Context

• Global status report on physical activity is WHO’s first dedicated global assessment of global progress on country implementation of policy recommendations of the Global Action Plan on Physical Activity (GAPPA) 2018-2030.

What are the findings of the report?

• Poor physical activity standards: Over 80 per cent adolescents and 27 per cent adults do not meet the physical activity standards set by the World Health Organization (WHO), according to a new report.
• developing non-communicable diseases: This will lead to 500 million additional people developing non-communicable diseases from 2020-2030 and cost the global economy $27 billion annually, it added.

How physical Inactivity impacts health and Economy?

• Changing lifestyles: Sedentary lifestyle of a large share of the global population has been linked to rising prevalence of heart diseases, obesity, diabetes or other noncommunicable diseases.
• Increasing Hypertension and depression: Of the 500 million new cases projected, nearly half will be attributed to hypertension and 43 per cent to depression, the authors of the report said.
• A strain on the health systems: The report quantified the economic burden of not being able to meet the GAPPA target. The sharp rise in non-communicable diseases will also put a strain on the health systems in every country.
• Rising cost of treatment: If the current prevalence of physical inactivity doesn’t change, the world will incur treatment costs of just over $300 billion till 2030, the report mentioned.
• 70 per cent of health-care expenditure: The largest economic cost is set to occur among high-income countries, according to the analysis. This will account for 70 per cent of health-care expenditure on treating illness resulting from physical inactivity, it showed. Around 75 per cent of the cases will occur in low- and middle-income countries, it added.

What are the government efforts to address the physical inactivity menace?

• National physical activity policy: Less than half the countries in the world have any national physical activity policy, showed the analysis of 194 countries by WHO published October 19, 2022.
• National policies are in operation: Less than 40 per cent of the existing national policies are in operation, the United Nations health agency noted in the Global status report on physical activity 2022.
• Monitor physical activity among adolescents: As many as 75 per cent of countries monitor physical activity among adolescents, and less than 30 per cent monitor physical activity in children under 5 years.
• Addressing lack of public Infrastructure: The report highlighted that data regarding progress on certain policy actions is missing. These include provision of public open space, provision of walking and cycling infrastructure, provision of sport and physical education in schools.
• National physical activity guidelines: only 30 per cent of countries have national physical activity guidelines for all age groups, according to the findings of the report.

What are the Recommendations of WHO?

• Exercise benefits mental and physical health: Light exercise and even walking has proven benefits for mental and physical health, studies have shown.
• Infrastructural changes by governments: Citizens cannot make healthier lifestyle choices without infrastructural changes by governments such as safe walking and cycling lanes. “In policy areas that could encourage active and sustainable transport, only just over 40% of countries have road design standards that make walking and cycling safer,” the WHO analysts found.
• Five ways to address the policy gaps: 

1. Strengthen whole-of-government ownership and political leadership
2. Integrate physical activity into relevant policies and support policy implementation with practical tools and guidance
3. Strengthen partnerships, engage communities and build capacity in people
4. Reinforce data systems, monitoring, and knowledge translation
5. Secure sustainable funding and align with national policy commitments

• Four areas of policy intervention:

1. Active societies,
2. active environments,
3. active people and
4. active systems.

Government of India’s efforts to promote physical activity

• FIT India Movement: FIT INDIA Movement was launched on 29th August 2019 by Honorable Prime Minister with a view to make fitness an integral part of our daily lives. The mission of the Movement is to bring about behavioral changes and move towards a more physically active lifestyle.
• Objectives of Fit India: Fit India proposes to undertake various initiatives and conduct events to achieve the following objectives:

1. To promote fitness as easy, fun and free.
2. To spread awareness on fitness and various physical activities that promote fitness through focused campaigns.
3. To encourage indigenous sports.
4. To make fitness reach every school, college/university, panchayat/village, etc.
5. To create a platform for citizens of India to share information, drive awareness and encourage sharing of personal fitness stories.

Conclusion

• Physical inactivity is silent poison, killing the future of the citizens. Work from home, remote working has increased the physical inactivity among the working populations. Indoor games, mobile addictions, e-learning have reduced the physical activity of children. It’s a collective responsibility of parents, society and government to promote and encourage the physical activity among citizens.

Mains Question Q.

What are the ill effects of physical inactivity on health and economy? What are the policies of government India to promote healthy life style?

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Context

• The death of a 12-year-old girl in Pathanamthitta has sharpened the focus on the rising number of rabies cases and the growing population of stray dogs in Kerala

What is rabies?

• The rabies virus attacks the central nervous system of the host, and in humans, it can cause a range of debilitating symptoms including states of anxiety and confusion, partial paralysis, agitation, hallucinations, and, in its final phases, a symptom called “hydrophobia,” or a fear of water.

What are rabies caused by?

• Rabies is a preventable viral disease most often transmitted through the bite of a rabid animal. The rabies virus infects the central nervous system of mammals, ultimately causing disease in the brain and death.

Can rabies person survive?

• Once clinical signs of rabies appear, the disease is nearly always fatal, and treatment is typically supportive. Less than 20 cases of human survival from clinical rabies have been documented.

How long can a human live with rabies?

• Death usually occurs 2 to 10 days after first symptoms. Survival is almost unknown once symptoms have presented, even with intensive care.

Facts on rabies

• What animal has the most rabies?
• Bats
• Wild animals accounted for 92.7% of reported cases of rabies in 2018. Bats were the most frequently reported rabid wildlife species (33% of all animal cases during 2018), followed by raccoons (30.3%), skunks (20.3%), and foxes (7.2%).

What is the issue?                                  

