Dr. Devadasan in Nagaland to orient the Government on Health Financing (10-08-2015 to 14-08-2015)
Community Volunteers/Health workers – contribution in improving health services: By Jatinder Chhatwal
As we all know and recognise that community health workers (CHW) are the part of the community and have a significant role to play for our health improvement. There is plenty of scientific evidence wherein community involvement has increased the reach and impact of health systems. This works for communicable and non-communicable disease programmes as well as health promotion and prevention (TB, malaria and HIV care and prevention). I strongly believe that the success of pulse-Polio programme, was immensely contributed to CHW and similarly we could say that the TB-DOT programme has its success attributed to CHW. It has become clear that their support have unique advantages including their closeness with the community, their ability to communicate through people’s own culture and language and also to understand the needs of the communities and their ability to mobilize the community members.
Based on my experience with the CHW, I feel following are some of the objectives for their involvement into any programme:
1. They have acces
s to the target community, as they are from the community and have acceptability within the community.
2. Bridges the gap between the community and programme
3. Increases outreach for the programme
4. Community empowerment
5. Prompt response for any emergency need of the community
6. Facilitate improvement in surveillance and monitoring of any programme.
7. Facilitates in community mobilization for any activity.
Our government has acknowledged their contribution to the improvement of health status. I could easy quote an example from India, like ASHA (Accredited Social Health Associate) are local volunteers who are recruited through panchayat system and Village Health Committee
Under National Health Mission Programme (NRHM) with specific selection criteria. Following their recruitment, they are imparted training on regular basis for various programmes. For eg. in malaria programme, they are responsible for mobilizing community to accept the Indoor Residual Spray (IRS) and Long Lasting Insecticide Nets (LLINs) and also how to diagnose the case by using Rapid Diagnostic Treatment (RDT) kit, preparation of blood smear/slide for further investigation etc. They are also involved in collecting data from the villages for further assessment by the programme managers. Their performance is assessed from time to time by the state/district team and accordingly they are paid their incentives.
However, I have experienced that it was difficult to sustain them for a longer duration and we came across the following few challenges in the programme:
● Lack of supportive supervision and motivational activities.
● Overloaded with activities of multiple programmes;
● Logistic and supply management for various programmes;
● Acceptance by the community;
● Dependency of community on volunteers;
● Timely payment of performance linked incentive through single window system;
We felt that these challenges be addressed jointly by the community and the government authorities to sustain them for the benefit of the programme. Few suggestions include; a CHW should be assigned to manageable number of households instead of villages to avoid overburden of work; to provide integrated training; community could also contribute in supporting CHW through motivational programmes including honouring them and acknowledging their work from time-to-time. Having said this, we still cannot see a programme without their involvement and it would not be out of place to mention that the success of any health programme primarily depends on the these community volunteer.
Jatinder Chhatwal was a student of e-learning course in Public Health Management(ePHM) conducted by Institute of Public Health, Bangalore, India.
Disclaimer: IPH blogs provide a platform for ePHM students to share their reflections on different public health topics. The views expressed here are solely those of the authors and not necessarily represent the views of IPH.
Health Promotion- Rethinking Our Disease Control Strategy: By Janelle de Sa
Health has long been defined as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity ’. This clearly implies the need for promoting ‘holistic’ well-being and comprehensive healthcare that enables people to increase control over improving their own health. This process entails raising health awareness, enabling informed choice, disease prevention and control. Action in health promotion requires that efforts move beyond the boundaries of an absolute biomedical approach, towards one that takes into account the wider determinants of health including social, economic, political, cultural and ecological factors.
Incorporating health promotion mechanisms at every level of our health system is essential. In this blog, I share a few reflections derived from my experiences with health promotion and disease control activity.
HEALTH PROMOTION AND DISEASE CONTROL
I have in the past, had the opportunity to closely observe and be a part of health promotion programmes dealing with cancer awareness, prevention and care. While I had the opportunity to work within the Cancer Screening Programmes in the UK, it was clear that the programmes had been carefully designed, strategized, piloted and rolled out in an evidence-based manner. Understanding the disease, its anatomical symptoms and more so its aetiology at a molecular level, and the social factors influencing its development, held centre focus in the design and implementation of the population-wide disease control programmes. In Bangalore, I had the opportunity to set up a hospital-based cancer registry programme as part of the wider national programme. Being hospital- based, it was the first time that the ‘patient’ was brought into focus in my work with cancer, and in the process; the seriousness, complexity and reality of the disease with its wider issues governing all aspects of disease awareness, prevention or cure became more apparent and significant.
