Defining Health & Population
The recent decision to scrap the Public Health Foundation of India (PHFI)’s Foreign Contribution Regulation Act (FCRA) licence has stunned the public health community. Although the Foundation has had its share of detractors, it received patronage from the government, some of India’s richest industrialist-philanthropists and foreign organisations such as the Bill & Melinda Gates Foundation. Over the years, PHFI has also benefited from allotment of vast tracts of land and government support to establish state chapters.
The denial of FCRA permission to PHFI signifies a sudden fall from grace. While it is curtains for future foreign funding, it is important to examine what soured the milk. If, as has been reported, PHFI was cutting corners on FCRA conditions, it must get just deserts. However it seems that was not the primary reason for the retribution meted out by the ministry of home affairs, which grants FCRA clearances. The objection was: “[PHFI] used the contributions to lobby parliamentarians, the media and the government on tobacco control issues.”
How can doing tobacco control advocacy and that too at the behest of the ministry of health invite reprisal? Didn’t the MHA talk to the ministry of health before taking the step? Interdepartmental co-ordination is sacrosanct in the functioning of the government. Unfortunately, the fallout of PHFI’s FCRA cancellation has been an all-round perception that big tobacco has won. This exposes us to international criticism.
For decades the anti-tobacco movement has been spearheaded by the ministry of health and the World Health Organization (WHO). India is a signatory to the WHO Framework Convention on Tobacco Control. Despite incremental gains, India’s track record of controlling tobacco consumption has been abysmal. Tobacco deaths are rising and the sad part is that around half of those dying are among the illiterate.
The Indian Council of Medical Research data shows that 50% of cancers in men and 20% in women is due to tobacco use. India has another problem. Non-smoking tobacco is the greater cause of mortality and children and adolescents are falling prey to tobacco addiction. When every avenue should be pursued to build maximum awareness about tobacco use, we pride ourselves on being the second-largest consumer (275 million users) of tobacco products.
The government must clarify that it is dead against smoking and tobacco consumption by proactively encouraging anti-tobacco advocacy. And then to back it with fiscal and administrative measures that hurt enough to make a big difference.
Shailaja Chandra is former chief secretary, Delhi The views expressed are personal
India’s population stabilisation programmes require the dedicated attention of the CMs of Bihar, UP and Rajasthan.
Written by Shailaja Chandra | Published:July 15, 2016 12:03 am
Scared off by the popular backlash to family planning excesses during the Emergency, India’s political and social leadership abandoned the subject of population growth decades ago. The 10-year goals set out in the Population Policy 2000 were mostly neglected. So when Shanta Kumar, Himachal Pradesh’s former chief minister, resurrected this long forgotten issue and even sought the prime minister’s intervention, it came as a surprise. His fears are genuine but his idea of an all-party meeting is off-track. The problem does not need a political solution. It needs the dedicated attention of the chief ministers of three states — Bihar, Rajasthan and Uttar Pradesh — in whose hands lie the attainment of a goal that 24 states have already realised: Reducing fertility rates to replacement level.
With over 26 million births each year, the country’s population momentum is akin to a super-fast train which cannot be stopped. With determination, it can, however, be slowed down. Stopping the momentum is impossible: It is like telling generations of Indians, including newly-weds, to not have children or to mandate a small family norm. Fortunately, neither strategy is feasible in a democracy.
But chief ministers can certainly encourage people towards an optimum family size and provide couples with the tools to space and limit the arrival of their children — but voluntarily. Such an approach — soft and easy-going as it may sound — has, by and large, succeded.
But what is “optimum”? Demographers agree that if women in child-bearing years produce an average of 2.1 children per head — so as to replace both parents — the population gets stabilised. This number is referred to as the total fertility rate (TFR). Both low and high TFR can pose problems. With Japanese and European couples opting for fewer children, TFR in Europe and Japan has fallen below 1.5; that raises fears of societies disappearing. India’s TFR is presently at 2.3 with huge variations between states.
