Yojana Notes Indias Health issues and Challenges 1.

Divergent Attitudes to Birth Control- In 1994, India adopted a target free policy and the states were encouraged to implement a cafeteria approach. In this, the Southern states performed pretty well and had all the political and administrative support. Whereas, North India failed to implement this policy, most of the sterilizations are emergency driven and family planning remains a distant dream. 2. The Challenge of Reducing Maternal and Infant Mortality- Till date, most of the marriages in Northern India take place well below the legal ages of 18 and 21. It has various repercussions such as malnourishment and anaemia amongst the girls and children. Schemes for nutrition, education and literacy have remained hollow expressions and girls have no control over their pregnancy. Instead of waiting for incremental improvements, there is a need to bring this issue to centre stage and adopt a long term planning. However, the situation in Southern states is relatively better. 3. Health Management and Manpower Planning- MCI, Dental Council, Nursing Council and Pharmacy Council were established with intent to elect a cross-section of doctors and to entrust them the responsibility for designing and executing the professional courses. However, because of the political processes adopted in these councils, these councils failed to achieve their goals and today, entry to the medical colleges is very costly and commercialized because of which the students want to reap back benefits from the huge investments incurred. The numbers of super specialists and specialists have risen but the technical man power has declined and there is no vision for the health needs of the country. 4. The Challenge of establishing NCHRH- The proposal to replace MCI with National Council for Human Resources in Health (NCHRH) was a well thought out strategy to ensure that goals of preserving ethical standards and health manpower planning are achieved. But, IMA and other doctors are vehemently opposing as they see it as a threat to their autonomy. The NCHRH is presently before the Standing Committee of Parliament. 5. The Challenge of Allopathy and AYUSH- Health is a state responsibility and public health cannot be contracted to private companies and other institutions. The NRHM has been a big success in a lot places and has improved birth delivery facilities. Some states have engaged AYUSH doctors under NRHM and these AYUSH doctors dispense allopathic drugs and administer IVs and Injections. They get assistance from the AYUSH pharmacists and the nursing staff. This reality must be accepted and the controversy over what AYUSH doctors can and cannot do must be settled. 6. The Challenge of Retaining Doctors- It is true that a lot of doctors go for post-graduation or abroad failing which they even go for administrative or management jobs. This is their choice and it cannot be stopped. But what can be done is fixing a term requirement to stay bonded to public health sector for state sponsored medical graduates. But, if that is done, the working conditions, facilities and remuneration for such doctors also needs to be improved.

Drug Pricing and Pharmaceutical Policy 1. Department of Pharmaceuticals established for ensuring the availability of medicines at reasonable prices in the country. 2. Under, Drug Policy, 1994, DPCO [Drugs (Price Control) Order, 1995] was framed with following features: a. 74 bulk drugs and their formulations under price control. b. Cost based pricing of bulk drugs c. Pricing of indigenously manufactured scheduled formulations under a specified formula. d. For imported formulations- Landed cost + margin not exceeding 50 per cent. e. Control of price of any non-scheduled formulation in public interest. 3. NPPA (National Pharmaceutical Pricing Authority) formed for regulating the prices of specified drugs. It has been entrusted the task of price fixation/revision and other related matters such as updating the list of drugs under price control by inclusion and exclusion on the basis of the established guidelines. 4. NPPA is empowered to take final decisions subject to review by the Central Government. 5. NPPA monitors the availability of drugs throughout the country and take corrective action if any shortage of medicine is noticed. 6. NPPA while implementing DPCO, 1995 undertakes: a. Pricing of Pharmaceutical Drugs i. Price Fixation ii. Review of Prices iii. Check and Correction iv. Enforcement b. Overcharging of Pharmaceutical Drugs i. Detect ii. Demand iii. Deposit c. Monitoring of Pharmaceutical Drugs i. Monitor Prices ii. Monitor Availability- Monthly Field Report from State Drug Controllers. Shortage is generally brand specific where alternate brands are available. iii. Market-Surveillance 1. Purchase of Samples by NPPA officers to ensure compliance. 2. Examine complaints. iv. Market Intervention v. Maintain Price Line 7. Cost of medicine is the major cost driver constituting 60-70% of total healthcare. 8. Most of the people out of risk buffer and have no health insurance. 9. India is recognized as a low cost producer of quality drugs. 10. Government taking steps to give support to the pharmaceutical industry by providing various fiscal and non-fiscal incentives for R&D and minimal price control. 11. NPPA needs to balance the conflicting interests of the consumers and the producers.

