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Subject: Health

  • ASHA Program

    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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  • Malnutrition in India is a worry in a modern scenario

    Context

    The country’s response to its burden of malnutrition and growing anaemia has to be practical and innovative.

    What is malnutrition?

    • Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients.
    • The term malnutrition covers 2 broad groups of conditions.
    • One is ‘undernutrition’—which includes stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals).
    • The other is overweight, obesity and diet-related non-communicable diseases (such as heart disease, stroke, diabetes, and cancer).

    What are the root causes of malnutrition in India?

    The following three deficits are the root cause of malnutrition in India.

    1) Dietary deficit

    • There is a large dietary deficit among at least 40 per cent of our population of all age groups, shown in— the National Nutrition Monitoring Bureau’s Third Repeat Survey (2012), NFHS 4, 2015-16, the NNMB Technical Report Number 27, 2017.
    • Our current interventions are not being able to bridge this protein-calorie-micronutrient deficit.
    • The NHHS-4 and NFHS-5 surveys reveal an acute dietary deficit among infants below two years, and considerable stunting and wasting of infants below six months.
    • Unless this maternal/infant dietary deficit is addressed, we will not see rapid improvement in our nutritional indicators.

    2) Information deficit at household level

    • We do not have a national IEC (information, education and communication) programme that reaches targeted households to bring about the required behavioural change regarding some basic but critical facts.
    • For example, IEC tells about the importance of balanced diets in low-income household budgets, proper maternal, child and adolescent nutrition and healthcare.

    3) Inequitable market conditions

    • The largest deficit, which is a major cause of dietary deficiency and India’s chronic malnutrition, pertains to inequitable market conditions.
    • Such market conditions deny affordable and energy-fortified food to children, adolescents and adults in lower-income families.
    • The market has stacks of expensive fortified energy food and beverages for higher income groups, but nothing affordable for low-income groups.

    The vicious cycle of malnutrition

    • Link with mother: A child’s nutritional status is directly linked to their mother.
    • Poor nutrition among pregnant women affects the nutritional status of the child and has a greater chance to affect future generations.
    • Impact on studies: Undernourished children are at risk of under-performing in studies and have limited job prospects.
    • Impact on development of the country: This vicious cycle restrains the development of the country, whose workforce, affected mentally and physically, has reduced work capacity.

    Marginal improvement on Stunting and Wasting

    • The National Family Health Survey (NFHS-5) has shown marginal improvement in different nutrition indicators, indicating that the pace of progress is slow.
    • This is despite declining rates of poverty, increased self-sufficiency in food production, and the implementation of a range of government programmes.
    • Children in several States are more undernourished now than they were five years ago.
    • Increased stunting in some states: Stunting is defined as low height-for-age.
    • While there was some reduction in stunting rates (35.5% from 38.4% in NFHS-4) 13 States or Union Territories have seen an increase in stunted children since NFHS-4.
    • This includes Gujarat, Maharashtra, West Bengal and Kerala.
    • Wasting remains stagnant: Wasting is defined as low weight-for-height.
    • Malnutrition trends across NFHS surveys show that wasting, the most visible and life-threatening form of malnutrition, has either risen or has remained stagnant over the years.

    Prevalence of anaemia in India

    • What is it? Anaemia is defined as the condition in which the number of red blood cells or the haemoglobin concentration within them is lower than normal.
    • Consequences: Anaemia has major consequences in terms of human health and development.
    • It reduces the work capacity of individuals, in turn impacting the economy and overall national growth.
    • Developing countries lose up to 4.05% in GDP per annum due to iron deficiency anaemia; India loses up to 1.18% of GDP annually.
    • The NFHS-5 survey indicates that more than 57% of women (15-49 years) and over 67% children (six-59 months) suffer from anaemia.

    Way forward

    1] Increase investment:

    • There is a greater need now to increase investment in women and children’s health and nutrition to ensure their sustainable development and improved quality of life.
    • Saksham Anganwadi and the Prime Minister’s Overarching Scheme for Holistic Nourishment (POSHAN) 2.0 programme have seen only a marginal increase in budgetary allocation this year (₹20,263 crore from ₹20,105 crore in 2021-22).
    • Additionally, 32% of funds released under POSHAN Abhiyaan to States and Union Territories have not been utilised.

