The National Health Policy 2017 was notified last week. Coming 15 years after its predecessor, it presented an opportunity to do things differently. First, the recognition that strong state intervention is needed to control the surge of diabetes, heart and respiratory diseases hasn’t come a day too soon. With early screening and diagnosis becoming a public responsibility, the lives of millions of Indians could be saved from debilitating illness and premature death. This shift in emphasis is noteworthy.
Second, establishing a professionally-managed state public healthcare cadre makes eminent sense. A dedicated cadre of healthcare professionals can detect state-specific health hazards and contain them before they spread. The inclusion of professionals from sociology, economics, anthropology, nursing, hospital management and communication is a recognition of a multi-disciplinary approach and an acknowledgment that cultural attitudes must be understood if public health strategies are to gain community acceptance.
The third takeaway is the goal of pushing up male sterilisation “by 30 per cent and, if possible, much higher”. After Sanjay Gandhi’s blighted nasbandi programme, even the mention of male sterilisation made political parties, particularly in North India, squirm. Even after four decades, no politician was prepared to listen, leave alone act. Putting male sterilisation upfront also exhibits concern for the plight of women, who, after dealing with unwanted pregnancies and repeated childbirths, also undergo harrowing tubectomies. Thailand successfully made vasectomies into a routine affair more than 25 years ago. If six Indian states that account for almost half of India’s population and its annual growth, can incentivise (not coerce) men to limit family size by sterilisation, it could be a game changer.
The fourth good idea is piggy-backing medical and paramedical education on service delivery. Generations of health planners have been telling the Medical Council of India to factor in the ground realities that reduce the relevance of even the best medical curriculum. Indeed, students and patients would gain vastly if such facility-based training gets implemented.
The fifth half-positive takeaway is the recognition that AYUSH needs to be integrated into the research, teaching and therapeutic components of health systems; stressing that traditional systems need to back their claims with evidence is equally positive. But by repeating the unsuccessful strategy of appointing contractual AYUSH doctors in primary health facilities, the policy goes into reverse gear. AYUSH practitioners posted in PHCs do precious little traditional medicine and simply function as spare wheels or substitutes for allopathic doctors. That pads up manpower shortfalls but devalues the strength of AYUSH. Had the policy supported recognition of approved district specialty AYUSH centers for a host of chronic problems, lakhs of patients in search of reliable AYUSH treatment could have benefited.
The policy has neatly sidestepped some basic concerns. The Clinical Establishments Act 2010 was passed by Parliament with the aim of regulating clinical standards, both in the private and public health sector, and ending quackery. It has received scant backing from the state governments and was rejected by the Indian Medical Association. Instead of emphasising the importance of oversight of all medical establishments, the policy has soft-peddled by recommending mere “advocacy”.That leaves a hapless public at the receiving end of much care, malpractice and exorbitant treatment costs with no protection. Leaving health regulation up in the air with talk of yet another standard-setting organisation will not insulate consumers from exploitation.
The policy is also hazy about generating resources. One wonders whether the reference to medical tourism earnings and “a high degree of associated hospitality arrangements” implies a desire to tax hospitals that offer frills. This sounds egalitarian but could drive away the relative advantages that Indian medical tourism presents.
The policy places enormous reliance on the eighth standard-pass female volunteer, ASHA — the lynchpin of the National Rural Health Mission. But it does not even allude to how the poor, both in rural and urban areas, are driven by a desperation to overcome acute illnesses (that result in a loss of wages) to seek medical treatment from quacks, RMPs or self-styled doctors with no medical qualifications. Fluff about upgrading sub-centres or providing additional multipurpose workers does not confront the pervasiveness of RMPs or jhola chaap doctors who administer IV fluids, antibiotics and steroid injections with impunity. The policy shows no recognition of the magnitude of what is happening on the ground, even when a WHO report shows that unqualified medical practitioners constitute more than half the “doctors” in India. The WHO’s report is based on data provided by the Census office and the erstwhile Planning Commission. Recognising that they cannot be wished away, the West Bengal government has even embarked on training quacks “to cause less harm”. This problem is too pervasive to be ignored. The policy should have confronted it.
The policy has rightly explained why the time is not ripe to make health into a justiciable right. It is good that symbolism hasn’t held sway as it did with the impractical Right to Education Act. What is more important, however, is for the states to accept the policy and implement the law. It is time that registration, accreditation and regulation of clinical establishments and standards is put in the Constitution’s concurrent list in much the same way as drugs, food and medical education. Too much is at stake to be left to the states that often look the other way when it comes to maintaining critical health standards — this is something that ought to be non-negotiable.
The challenge now is to translate the policy’s stated noble intentions into schemes and programmes supported by the requisite financial backing. It is accountability that needs early deliverance.
The writer is former secretary, Department of AYUSH, government of India, and former chief secretary, government of Delhi
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Published on 1 Jan 2017
Thanking people for their support and co-operation to his demonetisation drive, Prime Minister Narendra Modi on December 31 made a series of announcements reiterating his government’s focus on the welfare of farmers and the poor.
He was making a televised address to the nation on New Year’s eve and said he was grateful for the patience that people had shown amid a cash crunch that followed the ban on Rs 500 and Rs 1000 notes that he announced on November 8.
The decision was aimed at combating tax evasion and money laundering and the Prime Minister praised the people for working shoulder to shoulder with the government to defeat corruption.
Shailaja Chandra, former Secretary in the Ministry of Health and Family Welfare and the Chairman of the Public Grievances Commission and Appellate Authority under the Delhi Right to Information Act, says: “A poor woman can earn anything between Rs1-3 lakh from surrogacy, and with debts and growing expenditures hanging over her head, she agrees or is forced to agree. In most cases, it’s actually the women’s relatives and middlemen who compel them to go through it.”
