What are the preconditions of a healthy infant:

• During pregnancy, the mother must have access to sufficient quality and quantity food including during pregnancy and lactation
• During pregnancy woman and breastfeeding period, the mother must take iron folic acid supplements daily to reduce maternal anaemia and improve pregnancy and lactation outcomes
• During adolescence, girls must be protected against undernutrition and nutritional deficiencies like anaemia through dietary counseling, weekly iron and folic acid supplementation, twice yearly de-worming prophylaxis
• Regular consumption of salt with adequate levels of iodine is required by all pregnant women in order to prevent foetal brain damage associated with iodine deficiency
• Women must avoid early marriage and pregnancy

What this indicates is that at the core of any nutrition program for the infants is actually a program to improve the health outcomes of the mothers. Of course, woman’s health and well-being has its own inherent qualities and every women has a right to good health whether or not she is a mother. However, the point here is that any program that addresses nutritional needs of the children acknowledging it as the building block of the future must start with the women. This pertains not just to health but also to education as significant disparity in nutritional status can be explained by mothers’ education and literacy. Studies have found a significant association between low maternal literacy and poor nutrition status of young children. A healthy and educated mother who enjoys a good social standing is the best guarantee for a healthy child and indeed of development.

• 56 percentage of children aged 12-23 months do not receive all recommended vaccines

• 46 percentage of children under age 3 are underweight

• 57 number of infant deaths per 1,000 live births in the last 5 years

• Only 26.2 percent of children with diarrhoea receive ORS

• 79.2 percent Children age 6-35 months are anaemic

National Family Health Survey 3

Clearly, child health indicators of India are anything but encouraging. While the country talks about reaping demographic dividend with a high proportion of young population, the truth is that, it is doing little to ensure that the young have access to basics of nutrition and healthcare. The current share of programs on children in the budget is around 4.86 per cent. Out of this, nearly 70 per cent is marked for education while health gets a modest 11.43 per cent. In these circumstances, it is not surprising that problems like Infant mortality and malnourishment persist.

What is most unfortunate is that a lot of this is preventable- it needs penetration of the programs. However, despite a fleet of programs, achievements remain far from satisfactory. While budgetary ‘constraints’ – or should we say ‘priorities’- remain a challenge, the questions of accountability cannot be evaded. The anganwadi worker (AWW), for example, has it in her job description to provide care to expectant and lactating mothers and their infants. However, this is rarely done. One of the reasons for low motivation levels is the poor remuneration. Improved pay, with training in identifying and solving some newborn health problems, could go a long way in promoting neo natal health. Unfortunately, we fall short on doing the additional bit.

Talking about accountability, a WHO study reports about the Child Survival and Safe Motherhood (CSSM) intervention undertaken by the National Neonatology Forum (NNF) with support from the government. Under the program, operationalization of newborn care was initiated at district level. This included training of medical officers and nurses in newborn care at the Primary Health Centre (PHC), first referral unit (FRU) and District Hospitals in 30 districts along with the supply of essential neonatal care equipment.. The project monitoring report revealed that at PHCs and FRUs the utilization of neonatal care equipment such as weighing machines, thermometers and warmers was a mere 50%. In some facilities the NNF review staff found the equipment still in their packing cases even after a year. Most of the trained medical staff had been transferred and the new incumbents were unaware of the use of the equipment or the principles of essential newborn care. (Source: http://www.whoindia.org/LinkFiles/Commision_on_Macroeconomic_and_Health_Bg_P2__Newborn_and_child_health_in_India.pdf).

Why do we put up with this? Where do we fix accountability?

It is important to empower communities, families and mothers, so that they not only seek but demand health care for the children. Let this demand be articulated through political forums. Sensitize the media to report about these chronic issues so that it hits the collective conscience of the society. Fight elections on these issues. Make it a national priority. Else, we will lose another generation before we can hand over the mantel of development to them.