Kerala and Tamil Nadu achieved the ideal TFR of 2.1 in 1989 and 1992. The good news is that since then, several big states — Andhra Pradesh, Himachal Pradesh, Jammu and Kashmir, Karnataka, Maharashtra, Odisha, Punjab and West Bengal — have brought down fertility rates to replacement levels. Three other states — Gujarat, Haryana and Assam — are poised to join them in a year. The TFR in some states like Goa and West Bengal has fallen to nearly European levels.
Bihar, Rajasthan and Uttar Pradesh (30 per cent of India’s population) are, however, responsible for pulling the country back. Their neighbours, Madhya Pradesh, Chhattisgarh and Jharkhand (10 per cent of the country’s population) have also been tardy but they are moving towards the 2.1 TFR goal; for them the target looks attainable by 2020. The National Family Health Survey and the District Level Health Surveys show that most poor families if assured of two living children do not want more. But this is not the case in Bihar, Uttar Pradesh and Rajasthan where poor parents consciously want more than two children; it is also ironical that the unmet need for contraception is also the highest in these states. Higher fertility levels, early marriages, repeated pregnancies and mothers giving birth in their 40s are exacerbating the problem. Contraception is not used by 50 per cent of those who need it the most.
According highest primacy to population stabilisation in these three states is, therefore, essential. By tracking every married couple in underserved villages, a lot can be achieved. One strategy would be to give incentives to the local health volunteers who should be remunerated for every year’s delay in child birth after the age of 19 (the legal age for women to marry being 18), promoting a gap of three years between children and facilitating family planning methods.
The health minister has recently announced that his ministry will focus on high TFR districts, mostly in Bihar, Uttar Pradesh, Madhya Pradesh and Rajasthan. While this is a good strategy, the engagement of the top leadership is indispensable.
Only chief ministers carry the authority to extract work from the state health bureaucracies. As Tamil Nadu’s example shows, they can requisition the workforce of every department as well that of the private sector. At stake is not just population stabilisation but more importantly women’s liberation and a greater chance for the unborn children to live, learn and become employable. Such reasons to reduce population can swing elections, if presented intelligently.
India’s “demographic dividend” boast is sounding more and more clichéd when one sees the abysmal impact of health and education on millions of young men and women, particularly in the northern states. In the West, the term is used to signify the proportion of working people vis-a-vis the retirees. In India, the so-called dividend is actually represented by disproportionately high number of young people in six high fertility states, many of whom are unemployable. Malnutrition and illiteracy persist.
Shanta Kumar has shown initiative by raising the population issue. He should now find a way of making it worthwhile for the CMs of the lagging states to give primacy to population stabilisation. He should also distinguish between natural growth and population growth caused by unplanned in-migration from other states which is largely responsible for the polluted, slum-ridden picture that he has painted for urban India. That, however, is a matter for another story on how appeasement politics is replacing basic governance.
The writer is former executive director of the National Population Stabilisation Fund.
5 January 2016
Delhi is among the world’s top ten most populous cities with 18 million people. United Nations projections for 2025 predict that it will rank third, overtaking Sao Paolo, Mexico City, Dhaka, New York and Shanghai. Colossal challenges confront the city’s development, and finding money is the least of those problems. Delhi garners more resources than any other city in India, has the highest per capita income and wages, and boasts more private vehicles than the three metropolitans of Mumbai, Kolkata and Chennai combined. In early 2015, the new city government slashed the power tariff in half and provided 20 000 litres of free water for all residents — clearly affordable measures.
Visitors are initially struck by Delhi’s pristine enclaves that house the President’s estate, foreign missions, government complexes and sprawling colonial bungalows set along avenues of shady trees and landscaped foliage. The residents of these exclusive enclaves account for less than 2% of Delhi’s population, while a cash-rich, non-elected municipal body maintains their wide, radial roads and lush greenery to perfection.
