Subject: Social Justice

Context

As the government tries to overhaul the public health system in India, its time to take into account the advent and the role played by the private sector and its implications.

The advent of the private sector

• Increase in the role of the private sector in the post-Independence era: Post-Independence, the private sector increased its footprint in India.
  • Perpetual sub-optimal investments in public health allowed the private sector to capitalise, flourish, and increasingly gain the confidence of the masses.
  • The private sector went from having about 1,400 enterprises in 1950 to more than 10 lakh in 2010-11.
  • To doctors, this promised greater professional liberty, lesser restrictions, and higher incomes.
  • After liberalisation, the greater focus shifted to the lucrative tertiary-care sector and led to an onslaught of sophisticated private health care in cities.

The dominance of the private sector and malpractices

• The scale of dominance: Private sector has over 70% of the health-care workforce and 80% of allopathic doctors, has meant that it is scarcely possible for a health-care provider to function in defiance of its norms.
  • Pervasive malpractices: The pervasiveness of malpractices in this market has come to ensure that few could survive without condoning them.
  • Nexus of the private players: Players in this market, in much of their malpractices, have also learnt to function as a harmonious family.
  • Organised form to safeguard interest: The family plays its role in safeguarding its members, acquainting them with its norms and interests, and leveraging the power of its patriarchs to defend its interests in society.
  • Standards of success dictated by the markets: It is little wonder that the market has also come to dictate the avenues of aggrandisement and yardsticks of professional success for health-care professionals.
  • Benchmark of quality changed: Business finesse and social adroitness rather than clinical excellence and empathy become the touchstones of calibre in this market.

Failure of the government

• Absence of national system: The larger chunk of Indian health care (and health workforce) could not be brought under a “national system” having some form of overarching state control or involvement.
  • If such a system existed it could avail of essential health care without most people having to rely on a vagarious market, except as a luxury.
  • Example of the UK’s NHS: The National Health Service of the United Kingdom, remains the single largest health-care provider.
  • NHS employs nearly the entire health-care workforce.
  • NHS makes essential health care available to all practically free at the point of service.
• Consequences of the absence of such system: The absence ensures is that the profit-driven private sector, the minor component, caters mainly to the affluent lot as largely a matter of deliberate choice rather than desperate compulsion.
  • Hopes of benefits of free-market belied: The Indian example, much like the United States’, bespeaks the failure of the idea that a free market will compel players to be more efficient.
  • The exploitation of the loops by the private players: Rather than increasing efficiency, the players have found it expedient to scrupulously exploit the prevailing cracks in the system and employ devious methods in order to maximise profits.

Conclusion

• Health-care providers, just like others, are moulded by their social surroundings. When necessary controls are loosened, the connatural vices are let loose; when the habitat is conducive to values, the right traits develop.
• A system that starts off with health care as an overt tradable commodity it threatens the development of virtues in the system.
• On the other hand, a system founded on the concept of equity cultivates a totally different culture of patient care.

Context

The advent of a new tetravalent vaccine against the dengue virus has thrown new light into the evidence-based management of dengue.

Why the holistic approach is needed

• Apart from promoting the use of the vaccine, gaining control over dengue will also require a holistic approach that has to include within its ambit vector control and proper case management.
• Tetravalent vaccine: The vaccine is tetravalent i.e. it provides protection against all the four types of dengue viruses.
  • The vaccine confers about 80% protection to children vaccinated between 4 and 16 years of age without any major side effects.
• Climatic factors: It is essentially a tropical disease that occurs in the countries around the Equator; hot weather and intermittent rainfall favour the sustenance of Aedes aegypti.
  • Aedes eggs can remain dormant for more than a year and will hatch once they come in contact with water.
• Risk factors: Urbanisation, poor town planning, and improper sanitation are the major risk factors for the multiplication of such mosquitoes.
  • Aedes eggs can remain dormant for more than a year and will hatch once they come in contact with water.
  • Aedes mosquitoes cannot fly beyond a hundred meters. Hence, keeping the ambiance clean can help prevent their breeding.
  • Further, these mosquitoes bite during the daytime, so keeping the windows shut in the day hours is also useful.

What needs to be done?

• Source reduction activities: Activities like preventing water stagnation and using chemical larvicides and adulticides.
  • These chemicals need to be applied in periodic cycles to kill the larvae that remain even after the first spray.
• Dealing with the manpower shortage: The number of skilled workers available for such measures is low; many posts in government departments remain vacant despite there being a dire public health need.
  • Due to this deficiency of manpower, active surveillance is not being done in India, says the National Vector Borne Disease Control Program.
• Ending the Under-reporting: Dengue cases are often under-reported due to political reasons and also to avoid spreading panic among the common people. Under-reporting needs to be dealt with.
• Increasing coordination: There is a lack of coordination between the local bodies and health departments in the delivery of public health measures.
  • A comprehensive mechanism is required to address these issues.
• Need for epidemiological measures: Any communicable disease needs the epidemiological approach. Singapore uses one successful model of mapping and analysing data on dengue, using Geographical Information System (GIS).
  • The use of GIS involves mapping the streets with dengue cases for vector densities.
• Emphasis on the WHO guidelines: Fluid management in the body is the cornerstone in the management of severe diseases like dengue hemorrhagic fever and dengue shock syndrome.
  • According to the guidelines, coagulation abnormalities are not due to a reduction in the number of platelets alone.
  • This is why the WHO recommends fresh whole blood or packed cell transfusion in the event of bleeding.
• Caution in using alternative medicine drugs: Modern medicine is not against any complementary medicine; when such a medicine is approved after rigorous testing.
  • However, in the absence of evidence, the efficacy of such medicines remains in the realm of belief instead of science.
  • So, medicines like Nilavembu kudineer and papaya leaf extract are only belief based.