• There is a blame game over the rising rabies cases: With the rabies deaths causing panic and reports of residents killing stray dogs through poisoning and strangulation, there is a blame game over the rising canine population and rabies cases. Some legal experts blame it on conflicts in the Prevention of Cruelty to Animals Act, 1960 and the Animal Birth Control (Dogs) Rules, 2001; others point to the flawed implementation of birth control measures.
• Legal battle over the issue in the Supreme Court: Canine culling campaigners and advocates of animal rights are also engaged in a protracted legal battle over the issue in the Supreme Court. V.K. Biju, a lawyer of the Supreme Court, who brought the issue of the “stray dog menace” before the apex court, contends that the root cause is the enactment of the Rules, which according to him, were passed in contravention of the parent Act, the Prevention of Cruelty to Animals Act.
• Existence of stray dogs has adversely affected the fundamental rights of citizens: Biju says that while the Act stands for the “destruction” of stray dogs, the rules are against the “destruction” of stray dogs, including the rabies affected ones, besides providing specific protection of stray dogs. In his submission before the Supreme Court, he argues that the existence of stray dogs has adversely affected the fundamental rights of citizens, i.e. the right to life and free movement.
• The quashing of the Rules to make India free of stray dogs: In his writ petition filed before the apex court, Biju has sought orders for the strict implementation of the Act and the quashing of the Rules to make India free of stray dogs.
• Animal rights campaigners are apprehensive: In the light of this, animal rights campaigners are apprehensive over the campaign to cull dogs to check rabies.

How can we prevent rabies in animals?

1. First, visit your veterinarian with your pet on a regular basis and keep rabies vaccinations up-to-date for all cats, ferrets, and dogs.
2. Second, maintain control of your pets by keeping cats and ferrets indoors and keeping dogs under direct supervision.
3. Third, spay or neuter your pets to help reduce the number of unwanted pets that may not be properly cared for or vaccinated regularly.
4. Finally, call animal control to remove all stray animals from your neighbourhood since these animals may be unvaccinated or ill.

How can we prevent rabies in humans?

• Leave all wildlife alone.
• Know the risk: contact with infected bats is the leading cause of rabies deaths in people followed by exposure to rabid dogs while traveling internationally.
• Wash animal bites or scratches immediately with soap and water.
• If you are bitten, scratched, or unsure, talk to a healthcare provider about whether you need postexposure prophylaxis. Rabies in people is 100% preventable through prompt appropriate medical care.
• Vaccinate your pets to protect them and your family.

Initiatives by Government to curb Neglected Tropical Diseases

National Rabies Control Programme: This programme is being restructured as Integrated National Rabies Control Programme under ‘One Health Approach’, with a aim to provide vaccination to stray dogs and free vaccines through Government hospitals.

Way forward

• Think globally, act locally. Study and adopt global ‘best-practices’ after customising them to local needs.
• Apply integrated approach. Follow a holistic strategy.
• Ensure efficient and effective collaboration across various government departments.
• Partner with Civil Society Organisations (especially with WASH – Water, Sanitation and Hygiene – sector) for ground-level implementation and monitoring.

Mains question

Q. What is rabies? What ethical challenges are involved in culling of stray dogs? Explain the control measures for the same.

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Context

• The recent National Family Health Survey (NFHS-5) data shows anaemia rates increased from 53 per cent to 57 per cent in women and 58 per cent to 67 per cent in children in 2019-21.

Definition of anaemia

• The WHO defines anaemia as a condition where the number of red blood cells or the haemoglobin concentration within them is lower than normal. This compromises immunity and impedes cognitive development.

Why anaemia is a concern?

• Adverse effects of anaemia affect all age groups lower physical and cognitive growth and alertness among children and adolescents, and lesser capacity to learn and play, directly impacting their future potential as productive citizens.
• Anaemia among adolescent girls (59.1 per cent) advances to maternal anaemiaand is a major cause of maternal and infant mortality and general morbidity and ill health in a community.

What causes anaemia?

• Imbalanced diet: Cereal-centric diets, with relatively less consumption of iron-rich food groups like meat, fish, eggs, and dark green leafy vegetables (DGLF), can be associated with higher levels of anaemia.
• Underlying factors: High levels of anaemia are also often associated with underlying factors like poor water quality and sanitation conditions that can adversely impact iron absorption in the body.
• Iron deficiency is major cause: A diet that does not contain enough iron, folic acid, or vitamin B12 is a common cause of anaemia.
• Some other conditions: That may lead to anaemia include pregnancy, heavy periods, blood disorders or cancer, inherited disorders, and infectious diseases.

Why is anaemia so high in the country?

• Low vitamin intake: Iron-deficiency and vitamin B12-deficiency anaemia are the two common types of anaemia in India.
• High population and nutrition deprivation: Among women, iron deficiency prevalence is higher than men due to menstrual iron losses and the high iron demands of a growing foetus during pregnancies.
• Overemphasis on cereals: Lack of millets in the diet due to overdependence on rice and wheat, insufficient consumption of green and leafy vegetables could be the reasons behind the high prevalence of anaemia in India.

What is Iron fortification?

• Iron fortification of food is a methodology utilized worldwide to address iron deficiency. Iron fortification programs usually involve mandatory, centralized mass fortification of staple foods, such as wheat flour.

Why need iron fortification?

• Iron deficiency anaemia is due to insufficient iron.
• Without enough iron, the body can’t produce enough of a substance in red blood cells that enables them to carry oxygen (haemoglobin).
• Severe anaemia during pregnancy increases risk of premature birth, having a low birth weight baby and postpartum depression. Some studies also show an increased risk of infant death immediately before or after birth.