12. There is a need for a National Medicine price Monitoring Mechanism in form of information system. Women and Child Health A. There can be no improvement in maternal health without eradicating poverty and hunger. B. The term Maternal Health to be used in its broadest sense and must include all that goes wrong with women generally and those from the poorer sections in particular. C. Health services are not accessible to a majority of women. D. One of the main reasons is the already overburdened Out Patient Load (OPD) which leaves the medical staff at primary health centres with little time for postpartum care. E. Family members are ill equipped to handle complications. F. Vulnerable sections not aware about the welfare schemes such as Janani Suraksha Yojana. G. User Fee for either transportation or investigations further minimizes the access to services. H. Poor functioning and unfriendly attitude on part of the hospital staff renders health services ineffective. I. Ministry of Health and Family Welfare has issued operational guidelines for Home Based New born Care. This is to be implemented by ASHAs (Accredited Social Health Activists). J. Women take the medicine but often do not consume defeating the entire purpose of the schemes. K. A lot of Mobile Medical Units, New born Care Corners and New born Stabilization Units have been set up. L. The name based Mother and Child Tracking System is established to record every pregnant women and child. A database of more than 3.25 Crores has already been created. M. Government has taken a policy decision to review maternal death find gaps in the service delivery which lead to maternal deaths and take corrective action to improve the quality of service, and not for taking punitive action against service providers. N. Janani Shishu Suraksha Karyakaram- It guarantees free entitlements to pregnant women and sick new born till 30 days after birth such as exemption from user charges, free transport, diet and drugs. But, it has failed because the benefits of the scheme are not known even at the hospitals. O. Adolescent Sexual Reproductive Health Strategy has been started for the promotion of menstrual hygiene in the rural areas. NRHM brand Sanitary Napkins will be to the girls at subsidized cost. P. Pulse Polio Immunization has been a great success. WHO declared India as polio-free. Q. Universal Immunization Programme is carried out to prevent seven vaccine preventable diseases i.e. Diphtheria, Pertussis, Tetanus, Polio, Measles, Child TB and Hepatitis B. R. Pentavalent vaccines have also been introduced in some states. (Diphtheria, Pertussis, Tetanus, Hepatitis B and Haemophilus Influenzae B) S. Under the Family Planning Programme, eligible couples are now being counselled to delay their first and then better space their children for which contraceptives are being provided at the doorsteps. T. However, there can be no improvement in maternal health unless women are enlightened through education at least till the primary level and gender equality needs to be reinforced.

Rediscovering the Traditional Wisdom of Nutrition A. Ragi was once the staple diet of major part of rural India but has long been basnished from their plate by the trend of mono agriculture limiting farm yields only to rice and wheat. Other coarse grains like Jowar, Bajra and Maize have met the same fate. B. The Green Revolution proved a bane in the sense that it banished those coarse grains and pulses from the rural India. C. Malnutrition is a major reason for percolation of modern day diseases in the Rural India. D. National Nutrition Monitoring Bureau (NNMB) has said that Iron, Protein and micronutrients are deficient in rural India. E. Food Security cannot be achieved by simply providing rice and wheat but it calls for a delivery of balanced diet entailing sufficient calcium, protein, vitamin and other nutrients. F. Customized diet must be given for every illness. G. Previous budget allocated 400 Crores for the promotion of coarse grains but NGOs say that the announcement should have been coupled with MSP and facilities for storing them. H. Fish, a rich source of protein, came to the rescue of those who live in coastal states. Pulses would have done this for Northern States. I. There is a need to embed pulses and coarse grains in the measures taken up towards the National Campaign against Malnutrition. J. In urban India, most of the nutrition comes from milk, curds, vegetables, spices and meat but in Rural India, nutrition mainly comes from grains. K. There are a number of programs for this purpose like the Mid-day Meal Program, ISKON catering to 5 lakh children in Delhi etc. L. The changing food pattern presents new dangers to our younger generation especially in the light of the cold drinks (empty calorie) making a dent in rural bastion.