    2] Adopt outcome oriented approach on the nutrition programme

    • India must adopt an outcome-oriented approach on nutrition programmes.
    • It is crucial that parliamentarians begin monitoring needs and interventions in their constituencies and raise awareness on the issues, impact, and solutions to address the challenges at the local level.
    • Direct engagement: There has to be direct engagement with nutritionally vulnerable groups and ensuring last-mile delivery of key nutrition services and interventions.
    • This will ensure greater awareness and proper planning and implementation of programmes.
    • This can then be replicated at the district and national levels.

    3] Increase awareness and mother’s education

    • With basic education and general awareness, every individual is informed, takes initiatives at the personal level and can become an agent of change.
    •  Various studies highlight a strong link between mothers’ education and improved access and compliance with nutrition interventions among children.

    4] Monitoring

    • There should be a process to monitor and evaluate programmes and address systemic and on the ground challenges.
    • A new or existing committee or the relevant standing committees meet and deliberate over effective policy decisions, monitor the implementation of schemes, and review nutritional status across States.

    Conclusion

    We must ensure our young population has a competitive advantage; nutrition and health are foundational to that outcome.

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  • Allow Surrogacy For Single Men, Mothers: Delhi HC

    The Delhi High Court issued a notice to the Union government on a petition challenging some provisions of the Surrogacy (Regulation) Act and the Assisted Reproductive Technology (Regulation) Act.

    Issues raised by the petition

    • Currently, the laws does not allow single men to have child through surrogacy.
    • Married women can only avail surrogacy services if they are unable to produce a child due to medical conditions.
    • Otherwise, for women to avail of surrogacy services, they must be aged between 35 and 45 and widowed or divorced.
    • Women can only offer surrogacy if they are aged between 25 and 35 and married with at least one biological child.
    • The laws also require a surrogate to be genetically related to the couple who intend to have a child through this method, their petition said.

    Basis of the Petition

    • The personal decision of a single person about the birth of a baby through surrogacy, i.e., the right of reproductive autonomy is a facet of the right to privacy guaranteed under Article 21 of the Constitution.
    • Thus, the right to privacy of every citizen or person affecting a decision to bear or beget a child through surrogacy cannot be taken away.

    Distinct features of the Surrogacy (Regulation) Act, 2021

    • Definition of surrogacy: It defines surrogacy as a practice where a woman gives birth to a child for an intending couple with the intention to hand over the child after the birth to the intending couple.
    • Regulation of surrogacy: It prohibits commercial surrogacy, but allows altruistic surrogacy which involves no monetary compensation to the surrogate mother other than the medical expenses and insurance.
    • Purposes for which surrogacy is permitted: Surrogacy is permitted when it is: (i) for intending couples who suffer from proven infertility; (ii) altruistic; (iii) not for commercial purposes; (iv) not for producing children for sale, prostitution or other forms of exploitation; and (v) for any condition or disease specified through regulations.
    • Eligibility criteria: The intending couple should have a ‘certificate of essentiality’ and a ‘certificate of eligibility’ issued by the appropriate authority ex. District Medical Board.

    Eligibility criteria for surrogate mother:

    • To obtain a certificate of eligibility from the appropriate authority, the surrogate mother has to be:
    1. A close relative of the intending couple;
    2. A married woman having a child of her own;
    3. 25 to 35 years old;
    4. A surrogate only once in her lifetime; and
    5. Possess a certificate of medical and psychological fitness for surrogacy.
    • Further, the surrogate mother cannot provide her own gametes for surrogacy.

    Also read

    [Burning Issue] Surrogacy in India

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  • ASHA workers earn WHO’s global plaudits

    The country’s frontline health workers or ASHAs (accredited social health activists) were one of the six recipients of the WHO’s Global Health Leaders Award 2022 which recognises leadership, contribution to the advance of global health and commitment to regional health issues.

    Who are ASHA workers?

    • ASHA workers are volunteers from within the community who are trained to provide information and aid people in accessing benefits of various healthcare schemes of the government.
    • The role of these community health volunteers under the National Rural Health Mission (NRHM) was first established in 2005.
    • They act as a bridge connecting marginalised communities with facilities such as primary health centres, sub-centres and district hospitals.