Success story / value addition

• Nepal’s success story to improve maternal anaemia by national action plan .

Anaemia Mukt Bharat

• The scheme aims to reduce the prevalence of anaemia in India.
• It provides bi weekly iron Folic acid supplementation to all under five children through Asha workers.
• Also, it provides biannual Deworming for children and adolescents. The scheme also establishes institutional mechanisms for advanced research in anaemia.
• It also focuses on non-nutritional causes of anaemia.

We need to focus on the following interventions

• Prophylactic Iron and Folic Acid supplementation.
• Intensified year-round Behaviour Change Communication Campaign (Solid Body, Smart Mind).
• Appropriate infant and young child feeding practices.
• Increase in intake of iron-rich food through diet diversity/quantity/frequency and/or fortified foods with focus on harnessing locally available resources.
• Testing and treatment of anaemia, using digital methods and point of care treatment, with special focus on pregnant women and school-going adolescents
• Mandatory provision of Iron and Folic Acid fortified foods in government-funded public health programmes

Way forward

• India’s nutrition programmes must undergo a periodic review.
• The Integrated Child Development Services (ICDS), which is perceived as the guardian of the nation’s nutritional well-being must reassess itself and address critical intervention gaps, both conceptually and programmatically, and produce rapid outcomes.
• The nutritional deficit which ought to be considered an indicator of great concern is generally ignored by policymakers and experts. Unless this is addressed, rapid improvement in nutritional indicators cannot happen.

Conclusion

• When a person is anaemic, the capacity of his blood cells to carry oxygen decreases. This reduces the productivity of the person which in turn affects the economy of the country. Therefore, it is highly important to cover Anaemia under National Health Mission.

Mains question

Q. “Every second adolescent girl has anaemia. Every second woman of reproductive age is anaemic”. In this context do you think Women’s empowerment will not have any meaning without tackling anaemia? Discuss.

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Context

• Doctor shortages are creating hurdles in health emergency response

What is the crux of the article in simple words?

• Medical qualification and expertise is necessary to deliver quality health services by medical professionals unlike by general health care workers who lack competency.

What is public health?

• Public health has been defined as “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals”.

Why there is need of qualification?

• Lack of training: Health workers have no training in public health; they are grassroots-level service providers. Asking them to be part of public health cadre trivialises the profession of public health.
• Separate profession: It is important to understand that public health is a separate profession with a specific set of competencies.

What are 4 pillars of public health?

• Academics: Academics refers to a good understanding of evidence generation and synthesis by having a good grounding in epidemiology and biostatistics. These competencies are also critical for monitoring and evaluating programmes, conducting surveillance, and interpreting data and routine reporting.
• Activism: Public health is inherently linked to ‘social change’ and an element of activism is core to public health. Public health requires social mobilisation at the grassroots level by understanding community needs, community organisation, etc. This requires grounding in social and behavioural sciences.
• Administration: Administration refers to administering health systems at different levels from a primary health centre to the district, State, and national level. This includes implementing and managing health programmes, addressing human resource issues, supply and logistical issues, etc. It includes microplanning of programme delivery, team building, leadership as well as financial management to some extent.
• Advocacy: In public health, there is little that one can do at an individual level; there must be communication with key stakeholders to change the status quo at different levels of government. This requires clear enunciation of the need, analysis of alternative set of actions and the cost of implementation or non-implementation. Good communication and negotiation skills are critical to perform this function. The related subjects are health policy, health economics, health advocacy and global health.

What are the hurdles in absorbing others as public health professionals?

• Lack of skill: Many doctors and other health professionals work at the grassroots level and develop a good sense of public health due to their inclination. But they do not become public health professionals as they may not have the necessary skills. Nevertheless, they are valuable.
• Lack of critical expertise: Clinicians with training in epidemiology and biostatistics would not qualify to be public health professionals as they lack not only other essential and critical expertise but also an appropriate perspective.
• Compromise on quality:

Current challenges faced by public healthcare in India

• Deficiency: The doctor-patient ratio of 1:1655 in India as against WHO norm of 1:1000 clearly shows the deficit of MBBS. While the government is working towards a solution and targeting to reach the required ratio, there is a need to relook at the overall medical education.
• Post pandemic scenario: The lag in formal medical education has come up evidently post-pandemic when the nation saw the medical fraternity struggling to fill the doctor deficit.
• Limited government seats: The number of seats available for medical education in India is far less than the number of aspirants who leave school with the dream of becoming doctors.
• Lack of skills: Though the institutes are managing to hire professors and lecturers, there is a lack of technical skills. Finding faculties in clinical and non-clinical disciplines is difficult and there are very few faculty development programs for upskilling the existing lot.
• Lack of infrastructure: The gap in digital learning infrastructure is currently the biggest challenge the sector is facing. There is an urgent need to adopt technology and have resources available to facilitate e-learning.
• Lack of research and innovation: The medical research and innovation needs an added push as there haven’t been many ground-breaking research here. The education system needs to focus more on increasing the quality of research. Additionally since industry academia partnership is not available, hence innovation also takes a back-seat.

Conclusion

• By establishing new medical colleges, the government can increase student intake as well as enhance equitable access to public health as separate profession. This will attract the best and the brightest people into this discipline, which is very important for the nation’s health. This is one lesson that we should learn from the pandemic.

Mains question

Q. What do you understand by public health? Do you think it is a separate profession requiring a specific set of competencies? Examine.

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Context

• How to deal with mental wellness challenges in the uniformed forces

What is stress?