Responding to HIV and AIDS in India A. The first HIV case in India was diagnosed in 1982 and the first HIV case through Injection Drug Use (IDU) was diagnosed in Manipur in 1986. B. HIV is mostly concentrated among sex workers, men who have sex with men, transgender, injecting drug users and bridge populations like clients of sex, street children and migrants. At present there are 2.39 million people living with HIV in India. C. National AIDS Control Organization (NACO) was created in 1992 by the government to prevent and contain HIV. It formulates policies in this regard. D. These have been done through three consecutive phases of National AIDS Control Programme. (NACP- I,II and III) E. NACP Phase I- (1992-1999) - The overall objective was to slow and prevent the spread of HIV with a thrust prevent HIV transmission. F. NACP Phase II- (1999-2004)- The focus was to reach out to high risk groups through targeted interventions- a package of services which entailed behaviour change communication, peer education, treatment of sexually transmitted infections, condom promotion, needle, creating an enabling environment, community mobilization. G. NACP Phase III- (2007-2012)- This phase aimed to reverse the epidemic through integration of prevention and treatment programmes, decentralized effort at the district level and engage more NGOs. H. NACO has enabled access to safe blood through a network of blood banks, Syndromic case management, counselling and testing, information education and communication. The Red Ribbon Express train travelling around 25000 km has also been instrumental in this regard. I. National AIDS Prevention and Control Policy- It believes that to adopt the right strategy for prevention and control of HIV/AIDS/STDs, it is necessary to build up a proper system of surveillance to assess the magnitude of HIV infections in the community. For this purpose, three systems have been setup: a. HIV Sentinel Surveillance (HSS) b. Behavioural Sentinel Surveillance (BSS) c. STD Surveillance systems J. NACO has recently initiated a computerized management information system and a computerized project financial management system for strengthening tracking and programme monitoring. K. The National AIDS Research Institute, Pune was set up by Indian Council of Medical Research in 1992. L. The Translational Health Sciences and Technology Institute was recently launched by Dr. APJ Abdul Kalam. M. Rural Population, particularly those along truck routes, migrant labour from rural to urban areas and wives/partners of male migrants are the most vulnerable groups to contract and transmit HIV. N. There is a need for a Combination Approach addressing all the aspects- Prevention, Care, Treatment and Support, tailored for rural areas.

Janani Shishu Suraksha Karyakram A. In June 2011, Ministry of Health and Family Welfare, Government of India launched the Janani-Shishu Suraksha Karykram. (JSSK) B. The scheme emphasizes utmost importance on Free entitlements. The idea is to eliminate out of pocket expenses for both pregnant women and sick neonates. C. The numbers of institutional deliveries have increased significantly, after the launch of Janani Suaksha Yojana, 2005 but many of those who opted for institutional deliveries were not willing to stay for 48 hrs. hampering the provision for essential services both to the mother and neonate. First 48 hrs. of delivery are critical as complications can arise. D. Entitlements for Pregnant Women a. Medicines such as Iron Folic acid are given free of cost. b. Desirable investigations like Blood, Urine Tests and Ultra-Sonography etc. c. Free diet during the stay in the health institution. d. Provision for free blood transfusion if the need arises. e. Referral Transport Facility. f. Free transport from home to health centre. g. Exemption from all kinds of User Charges including OPD fees and admission charges. E. Entitlements for sick New born a. Free Treatment up to 30 days after birth. b. All drugs and consumables required are provided free of cost. c. Free diagnostic Services. d. Free Blood Transfusion. e. Free Transport Facility. F. Implementation of JSSK- JSSK supplements the cash assistance under Janani Suraksha Yojana but the actual implementation hinges on the proactive role played by state governments. Its degree of success is dependent upon the implementation carried out by the state functionaries. G. Key Positives a. In 2012-13, 2082 Crores have been allocated to the states. b. User Charges have been exempted in 10 states. c. Availability of drugs has improved considerably. d. Availability of diagnostic facilities has also improved. e. Provision of free diet has been started in 12 states. f. 10 states have started the transport facility under the PPP model. g. Grievance Redressal Mechanism has also been set up in some districts.

