 19 such people are forced by the destiny to live in filth and then die a disrespectful death where their bodies are burnt by putting on wood, without performing religious rites, a RTI query revealed.

"Mujhe Haridwar ke kisi ghat par chhod do kyunki wahan marne par koi mera antim sanskar toh kardega. Yahan se toh nark hi jayenge," (Drop me on some ghat in Haridwar. Someone would at least perform my last rites there. I will directly go to hell, if I stay here) wailed fragile Jaiwanti whose spinal cord has almost twisted. The thought of dying without proper last rituals hovering over inmate's mind is increasing psychological pressure and trauma tremendously.

Hari Ram, a physically disabled and hearing impaired, is missing from the Old Age Home since July 1, 2012. According to other inmates, he used to ask them to drop him to his one known person living in Junaga village as he believed that the said person would perform his last rituals at least. Hari Ram also regularly used to send some amount from his old age pension of Rs. 330 to him for his last rituals.

The home with dingy 20 rooms has pathetic sanitation system with no safe water even for drinking purpose. Constitutional rights like Right to Life, Right to live with dignity and Right to die with dignity are being violated each day in the old age home. Frequent untimely deaths are being observed in the home because of the dreadful living conditions. The government had lodged 16 disabled persons in the old age home, although many of them are not old. The home is not meant for them as there is no specially trained care giver for them.

"Extreme violation of Human Rights can be seen in the old age home. We have raised this serious issue in the media but government has indifferently rejected all the allegations", exclaimed Ajai Srivastava, who personally visited the place with his team. He said after he highlighted this issue in the media; a question was raised in Vidhan Sabha by Congress MLA Sukhwinder Singh Sukhu. But in her reply, the minister for social justice and empowerment Mrs. Sarvin Chaudhary refuted all allegations.

"We were forced to file an application in the High Court to seek immediate admission poor mentally sick inmates in to mental hospital as the minister had stated in her reply in the assembly that there are no inmate with mental sickness in the Home. The court ordered to shift three severely mentally sick persons including Krishna, who was diagnosed to be a severe patient of TB, to local state mental hospital", Ajai Srivastava added.

He also said that the state has not followed mandatory guidelines of High Court for mental health checkup of all inmates of old aged home in the state. After the efforts of the Foundation, government started old age pension of Rs. 330 of the inmates.

With in such appalling conditions, lives Sonam Bahadur (42), who lost both his legs after he fell into a furnace, has designed an indigenous method that doesn't let him confined to a single place. "I just try to motivate people and make them forget all their problems. That is all I can do, I guess," shares Sonam with a spark of liveliness in his pale eyes. He says," We have not even provided with disability certificate by the authorities that could give us a legal status of being disabled to avail facilities meant for us."

Rural job plan is half-filled glass

Sangita Jha/ New Delhi

The Centre has reworked the flagship programme to make it more effective. But whether the scheme in its new avatar would serve the purpose is yet to be seen

Bihar chief minister Nitish Kumar had confided to Union rural development minister Jairam Ramesh, that thanks to Mahatma Gandhi National Rural Employment Guarantee Act (MNREGA) there had been spurts in village heads roaming around in Scorpio in his state. Just before the Bihar Assembly elections, the Delhi residence of RJD chief Lalu Prasad Yadav was surprised to find a huge number of village sarpanch and mukhiya at his door-step. Yadav found much to his surprise that five years of MNREGA had produced wealthy tribes of village head-men, whose ambitions only soared.

Prime Minister Manmohan Singh recently released Mahatma Gandhi NREGA Sameeksha, after the flagship in over five years since inception cost the Centre a whopping Rs 1.17 lakh crore. The release of the report card also came at a time when the job demands within MNREGA have seen more than 20 per cent decline in the last financial year. At the same time a number of states are struggling to spend their allocated funds under the flagship scheme. In the last five years, the report card claims to have generated over 1200 crore work mandays.

Union rural development minister Jairam Ramesh in his foreword of the report mentioned that five crore families on an average have got employment each year since 2008 under MNREGA. "About 19 per cent of works taken under MNREGA have been for rural connectivity, while another 25 per cent had been for water conservation and rain water harvesting. Also, 14 per cent of works had been related to irrigation and 13 per cent dealing with flood control and drought management," Ramesh stressed to highlight the achievements of the flagship scheme.