    Genesis & evolution

    • The ASHA programme was based on Chhattisgarh’s successful Mitanin programme, in which a Community Worker looks after 50 households.
    • The ASHA was to be a local resident, looking after 200 households.
    • The programme had a very robust thrust on the stage-wise development of capacity in selected areas of public health.
    • Many states tried to incrementally develop the ASHA from a Community Worker to a Community Health Worker, and even to an Auxiliary Nurse Midwife (ANM)/ General Nurse and Midwife (GNM), or a Public Health Nurse.

    Qualifications for ASHA Workers

    • ASHAs are primarily married, widowed, or divorced women between the ages of 25 and 45 years from within the community.
    • They must have good communication and leadership skills; should be literate with formal education up to Class 8, as per the programme guidelines.

    How many ASHAs are there across the country?

    • The aim is to have one ASHA for every 1,000 persons or per habitation in hilly, tribal or other sparsely populated areas.
    • There are around 10.4 lakh ASHA workers across the country, with the largest workforces in states with high populations – Uttar Pradesh (1.63 lakh), Bihar (89,437), and Madhya Pradesh (77,531).
    • Goa is the only state with no such workers, as per the latest National Health Mission data available from September 2019.

    What do ASHA workers do?

    • They go door-to-door in their designated areas creating awareness about basic nutrition, hygiene practices, and the health services available.
    • They focus primarily on ensuring that pregnant women undergo ante-natal check-up, maintain nutrition during pregnancy, deliver at a healthcare facility, and provide post-birth training on breast-feeding and complementary nutrition of children.
    • They also counsel women about contraceptives and sexually transmitted infections.
    • ASHA workers are also tasked with ensuring and motivating children to get immunised.
    • Other than mother and child care, ASHA workers also provide medicines daily to TB patients under directly observed treatment of the national programme.
    • They are also tasked with screening for infections like malaria during the season.
    • They also provide basic medicines and therapies to people under their jurisdiction such as oral rehydration solution, chloroquine for malaria, iron folic acid tablets to prevent anaemia etc.
    • Now, they also get people tested and get their reports for non-communicable diseases.
    • The health volunteers are also tasked with informing their respective primary health centre about any births or deaths in their designated areas.

    How much are ASHA workers paid?

    • Since they are considered “volunteers/activists”, governments are not obligated to pay them a salary. And, most states don’t.
    • Their income depends on incentives under various schemes that are provided when they, for example, ensure an institutional delivery or when they get a child immunised.
    • All this adds up to only between Rs 6,000 to Rs 8,000 a month.
    • Her work is so tailored that it does not interfere with her normal livelihood.

    Success of the ASHAs

    • It is a programme that has done well across the country.
    • In a way, it became a programme that allowed a local woman to develop into a skilled health worker.
    • Overall, it created a new cadre of incrementally skilled local health workers who were paid based on performance.
    • The ASHAs are widely respected as they brought basic health services to the doorstep of households.
    • Since then ASHA continues to enjoy the confidence of the community.

    Challenges to ASHAs

    • The ASHAs faced a range of challenges: Where to stay in a hospital? How to manage mobility? How to tackle safety issues?
    • There have been challenges with regard to the performance-based compensation. In many states, the payout is low, and often delayed.
    • It has a problem of responsibility and accountability without fair compensation.
    • There is a strong argument to grant permanence to some of these positions with a reasonable compensation as sustaining motivation.
    • Ideally, an ASHA should be able to make more than the salary of a government employee, with opportunities for moving up the skill ladder in the formal primary health care system as an ANM/ GNM or a Public Health Nurse.

    Way forward

    • The incremental development of a local resident woman is an important factor in human resource engagement in community-linked sectors.
    • It is equally important to ensure that compensation for performance is timely and adequate.
    • Upgrading skill sets and providing easy access to credit and finance will ensure a sustainable opportunity to earn a respectable living while serving the community.
    • Strengthening access to health insurance, credit for consumption and livelihood needs at reasonable rates, and coverage under pro-poor public welfare programmes will contribute to ASHAs emerging as even stronger agents of change.

     

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  • India Hypertension Control Initiative (IHCI)

    The IHCI project has demonstrated that blood pressure treatment and control are feasible in primary care settings in diverse health systems across various States in India.