Simultaneously, my background in Immunology began to re-iterate the significant role our human immune system plays in linking the impacts of our environment with our health outcomes. The Government of India has made efforts to incorporate health promotion into the health system through various intervention-based disease control programmes. Such programmes are important in the short term; however their predominant vertical, biomedical (drug-based) approach is futile for sustained disease control. They fail to consider the wider social determinants of health (SDH) that govern individual and population immunity. One such vertical intervention is the DOTS–TB Control.
Programme introduced under the NRHM.
Tuberculosis (TB) remains a major national and global health problem and is no longer only a disease of the poor; but rather a disease of compromised immunity. Various factors like financial poverty, undernourishment, small, overcrowded and unhygienic living conditions, lack of health awareness and poor health / medical practices; all culminate, to directly or indirectly impact on human immunity and influence susceptibility to TB. The evolution of multidrug-resistant TB strains greatly challenges the efficacy of anti-TB drugs. Furthermore, Directly Observed Treatment, Short Course (DOTS) despite its advantages, fails to address the basic principles of autonomy, appropriateness, accessibility and acceptability; essential for successful adherence and compliance to such a disease control strategy. Responsibility to one’s own health and the sense of personal agency is crucial in positively influencing the SDH and thereby health outcomes.
Recent media campaigns promote the importance of TB diagnosis and uninterrupted treatment via the DOTS programme. While this is a powerful effort in health promotion, it fails to convey the very significance of nutrition and a healthy immunity in TB prevention and control.
HEALTH PROMOTION AND THE INDIAN HEALTH SYSTEM
Health promotion is complex and requires adequate reflection, effort and resources. We are fortunate as a country to have the aptitude and the means to build a massive and effective health promotion campaign as a part of our existing public health system. A successful example of disease control through health promotion activities (education and prevention strategies) and multi-sectoral efforts (including The Ministry of Rural Development, Govt. of India, State Public Health Engineering Departments, and the Rajiv Gandhi National Drinking Water Mission (Rural Water Supply) in India; is the Guinea Worm Eradication Programme. Health promotion has the potential to move beyond the NRHM’s vertical interventions through cross sectoral engagement (sectors that influence the daily lives of the public and their health). Addressing the SDH through such an approach would ensure that important disease–contributing factors like micronutrient deficiencies are addressed even via the food industry, for example.
Health protection through immunity building and addressing the SDH from within the Public Health system and across sectors, to introduce well-planned horizontal efforts together with vertical interventions is a way forward.
Janelle de Sa was a student of e-learning course in Public Health Management(ePHM ) conducted by Institute of Public Health, Bangalore, India.
Disclaimer: IPH blogs provide a platform for e-PHM students to share their reflections on different public health topics. The views expressed here are solely those of the authors and not necessarily represent the views of IPH.
Road Traffic Injuries-An Ignored Public Health Issue in India
(Photo Credits- Biswarup Ganguly)
The World Health Organization (WHO) estimates that 1.24 million road traffic deaths occur every year globally. Of those, the majority (80%) of deaths occur only in middle income countries.Road traffic injuries are never considered a public health issue in India, rather reported as just any other event. India leads the world in terms of mortality from road traffic injuries.In India, road traffic injuries pose a significant public health challenge to the already overburdened health system, and hamper the economic development of the country.Three Es are important in preventing lots of death from road traffic injuries. Education in increasing awareness on road safety measures and behavior change among general public is important. Establishing and designing proper roads is more important. Most important is political will in stricter Enforcement of road safety laws.
Link to Manoj Pati’s blog in BMJ can be found from here.
Corporate social responsibility in India
This article originally appeared on BMJ Blogs on May 09, 2014 under the same title.
India’s new Companies Act with its rules mandating corporate social responsibility (CSR) came into effect on 1 April 2014.
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. [1] 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.
Kingfisher airlines, whose parent company is United Breweries, was reportedly able to acquire loans based on its brand equity. This is the same Kingfisher brand that is best known for the beer manufactured by the same company.
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.
Re-imagining the response to non-communicable diseases in India
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.
The health service’s response to the epidemic nature of diabetes and hypertension is the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular disease, and Stroke (NPCDCS). The programme was piloted in 100 districts (of the 646 districts in India) during 2010-12, and is still active, with plans for the programme to be rolled out to more districts. Doctors and many health workers are being trained to provide care for non-communicable diseases. Early screening and diagnoses are being carried out for people who are age 40 and over. However, the programme, as with many others, suffers from the consequences of a poorly financed and sub-optimally functioning health system.
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.
| PHC 1 | PHC2 | PHC 1 | PHC2 | |
| Medicines | Indented | Received | ||
| Metformin | 2000 | 5000 | 0 | 0 |
| Glibenclamide | 5000 | 4000 | 0 | 0 |
| Atenolol | 3000 | 4000 | 3000 | 500 |
| Amlodipine | 5000 | 4000 | 3000 | 1500 |
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.
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