Conclusion

The communicable nature of Dengue and its asymptomatic nature requires the holistic approach to successfully tackle the disease.

Context

The deaths of nearly 200 children in Kota, from largely preventable diseases, lays bare the condition of the healthcare system in India.

Where does India stand?

• According to UNICEF’s ‘State of World’s Children 2019’ report, India reported the maximum number of deaths of children under five in the world in 2018.
• 8,82,000 children under five died that year.
• That means around 2,416 deaths per day.
• The death of children due to largely-preventable illnesses is a matter of serious concern and calls for urgent introspection.

Factors that govern child health

• Most of the children who died in Gorakhpur, Muzaffarpur and Kota belong to the lowest strata of the society.
• It won’t be wrong to conclude that they were victims of structural violence.
• This structural violence is unleashed through a multitude of social, political and economic factors apathy of healthcare professionals, poor health services/infrastructure
• And low rates of female literacy, economic inequality, the rigid caste system, social apartheid, lack of political will and patriarchy play role.
• As a society, we have stopped looking at the deaths of our citizens through the prism of compassion and concern.
• Structural violence influences the nature and distribution of extreme suffering.

What is being done in the wrong way?

• The government is considering the takeover of 750 district hospitals by private medical colleges through a public-private partnership (PPP) model.
• This, despite ample evidence about the failure of the model in the country’s healthcare system.
• Nobel laureate Kenneth Arrow demonstrated that profit and private involvement in healthcare lead to an erosion of trust.
• An Individual’s demand for medical services is irregular and unpredictable, the involvement of a private market model for such services can be disastrous.
• The U.S.’s experiences in the PPP model in healthcare have shone a light on the deficits in transparency and highlighted the lack of care of vulnerable groups.

Conclusion

• What urgently a sincere engagement by the state in matters concerning peoples’ health.
• We need to question the government’s priorities in a country where nearly a million children die every year

At the End TB summit, 2018 the prime minister of India made a bold commitment to end tuberculosis by 2025-five years ahead of the global target. Which is possible to achieve if the efforts are put at the level it was done in case of polio.

The toll taken by TB

• Despite the disease being fully curable, people still die from it.
• TB usually affects people in their most productive years and drives families into debt.
• It has a direct link to human suffering, discrimination and also poverty.
• Due to its infectious spread, it directly affects our economic growth as well.
• With resilience, sufficient investment, innovative approaches and strategies and the participation of all stakeholders, TB can be defeated.

First Step- Awareness

• The first step is the creation of awareness and empowering of communities.
• TB affects millions, yet very few know enough about it.
• Multilingual, multi-stakeholder awareness effort to ensure that all Indians knows about the challenges of TB and where to seek treatment is required.
• With the expansion of the media and evolving technology, it is possible to reach everyone with the right information.

Second Step- Access to diagnosis and treatment

• Ensuring that every Indian get access to correct diagnosis and treatment for TB, regardless of their ability to pay for it is the second step.
• To do so, working with the private sector is necessary as was done in the case of polio.
• There are numerous innovative private-sector programmes and partnership schemes for TB.

Role of  Private sector

• Recently launched programmes for doctors and labs offer the private sector various incentives.
• Even today, about half a million TB cases go unnotified, especially those seeking care in the private sector.
• Those cases need to be tracked and ensured that everyone in the need of treatment and care gets it.
• Organisations like Indian Medical Association and Indian Academy of Paediatrics are working with the private sector to ensure patient-centric care as per “Standards of TB Care in India” (STCI).

Drug-resistant TB

• A key challenge is building a forward-looking plan to address and control drug resistance.
• Drug-resistant TB is a man-made menace that is a major roadblock in a fight against TB.
• Every TB patient must be tested for drug resistance at the first point of care, whether in the public or private sector, to rule out any drug resistance.

Efforts by the government

• Nikshay Poshan Yojana -in which TB patients receive Rs 500 every month while on treatment was launched.
• Nikshay Poshan Yojana ensure that the patients have economic support and nutrition during the required period.
• ‘TB Harega Desh Jeetega Campaign’ was launched to accelerate the efforts to end TB by 2025.
• The campaign aims to initiate preventive and promotive health approaches.
• By applying “multi-sectoral and community-led” approach, the government is building a national movement to end TB by 2025.
• Resource allocation towards the TB Elimination Programme has been increased by four-fold.
• Sincere efforts need to be made to make our health systems more accessible and reliable.
• It also required to ensure that those seeking care trust the healthcare system and get the appropriate care for completing treatment.
• There is a need to create more labs, point of care tests, an assured drug pipeline, access to new drugs.
• The government should also ensure counselling and support for those affected.
• Every patient who is diagnosed late and does not receive timely treatment continues to infect others.
• To break this cycle, government machinery at the field level should work with communities and provide free diagnosis and treatment to every affected individual.

Conclusion

With all the efforts, planning and resource put in place to eradicate the menace of TB from India, it is possible to achieve the goal by 2025.