Further, the report claimed that based on a study conducted in six states it was found that 82 per cent widows depended on MNREGA for the source of their income, while 69 per cent women in the sample study stated that the flagship scheme saved them from starvation. Also, the report rejected the contention that the MNREGA has been responsible for shortage of farm labour by claiming that 70 per cent of the job demands under the flagship scheme in 2010-11 came during lean farming season.

The Sameeksha also claimed to have slowed down the rural-urban migration. It stated that the MNREGA has slowed down migration of the poor and to drive home the point has mentioned a study conducted in the western Odisha where migration came down by 45 per cent in 2009-10.

However, on the negatives, the Sameeksha has noted that as per the NSO sample over 19 per cent who sought jobs under the MNREGA could not get employment. The report card takes pain to explain that the state governments could not help the Gram Panchayats to build enough capacity to give jobs to all those who demanded. As per the MNREGA Act, all those who seek jobs must be given works or they should be given financial compensation as per the rules.

Prime Minister was, however, all praise for the rural job scheme, as he described it a "silver bullet" for rural revival. He also brushed aside farmers' concern about MNREGA's role in increasing agricultural wages. Dr Singh was of the view that rising manual labour opportunities the scheme provides are the only way to help the landless poor in rural India.

While urging Panchayati Raj institutions (PRIs) to gear up for its effective implementation. Prime Minister said, "PRIs have to gear up to play the central role assigned to them and we have to provide resources to equip panchayats to perform these functions effectively. If these bodies can rise to the challenge, MNREGA can very well become a silver bullet for India's rural renewal." He further stressed MNREGA's potential of becoming the spearhead of rural transformation.

However, critics state that MNREGA was meant to work towards making itself redundant but on the contrary it's self-perpetuating. They base their arguments on the surprise exprssed by Prime Minister himself that concurrent evaluation of MNREGA was not being done. The department of industrial policy and promotion in a study has found that MNREGA's assurance of unskilled employment is slowing the growth of skilled and semi-skilled labour.

The critics have sought from the government to face up to the challenge of responding to demands of continuing economic growth for millions of unskilled and casual workers to acquire new skills and enter the manufacturing sector.

However, sameeksha, which is based on numerous studies carried out in a number of states, gives many examples to show that MNREGA is at least a half-filled glass and not just full empty.

The Sameeksha in fact claims that MNREGA has revived the rural economy with surplus money at the hands of the poor, which is giving demands for goods for consumption. In an ambitious statement, the Sameeksha even claims that "MNREGA can insulate Indian economy from the slowdown in the world economy by creating enough demands for goods".

"MNREGA is helping private investments in the rural economy, while helping people to engage in permanent livelihoods works. With revival of lands, marginal farmers are getting back to their own lands to work, which in turn would generate more demands for rural jobs," the Sameeksha noted.

It further quotes studies conducted in Karnatka to drive home the point that the growing productivity is helping people in the rural areas in improving their buying capacity. Due to MNREGA men and women can spend 48 per cent and 66 per cent of the income in buying products of the rural economy itself, noted theSameeksha.

After the flagship scheme allowed the villages to take up works on the private land, a study quoted by the Sameeksha in Madhya Pradesh stated that 52 per cent people found qualitative improvement in the productivity of their land. This study also revealed that there were 15 per cent growth in farm productivity due to works under MNREGA undertaken on them. "This helped in the food security of the people as well. The food availability of the participating families under the scheme improved from six months to nine months," it stated. The study further revealed that 50 per cent of the people who claimed jobs under the MNREGA later started working on their own lands and did not claim benefit under any other scheme. So, the sameeksha claims, that MNREGA workers are becoming self-reliant.

The scheduled castes and scheduled tribes have been the largest beneficiaries of the MNREGA. The Sameeksha also stresses this point by stating that the participations of the SCs and STc on the national average have been about 40 to 50 per cent. A survey spanning six states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Rajasthan, and UP revealed that among the MNREGA beneficiaries 81 per cent had kutcha houses, 61 per cent were illiterate, 72 per cent had no access to electricity. Further, in another study spanning five districts in UP threw light on the fact that 85 per cent of the MNREGA beneficiaries were living below the poverty line, which included 50 per cent people belonging to scheduled castes and another 45 per cent to other backward castes. While the Centre has unveiled MNREGA 2.0 to make the flagship scheme more meaningful in the coming years, it's to be seen whether the scheme remains a case of half-filled glass or it really serves the purpose originally intended for.

