The World Health Organization , Government of India (GoI) and other technical and donor partners undertook a Joint Monitoring Mission (JMM) to review the India’s Revised National TB Control Programme (RNTCP) from 10-23 April 2015. The last JMM was undertaken in August 2012.
The objectives of the JMM are to:
Review India’s progress in implementation of the National Strategic Plan and follow-up on the recommendations of JMM 2012.
Review the country’s progress as per the National Strategic Plan 2012-1, towards universal access to TB care and to advise GoI and partners on the pathway towards strategies in line with End TB Strategy.
The JMM constituted 100 national and 50 international experts partnering with the RNTCP. Dr.Vijayashree Yellappa, faculty and PhD fellow at IPH participated in the JMM (Private sector engagement). She was deployed in Mehsana district of Gujarat to observe the private sector engagement in RNTCP.
This article originally appeared on BMJ Blogs on April 24, 2015 under the same title.
Tobacco use is one of the single largest preventable causes of death and a leading risk factor for non-communicable diseases. The burden of tobacco related illnesses prompted the Government of India to initiate various measures for tobacco control. India adapted the WHO Framework Convention of Tobacco Control (FCTC) and passed the “Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce Production, Supply and Distribution)” Act in 2003. The National Tobacco Control Program (NTCP) was launched in 2007-08 and it listed a wide array of regulatory activities for tobacco control, including setting up the National Regulatory Authority (NRA), state and district tobacco control programmes, public awareness campaigns, establishment of tobacco testing laboratories, prohibition of smoking in public places, prohibition of advertisement, sponsorship and promotion of tobacco products, prohibition of sale of tobacco products near educational institutions, and regulation of health warning in tobacco products packs.
Even after having active tobacco control programmes for well over a decade, we see that the focus is mainly on preventive measures such as educational campaigns and banning tobacco usage in public places. Though the National Tobacco Control Program recognized tobacco cessation as an important component and a critical step in controlling tobacco related mortality and morbidity, cessation activities have still not kept pace with other tobacco control activities. Less than half of the states under the programme have established tobacco cessation facilities at a district level. The recent ban of smokeless tobacco products was a major development in the history of tobacco control in India. A few state governments have taken other proactive steps towards tobacco control including declaring those states as smoke free. The latest policy debates are on banning the sale of loose cigarettes and increasing the legal age to buy cigarettes from 18 years to 25 years. While these efforts go a long way in tobacco control, which need to be appreciated, it also raises an important question: what services are available for a large number of regular users who require assistance to quit the tobacco use? It is interesting to note that while many of these states boast of being tobacco free, they are neglecting a vast number of active users who may need assistance to quit. It is estimated that around about 40% of tobacco users want to quit at any given point in time. A handful of exclusive Tobacco Cessation Centers (TCCs), attached to either medical colleges or tertiary care hospitals cannot guarantee access to millions of users who will require cessation services. Though there are some isolated private and Non-Governmental Organisation (NGO) initiatives, they are very limited in number and thus have very minimal outreach and impact.
In 2001, the National Human Rights Commission (NHRC) pointed out that India’s tobacco control initiatives are not effective enough and it violates the rights of tobacco users in many aspects including the right to access tobacco cessation programmes (as part of right of health). It was recommended that along with more effective information, education, and communication programmes on the effects of tobacco, assistance for tobacco cessation should be integrated into healthcare services to ensure access. Tobacco users are often faced with a counter argument saying “it is question of personal choice.” But in the case of a country like India, we see that tobacco users often do not have adequate information about the harmful effects of tobacco products. The latest global adult tobacco survey reported that only 50% of users were aware of the harmful effects of tobacco. It found that tobacco usage is higher among the disadvantaged and less educated, who may not be well informed and may not be able to make such conscious decisions.