• Stress is a feeling of emotional or physical tension. It can come from any event or thought that makes you feel frustrated, angry, or nervous. Stress is your body’s reaction to a challenge or demand.

What is mental wellness?

• Mental wellness encompasses emotional, psychological, and social well-being. It influences cognition, perception, and behaviour. It also determines how an individual handles stress, interpersonal relationships, and decision-making.

Why is Mental Health Important?

• Mental health is more important now than ever before; it impacts every area of our lives. The importance of good mental health ripples into everything we do, think, or say.

Reasons for Persistence of Mental Illness

• Stigma to seek help: The staggering figures are void of millions of others directly, or indirectly impacted by the challenge and those who face deep-rooted stigma, many times rendering them unable to seek help.
• Lack of awareness: This growing challenge in dealing with mental health issues is further compounded by a lack of information and awareness, self-diagnosis, and stigma.
• Psycho-social factors: Institutions like gender, race and ethnicity, are also responsible for mental health conditions.
• Post-Treatment gap: There is a need for proper rehabilitation of the mentally ill persons post/her treatment which is currently not present.
• Rise in Severity: Mental health problems tend to increase during economic downturns, therefore special attention is needed during times of economic distress.

Ongoing challenges in mental wellness regime

• There is a need to expand understanding of the full scope of what uniformed Services and other mental health experts can achieve.
• Stigma regarding mental health both domestically and around the world remains strong.
• There is a lack of trained personnel and healthcare and public health systems in many areas of the world.
• Training needs are broad and reach beyond direct patient care, especially regarding cultural competence, crisis communication, and consultation.
• There is a need for expanded support for the value of multi-professional and multi-organizational integration and collaboration.

Government Policy initiatives

• National Mental Health Program (NMHP): To address the huge burden of mental disorders and shortage of qualified professionals in the field of mental health, the government has been implementing the NMHP since 1982.
• Mental HealthCare Act 2017: It guarantees every affected person access to mental healthcare and treatment from services run or funded by the government.
• Rights of Persons with Disabilities Act, 2017: The Act acknowledges mental illness as a disability and seeks to enhance the Rights and Entitlements of the Disabled and provide an effective mechanism for ensuring their empowerment and inclusion in the society
• Manodarpan Initiative: An initiative under Atmanirbhar Bharat Abhiyan aims to provide psycho-social support to students for their mental health and well-being.

What needs to be done?

• Open dialogue: The practice of open dialogue, a therapeutic practice that originated in Finland, runs through many programmes in the Guidance. This approach trains the therapist in de-escalation of distress and breaks power differentials that allow for free expression.
• Increase investment: With emphasis on social care components such as work force participation, pensions and housing, increased investments in health and social care seem imperative.
• Network of services: For those homeless and who opt not to enter mental health establishments, we can provide a network of services ranging from soup kitchens at vantage points to mobile mental health and social care clinics.

Conclusion

• Persons with mental health conditions need a responsive care system that inspires hope and participation without which their lives are empty. We should endeavour to provide them with such a responsive care system.

Mains question

Q. Mental disorders are now among the top leading causes of health burden worldwide, with no evidence of global reduction since 1990. Examine.

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Context

• The covid-19 pandemic has presented a watershed moment, bringing the world’s healthcare systems to a halt, forcing us to rethink existing healthcare delivery models and embrace the digital health transformation of the sector.

Definition of digital health care

• Digital health is a discipline that includes digital care programs, technologies with health, healthcare, living, and society to enhance the efficiency of healthcare delivery and to make medicine more personalized and precise.

Digital Health: A Backgrounder

• The National Health Policy 2017 had envisaged creation of a digital health technology eco-system aiming at developing an integrated health information system.
• A Digital Health ID was proposed to reduce the risk of preventable medical errors and significantly increase the quality of care.
• It recognised the need to establish a specialised ecosystem, called the National Digital Health Mission (NDHM).

The National Digital Health Mission

• The NDHM is a digital health ecosystem under which every Indian citizen will now have unique health IDs, digitized health records with identifiers for doctors and health facilities.
• The mission will significantly improve the efficiency, effectiveness, and transparency of health service delivery and will be a major step towards the achievement of the UN Sustainable Development Goal 3.8 of Universal Health Coverage, including financial risk protection.

Significance of digital health

• Prioritizing patients: Say, mortality from Covid-19 is significantly increased by comorbidities or the presence of other underlying conditions like hypertension or diabetes.With digital health records, doctors can prioritise patients based on their test results.
• Portability of health records: Portability of records fairly eases in a patient with the first hospital visit, or her/his most frequently visited hospital. If she/he wishes to change a healthcare provider for cost or quality reasons, she can access her health records without carrying pieces of paper prescriptions and test reports. People will able to access their lab reports, x-rays and prescriptions irrespective of where they were generated, and share them with doctors or family members — with consent.
• Easy facilitation: This initiative will allow patients to access healthcare facilities remotely through e-pharmacies, online appointments, teleconsultation, and other health benefits. Besides, as all the medical history of the patient is recorded in the Health ID card, it will help the doctor to understand the case better, and improved medication can be offered.
• Technology impetus in policymaking: Meanwhile, it is also not just individuals who could emerge beneficiaries of the scheme. With large swathes of data being made available, the government too can form policies based on geographical, demographical, and risk-factor based monitoring of health.

Critical point to remember

In the case of lung cancer, only 18.5 % of patients survive five or more years once diagnosed. These are threats that data-led technology will help address.