Reworked Bill likely to land safely

Sangita Jha/ New Delhi

Centre in reworked Bill seeks to grant state governments the flexibility to prescribe the floor level of private land purchases

The overriding objective of the Land Acquisition and Rehabilitation and Resettlement Bill has been to strike a balance between needs of industrialisation and urbanisation and fair compensation to the land owners and livelihood losers. The industry had been livid at laggard pace of acquisition of land for the purposes of industrialisation. The industry has also been miffed at the prospect of being burdened with higher compensation obligation. The farmers want a share in the assets being created on their land. At the same time a number of state governments do not want any role in acquisition of land at all. Thus, the move to arrive at a consensus on Land Bill is clearly tricky. The government may not be able to make all the stakeholders happy.

The move is afoot to expedite the passage of the Land Bill in the Monsoon session of the Parliament. A month long Monsoon session of the Parliament is set to commence from August 8. Therefore, the Union rural development ministry, which is piloting the Land Bill, is faced with huge task of bringing all parties on board and win crucial support for the passage of the legislative proposal in the Parliament.

The Centre has made certain things very clear about the Land Bill. These include definite role of the government in acquisition of land. The government is of clear view that without the support of the government it would not be possible for the industrial houses to acquire land to set up their businesses. However, the ratio of the responsibility that the Centre would like state to bear in acquisition of land is being given thought to. But, sources say, it could be 80:20, that is the private party would have to first acquire a minimum 20 per cent land for the government to step in and facilitate acquisition of rest of the land.

Government's role in the draft Bill is tricky, as West Bengal does not want to play any role at all in the acquisition of land in the backdrop of a series of violent protest by farmers and land owners against government acquiring their land. Even the Parliamentary standing committee, which deliberated for months on the draft legislative proposal, had sought no role for the government in acquisition of land, while citing example of developed countries.

Further, according to the reworked draft of the Land Bill, which has been again circulated among various ministeries, seek that if the acquired land is not utilised for the stated purpose in five years it would be given back to land bank. In the Land Bill, which was introduced in the Lok Sabha, the period was 10 years.The industries are not pleased with reduction in the period, for the reason that the largescale infrastructure projects take much longer time to take off.

In anorther interesting twist to the reworked Land Bill, the move is afoot to make the compensation better. The Ministry of rural development is said to be inclined to move an amendment to the Bill in which the valuation of the land would also factor in its distance from the urban areas, while arriving at the compensation amount. This is clearly been done due to the farmers' unrest in the Greater Noida last year. In the Land Bill, which was introduced in the Lok Sabha last year, the compensation was proposed at two times the market value in the urban areas and four times in the rural areas , which, however, had been a climb down from the earlier assertions of five times compensation by National Advisory Council. Also, it's intended to course-correction for the reason, that the earlier proposal would have led to a situation to rural areas on the outskirts of urban areas fetching four times the market value while the adjacent land falling under urban area being eligible for only two times the market value despite little difference in the market value of the two adjacent land.

While perception matters and names more, the idea is also gaining ground that the name of the legislative proposal itself be changed from Land Acquisition and Rehabilitation and Resettlement (LARR) Bill, 2011 to the Right to Compensation, Resettlement, Rehabilitation and Transparency in Land Acquisition Act (RTCRRTLA). This is in fact very curious and interesting for the reason that those who are calling shots in arriving at a set of amendments feel that the primacy to "acquisition" in the original proposal gives a bad name to the government among farmers and livelihood losers. In fact the Hindi translation of "Acquisition", that is "Adhigrahan" is being considered among a set of officials giving notion to farmers that the government is authoritarian. Therefore, there appears urgency to recommend an amendment to change the name itself with strong focus bon "Right", "Compensation", "Resettlement", "Rehabilitation", and "Transparency". Some may take the luxury to laugh at the desperation on the parts of the government not to be seen as coercive.