It is evident that tobacco cessation has not received enough attention in our tobacco control programmes and often gets sidelined for various reasons, including resource crunch. So we need to think of alternative/additional strategies to reach out to more people and in a more sustainable, cost effective way. One possible solution is to integrate cessation activities into formal health services. While looking at the feasibility of integration at a primary care level, the major challenge is the shortage of human resources. However, it would be feasible to assess tobacco usage, and provide brief counseling and referral. Routine assessment of tobacco usage and brief counseling is known to have a positive effect on users. Comprehensive tobacco cessation services need to be made available in district and Taluka hospitals in order to cater for the vast number of users. Health workers, who are often the first point of contact for patients, can also play an important role in tobacco cessation counseling. Due to its prominence, the private healthcare sector can also play a crucial role in tobacco cessation.
Another area that needs attention is training health professionals in tobacco cessation. Often we see that medical practitioners and health workers are not aware of the harmful effects of tobacco and do not have the necessary skills to provide cessation services including counseling. One way to do this is to include tobacco related issues and its management in the medical curriculum and CME. The training has to be extended to different allied medical practitioners such as dentists and health workers as they come across more people using tobacco. Training on tobacco cessation strategies should also be imparted to teachers in school and colleges and “tobacco and its harmful effects” should be introduced as a topic in the school curriculum.
Telephone helplines have played a major role in tobacco cessation in the West. This can be tried out as a more cost effective intervention method. Innovative measures such as mobile apps and peer support platforms using social media could also be tried out as additional strategies.
Written by –Maya Annie Elias, Faculty memberat the Institute of Public Health, Bengaluru.
The objective of CSR is for businesses to exist as responsible citizens of their socio economic milieu and contribute to social good. As such, CSR pervades every aspect of a corporate organization’s functioning. How then do we regard CSR activities of companies whose products are conspicuously against public good—the so-called sin industries?
Section 135 of the law requires companies of a particular size to spend a prescribed amount on CSR and report these activities, or explain why they failed to do so. Specifically, companies with a net worth of Rs 5 crore or more, or a turnover of Rs 1000 crore or more or net profit of Rs 5 crore or more, are required to constitute a CSR committee. This committee is expected to formulate a CSR policy and oversee its implementation. The law specifies the activities that qualify as CSR, but it does not define the term itself. Activities undertaken by companies to improve conditions for their own employees or better corporate governance alone, do not qualify as CSR under the law.
Superficially, CSR may seem like a win-win where companies improve their social capital while society gains from these activities as the government’s resources are augmented. In practice, however, CSR can become one more tool for unscrupulous companies to circumvent the public health laws. While these laws prohibit the advertising of products that have been proven to be harmful, companies will now be allowed, and in fact required, to publicize CSR programmes that may improve their brand image.
Studies have already established that controversial industries tend to be more active in CSR communication than others.  The reporting requirement contained in the CSR clause of the companies law can end up as an avenue for proxy advertising by these “sin companies.”
This is compounded by the fact that avenues for proxy advertising and brand building are already readily available and are exploited by both tobacco and alcohol giants. Chief among them is the ability of these companies to operate in multiple sectors and then leverage their businesses in other sectors to drive their liquor or tobacco operations. Many companies make strategic choices in designing and implementing their CSR agenda to reinforce their business interests and build goodwill among consumers, stakeholders, and the government. Tobacco and liquor giants in India now have operations in virtually every industry.
India’s leading cigarette manufacturer, ITC Ltd, for example, has initiated e-Choupals that can been used by tobacco farmers to directly negotiate the sale of their produce with companies such as ITC. Food products manufactured by iITC carry the ITC label. ITC hotels routinely become destinations for celebrity weddings that are widely publicized in the media.
Consumers repeatedly encounter these brands in benign contexts that are often aggressively marketed, serving as proxy advertisements for their tobacco or liquor products and lending them legitimacy.
Another side effect of the large scale operations of companies across industries is the increased ability to interact with and influence policymakers.