Tuberculosis (TB) is a major public health problem in India. According to the World health Organization (WHO), India accounts for one-fifth of the global TB incident cases. Each year nearly 2 million people in India develop TB, of which around 0.87 million are infectious cases. It is estimated that annually around 330,000 Indians die due to TB. (http://www.whoindia.org/en/section3/section123.htm)

Since 1993, the Government of India (GoI) has been implementing the WHO-recommended DOTS strategy through the Revised National Tuberculosis Control Programme (RNTCP). By March 2006, the programme was implemented nationwide in 633 districts, covering the entire population of the country. RNTCP has established more than 12,000 quality assured designated microscopy centres (DMC) providing sputum microscopy services, across the country. Patients are provided directly observed treatment (DOT) by either a health care worker or a community worker/volunteer at hundreds of thousands of sites called DOT-centres. The entire course of anti-TB drugs for individual patients is packaged in a ‘patient wise box’ which simplifies drug logistics, restores the confidence of the patient on the health system and ensures that the patient never interrupts treatment due to want of drugs. (http://www.whoindia.org/en/section3/section123.htm)

However, the incidence of tuberculosis in India remains unacceptably high despite DOTS. It is possibly because DOTS is a passive system that can be started only after a person takes the initiative and gets tested for the disease. Despite the high prevalence and mortality rate, there is still no system in place that can proactively work to identify all people with active TB and treat them.

Similarly, Malaria continues to be prevalent in many pockets of the country. While WHO estimates that annually, 15,000 Indians under the age of 70 die of Malaria, a recent report, part of the Indian government’s Million Death Study published in the Lancet put the figure at 205,000. It is also believed that the WHO number is a gross underestimate because it relies mostly on government and health records. Many malaria deaths occur outside of hospitals and thus aren’t easily recorded. And unlike more prolonged diseases, malaria can strike fast, making it even harder to track.

Why is this that despite these killer diseases, there is so little happening on this front? Is it because these are the diseases of the ‘poor’? Is it because the international donor agencies have a greater focus on such issues as HIV and HIDS with a spiraling effect at the NGOs level? Is it because the tribal belts are the worst–hit and issues pertaining to access intimidate health workers? Whatever the reason, there cannot be any excuse for not paying adequate attention to these grave public health concerns.

Do you think that public health issues are neglected in India?

“Well over 3.5 billion mobile phones are in use around the world and organizations are harnessing this technology to help overcome humanitarian challenges. Mobile technology is transforming the way advocacy, development and relief organizations accomplish their institutional missions”, according the results of a global survey and a series of case studies in the report Wireless Technology for Social Change: Trends in NGO Mobile Use, released today by the United Nations Foundation and The Vodafone Group Foundation. (The complete report is available at http://www.unfoundation.org/vodafone/communications_publication_series.as).

With increased competition, the costs associated with mobile phones are diminishing. It is no longer a rich person’s gadget but nearly ubiquitous throughout the developing world. Seventy percent of all mobile phone users today are in the developing world. Almost 90 percent of the world’s population is covered by a commercial wireless signal. By 2012 half of all people in rural areas will have mobile phones. So even if a person doesn’t have their own phone, most have access to one.

At the same time, there is an increased understanding of the potential of mobile phones to break barriers of geography and to enhance access to useful information and communication. In a mobile enabled world, people are increasingly connected to each other and to various information sources, and the potential to increase the sources and create more linkages is substantial.

In many of the African countries mHealth (Mobile Health) is being tried out with a wide variety of applications for heath workers, governments and the general public. It makes the such processes as keeping track of people, their appointments and their records fast and efficient. It can deliver checklists to front line health providers to make sure they follow protocols. It can help monitor epidemics, track the progress of vaccination campaigns, measure drug supply stocks, and broadcast health information and public service announcements to millions of people. This is just the tip of the iceberg and many more sophisticated uses are in the process of getting evolved.