Major privacy issues involved

• Informed Consent:The citizen’s consent is vital for all access. A beneficiary’s consent is vital to ensure that information is released.
• Data leakages issue:Personalised data collected at multiple levels are a “sitting gold mine” for insurance companies, international researchers, and pharma companies.
• Digital divide:Other experts add that lack of access to technology, poverty, and lack of understanding of the language in a vast and diverse country like India are problems that need to be looked into.
• Data Migration:The data migration and inter-State transfer are still faced with multiple errors and shortcomings in addition to concerns of data security.

Other challenges

• Existing digitalization is yet incomplete:India has been unable to standardise the coverage and quality of the existing digital cards like One Nation One Ration card, PM-JAY card, Aadhaar card, etc., for accessibility of services and entitlements.
• Lack of healthcare facilities:The defence of data security by expressed informed consent doesn’t work in a country that is plagued by the acute shortage of healthcare professionals to inform the client fully.
• Lack of finance:With the minuscule spending of 1.3% of the GDP on the healthcare sector, India will be unable to ensure the quality and uniform access to healthcare that it hoped to bring about.

Conclusion

• With an enabling ecosystem, supported by effective policies for digital healthcare and increased innovation, the promise of digital solutions in healthcare is immense. It’s not long before precision healthcare becomes central to the health and well-being of every citizen.

Mains question

Q. The covid-19 pandemic has presented a watershed moment, bringing the world’s healthcare systems to a halt, forcing us to rethink existing healthcare delivery models. In this context discuss challenges and opportunities of digital health ecosystem in India.

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Context

The lesson emerging from the pandemic experience is that if India does not want a repeat of the immeasurable suffering and the social and economic loss, we need to make public health a central focus.

Need for institutional reforms in the health sector

• The importance of public health has been known for decades with every expert committee underscoring it.
• Ideas ranged from instituting a central public health management cadre like the IAS to adopting an institutionalised approach to diverse public health concerns — from healthy cities, enforcing road safety to immunising newborns, treating infectious diseases and promoting wellness.
• Covid has shifted the policy dialogue from health budgets and medical colleges towards much-needed institutional reform.

About National Health Mission (NHM)

• The National Health Mission (NHM) seeks to provide universal access to equitable, affordable and quality health care which is accountable, at the same time responsive, to the needs of the people, reduction of child and maternal deaths as well as population stabilization, gender and demographic balance.
• The Framework for Implementation of NUHM has been approved by the Cabinet on May 1, 2013.
• NHM encompasses two Sub-Missions, National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM).
• The National Rural Health Mission (NRHM) was launched in 2005 with a view to bringing about dramatic improvement in the health system and the health status of the people, especially those who live in the rural areas of the country.

Learning from the failure of National Health Mission (NHM)

• The National Health Mission (NHM) has been in existence for about 15 years now and the health budget has trebled— though not as a proportion of the GDP.
• Despite this less than 10 per cent of the health facilities below the district level can attain the grossly minimal Indian public health standards.
• Clearly, the three-tier model of subcentres with paramedics, primary health centres with MBBS doctors and community health centres (CHC) with four to six specialists has failed.
• Lack of accountability framework: The model’s weakness is the absence of an accountability framework.
• The facilities are designed to be passive — treating those seeking care.

Suggestions

• 1] FHT: Instead of passive design of NHM, we need Family Health Teams (FHT) like in Brazil, accountable for the health and wellbeing of a dedicated population, say 2,000 families.
• The FHTs must consist of a doctor with a diploma in family medicine and a dozen trained personnel to reflect the skill base required for the 12 guaranteed services under the Ayushman Bharat scheme.
• A baseline survey of these families will provide information about those needing attention.
• Family as a unit: The team ensures a continuum of care by taking the family as a unit and ensuring its well-being over a period.
•  Nudging these families to adopt lifestyle changes, following up on referrals for medical interventions and post-operative care through home visits for nursing and physiotherapy services would be their mandate.
• 2] Health cadre: The implication of and central to the success of such a reset lies in creating appropriate cadres.
• 3] Clarity to nomenclatures: There is also a need to declutter policy dialogue and provide clarity to the nomenclatures.
• Currently, public health, family medicine and public health management are used interchangeably.
• While the family doctor cures one who is sick, the public health expert prevents one from falling sick.
• The public health management specialist holds specialisation in health economics, procurement systems, inventory control, electronic data analysis and monitoring, motivational skills and team-building capabilities, public communication and time management, besides, coordinating with the various stakeholders in the field.
• 4] Move beyond doctor-led systems: India needs to move beyond the doctor-led system and paramedicalise several functions.
• Instead of wasting gynaecologists in CHCs midwives (nurses with a BSc degree and two years of training in midwifery) can provide equally good services except surgical, and can be positioned in all CHCs and PHCs.
• This will help reduce C Sections, maternal and infant mortality and out of pocket expenses.
• 5] Counsellors and physiotherapists at PHC: Lay counsellors for mental health, physiotherapists and public health nurses are critically required for addressing the multiple needs of primary health care at the family and community levels.
• 6] Review of existing system: Bringing such a transformative health system will require a comprehensive review of the existing training institutions, standardising curricula and the qualifying criteria.
• Increase spending on training: Spending on pre-service and in-service training needs to increase from the current level of about 1 per cent.
• 7] Redefining of functions: A comprehensive redefinition of functions of all personnel is required to weed out redundancies and redeploy the rewired ones.

Conclusion

Resetting the system to current day realities requires strong political leadership to go beyond the inertia of the techno-administrative status quoist structures. We can.

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Context

India’s one million Accredited Social Health Activists (ASHA) volunteers have received World Health Organization’s Global Health Leaders Awards 2022.