    India Hypertension Control Initiative (IHCI)

    • It is a multi-partner initiative involving the Indian Council of Medical Research, WHO-India, Ministry of Health and Family Welfare, and State governments.
    • It aims to improve blood pressure control for people with hypertension.
    • The project initiated in 26 districts in 2018 has expanded to more than 100 districts by 2022.
    • More than two million patients were started on treatment and tracked to see whether they achieved BP control.

    The project was built on five scalable strategies:

    1. Simple treatment protocol with three drugs was selected in consultation with the experts and non-communicable disease programme managers.
    2. Supply chain was strengthened to ensure the availability of adequate antihypertensive drugs.
    3. Patient-centric approaches were followed, such as refills for at least 30 days and assigning the patients to the closest primary health centre or health wellness centre to make follow-up easier.
    4. The focus was on building capacity of all health staff and sharing tasks such as BP measurement, documentation, and follow-up.
    5. There was minimal documentation using either paper-based or digital tools to track follow-up and BP control.

    Prevalence of hypertension in India

    • Cardiovascular diseases (CVD) are the leading cause of death among adults in India.
    • One of the major drivers of heart attack and stroke is untreated high blood pressure or hypertension.
    • Hypertension is a silent killer as most patients do not have any symptoms.
    • India has more than 200 million people with hypertension, and only 14.5% of individuals with hypertension are on treatment.

    Success of IHCI

    • Blood pressure treatment and control were feasibly controlled in primary care settings in diverse health systems across various States in India.
    • Before IHCI, many patients travelled to higher-level facilities such as community health centres (block level) or district hospitals in the public sector for hypertension treatment.
    • Over three years, all levels of health staff at the primary health centres and health wellness centres were trained to provide treatment and follow-up services for hypertension.
    • Nearly half (47%) of the patients under care achieved blood pressure control.
    • The BP control among people enrolled in treatment was 48% at primary health centres and 55% at the health wellness centres.

    Contributing to its success: A data-driven approach

    • One of the unique contributions of the project was a data-driven approach to improving care and overall programme management.
    • The list of people who did not return for treatment was generated through a digital system or on paper by the nurse/health workers.
    • Patients were reminded either over the phone or by home visit (if feasible).
    • This strategy motivated a large number of patients to continue treatment.
    • In addition, programme managers reviewed aggregate data at the district and State levels to assess the performance of facilities in terms of follow-up and BP control.
    • Patients were provided generic antihypertensive drugs costing only ₹200 per year.
    • In addition, E-Sanjeevani, a telemedicine initiative, facilitated teleconsultations.

    Back2Basics: Hypertension

    • Hypertension also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated.
    • High blood pressure usually does not cause symptoms.
    • Long-term high blood pressure, however, is a major risk factor for stroke, coronary artery disease, heart failure, atrial fibrillation, peripheral arterial disease, vision loss, chronic kidney disease, and dementia.
    • High blood pressure is classified as primary (essential) hypertension or secondary hypertension.
    • For most adults, high blood pressure is present if the resting blood pressure is persistently at or above 130/80 or 140/90 mmHg.

     

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  • Bridging the health policy to execution chasm

    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.

  • Ensuring a sustainable vaccination programme

    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.

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  • Public health engineering

    Context

    As we confront the public health challenges emerging out of environmental concerns, expanding the scope of public health/environmental engineering science becomes pivotal.

    Why does India need a specialised cadre of public health engineers

    • Achieving SDGs and growing demand for water consumption: For India to achieve its sustainable development goals of clean water and sanitation and to address the growing demands for water consumption and preservation of both surface water bodies and groundwater resources, it is essential to find and implement innovative ways of treating wastewater.
    •  It is in this context why the specialised cadre of public health engineers, also known as sanitation engineers or environmental engineers, is best suited to provide the growing urban and rural water supply and to manage solid waste and wastewater.
    • Limited capacity: The availability of systemic information and programmes focusing on teaching, training, and capacity building for this specialty cadre is currently limited.
    • Currently in India, civil engineering incorporates a course or two on environmental engineering for students to learn about wastewater management as a part of their pre-service and in-service training.
    • However, the nexus between wastewater and solid waste management and public health issues is not brought out clearly.
    • India aims to supply 55 litres of water per person per day by 2024 under its Jal Jeevan Mission to install functional household tap connections.
    • The goal of reaching every rural household with functional tap water can be achieved in a sustainable and resilient manner only if the cadre of public health engineers is expanded and strengthened.
    • Different from the international trend: In India, public health engineering is executed by the Public Works Department or by health officials. This differs from international trends.

