This article originally appeared on BMJ Blogs on April 24, 2015 under the same title.
This blog is my reflection on regular field visits as part of the urban health action research project that I am currently working on. The field site for the project is a very poor neighbourhood of Bengaluru called K.G.Halli. This neighbourhood has families who earn their living as daily wageworkers to a few upper middle class families.
Let me give a brief overview of the project. It is an action research project which aims to improve access to quality healthcare especially for people with chronic conditions among the urban poor. As a project initiative, we identified three ladies from the same community and trained in providing awareness sessions for chronic conditions. These community health assistants have been working in the neighbourhood since 2009. They go door to door to deliver awareness sessions on diabetes and hypertension, to inform patients what the preventive measures are that the patient and the family can adopt on a daily basis, how diet plays an important role in managing their conditions, and the importance of regular medical check ups. These ladies are an important interface between the community and healthcare providers. Over the years they have become the “go-to” people to seek advice.
Recently I accompanied these ladies for their regular home visits. As they were walking in the lanes, familiar faces greeted them, some asked them to come and join them for a cup of coffee. These were greetings on one end of the spectrum, on the contrary we had to knock on an average of 20- 25 houses and then there would be one patient or a family who would greet us. A few passers by whom we met on the way had curious questionable looks on their faces, and a few even said: “There is no patient in the family.”
Some responses I found were very startling and some of the interesting ones, which did capture my attention, were:
“I already have the disease, how will this awareness bring about a change?”
“ I do not have a ration card, that is more important to me, awareness is not.”
“ Why don’t you give us money?”
“ It is your job as a doctor to find cure and medicines, it is not the responsibility of the patient to make any dietary changes.”
“ Why are you scaring me after me being diagnosed with the disease? I do not need this information.”
“Do you have to meet certain targets? How many houses do you have to visit like these in a day?”
Another experience cited by the health assistants was, “we are educated people, we do not need your information: you would be better off educating the poor people.”
These reactions from the community, which I worked in for almost two years, made me realize that I was wearing blinkers as a young researcher and a medical doctor. It made me realize that the training in research or medical school did not give me any skills to understand these reactions or even think which other strategy I could use to communicate effectively and motivate people.
They sought a completely different path to find out about or understand their disease. Most of the patients that we visited asked us “why aren’t you carrying a glucometer to let me know if my blood sugar levels are under control.” The patients just wanted a figurative number, which is simpler for them to understand and to reassure them that their disease is under control. They would rather not listen to the “science” but to an immediate solution to their problem.
Their voices echoed completely different priorities, such as ration cards, cheaper sources of medicines, or jobs. Another question which came to my mind was whether my chosen strategy of conducting door-to-door awareness sessions was indeed the best strategy for the community or for the researcher?
The comfort of science and research were no longer my allies in solving my dilemma, reiterating the steps to actually listen to the community and understand their priorities better than going with my priorities as a researcher. How can a young researcher like me help them in securing a ration card of any other welfare schemes? Maybe there were unexplored pathways to find a common ground which has a possibility to solve some demands of the community as well as bring in about motivation in the community for adopting a healthier lifestyle.
Written by – Mrunalini Gowda, Research Officer at the Institute of Public Health, Bengaluru.
KEYSTONE is a collective initiative of several Indian health policy and systems research (HPSR) organizations to strengthen and build national capacity in HPSR.
KEYSTONE was convened by the Public Health Foundation of India as Nodal Institute for the Alliance for Health Policy and Systems Research (AHPSR).
The Inaugural course which was held in New Deli from 23rd February to March 5th 2015 had twenty fellows from various disciplines participating in this course from across the country.
Institute of public health, Bengaluru also was one of the members for this intiative. Dr. Devadasan was on the core selection committee, Dr. Prashanth N.S was one amongst the facilitators who helped developing the curriculum of the course and also taught the lens of realist evaluation. Dr. Mrunalini Gowda, was selected as a fellow to partcipate in this course. This two week intensive course covered different lenses of health policy and systems research and the to bring about a learning platform for the fellows and the facilitators to share learning material and also establish a active discussion forum. Learning management system called MOODLE which is managed by IPH was used throughout the course . The learning management system was appreciated by all the members of KEYSTONE initiative.
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.