While these are exciting and we should do everything to harness the power of the mobile technology, it is important that we are not overwhelmed or distracted by this and keep focused on the most important goals: trained doctors, nurses, health workers, infrastructure, decent salaries for all the workers and robust mechanisms for transparency and accountability. These are finally the building blocks of good health that can be well-complemented by technology assisted services.

What is the potential of technology assisted social change?

India has a strong capability in producing quality branded and generic medicines in most of the therapeutic categories. However, although these medicines are  reasonably priced, as compared to the prices of their equivalent medicines in most other countries, a large population of poor people in the country, find it difficult to afford the more expensive branded category of medicines. Cost of medicines constitutes a large percentage of the total medical costs of an individual. As over 95% of the Indian population is not covered by medical insurance such medical expenditure continues to haunt the common man. Spending on medicines now account for up to 80% of total healthcare expenditure.

With a view to make medicines affordable to a common man, the Department of pharmaceuticals, Government of India, had launched the ‘Jan Aushadhi’ meaning drugs for the people in the year 2008. The plan was to provide generic medicines at lower prices than the branded ones available in the market. Subsequently Jan Aushudi stores were opened in the premises of the government hospitals in collaboration with various state governments that provided space free of charge on the premises of public hospitals. The Red Cross Society and a few other NGOs run these drug storesand make available quality generic medicines at reasonable margins of (18‐26 per cent). These stores sell generic medicines (230 different kinds of formulations are presently available) manufactured by five central public sector drug manufacturing units including antibiotics, antipyretics, analgesics, anti-inflammatory, anti-histaminic and fixed dose combinations.

However, as it is with most government programs- implementation is slow. Till March 2010, there were only 55 Jan Aushadhi against the target of 276 11 including 20 in the state of Punjab alone. An important study of the program was published in International Journal of Pharmacy and Pharmaceutical Sciences state that early reports suggest that the sales are low. There is somehow a reluctance among the patients to purchase generic medicides from such stores on the premises of public facilities as the perception is that the quality of medicines are poor. The study found that even the doctors as well as pharmacists are not exception to such misconception ( http://www.ijppsjournal.com/Vol3Issue1/1065.pdf). Also the role and the influence of the mutli-national pharmaceutical companies to spread such misconceptions cannot be ruled out.

There are also other issues like the location of the stores in cities rather than in villages where availability and accessibility is a greater problem. There are supply issues as the five Central Public Sector Units (CPSUs) are not able to ensure continuous supply of medicines. In order to ensure uninterrupted supply of generic medicines to these Jan Aushadhi Stores as well as widen the range of drugs available through these stores, recently, the Government of India has decided to procure generic medicines from small and medium enterprises (SMEs) in the pharmaceutical industry.( http://www.ijppsjournal.com/Vol3Issue1/1065.pdf)

 Despite the teething issues, in the India context, the program is really useful and can help to reduce out of pocket expenses that people have to make for medicines. However, it needs strengthening and it is important that public awareness about the program is built.

How can the Jan Aushudhi program be strengthened?

For the first time in history, more people are now living in cities than in rural areas. Worldwide, virtually all population growth over the next 30 years will be in urban areas, with the most explosive growth taking place in Asia and Africa. By mid-century, seven out of every ten people will live in a city.

This scenario presents both opportunities and challenges. In general, urban populations are better off than their rural counterparts. They tend to have greater access to social and health services, literacy rates are higher, and life expectancy is longer. When cities are planned, managed, and governed well, life flourishes for most residents and health outcomes surpass those seen in rural areas.