In the rest of Delhi, seven different kinds of vehicles — BMWs to hawkers’ carts — maintain an average speed of 7 kilometres per hour despite the construction of 50 flyovers and underpasses. Hundreds of planned colonies — ranging from the ultra-posh where residents live behind formidable iron gates with private security guards to middling housing communities — are managed by three elected municipal corporations that show erratic degrees of attentiveness to their obligatory functions. The two massive townships of Dwarka and Rohini, for example,each independently house around a million middle-class residents.
For the politician, these “organised” colonies taken collectively are unpredictable as voters. Instead, three unorganised clusters living in close proximity to one another possess the power to swing votes. That’s why seven members of Parliament, 70 members of Delhi’s legislative assembly and 272 municipal councillors – all elected representatives – rivet their attention on the other half of Delhi’s population. Bettering their lives has little to do with advancing clean air, reliable drinking water, drainage or sewerage — though scores of plans exist on paper. Rather, it has more to do with indulging existing and future voters.
Three disadvantaged citizens’ groups are important to political parties. These include some 500 slums and their successor resettlement colonies, over 1 000 unauthorised colonies and 135 urban villages. Compared to neighbouring planned colonies, the inequality in living standards is stark.
The first group comprises some 3 million slum dwellers — politically the most important. They are families of original or new migrants who squatted on publicly owned land, driven by poverty and lack of jobs in rural villages. Political parties have united in making sure they received immunity from removal, drinking water, a modicum of sewage, food subsidies and an election voting card. Come election time, the handing out of special incentives — including liquor and cash — is well-known, often seeing these citizens vote as a block. Once elected, all city governments announce populist policies as a reward. For example, the newly elected city government put a moratorium on demolitions, prompting dangerous construction in already congested spaces. Extreme squalor and regular breakdowns of public order are accepted as a way of life. Drunkenness, knife-wielding and assaults are daily occurrences.
Every political party has promised to build alternative accommodations for the slum dwellers or undertake in situ development. The communities are shrewd enough to realise that neither will happen, but with each passing year their adverse possession of tenure security grows. It is an astute investment despite living in sub-human conditions. Happily, the insatiable demands of the planned colonies next door for domestic and office staff as well as support services guarantee employment.
The second group consists of over 1 000 unauthorised colonies. They are disproportionately important to political parties. Years ago, the occupants bought agricultural land privately and cheaply, an illegal transaction since converting or subdividing agricultural land required a plethora of approvals that were never obtained. Without sale deeds or building plans, tens of thousands of shoddy structures burgeoned city-wide, mostly with weak foundations, deficient sewerage systems and insubstantial basic amenities. Initially, the municipal system shunned them, but with every election more and more colonies got “regularised”. The High Court of Delhi described this arrangement as robbing Peter (the honest taxpayer) to pay Paul (the dishonest coloniser), but regularisation has officially become a flagship programme even backed by a statute. Each time elections draw near, many more such ghettos spring up and are promised, and eventually granted regularisation. More than the promise of services, it is the protection from rent-seeking that matters. Living standards remain, however, sub-standard.
The third large group comprises 135 urban villages. Dotted all over Delhi and interspersed among planned residential and commercial complexes, these overcrowded villages pose health and fire hazards. Their precariously built structures stand amidst jungles of electric wires, gas fires, shanty eateries and garbage. Ironically, the elected Municipal Corporation of Delhi, which is the custodian of public health and safety, exempted all urban villages from paying property tax or following any building regulations.
Given these present realities, the future of Delhi’s urban development appears doomed. Unless political parties mature beyond appeasement, citizens start valuing quality of life and migrants seek employment in smaller cities and towns, Delhi’s frenzied expansion is unlikely to change.
For a chaotic country full of argumentative Indians many of whom are poor and uneducated, India’s continuous economic growth (not prosperity) remains a surprise. But something else is even more striking. The country has the world’s largest youngest population: 27 million babies are added each year. With such youth to bank on, India’s productivity seems to possess the best ingredients for success for decades to come.