Background of the ASHA program

• In 1975, a WHO monograph titled ‘Health by the people’ and then in 1978, an international conference on primary health care in Alma Ata (in the then USSR and now in Kazakhstan), gave emphasis for countries recruiting community health workers to strengthen primary health-care services that were participatory and people centric.
• Soon after, many countries launched community health worker programmes under different names.
• India launched the ASHA programme in 2005-06 as part of the National Rural Health Mission.
• The biggest inspiration for designing the ASHA programme came from the Mitanin (meaning ‘a female friend’ in Chhattisgarhi) initiative of Chhattisgarh, which had started in May 2002.
• The core of the ASHA programme has been an intention to build the capacity of community members in taking care of their own health and being partners in health services.
• Each of these women-only volunteers work with a population of nearly 1,000 people in rural and 2,000 people in urban areas, with flexibility for local adjustments.

A well thought through and deliberated program

• The ASHA programme was well thought through and deliberated with public health specialists and community-based organisations from the beginning.
• 1] Key village stakeholders selected: The ASHA selection involved key village stakeholders to ensure community ownership for the initiatives and forge a partnership.
• 2] Ensure familiarity: ASHAs coming from the same village where they worked had an aim to ensure familiarity, better community connect and acceptance.
• 3] Community’s representative: The idea of having activists in their name was to reflect that they were/are the community’s representative in the health system, and not the lowest-rung government functionary in the community.
• 4] Avoiding the slow process of government recruitment: Calling them volunteers was partly to avoid a painfully slow process for government recruitment and to allow an opportunity to implement performance-based incentives in the hope that this approach would bring about some accountability.

Contribution of ASHA

• It is important to note that even before the COVID-19 pandemic, ASHAs have made extraordinary contributions towards enabling increased access to primary health-care services; i.e. maternal and child health including immunisation and treatment for hypertension, diabetes and tuberculosis, etc., for both rural and urban populations, with special focus on difficult-to-reach habitations.
• Over the years, ASHAs have played an outstanding role in making India polio free, increasing routine immunisation coverage; reducing maternal mortality; improving new-born survival and in greater access to treatment for common illnesses.

Challenges

• Linkages with AWW and ANM: When newly-appointed ASHAs struggled to find their way and coordinate things within villages and with the health system, their linkage with two existing health and nutrition system functionaries — Anganwadi workers (AWW) and Auxiliary Nurse Midwife (ANM) as well as with panchayat representatives and influential community members at the village level — was facilitated.
•  This resulted in an all-women partnership, or A-A-A: ASHA, AWW and ANM, of three frontline functionaries at the village level, that worked together to facilitate health and nutrition service delivery to the community.
• No fixed salary to ASHAs: Among the A-A-A, ASHAs are the only ones who do not have a fixed salary; they do not have opportunity for career progression.
• These issues have resulted in dissatisfaction, regular agitations and protests by ASHAs in many States of India.

Way forward

• The global recognition for ASHAs should be used as an opportunity to review the programme afresh, from a solution perspective.
• 1] Higher remuneration: Indian States need to develop mechanisms for higher remuneration for ASHAs.
• 2] Avenues for career progression: It is time that in-built institutional mechanisms are created for capacity-building and avenues for career progression for ASHAs to move to other cadres such as ANM, public health nurse and community health officers are opened.
• 3] Extend the benefits of social sector services: Extending the benefits of social sector services including health insurance (for ASHAs and their families) should be considered.
• 4] Independent and external review: While the ASHA programme has benefitted from many internal and regular reviews by the Government, an independent and external review of the programme needs to be given urgent and priority consideration.
• 5] Regularisation of temporary posts: There are arguments for the regularisation of many temporary posts in the National Health Mission and making ASHAs permanent government employees.

Conclusion

The WHO award for ASHA volunteers is a proud moment and also a recognition of every health functionary working for the poor and the underserved in India.  It is a reminder and an opportunity to further strengthen the ASHA programme for a stronger and community-oriented primary health-care system.

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Context

In April this year, the Union government released a guidance document on the setting up of a ‘public health and management cadre’ (PHMC) as well as revised editions of the Indian Public Health Standards (IPHS) — for ensuring quality health care in government facilities.

Background

• The need for a public health cadre and services in India rarely got any policy attention.
• Limited understanding: The reason was that even among policymakers, there was limited understanding on the roles and the functions of public health specialists and the relevance of such cadres, especially at the district and sub-district levels.
• However, the last decade and a half was eventful.
• The initial threat of avian flu in 2005-06, the Swine flu pandemic of 2009-10; five more public health emergencies of international concern between years 2009-19; the increasing risks and regular emergence and re-emergence of of new viruses and diseases (Zika, Ebola, Crimean-Congo Hemorrhagic fever, Nipah viruses, etc.) in animals and humans, resulted in increased attention on public health.
• National Public health Act: In 2017, India’s National Health Policy 2017 proposed the formation of a public health cadre and enacting a National Public Health Act.
• The COVID-19 pandemic changed the status quo.
• In the absence of trained public health professionals at the policy and decision making levels, India’s pandemic response ended up becoming bureaucrat steered and clinician led.

Different cadres and its implications

• Lack of career progression opportunities: At present, most Indian States (with exceptions such as Tamil Nadu and Odisha) have a teaching cadre (of medical college faculty members) and a specialist cadre of doctors involved in clinical services.
• This structure does not provide similar career progression opportunities for professionals trained in public health.
• Limited interest: It is one of the reasons for limited interest by health-care professionals to opt for public health as a career choice.
• The outcome has been costly for society: a perennial shortage of trained public health workforce.