As far as distance from the urban centres for the land being acquired is concerned, the Department of Land Resources has proposed introducing an amendment to provide for a "sliding scale" of compensation "based on the distance of project from urban area". According to the proposal, land falling within 10 km radius of the urban area will get two times the market value while land falling within 40-50 km radius will fetch four times the market value as compensation with land falling in between getting proportional increase.

Further, the Centre in its reworked Land Bill seeks to grant state governments a flexibility to prescribe the floor level of private land purchases over which a minimum level of rehabilitation and resettlement burden will have to be incurred by private purchases. Also, the reworked Land Bill also seeks compliance from the Special Economic Zone (SEZ). In fact the Parliamentary standing committee had recommended that 16 various kinds of exisiting laws need to be amended to make them consistent with the new law which is being proposed.

Therefore, the reworked Bill seeks to remove the exemption granted to the SEZ Act, 2005, which was proposed in the legislative proposal introduced in the Lok Sabha last year, along with two other laws -- Cantonment Act, 2006, Works of Defence Act, 1903 -- from complying with the LARR Bill provisions. Furthermore, the draft of the Land Bill notes that it will have overriding force over these three laws while providing exemption to the other 13 from the original list of 16. However, the other 13 will have to be amended in next two years to comply with the new Land law being proposed.

Also, since the proposed law seeks to compensate not only the land owners but even those who lose their livelihoods, the move is afoot to make sure that even those not holding the title deeds but having evidence to prove that they had been occupying the land being acquired for the past three years would be entitled for compensation. So, even squatters and encroachers are being given a thought as per the amendments being deliberated to move into the official Bill.

The industry has reasons to be livid at such suggestions as to enable even squatters to be entitled for compensation. The anger is more for the period in question being just three years. Some of the Union ministeries related to infrastructure have red-flagged this suggestion. The suggested amendment states "affected persons" as families that do not own land but may be working in the affected area for three years prior to the acquisition, which would affect their primary source of livelihood. This sub-clause would extend the benefit of compensation to squatters or people who have been living on the land, which is to be acquired. With this the proposed legislation seeks to treat squatters on par with agricultural labourers, tenants, sharecroppers or artisans.

Now, that the Union Cabinet will soon discuss the amendments being moved to the Land Bill, it's to be seen if it passes the first hurdle, while a daunting task awaits it in the Parliament.

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.

विकास के नाम पर उजड़ते लोग

बीरेन्द्र कुमार चैधरी/ ग्वालियर

मध्य प्रदेश के तमाम आदिवासियों का आरोप है कि ‘म.प्र. भूमि सुधार अधिनियम-1969’ को सही से न लागू करने का परिणाम है कि उनकी जमीनों पर बाहर से आए लोग कब्जा कर रहे हैं

पनी छोटी-मोटी जरूरतों की पूर्ति के लिए वन एवं वन्य उत्पाद पर निर्भर रहने वाले आदिवासी आज बढ़ते पुंजीवाद और बाजारवाद का शिकार हो रहे हैं। स्वभाव से भोले-भाले इन आदिवासियों की जमीन पैसे वाले लोग, सरकारी महकमे के अधिकारियों व भू-राजस्व विभाग के कर्मचारियों की मिली भगत से हड़प रहे हैं। इन्हें न केवल इनके पारंपरिक अधिकारों से वंचित किया जा रहा है बल्कि गैरकानूनी तरीके से इनकी जमीन भी छीनी जा रही है। इस विषय में श्योपुर के एकता गांव के सरपंच गंगाराम आदिवासी कहते हैं- हमारा कोई सहारा नहीं, हमारी जमीन पैसे वाले जोत रहे हैं। वन अधिकारी पूरे जिले के आदिवासियों के वन अधिकार के फार्म को खारिज कर देते हैं। कारण कुछ भी स्पष्ट नहीं बताते। सच तो ये है कि पटवारी से लेकर ऊपर के अधिकारी की मिलीभगत से ऐसा होता है।