But all great stories have another side that also must be told. Most births in India take place in some of the country’s poorest states where high fertility, low age of marriage, and a disproportionately large number of mother’s and children’s deaths present an ever-distressing picture. A group of five states have had the dubious distinction of accounting for around 45% of the country’s population, suffering and stymied from poor investments in health and education. No wonder these states were officially referred to as the BIMARU states, an acronym for their names of Bihar, Madhya Pradesh, Rajasthan, Odisha and Uttar Pradesh, which denotes much more since the word bimaru in Hindi means sickly.
For decades, these states have defied conventional experience about the process of development and held back the achievements of the rest of the country. The differences are stark: some other states in India reached replacement level of fertility as early as 1989 and 1992. Bihar, Madhya Pradesh, Rajasthan, Odisha and Uttar Pradesh, however, may need another five years to get there. The infant and maternal mortality in the progressive states is lower by half, and in some cases even 70% less, than in these laggard states.
Some 15 years ago, the Indian government decided to pay focused attention to these states, particularly in the highly neglected area of reproductive health. Around the same time, the five states were reorganised and became eight in number with the hope that being smaller would help them respond better to the process of development. They were rechristened the Empowered Action Group (EAG), and the pejorative title BIMARU was wiped out of the official vocabulary. In 2005, the National Rural Health Mission, India’s largest-ever health programme, started pumping resources into these “high-focus states.” Strategies included revamping rural health infrastructure, promoting health centre-based deliveries, facilitating access to emergency obstetric care, and assigning a trained health activist to make family-level contact, undertake pregnancy tracking and provide access to contraceptives.
Many hoped that with such a high dose of attention, the EAG would eventually catch up. Most, however, did not share this optimism, and not without reason. Even today, strong patriarchal attitudes continue to discriminate against women. Girls are denied access to schooling once they reach puberty. They are married off well before the legal age of 18 and subjected to a host of discriminatory barriers. The political leadership in most of these states has seldom accorded high priority to health or education; many have invested in perpetrating caste-based divisions in society. This backdrop naturally fails to inspire change.
Yet the good news is that by focusing attention on these laggard states and monitoring health indicators annually, a decline in fertility has begun and it is faster than anywhere else in the country. The increase in institutional deliveries has been impressive, and family health surveys and other research show that an increase in the age of marriage and greater use of contraception have contributed to lowering fertility. After decades of stagnation, the population growth rate in these states has registered a significant fall for the first time, dropping from 25% to 20.9%. From the point of view of women, the opportunity to have hospital-based deliveries stands out, complemented by such popular incentives as transportation to a health facility, compensation for leaving home, supplementary nutrition and contraception advice.
While these are positive trends, the push has to continue. These states will contribute 50% of India’s population within the next five years, equalling if not exceeding the combined population of the rest of India. The prospect of half of India holding back the other half is a dismal one. Only if the special efforts mounted receive commensurate political support that simultaneously encourage girls’ education and skill learning, later marriages and spacing between children will the laggard 50% eventually catch up. Happily, the process has begun.
India has been a member of the OECD Development Centre since 2001.
The dengue deaths in Delhi have brought to the fore the apathy and ineptitude of the city’s hospitals. They have also exposed the acute absence of coordination between those responsible for health care services and the people.
The dengue epidemic in Delhi is still to peak: It is only by mid-November that the visitation from Aedes Aegypti mosquitoes that spread dengue will end. So unless and until there is clarity about response and responsibility, the number of cases and deaths will spiral, not just in Delhi but in other states too. In fact, of late, there has been an increase in the number of dengue cases across Southeast Asia. The World Health Organization has put out several preventive strategies that are being used by other countries, underscoring the point that dengue epidemics are an indication of the failure of a country’s public health system.
The preventive measures undertaken by the three municipal corporations of Delhi this year have been abysmal and we must seek answers to several questions: How many sanitary inspectors are available for each of the city’s 272 wards? How many institutions and individuals have been fined for ignoring mosquito breeding on their premises? What is the amount of fines levied on them each month? How many places with stagnant water have been covered or treated? What is the ward-wise result of anti-larval measures undertaken in July, August and September? Did the city’s health department provide resources on a normative basis for insecticides, wages and test monitors? Did the officials take notice when the preparation for the dengue season was found unsatisfactory? No one seems to have hard data or credible answers to these questions.