CSR activities can prove especially useful in providing more opportunities for interactions between corporate companies and the government since they can now cooperate in the seemingly neutral sphere of social development. This is an extremely dangerous trend that has already become prevalent in India. The chairperson of United Breweries, India’s number one liquor company, is a member of the upper house of the Indian Parliament, and the chairman of ITC was a member of the committee constituted by the government of India that made recommendations, many of which were incorporated in the new companies law. (See page 78 of the report)
In short, CSR can potentially constitute a form of political interference by corporates who can influence government policy. The political use of CSR is a known danger that has not been given enough attention in the current law. In addition to the policy measures, civil society needs to be vigilant to ensure that the spirit of the CSR clause is upheld while its misuse is actively prevented.
Written by –Neethi V Rao, Research Officer at the Institute of Public Health, Bengaluru.
This article originally appeared on BMJ Blogs on December 30, 2014 under the same title.
It was just another day at the primary health centre (PHC) that I work closely with in the south Indian state of Karnataka. I was in the pharmacy of the PHC, discussing the availability of medicines for diabetes and hypertension with the pharmacist.
Meanwhile, an elderly woman arrived at the dispensary window along with a small diary. She had come for her monthly refill of anti-diabetic medicines. She passed her book through the window to get her monthly supply of medicines. The pharmacist returned her diary. “These medicines have not been available for a month, buy them at the private pharmacy outside,” he said.
I looked on as the woman stared back with a blank face, unable to understand why there were no medicines in the PHC. She repeated her request, this time emphasising that she was poor and had travelled a long distance to the PHC to get the medicines. She would not leave without her medicines. The pharmacist was able to “manage” the situation eventually, by convincing her that no amount of appeals could work as there were no medicines at the PHC. The woman left the PHC saying she would return next month.
This is no isolated incident specific to the PHC that I was visiting. In most of rural India, patients who are poor and/or older routinely visit PHCs in the hope for free medicines, often promised by one government scheme or another. But the situation has not changed much in many states of India. Along with my colleagues, I have been visiting various PHCs in Karnataka. Pharmacists keep telling us about frequent stock-outs and an erratic supply of medicines. This especially affects patients with diabetes and hypertension, many of whom are older patients.
Diabetes, a major risk factor for stroke and kidney disease, also contributes to increased death and disability. According to the Diabetes Atlas 2006, published by the International Diabetes Federation, the number of people with diabetes in India is currently around 40.9 million and is expected to rise to 69.9 million by 2025, unless urgent preventive steps are taken. Similarly, 118 million people were estimated to have high blood pressure in the year 2000, which is expected to go up to 213 million in 2025.
We found that many people who have been diagnosed with diabetes or hypertension do not have any clear idea about what they have to do in terms of taking treatment or lifestyle adaptations. Neither the PHC, nor the hospitals at the sub-district and district level, are equipped to manage chronic conditions such as diabetes and hypertension. To begin with, most of these facilities do not have a regular stock of medicines or diagnostic reagents. There are no special staff to counsel the patients about the disease and its management. Continuity of care is affected because there are no records of the patient, so a clinician has no idea about the past treatment history of the patient. This is all the more important as many patients in rural India are semi-illiterate.
Care and follow-up for diabetes and hypertension involves a lot of lifestyle modification. However, it is not entirely about people’s lifestyles; there is a need for medicines too. In spite of increasing the money invested in government services, several management gaps have resulted in the poor availability of medicines in government centres, unnecessarily pushing people to rely on private pharmacies, and thus disadvantaging patients who are poor and/or older. Even the most basic medicines for diabetes and hypertension, which are a part of the state’s essential drugs list—Metformin, Glibenclamide, Atenolol and Amlodipine—are not available for several months in the year in many PHCs.
Source: PHCs pharmacists (2013)
I recently heard the news that the NPCDCS programme is going to be expanded to some more districts in India. This brings up the question of what lessons have been learned from the piloting of the programme. How is this programme going to deal with the problem of access to medicines, which is affecting all health programmes, be it infectious diseases or others?
While many states in India are thinking of new programmes and initiatives for many diseases and health conditions, it is very important to first address the basic issue of availability of medicines—an unfortunate victim of the poor management of public services. The ill effects of this are mostly borne by those who are poor and older, and who depend on our public services.