Public health cadre

• The proposed public health cadre and the health management cadre have the potential to address some of these challenges.
• With the release of guidance documents, the States have been advised to formulate an action plan, identify the cadre strengths, and fill up the vacant posts in the next six months to a year.
• A public health workforce has a role even beyond epidemics and pandemics.
• A trained public health workforce ensures that people receive holistic health care, of preventive and promotive services (largely in the domain of public health) as well as curative and diagnostic services (as part of medical care).

Revised version of IPHS and significance

• This is the second revision in the IPHS, which were first released in 2007 and then revised in 2012.
• The regular need for a revision in the IPHS is a recognition of the fact that to be meaningful, quality improvement has to be an ongoing process.
• The development of the IPHS itself was a major step.
• The revised IPHS is an important development but not an end itself.
• In the 15 years since the first release of the IPHS, only a small proportion — around 15% to 20% — of government health-care facilities meets these standards. .
• If the pace of achieving IPHS is any criteria, there is a need for more accelerated interventions.
• Opportunities such as a revision of the IPHS should also be used for an independent assessment on how the IPHS has improved the quality of health services.

Implementation challenges

• The effective part of implementation is interplay: policy formulation, financial allocation, and the availability of a trained workforce.
• In this case, policy has been formulated.
• Financial allocations: Then, though the Government’s spending on health in India is low and has increased only marginally in the last two decades; however, in the last two years, there have been a few additional — small but assured — sources of funding for public health services have become available.
• The Fifteenth Finance Commission grant for the five-year period of 2021- 26 and the Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) allocations are available for strengthening public health services and could be used  as States embark upon implementing the PHMC and a revised IPHS.
• Availability of trained workforce: The third aspect of effective implementation, the availability of trained workforce, is the most critical.
• As States develop plans for setting up the PHMC, all potential challenges in securing a trained workforce should be identified and actions initiated.

Conclusion

The public health and management cadres and the revised IPHS can help India to make progress towards the NHP goal. To ensure that, State governments need to act urgently and immediately.

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Back2Basics: Indian Public Health Standards (IPHS)

• IPHS are a set of uniform standards envisaged to improve the quality of health care delivery in the country.
• The IPHS documents have been revised keeping in view the changing protocols of the existing programmes and introduction of new programmes especially for Non-Communicable Diseases.
• Flexibility is allowed to suit the diverse needs of the States and regions.
• These IPHS guidelines will act as the main driver for continuous improvement in quality and serve as the bench mark for assessing the functional status of health facilities.

Context

COVID-19, which disrupted supply chains across countries and in India too, marks an inflection point in the trajectory of immunisation programmes.

UIP: Showcasing India’s strength in managing large scale vaccination

• India’s Universal Immunisation Programme (UIP), launched in 1985 to deliver routine immunisation, showcased its strengths in managing large-scale vaccine delivery.
• This programme targets close to 2.67 crore newborns and 2.9 crore pregnant women annually.
• Full immunisation: To strengthen the programme’s outcomes, in 2014, Mission Indradhanush was introduced to achieve full immunisation coverage of all children and pregnant women at a rapid pace — a commendable initiative.
• India’s UIP comprises upwards of 27,000 functional cold chain points of which 750 (3%) are located at the district level and above; the remaining 95% are located below the district level.
• The COVID-19 vaccination efforts relied on the cold chain infrastructure established under the UIP to cover 87 crore people with two doses of the vaccine and over 100 crore with at least a single dose.

Why strong service delivery network is essential?

• While we have, over the years, set up a strong service delivery network, the pandemic showed us that there were weak links in the chain, especially in the cold chain.
• Nearly half the vaccines distributed around the world go to waste, in large part due to a failure to properly control storage temperatures.
• In India, close to 20% of temperature-sensitive healthcare products arrive damaged or degraded because of broken or insufficient cold chains, including a quarter of vaccines.
• Wastage has cost implications and can delay the achievement of immunisation targets.

Measures and initiatives in strengthening vaccine supply chains

• The Health Ministry has been digitising the vaccine supply chain network in recent years through the use of cloud technology, such as with the Electronic Vaccine Intelligence Network (eVIN).
• Developed with support from Gavi, the Vaccine Alliance, and implemented by the UN Development Programme through a smartphone-based app, the platform digitises information on vaccine stocks and temperatures across the country.
• This supports healthcare workers in the last mile in supervising and maintaining the efficiency of the vaccine cold chain.

Way forward

• Electrification: There is a need to improve electrification, especially in the last mile, for which the potential of solar-driven technology must be explored to integrate sustainable development.
• For instance, in Chhattisgarh, 72% of the functioning health centres have been solarised to tackle the issue of regular power outages.
• This has significantly reduced disruption in service provision and increased the uptake of services.

Conclusion

India has pioneered many approaches to ensure access to public health services at a scale never seen before. Robust cold chain systems are an investment in India’s future pandemic preparedness; by taking steps towards actionable policies that improve the cold chain, we have an opportunity to lead the way in building back better and stronger.

Context

There is no doubt that tobacco use is highly detrimental to public health. We have to find the ways and the means to reduce the demand for tobacco among existing as well as aspiring users.

Impact of tobacco

• Tobacco is a product that kills more than 13 lakh Indians every year.
• Annual burden: The annual economic burden from tobacco use is estimated to be ₹177,340 crore which is more than 1% of India’s GDP.
• About 27 crore people above the age of 15 years and 8.5% of school-going children in the age group 13-15 years use tobacco in some form in India.

Are price and tax measures effective against tobacco use?