Micronutrient Malnutrition- Ending Hidden Hunger A. Hidden Hunger is unlike the hunger that comes from a lack of food or calories. It is a chronic lack of vitamins and minerals that is often not evident and has no visible warning signs; therefore people who suffer from it may not even be aware of it. B. Its consequences are disastrous. It can increase child and maternal mortality, cause birth defects and developmental disabilities, contributes to and exacerbates global poverty, constrains womens empowerment and limits the productivity and economic growth of nations. C. Situation in India a. 62% of pre-school children are deficient in Vitamin A. b. 9% of under five children are affected by diarrhoeal diseases. c. 60% of pregnant women and 70% of pre-school children are anaemic. d. Only 71% of households currently consume adequate amount of iodine salt which is vital for brain development. D. Flour, Salt, Sugar and Oil are considered to be best buy in development, meaning it has the most benefits at a low cost. These commodities contain most of the essential vitamins and minerals. E. A Childs growth curve is set for the life in the first few years of life starting with its mothers pregnancy. Thus, during the initial years if proper care and nutrition is given to the child, it will enhance his learning ability over a life and can improve various other outcomes. F. Vitamin A- Vitamin A deficiency leads to an annual 330,000 deaths. Vitamin A supplements are recognized as one of the most cost-effective ways to improve child survival. G. Zinc- Zinc has emerged as a new opportunity to prevent global child deaths and achieve the 2015 Millennium Development Goals. Zinc, when administered with ORS Therapy helps the child combat and recover from diarrhoeal diseases. H. Iodine and Iron- Iodine deficiency can lead to hypothyroidism with marked mental and growth retardation. Also, iron deficiency can result in poor memory or poor cognitive skills and can result in poor performance in school and at work. Thus, there is a need for Universal Salt Iodization (USI) because salt is consumed, even in impoverished areas, thereby making it an ideal vehicle to carry iodine. I. Double Fortified Salt- Micronutrient Initiative (MI), an NGO, has developed a new way to combine iron and iodine in salt. It has provided technical support to Tamil Nadu State Salt Corporation to make Double Fortified Salt. J. It is important to include iron and folic acid in womens diet. These improve the quality of life of women and remove birth defects from new born babies. K. Policy Environment in India a. 4th Five Year Plan (1969-74)- The main emphasis was on the aggregate growth of the economy . b. 5th Five Year Plan (1974-79)- State Intervention increased to improve the purchasing power of the poor and a security system was devised to protect women and children. c. National Nutrition Policy, 1993, proposed to tackle nutrition as multi-sectoral issue through direct short term investments and indirect long term investments which focus on institutional and structural changes.

d. Several policy revisions on iron and folic acid supplementation, vitamin A supplementation, therapeutic zinc supplementation along with ORS for childhood diarrhoea and norms for supplementary nutrition in ICDS have been issued by various ministries. e. National Programs i. National Programme for Control of Blindness ii. National Iodine Deficiency Disorders Control Programme iii. National Anaemia Control Programme iv. Integrated Child Development Services Scheme v. Mid-day Mean Scheme vi. Targeted PDS vii. NRHM by increasing budgetary allocation to address micronutrient deficiencies. th f. 12 Five Year Plan It aims to remove gender discrimination, under nutrition and anaemia among women and provide maternity support. g. Existing Gaps i. Vitamin A supplementation needs to improve coverage and reach remote population. ii. Zinc Therapy Programme needs to disseminate and develop strong evidence on Zinc Treatment. iii. USI needs for more focus on strengthening monitoring system and enforcement. iv. Anaemic Programs need to strengthen implementation of Iron and Folic Acid and Iron Syrup Administration among women and children. It must also advocate for innovative approaches to address anaemia among infants. There is also need for evidence generation and consensus building on the issue.

Occupational Lifestyle Diseases in India A. Lifestyle Diseases is one associated with the way a person or group of people lives. Lifestyle diseases which are also called diseases of longevity or diseases of civilisation interchangeably are diseases that appear to increase in frequency as countries become more industrialized and people live longer. There are several factors leading to the occurrence of lifestyle diseases including factors like bad food habits, physical inactivity, wrong body posture and disturbed biological clock. B. 68% of working women in the age bracket of 21-52 years were found to be afflicted with lifestyle disorders such as obesity, depression, chronic backache, diabetes and hypertension. C. IT sector has been playing a dominant role in Indian Economy. People engaged in IT and ITES sectors are stricken with lifestyle disorders due to factors like hectic work schedules, unhealthy eating habits, tight deadlines and irregular and associated stress. D. Due to 24/7 working environment, people place orders to fast food outlets, street vendors and eat high calories processed food items like noodles, burgers, pizza and fried stud like samosas along with aerated drinks, coffee etc. E. Kerala is emerging as the lifestyle diseases capital of India with the prevalence of hypertension, diabetes, obesity and other risk factors for heart disease reaching levels comparable to those in America. F. The number of deaths from Non-communicable diseases is going to increase drastically in the future. These diseases not only cause enormous human suffering, they also threat the economies of many countries as they impact on the older and experienced members of the workforce. G. According to WHO and WEF, India will incur a loss of $236.6 billion by 2015 on account of unhealthy lifestyles and faulty diet. This will severely affect peoples earnings. H. Lifestyle diseases are estimated to have wiped out $9 billion off the countrys national income in 2005. There is an immediate need to take corrective action. I. The wrong choice of occupation in the blind run for higher salaries and the resultantly developing food habits generate all kinds of evil effects to the health of our youth. J. A healthy lifestyle must be adopted with a proper balanced diet, physical activity and giving due respect to biological clock. People should avoid sitting for long hours and overexploitation of the youth by the corporate sector must stop.