Instead, all we hear are persistent laments about the non-cooperation of private hospitals and implausible claims of increasing beds (sans commensurate medical manpower). This quest for adding more beds is diverting attention from the important referral and case management issues. Delhi’s health department had the responsibility (starting June 2015) to identify tertiary and secondary care hospitals (both in the government and private sectors) and link them for managing dengue-related medical emergencies.
Denouncing private hospitals without notifying the system to be followed by them is the best way of losing allies. The city has some 22 public sector hospitals and more than 30 hospitals in the private sector that have blood banks. At least, a third of all these hospitals could have been designated as nodal centres for providing blood components to attached satellite hospitals.
Undoubtedly public sector hospitals have to bear the brunt of epidemics, despite being over stretched even in normal times. But certainly more than 60 private hospitals in Delhi, which run emergency departments 24X7, can support them. Private hospitals cannot deny competence and refuse dengue patients. Most often, all that is required is to observe and interpret the vital parameters of a patient and provide immediate intervention. Checking blood pressure, administering intravenous fluids, assessing laboratory test results and getting fresh tests done are among the basics that any hospital claiming to run an emergency department has to provide. Hospitals which claim inability to perform these services should be directed to close down their emergency departments.
A canard is being spread that the government has no powers to enlist private hospitals. This is untrue. All private hospitals require a plethora of approvals from the government and they have to comply with a host of laws. As such they respect government authority and respond to reasonable appeals for short-term support during emergencies. No private hospital would wilfully risk losing goodwill by getting publicly shamed for callousness.
Every doctor wants to heal and emergencies often bring out their best. But for this to happen everyone in the hierarchy and in the wider network of health facilities must understand roles and responsibilities. Once they do that, written instructions need to be issued in simple, consistent and implementable language. Those links are missing today. Central monitoring of availability of beds and dengue admissions in designated hospitals would further promote quick response and accountability and the Union health ministry and the Delhi government need to jointly operationalise this. Most important, the network of emergency and tertiary facilities must be notified locality–wise, using all forms of communication.
Dengue management is comparatively routine work, but it can suddenly become complex and daunting. Unlike many other medical emergencies, dengue has the added disadvantage of becoming life-threatening just when signs of recovery show. So if a hospital (government or private) lacks the capacity to deal with a patient, there has to be a common protocol for transferring a case to another designated hospital. Otherwise the tendency to first refuse admission and then push less educated and poorer patients out will not abate.
This phenomenon was studied by the Law Commission, which gave a report in 2006 based on The Emergency Medical Treatment and Labour Act of the United States, also called the ‘Patient Dumping Law’. Once US hospitals too refused to accept poor or uninsured patients brought in an emergency medical condition. The Commission not only gave a comprehensive report on emergency medical care but also provided a model law for the use of state governments, including a protocol for transferring patients. The Delhi government would do well to adopt portions of the Bill. The Centre is unlikely to stand in the way.
Most importantly, without 24×7 political will to confront these challenges, prospects of overcoming dengue appear doomed, and mid-November is still a long way off.
Whatever may be the complexion of the next government, three areas of health policy require urgent rethinking. All three depend upon changing human behaviour which is often a bigger challenge than finding resources. But given the dramatic extent to which a few initiatives can better lives and reduce investments on health, the implication of continuing to function incrementally needs examination.
First there is the issue of fertility and here one refers to quality, not numbers. Fortunately by now, nearly half the country has achieved replacement levels of fertility. But Uttar Pradesh and Bihar, which together account for a third of the country’s annual 27 million births, would need another 15 years to reach there. And while the picture is somewhat better in Madhya Pradesh, Rajasthan, Jharkhand and Chattisgarh, these states too will need another decade to contain fertility.Pushing up the first birth to after the mother is 20 can bring a 50 per cent reduction in maternal mortality. It will allow the mother-to-be to overcome malnutrition and anaemia which predispose her to birth underweight, malnourished and sickly children. The expectation that trickle-down from economic growth will percolate and boost their health is unlikely, given fresh health findings.