• When tobacco products become more expensive, people either quit using them or use them less, and it incentivises many to not initiate the habit.
• Because it hurts both revenue and profits, the tobacco industry, globally, is always devising tactics and narratives that will pre-empt any kind of tax increases on tobacco products.
• The narrative of “increasing illicit trade” is something the tobacco industry has historically used to pre-empt potential tax increases on tobacco products in most countries around the world.
• The story is no different in India.
• In a recent report by the Tobacco Institute of India, it was said that the illicit cigarette volume in India has grown by 44% from 2011 to 2019 while adding that high and increasing tax rates provide a profitable opportunity for tax evasion and encourage growth in illegal trade.
• A study published in 2018 which used a survey of empty cigarette packs collected from retail outlets across different cities in India estimated that illicit cigarettes constitute 2.7% of the market.
• The second study published in 2020 used tax-gap analysis to estimate that the percentage of illicit cigarettes was 5.1% in 2009-10 and 6.6% in 2016-17.

Are taxes and prices key determinants of illicit trade?

• It is to be noted that taxes and prices are not the key determinants of illicit trade.
• There is sufficient evidence in the literature on illicit trade in cigarettes that shows tax increases only have a minimal impact, if at all, on illicit trade.
• There are several countries where tobacco taxes are quite high and yet have low levels of illicit trade, while there are also countries with high levels of illicit trade despite having relatively low tax rates.
• Several factors such as the quality of tax administration, the strength of the regulatory framework, government commitment to control illicit trade, the strength of governance, social acceptance, and the presence of informal distribution networks are known to play a larger role in determining the scale and the extent of an illicit market.

Way forward

• WHO protocol: Eliminating all forms of illicit trade in tobacco products through a package of measures is one of the major objectives of the Protocol to Eliminate Illicit Trade in Tobacco Products under the World Health Organization’s Framework Convention on Tobacco Control.
• The Protocol provides the tools and the measures to eliminate or minimise illicit trade which includes strong governance, establishing an international track and trace system, and securing supply chains.
• India has already ratified the World Health Organization Protocol and it should now show leadership in implementing these measures to effectively address even the relatively lower levels of illicit trade.

Conclusion

There is no scientific or public health rationale not to increase tax on tobacco products for unfounded fear of increasing illicit trade.

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Context

Over the past two decades, initiatives announced to extend health care coverage to the indigent sections have come under criticism due to their near-exclusive focus on hospitalisation (inpatient, IP) care.

Significance of outpatient health care

• What is outpatient health care: Outpatient (OP) health care, mainly comprising doctor consultations, drugs, and tests, can be called ‘the elephant in the room’ of Indian public health care policy.
• OP expenses have the majority share in total out-of-pocket (OOP) expenditure on health.

Why do we need to extend OP care coverage?

• How IP care differs from OP care? IP care comprises high-impact and unavoidable episodes that are less prone to misuse than OP care, for which demand is considerably more sensitive to price and is thus more prone to overuse under health insurance.
• IP insurance prioritised: This logic, among other reasons, has led to IP insurance schemes being prioritised.
• [1] OP care and preventive care is neglected: While a price-sensitive demand for OP care entails that it could be misused under insurance, it also means that OP care is the first to come under the knife when there is no insurance.
• In India, where there are many public IP insurance schemes but no OP coverage, this incentive is further amplified.
• The mantra of ‘prevention is better than cure’ thus goes for a toss.
• [2] Against economic sense: It defies economic sense to prioritise IP care over OP care for public funds.
• Preventive and primary care services which often come with externalities, elicit little felt need and demand, and must therefore be the primary recipients of public investment.
• Not conducive to epidemiological profile: Greater investments in IP care today translate to even greater IP care investments in future, further reduction in primary care spending, and ultimately lesser ‘health’ for the money invested.
• None of these are conducive to the epidemiological profile that characterises this country.

Issues with using private commercial insurance to extend OP care coverage nationwide

• Some recent policy pronouncements by the Centre have conveyed an inclination to expand healthcare coverage with little fiscal implications for the government.
• Challenges:
• [1] The OP practices are under-regulated and there is a lack of standards.
• [2] The difficulty to monitor OP clinical and prescribing behaviours and the concomitant higher likelihood of malpractices.
• [3] Low public awareness of insurance products and a low ability to discern entitlements and exclusions.
• [4] Add to it the inexperience that a still under-developed private OP insurance sector brings.
• All these entail tremendous and largely wasteful costs and administrative complexity, and it would be of little help even if the government was to step in with considerable subsidies.

Suggestion

• Need for fiscal and time commitment: Significant improvements in healthcare are implausible without significant fiscal and time commitments.
• No perfect model: There is no ‘perfect’ model of expanding healthcare — the emphasis must be on finding the best fit.
• Implementing even such a best fit could involve adopting certain modalities with known drawbacks.
• Expand public spending: The focus must be on expanding public OP care facilities and services financed mainly by tax revenues.
• For India, wisdom immediately points to successful countries that are (or were, at one point) much closer to its socioeconomic fabric, such as Thailand, than countries like the U.S. which we currently look to emulate.
• Now, the sparse number and distribution of public facilities offers various modes of rationing care, and their expansion is likely to result in a considerable spike in demand.
• Contracting with private players: Contracting with private players based on objective and transparent criteria would also be called for, with just enough centralised supervision to deter corruption while preserving local autonomy.
• To deter supply-side malpractices, low-powered modes of provider payment, such as capitation, may be considered for private providers wherever possible.

Conclusion

There are several compelling reasons for extending outpatient health care coverage even though there are several challenges to overcome to achieve this.

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