Written by –Bheemaray Manganavar, Research Officer at the Institute of Public Health, Bengaluru.
Yet, despite an increased allocation of spending on healthcare by the government in the past few years, out of pocket expenditure by patients at the point of service delivery has shown little respite. In this context, India’s role as a leading manufacturer of generic drugs could offer great potential for decreasing healthcare expenditure—by both the people and the government.
However, patients’ and healthcare workers’ perceptions of generic medicines influences their use. In this blog, I will discuss these perceptions and its implications on healthcare expenditure. I also include some personal reflections from my work in training health workers, while promoting the use of good quality generic medicines in health services.
Last year (2014), as part of a research study on access to medicines, the Institute of Public Health (IPH), Bengaluru, conducted household surveys on drug access, utilization, and health seeking behavior in Karnataka—a state in south India. We randomly selected villages that were situated within close proximity of several primary healthcare centers (PHC), which were participating in the study. We found that general awareness of generic medicines was very poor in rural India; less than one per cent had heard about such medicines.
The most disheartening part of our exercise was that most of the people we interviewed reported that the medicines supplied at the government facilities were of poor quality. Many interviewees shared a common perception that “anything you get for free is not of good quality.” And many of them compared such free government medicines to other government supplied materials, such as the monthly ration of food grain, which they also considered to be generally of poor quality. We found that many of the government health workers also concurred with this opinion. It seemed that this was a strongly and widely held perception in rural communities in the areas we surveyed.
Subsequently, when we were training health workers at the PHCs on the rational use of medicines and other non-drug, lifestyle based treatment options for NCDs, we found a similar pattern of perceptions; only a couple of them knew that generic medicines are low cost. However, they had no idea about where such cheaper alternatives to expensive branded drugs were available. The level of awareness among the village based community health workers (called accredited social health activists, or ASHAs, in most parts of India) was similarly low.
After this, we thought we may find some illumination (in contrast to health workers’ total lack of awareness) among private sector pharmacists. Most medicines are purchased in private pharmacies in India. We wanted to explore their role in stocking generic medicines. We also wanted to assess if the promotion of generic medicines by government health services could be perceived by them as affecting their business interests.
Most of the pharmacists we interacted with, however, were confident that generic medicines are ineffective. They thought that most patients prefer good quality medicines (which in their opinion were synonymous with branded medicines) and that very few patients, according to them, obtained their medicines from generic drug stores or PHCs. In their assessment, even if inexpensive generic medicines were promoted, this would not have a major impact on their revenue.
Preliminary analysis of our survey reveals that an average household spends up to 600 Indian rupees ($10) per month on procuring drugs for hypertension and diabetes, which is more than a week’s wages for many people in rural India. Many families discontinue medication because of financial difficulties; see, for example, my colleague’s experience visiting a poor family with an elderly diabetic patient in southern India. Many of these families have no knowledge about generic drugs, where to buy them, their quality, and how they can be helpful in their NCD care.
An important component of good NCD care is sustained provision of good quality, low cost medicines, which should be accessible without further barriers. Several years after launching generic medicines and other schemes to improve access, medicine availability is still poor in rural India. This affects those with NCDs even more because of the need for lifelong medication in some conditions.
Good quality generic medicines supplied through the government’s PHCs could be a simple, yet effective, solution to this problem. Yet, PHC health workers struggle with a shortage of medicines, as well as the adverse perceptions of generic drugs among communities and health workers. We need better promotion and regulation of drug quality by the government if we want to improve access to medicines for poor patients in rural India.
Written by – Bhanu Prakash, Researcher Officer at the Institute of Public Health, Bengaluru.
This article originally appeared on BMJ Blogs on February 26, 2015 under the same title.
AYUSH—an acronym for Ayurveda, Yoga, Unani, Siddha, and Homeopathy—is a system of medicine that has been integrated into the Indian national healthcare delivery system to strengthen public health in rural India. In 2005, when the Indian government launched the national rural health mission (NRHM) to improve healthcare delivery especially for the rural population,integration of AYUSH was an important strategy that was adopted. This was done with the objective of offering treatment choice to people as well as a strategy to overcome the human resource shortage in the government health facilities. The planning and implementation of AYUSH differs across various states, depending upon the existing level of development of AYUSH services in the state and the development emphasis of the state.