    Way forward

    • Introducing public health engineering as a two-year structured master’s degree programme or through diploma programmes for professionals working in this field must be considered to meet the need of increased human resource in this field.
    • Interdisciplinary field: Furthermore, public health engineering should be developed as an interdisciplinary field.
    • Engineers can significantly contribute to public health in defining what is possible, identifying limitations, and shaping workable solutions with a problem-solving approach.
    • Public health engineering’s combination of engineering and public health skills can also enable contextualised decision-making regarding water management in India.

    Conclusion

    Diseases cannot be contained unless we provide good quality and adequate quantity of water. Most of the world’s diseases can be prevented by considering this. Training our young minds towards creating sustainable water management systems would be the first step.

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  • Report flags Risk of Fortified Rice

    A report has flagged issues due to threats posed to anaemic persons over iron over-nutrition created by rice fortification.

    Highlights of the report

    • No prior education: The activists discovered that neither field functionaries nor beneficiaries had been educated about the potential harms.
    • No warnings issued: There were no warning labels despite the food regulator’s rules on fortified foods.
    • No informed choice: The right to informed choices about one’s food is a basic right. In the case of rice fortification, it is seen that no prior informed consent was ever sought from the recipients.

    What are the risks highlighted?

    • Thalassemia, sickle cell anaemia and malaria are conditions where there is already excess iron in the body, whereas TB patients are unable to absorb iron.
    • Consumption of iron-fortified foods among patients of these diseases can reduce immunity and functionality of organs.

    Endemic zones identified

    • Jharkhand is an endemic zone of sickle cell disorder and thalassemia, with a prevalence of 8%-10%, which is twice the national average.
    • Jharkhand is also an endemic zone for malaria — in 2020, the State ranked third in the country in malaria deaths.

    What is Fortification?

    • The Food Safety and Standards Authority of India (FSSAI) has explicitly defined fortification.
    • It involves deliberate increasing of the content of essential micronutrients in a food so as to improve the nutritional quality of food and to provide public health benefit with minimal risk to health.

    Types of food fortification

    Food fortification can also be categorized according to the stage of addition:

    1. Commercial and industrial fortification (wheat flour, cornmeal, cooking oils)
    2. Biofortification (breeding crops to increase their nutritional value, which can include both conventional selective breeding, and genetic engineering)
    3. Home fortification (example: vitamin D drops)

    How is fortification done for rice?

    • Various technologies are available to add micronutrients to regular rice, such as coating, dusting, and ‘extrusion’.
    • The last mentioned involves the production of fortified rice kernels (FRKs) from a mixture using an ‘extruder’ machine.
    • It is considered to be the best technology for India.
    • The fortified rice kernels are blended with regular rice to produce fortified rice.

    How does the extrusion technology to produce FRK work?

    • Dry rice flour is mixed with a premix of micronutrients, and water is added to this mixture.
    • The mixture is passed through a twin-screw extruder with heating zones, which produces kernels similar in shape and size to rice.
    • These kernels are dried, cooled, and packaged for use. FRK has a shelf life of at least 12 months.
    • As per guidelines issued by the Ministry of Consumer Affairs, Food and Public Distribution, the shape and size of the fortified rice kernel should “resemble the normal milled rice as closely as possible”.
    • According to the guidelines, the length and breadth of the grain should be 5 mm and 2.2 mm respectively.

    But why does rice have to be fortified in the first place?

    • India has very high levels of malnutrition among women and children.
    • According to the Food Ministry, every second woman in the country is anaemic and every third child is stunted.
    • Fortification of food is considered to be one of the most suitable methods to combat malnutrition.
    • Rice is one of India’s staple foods, consumed by about two-thirds of the population. Per capita rice consumption in India is 6.8 kg per month.
    • Therefore, fortifying rice with micronutrients is an option to supplement the diet of the poor.

    What are the standards for fortification?