A recently published Lancet survey which covered 36 low and middle income countries has shown that economic growth (GDP) makes little difference to child under-nutrition. That is precisely why demographers and economists need to demonstrate the implications of allowing generations of children to be born too early, only to become victims of malnutrition, infirmity and even stunting, wasting and poor mental development.
But this is far from easy. Rural mindsets favour early marriage and childbearing soon thereafter. To some extent mandatory registration of marriages will oblige more and more families to wait until a girl is 18 years of age. Although a welcome development, it will not address the issue of malnutrition and anaemia which afflict adolescent girls, leaving them in poor shape to bear healthy children.
Apart from the need to encourage postponement of the first childbirth to after 20, there is also a need to focus on spacing between children. WHO studies show that in rural areas, mortality is highest among infants born within a year, and the risks are progressively lower when followed by a gap of two, three and four years. Every encouragement needs to be given to spacing between children by persuading women at risk and their well-wishers to understand the need for longer birth intervals. Condoms and pills are known to have too many imponderables and when overall contraceptive use is less than 19 per cent among 15 to 24-year-olds, alternatives must be accessible.
In China, 40 per cent of the contraception is managed through IUDs (intrauterine device.) In Bangladesh, Indonesia, Iran and Sri Lanka the use of IUDs and injectables – both for spacing and limiting births – helped lower fertility years ago. In India, female sterilisation still accounts for 72 per cent of all contraceptive methods although it is an outmoded strategy. No other country promotes it so widely. The economic gains from widening newer contraceptive use among adolescent and young women needs to be calculated and tools that are reliable and trouble-free offered to them. The second policy area which needs urgent attention is the high incidence of oral cancer. The Union health ministry statistics show that 50 per cent of cancers among men and 25 per cent of cancers among women are related to tobacco use.
According to ICMR, the direct and indirect costs of three major tobacco related diseases – cardiovascular disease, cancer and chronic lung disease total 25 per cent of all public spending. Deaths caused by tobacco use are responsible for more fatalities than those caused by HIV/AIDS, TB and malaria combined. Although excise duties on smoked tobacco have increased, they do not affect the unbridled consumption of non-smoking tobacco – a huge contributor to oral cancer. The ultimate solution lies in phasing out tobacco cultivation. But unless the costs of cancer treatment are juxtaposed in economic terms with the “gains” from tobacco cultivation, including the employment it generates, the agriculture and labour ministries and tobacco growing states will evade conversion to alternative crops.
The third policy area relates to the growing incidence of hypertension, heart disease and diabetes which are ballooning in urban areas. Much of this has to do with high salt, fat and sugar intake, besides sedentary lifestyles. Occasional awareness campaigns and admonitions from doctors are not capable of commanding the lifestyle changes needed on a massive scale. Disincentives, higher duties and health warnings on product labels have succeeded substantially elsewhere in the world. We have to calculate the dangers of soft handling because society will pay the price.
Who should do it? Discouraging early wedlock and pregnancy will only be pushed by health bureaucracies, if chief ministers champion the need to lower fertility and thereby promote women’s and children’s health. Phasing out tobacco cultivation will need sustained leadership from a prime minister who alone can drive three powerful but reluctant ministries- finance, agriculture and labour to understand the urgency to depart from tobacco cultivation.
Finally, meddling with the consumer’s right to satiate his palate will be considered political hara-kiri. Yet finance and health ministries in progressive countries are helping citizens to alter life-styles. The challenge is even greater among Indians who value extra-fattening foodstuffs as a mark of big-heartedness. Surely, a combination of public health researchers and micro economists can contrast the cost of doing business as usual with the advantages of introducing strategies that could transform lakhs of lives. And at nominal cost.