She adds that the myths around being childless and the reluctance to consider adoption need to be addressed through proper awareness campaigns, and adoption promoted as a first choice. “Not only is that humane, but is also less exploitative on the surrogate, who has to be bolstered with hormones to prepare her to accept the embryo.”
Chandra also believes that IVF centres need to be registered. “The process should be open only to Indians or if one partner is of Indian origin. We must not permit foreigners to enter into surrogacy arrangements because it is akin to using Indian women to make a takeaway baby for them. While foreigners are generous in looking after the woman’s health and nutrition, problems of citizenship, and fulfilling the responsibilities attached to accepting the infant, even if it suffers from physical or mental deficiencies, can arise.”
About how it can be checked if the ban is being upheld once the Bill is passed, Chandra says, “Such a law, if made, will remain like so many other laws — unimplementable. There is no machinery to police what happens between two or three people by mutual consent; desperate couples and future surrogates’ families will find a way of doing it secretly. Can a woman who leaves for her native village for nine months be taken to task? It’s tough to push such laws. Do you think kidney transplant rackets have stopped and all such transplants are altruistic?”
The issue of demonetisation has divided political and public opinion. Inside Parliament, there have been stormy scenes, and outside at ATMs and banks, there have been serpentine queues. There are stories of hardship and suffering, but some also say the pain is worth the gain. On We The People, we look at the politics and economics of demonetisation. What is its aim – hit at black money or digitise the economy? Will it net the big fish? Will Modi government’s gamble pay off? We get you the stories of those who are struggling to cope with this move as well as of those who have adapted to the digital economy.
Consumer must be protected from misleadingly advertised
A colleague inherited diabetes from his father. For the last 20 years, he has been taking insulin injections. A few days ago he asked me about a new ayurvedic drug for diabetes formulated by a research body — the Central Council for Research in Ayurvedic Sciences (CCRAS) — under the AYUSH Ministry. He sent me a full page advertisement that used the Council’s logo and extolled the virtues of a commercially sold diabetes drug claiming that it was “based on tough clinical and lab experiments and scientific tests”. The faculty of reputed ayurvedic institutions were incensed and one of them sent me a YouTube link in which scientists from CCRAS were claiming their formulation was capable of reducing the allopathic drug dose. Worse, that with six months of use, the drug could end insulin dependency.
The Journal of Ayurveda and Integrative Medicine, which is a peer-reviewed, open access journal, wrote an editorial expressing shock over such claims as no supportive data was to be found from published sources. It has been reported that the controversial advertisement has been taken off, after four months. But a lot more must be done to protect the consumer.
A little background would put things into perspective. In 1964, India’s drug laws were amended and a new chapter was introduced for Indian medicine with a category called Patent and Proprietary (P&P) Ayurvedic medicine. By the end of the 1990s, branded products accounted for 90 per cent of the sales and classical ayurveda lost its pre-eminence. The commodification of ayurveda had commenced but it had also been “contemporised” to suit modern lifestyles.
By the new law, individual vaidyas were permitted to prepare formulations for their patients but factory-based manufacture, whether of classical ayurveda products or of the P&P category, required compliance with pharmacopoeial standards relating to the identity and purity of the ingredients and the process to be followed. In 2010, a new drug rule was added specifically for Indian medicine drugs .This was amplified in 2013 by notifying detailed guidelines spelling out how the safety and efficacy of ayurveda formulations were to be safeguarded. Government research councils, although they do not themselves manufacture drugs, have a responsibility to ensure that the prescribed regulatory requirements are met before their drugs are marketed. The laws on advertising prohibit claims about treating or curing specific medical conditions and making such assertions about diabetes is expressly proscribed. CCRAS should have shown greater circumspection knowing how desperate people are to find a cure for diabetes.
Undoubtedly, ayurvedic texts list scores of formulations to treat diabetes and ayurvedic drugs have been in the market for decades. The anti-diabetic properties of turmeric, cinnamon, fenugreek, aloe vera, tulsi, etc, are well known. They have been sold as single drugs or as formulations. But never before have claims about reducing the need for anti-diabetic allopathic drugs and ending insulin dependency been made so aggressively. When such statements come with the legitimacy of government backing, it is bound to lull already apathetic patients into a false sense of security. Intervention is, therefore, badly needed.
First, the CCRAS laboratories which conducted research must reveal the inclusion and exclusion criteria for patients who were enrolled in the clinical trials along with their informed consent and the result of pathological tests done before, during and after being treated with the ayurvedic formulation. They must clarify whether it was a stand-alone treatment or was used as adjuvant therapy alongside modern medicine. This is the only way now of safeguarding the credibility of the research and protecting the consumer. Second, the research councils must be prevented from making sensational claims referring to their diabetic drug as “revolutionary”, and endorsing the sale of what is now a commercial product. To blame the manufacturer is simply shirking responsibility. Nothing short of a public retraction can undo the damage. Third, the companies that are selling the drugs and using the logo and the name of government-run research labs to back their claims should be stopped. Regulatory authorities must ensure that the licensees do not exploit the government connection to promote sales.
Finally, with more than 50 million people in the country already suffering from diabetes, dependency on drugs is no answer. The advice of Nikhil Tandon, professor of endocrinology at AIIMS, needs to be heeded and broadcast in the media: “Diabetes cannot be controlled unless consumption of sugar and fat are reduced drastically and people start regular exercise.”
Guests: Shailaja Chandra, Former Chief Secretary, Govt of Delhi ; P D T Achary, Former Secretary General, Lok Sabha and Constitutional Expert ; Sanjay Hegde, Sr. Advocate, Supreme Court ; Sachidananda Murthy, Resident Editor, The Week magazine.
Anchor: Girish Nikam
Air date: Aug 31, 2016