    • Under the Ministry’s guidelines, 10 g of FRK must be blended with 1 kg of regular rice.
    • According to FSSAI norms, 1 kg of fortified rice will contain the following: iron (28 mg-42.5 mg), folic acid (75-125 microgram), and vitamin B-12 (0.75-1.25 microgram).
    • Rice may also be fortified with zinc (10 mg-15 mg), vitamin A (500-750 microgram RE), vitamin B-1 (1 mg-1.5 mg), vitamin B-2 (1.25 mg-1.75 mg), vitamin B-3 (12.5 mg-20 mg) and vitamin B-6 (1.5 mg-2.5 mg) per kg.

    How can a beneficiary distinguish between fortified rice and regular rice?

    • Fortified rice will be packed in jute bags with the logo (‘+F’) and the line “Fortified with Iron, Folic Acid, and Vitamin B12”.

    Advantages offered

    • Health: Fortified staple foods will contain natural or near-natural levels of micro-nutrients, which may not necessarily be the case with supplements.
    • Taste: It provides nutrition without any change in the characteristics of food or the course of our meals.
    • Nutrition: If consumed on a regular and frequent basis, fortified foods will maintain body stores of nutrients more efficiently and more effectively than will intermittently supplement.
    • Economy: The overall costs of fortification are extremely low; the price increase is approximately 1 to 2 percent of the total food value.
    • Society: It upholds everyone’s right to have access to safe and nutritious food, consistent with the right to adequate food and the fundamental right of everyone to be free from hunger

    Issues with fortified food

    • Against nature: Fortification and enrichment upset nature’s packaging. Our body does not absorb individual nutrients added to processed foods as efficiently compared to nutrients naturally occurring.
    • Bioavailability: Supplements added to foods are less bioavailable. Bioavailability refers to the proportion of a nutrient your body is able to absorb and use.
    • Immunity issues: They lack immune-boosting substances.
    • Over-nutrition: Fortified foods and supplements can pose specific risks for people who are taking prescription medications, including decreased absorption of other micro-nutrients, treatment failure, and increased mortality risk.

     

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  • India Hypertension Control Initiative (IHCI)

    A project called the India Hypertension Control Initiative (IHCI) finds that nearly 23% out of 2.1 million Indians have uncontrolled blood pressure.

    What is the IHCI?

    • Recognizing that hypertension is a serious, and growing, health issue in India, the Health Ministry, the ICMR, State Governments, and WHO-India began a five-year initiative to monitor and treat hypertension.
    • The programme was launched in November 2017.
    • In the first year, IHCI covered 26 districts across five States — Punjab, Kerala, Madhya Pradesh, Telangana, and Maharashtra.
    • By December 2020, IHCI was expanded to 52 districts across ten States — Andhra Pradesh (1), Chhattisgarh (2), Karnataka (2), Kerala (4), Madhya Pradesh (6), Maharashtra (13), Punjab (5), Tamil Nadu (1), Telangana (13) and West Bengal (5).

    What is Hypertension?

    • Hypertension is defined as having systolic blood pressure level greater than or equal to 140 mmHg or diastolic blood pressure level greater than or equal to 90 mmHg.
    • The definition also assumes taking anti-hypertensive medication to lower his/her blood pressure.

    Why need IHCI?

    • India has committed to a “25 by 25” goal, which aims to reduce premature mortality due to non-communicable diseases (NCDs) by 25% by 2025.
    • To achieve India’s target of a 25%, approximately 4.5 crore additional people with hypertension need to get their BP under control by 2025.

    What has the IHCI found so far?

    • Its most important discovery so far is that nearly one-fourth of (23%) patients under the programme had uncontrolled blood pressure, and 27% did not return for a follow-up in the first quarter of 2021.
    • There were an estimated 20 crore adults with hypertension in the country.
    • There weren’t enough validated high-quality digital blood pressure monitors in several health facilities, which affected accuracy of hypertension diagnosis.

    How prevalent is the problem of hypertension?

    • About one-fourth of women and men aged 40 to 49 years have hypertension.
    • Southern States have a higher prevalence of hypertension than the national average, according to the latest edition of the National Family Health Survey.
    • While 21.3% of women and 24% of men aged above 15 have hypertension in the country, the prevalence is the highest in Kerala where 32.8% men and 30.9% women have been diagnosed with hypertension.
    • Kerala is followed by Telangana where the prevalence is 31.4% in men and 26.1% in women.

     

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