Here I am sharing some of my reflections on the status of AYUSH medical officers who are posted in the government primary health centres. I have had opportunities to meet many AYUSH practitioners who are posted in government run primary healthcare centres during field visits for my research into access to medicines for the rural poor in Karnataka. As per the official mandates and guidelines, these practitioners are supposed to practice Indian systems of medicines at the primary healthcare centres and they are also supposed to manage different national programmes. But often what happens in practice is different. Due to the shortage of trained MBBS doctors, they are posted to primary health centres and are expected to manage outpatient and administrative responsibilities. The AYUSH medicines supplied to the primary healthcare centres are very minimal, most of the time there is no stock of any AYUSH medicines and they are forced to prescribe allopathic medicines due to the patients’s demands as well as the pressure from the district and sub district health authorities which is often “off the record.” Several times these AYUSH doctors have asked the health authorities to allow them to prescribe basic allopathic medicines in more legitimate manner, but the authorities keep rejecting their plea. While narrating his plight, one of the doctors sighed and said “we are forced to do quackery in our health system,” referring to the fact that he is being forced to prescribe and practice the allopathic system of medicine (which is not his area of expertise).
It is an irony when the official mandate expects these doctors to manage the patient load and implement national health programmes, but they do not have the legitimacy to prescribe the allopathic system of medicines which are often very basic and used to manage minor elements. The NRHM is almost a decade old and the problem still has not been addressed.
Allowing the AYUSH practitioners to undergo a bridge course to better orient them to allopathic system of medicine and then legitimize them to use at least some basic allopathic drugs would legitimize their position in PHCs. It is pity that in a country where a chemist can sell allopathic drugs over the counter boldly without any prescriptions, AYUSH doctors are finding themselves unsafe to prescribe allopathic medicines in existing health system.
Written by – Dr.Praveenkumar Aivalli, Research Officer at Institute of Public Health Bengaluru.
Under pressure from civil society, the Government of India is contemplating a legislation to deal with conflicts of interest. In 2013, a Private Member’s Bill on Prevention and Management of Conflicts of Interest was introduced in the upper house of Parliament, Rajya Sabha but lapsed without discussion.
Following this, the ‘Working Group on Conflict of Interest Legislation and Policies’ led by theAlliance Against Conflict of Interest (AACI) convened a national consultation in Delhi on the 13th September 2014. IPH staff member Dr. Neethi V Rao was invited to be a participant at that consultation based on her research on conflicts of interest in tobacco control in India. Subsequently she has continued to participate in the process of drafting and advocating for a new legislation on the Prevention and Management of Conflicts of Interest in India.
IPH has been working with Tumkur district in trying to strengthen various components of the district health system. One of the key interventions here has been to work with private practitioners in the district to better understand their integration into the National Tuberculosis control programme.This project being led by our Faculty and PhD Fellow, Vijayashree Yellappa. Earlier this month, her proposal was one of 26 proposals selected (from 460 submissions!) for the WHO-TDR IMPACT grants, a global grant-making mechanism to support innovative research on neglected priority needs for disease control. WHO-TDR is a special Programme of the WHO for research and training in Tropical Diseases and sponsored by UNICEF, the UNDP, the World Bank and WHO.
Few members from the tobacco control team participated in the 3rd National conference on tobacco or Health held at Mumbai on the 15th and 16th of December. We had three oral presentation and one poster presentation depicting the on going activities and learning from Karnataka. In the conference Upendra Bhojani presented the learning from success stories in states of India and also a poster on the health in all policies (HIAP) approach in tobacco control Neethi Rao presented the findings of an exploratory study on conflicts of interest in tobacco control in India Pragati Hebbar presented the insights of moving from policy to practice with examples of implementing tobacco control law in Karnataka.