However, there are many challenges to city life, especially for the poor. Poor living and working conditions expose them to a range of health hazards. In the cities, poor often live in large numbers in highly congested areas. Access to basic services like water and sanitation is impaired and the quality of service is poor leading to a range of problems from contamination of the food or water, high levels of indoor air pollution, etc. As such cities concentrate opportunities, jobs, and services, and, at the same time, also concentrate risks and hazards for health. In countries like India, urban growth has outpaced the ability of governments to build essential infrastructure and services. Today, around one third of urban dwellers, amounting to nearly one billion people, live in urban slums, informal settings, or pavement tents. More than 90% of slums are located in cities of the developing world. In many of these cities, slums have become the dominant type of human settlement. Such diseases are likewise numerous. Slums are productive breeding grounds for tuberculosis, hepatitis, dengue, pneumonia, cholera, and diarrhoeal diseases that spread easily in highly concentrated populations.

Cities also tend to promote unhealthy lifestyles, like cheap and convenient diets that depend on processed foods rich in fats and sugar, yet low in essential nutrients. Like sedentary behaviour, smoking, alcoholism and substance abuse. These lifestyle changes are directly linked to obesity and the rise of chronic conditions like heart disease, stroke, some cancers, and diabetes. These conditions are costly to treat, for households and societies, and they are increasingly concentrated in the urban poor.

The growth of urban centres in the 21st century is being accompanied by a shift in the burden of poverty. In previous centuries, poverty was greatest in scattered rural areas. Today, poverty has become heavily concentrated in cities.

It is therefore important to engage in removing health inequities in the cities. Cities with high degrees of inequity are also homes to violent crimes and history has demonstrated that economic class is no insulation during such emergencies such as a disease outbreak. It is therefore everybody’s business to ensure that when it comes to equity in health, it can not be ‘business as usual’.

What can be done to promote health equity in the cities?

Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period. While motherhood is often a positive and fulfilling experience, for too many women it is associated with suffering, ill-health and even death. According to WHO, every day, 1,500 women die from pregnancy- or childbirth-related complications. In 2005, there were an estimated 536, 000 maternal deaths worldwide. Most of these deaths occurred in developing countries, and most were avoidable.

A times of India report (http://timesofindia.indiatimes.com/articleshow/2461713.cms) quoting the Maternal Mortality report compiled by the World Health Organisation (WHO), UNICEF, UNFPA and the World Bank revealed that more women die in India during childbirth than anywhere else in the world. Of the 5.36 lakh women who died during pregnancy or after childbirth in 2005 globally, India accounted for 1.17 lakh. The maternal mortality ratio (MMR) in India is 450 deaths per 100,000 live births.

The newspaper report also says that this finding is consistent with the National Family Health Survey (NFHS-III) that found that women in India lack quality care during pregnancy and childbirth. Almost one in four women (23%), who gave birth in the last eight years, received no antenatal care, ranging from 1% or less in Kerala and Tamil Nadu to 66% in Bihar. At least 40% of pregnant women did not get any antenatal care in Jharkhand, Arunachal Pradesh and Nagaland.

Home births are still common in India - accounting for almost 60% of recent births. NFHS-III found that 37% of deliveries were assisted by a traditional birth attendant, and 16% were delivered by a relative or other untrained person. According to WHO estimates, only 47 percent of the births were attended by skilled health personnel in 2006 ( Source: http://apps.who.int/whosis/database/core/core_select_process.cfm?countries=ind&indicators=BirthsAttended).

While poor maternal health is indicative of many flaws such as poor quality and inadequacy of outreach services, low levels of awareness, early age of marriage and child birth etc, the core of the problem lies in the low social status of women that deprives them of the most basic services and does not prioritize her health and well-being even during such a vulnerable stage as pregnancy and child birth. Unless the social attitudes change, we will continue to have mothers suffering or dying due to entirely preventable causes. Unfortunately, it is still acceptable to us- it is still a low priority.

Why is maternal health such a neglected issue in India?

 What comes to mind when we think about access to medicine? Availability?

Unfortunately, that is not what those in charge of creating and or influencing access to drugs think about when the issue is debated in international arenas involving the major stakeholders. These discussions are all about of prices, patents, intellectual property protection, and competition. In these circles, medicines are treated just like any other commodity, despite their health-promoting and life-saving roles.