हाल में मुझे एकता परिषद द्वारा संचालित ‘जन सत्याग्रह’ का हिस्सा बनने का अवसर मिला। इस यात्रा के दौरान मैंने वंचित आदिवासियों के दर्द को करीब से समझा। इसी यात्रा में विजयपुर विधानसभा क्षेत्र के विधायक रामनिवास रावत को सुनने का मौका मिला। उनका आरोप है कि सभी सरकारी ;शासकीयद्ध जमीन जिसे आदिवासी जोत रहे हैं , मगर उसका पट्टा किसी और के पास है, जो यहां के स्थानीय निवासी भी नहीं हैं। रावत का मानना है, ऐसे पट्टों को तत्काल रद्द किया जाय, तभी समस्या से निजात पाया जा सकता है। श्योपुर के आदिवासियों के भोलेपन के चलते उनका दुख-दर्द सुनने को कोई भी अधिकारी तैयार नहीं है और पैसे वाले सेठ किसी न किसी बहाने उनकी जमीन छीन रहे हैं।

इसी यात्रा के दौरान आवास को लेकर जो आंकड़े सामने आए, उसे जानकर आप दंग रह जायेंगे। सहरिया आदिवासियों का 12000 परिवारों के पास रहने के लिए घर नहीं है। मध्य प्रदेश के आदिवासियों का आरोप है कि ‘मप्र भूमि सुधार अधिनियम-1969’ को सही से न लागू करने का परिणाम है कि उनकी जमीनों पर बाहर से आए लोग कब्जा कर रहे हैं। जमीन के मामले में केंद्र और राज्य सरकारों की नीतियां भी विराधाभाषी हैं। यह भी दुःखद है कि वर्तमान में 100 से अधिक आदिवासी सांसद होने के बावजूद, भूमि सुधार को लेकर कोई आवाज नहीं उठती।

यूं तो आदिवासियों के वन-अधिकार को सुनिश्चित करने के लिए केंद्र सरकार ने ‘वन-अधिकार अधिनियम-2006’ पारित कर दिया है लेकिन इस अधिनियम का लाभ जिसे मिलना चाहिए वे उससे वंचित हैं।

रणथंभोर अभ्यारण्य ;राजस्थानद्ध से सटे छाना गांव के सरपंच मो. हनीफ बताते हैं - ‘जंगली जानवर हमारी फसलों को उजार देते हैं और वन-अधिकारी उलटे हमलोगों को ही तंग करते हैं। यहां न तो शिक्षा की उचित व्यवस्था है और न स्तरीय बुनियादी सुविधाएं। वन-अधिकारी हमें यहां से चले जाने के लिए नोटिस तक दे चुके हैं, पर हम जाएं तो जाएं कहां?’ मो. हनीफ का ये दर्द सिर्फ उनका नहीं बल्कि उड़ीसा, प.बंगाल, बिहार, उ.प्र. आदि राज्यों में पड़ने वाले अभ्यारण्यों के आस-पास के लोगों का भी दर्द है। इन्हें भी वन-अधिकारी विस्थापन की नोटिस तो वर्षों पहले थमा चुके हैं पर इनके पुनर्वास की योजना उनके पास नहीं है। जबकि पूर्व के बने अधिनियम सभी सुविधाओं के साथ पुनर्वास की बात करता है। छान गांव के एक अन्य निवासी रामसेवक का आरोप है कि वन-अधिकारी उनकी जान को जानवरों की जान से कहींे कम आंकते हैं।

यात्रा के बढ़ते चरण के साथ हम भी बढ़ रहे थे व लोगों की समस्या से रू-ब-रू होते जा रहे थे। एसा लग रहा था कि मै देश के अंदर ही किसी दूसरे देश में आ गया हूंॅजहां लोगों के पास समस्याएं तो हैं और सरकारी महकमा उसे खत्म करने की जगह बढ़ाना बेहतर समझते। कहीं चारागाह की समस्या तो कहीं विस्थापन का नोटिश, कहीं आवासहीन लोग तो कहीं जीवन की बुनियादी सुविधाओं का बाट जोहता मानव। पर इन तमाम समस्याओं के बीच ये जन-सत्याग्रह, ऐसा लग रहा था कि मानो यह आशा की किरण हो।