At the same time, we live in a world of disparity. According to World Health Organization (WHO) estimates, a person in a wealthy country can expect to live more than twice as long as someone from a poor country. A woman in sub-Saharan Africa faces a risk of dying during pregnancy and childbirth that is more than 100 times greater than a woman living in Europe. These are largely preventable deaths, in which lack of access to essential medicines plays a major role.

Given the situation, what can make public health policies, and health outcomes, more equitable?

First, the mother statement- People should not be denied access to life-saving or health-promoting medicines for economic reasons. It might appear to be wishful thinking in a market-driven world, but all civilized societies should have at least some ethical considerations for the poor. According to WHO estimates, upto 90% of the population in developing countries purchase medicines through out-of-pocket payments. Medicines account for the second greatest household expenditure, right behind food (http://www.who.int/dg/speeches/2010/access_medicines_20100716/en/index.html).

 In this context, WHO states that government procurement practices have an impact on both the availability and the price of medicines, and are a good entry point for exploring ways to make medicines more accessible. The organization of a country’s pharmaceutical sector, its capacity for efficient and impartial procurement, quality control, regulation, and enforcement, affect the availability and price of medicines. Efficient distribution is also important. When facilities in the public sector experience stock-outs, patients turn to the private sector, where the prices of medicines and the quality of care are often beyond regulatory control. Surveys conducted by WHO in 30 low-income countries found that generic medicines, obtained in the private sector, cost more than 6 times more than their international reference price. Prices for both originator and generic medicines, in both the public and private sectors, are substantially much lower if procurement and distribution procedures were more efficient, corruption-free and mark-ups were reasonable. (http://www.who.int/dg/speeches/2010/access_medicines_20100716/en/index.html).

 It is important therefore to rope in the pharmaceutical companies meaningfully in developing strategies that bring together and synergies the interests of a profit-driven industry and ethically-driven public health.

What can be done to make medicines more accessible to the people, especially the poor?

• An estimated 1.3 million people died from TB in 2008. The highest number of deaths was in the South-East Asia Region
• Someone in the world is newly infected with TB bacilli every second.
• Overall, one-third of the world’s population is currently infected with the TB bacillus
• The largest number of new TB cases in 2008 occurred in the South-East Asia Region, which accounted for 34% of incident cases globally
• Funding for TB control has increased since 2002, and is expected to reach US$ 4.1 billion in 2010. Funding gaps remain, however; compared with the Global Plan, funding gaps amount to at least US$ 2.1 billion in 2010.

Source: World Health Organization (WHO) http://www.whoindia.org/en/section3/section123.htm

Tuberculosis (TB) is a major public health problem in India. India accounts for one-fifth of the global TB incident cases. Each year nearly 2 million people in India develop TB, of which around 0.87 million are infectious cases. It is estimated that annually around 330,000 Indians die due to TB.

Since 1993, the Government of India (GoI) has been implementing the WHO-recommended Directly Observed Treatment Strategy (DOTS) via the Revised National Tuberculosis Control Program (RNTCP). The program to date has treated about 10 million TB patients, with over 1.5 million registered for treatment in 2008.The program has achieved a treatment success rate of over 86% in new smear positive cases and the case detection in 2008 was 72%. The program has also developed partnerships with a wide range of stake holders. To date more than 2500 NGOs, over 19,000 private practitioners, 267 Medical Colleges and over 150 corporate sector health facilities are involved in the program. Public-private mix (PPM) DOTS has a significant role in achieving the national objectives of case detection and treatment outcomes.

While these are impressive figures, a large section of population continues to suffer from TB, especially the tribal groups often living in terrains that the health system fails to reach. These areas remain largely subserviced with TB resulting in preventable deaths. Unless outreach services to these areas improves, these groups will continue to remain excluded from the success story of RNTCP. Can we afford that?

How can the outreach of the TB program be improved?