यात्रा के साथ जब हम सुकार गांव पहुंचे तो ग्रामिणों से मिलकर पता चला कि उनके मन में राजस्थान सरकार के प्रति कितना गुस्सा है। अपने जीवन के आठ दशक पार कर चुके रामजीलाल भंवर बोले- ‘हम तो पढ़े लिखे हैं नहीं, अपने जमाने में स्कूल का मुंॅह भी नहीं देखा। आज गांव में स्कूल तो है और बच्चे पढ़ने भी जाते हैं पर जिसे पढ़ई कहते हैं वह नहीं है। यही नहीं यहां बिजली पानी समेत आजीविका की समस्याएं है जिस पर सरकार को तत्काल ध्यान देना होगा। और उसमें भी पानी पर सबसे पहले। 100 से अधिक परिवार वाले इस गांव में कम से कम 5नल लगने चाहिए। अभी गांव वाले स्कूल के सामने वाली टंकी से लोग अपना प्यास बुझाते हैं जहां हमेशा लोगों का तांता लगा रहता है।’ और जब मैं पूरा गांव घूमा तो रामजीलाल की बातों मे सच्चाई दिखी। गांव के सरपंच रामधन का आरोप है कि न तो सरकारी महकमा गांव की सुध लेते नविधायक और न ही सांसद। वहीं जब हम निवाई पहुंचे तो वहां के ग्रामिणों व किसानों की तीन समस्या मूल रूप से लागों ने बताया। इन समस्याओं को विस्तार से किसान सेवा समिति के अध्यक्ष मदनलालजी सूरमा ने बताया। पहली समस्या गांव के चारागाह की भूमि पर बाहुबलियों का अवैध कब्जा, दूसरा दलितों, आदिवासियों के लिए आवास और आजीविका की समस्या और तीसरा जो सबसे महत्त्वपूर्ण है वह है- विसनपुर के विस्थापितों को निवाई के चारागाह की जमीन दे दी गई और वे लोग इसे बेचकर कहीं चले गए मगर यहां के ग्रामिणों के हिस्से झंझट छोड़ गए। गांव वाल इन तीनो समस्या का समाधान चाहते हैं।

वहीं निवाई में ही एक अन्य जगह ग्रामदानी सभा से जुड़े गांवों की समस्या से अवगत हुआ जो विकराल रूप लेता जा रहा है। ग्रामदानी व्यवस्था के अनुसार पूरी जमीन पर सामाजिक स्वमित्व की अवधारणा थी जिसका देख-रेख ग्रामदानी बोर्ड करती थी। पर जब से राजस्थान सरकार ने ग्रामदानी बोर्ड को खत्म किया है यह विवाद का विषय बन गया है। इलाके के चनैरिया, नैनकी ढाली, लाखावास आदि दर्जन भर से अधिक गांवों के लोग इससे परेशान हैं। जब वे भू-राजस्व अधिकारी के पास जाते हैं वे संबंधित कागज मांगते हैं जो उनके पास नहीं है और जब वे सरपंच के पास जाते हैं तो वे ग्रमदानी बोर्ड का हवाला देकर अपना पल्ला झार लेते हैं। सबसे खास बात तो ये है कि इनमें से कुछ ग्रामीण तो ऐसे भी हैं जिनके पास 100बीघे से भी अधिक जमीन का मालिक होने के बावजूद भूमिहीनों के समान हैं। कारण उनकी जमीनों पर उनका ही कब्जा नहीं है। डिडावता के मोहनलाल वर्मा इसका एक उदाहरण है जिनके पास कहने को तो 213बीघा जमीन है पर उस पर उनका कब्जा आज नहीं है। ऐसे सैकड़ों उदाहरण आपको यहां मिल जाएंगे।

एक तरफ समस्या है तो दूसरी तरफ समाधान की तलाश और इनके बीच पीसती आम जनता। अब देखना होगा कि सरकार समय रहते इसका समाधान खोजती है या नहीं। पूरी यात्रा के दौरान जमीन से जुड़ी समस्या ही देखने को मिली मगर हमारी। लोगों को भू-अधिकार से वंचित कर विशेष आर्थिक क्षेत्र बना रही है। यदि वक्त रहते जनता की मंशा को न समझा गया तो हो न हो हमारा देश भी एक दिन विकास की पटरी से न उतर जाय।

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.