Four top industrialists are joining hands to establish a new Indian School of Business in Mohali. What is most interesting is that it would have a specialist healthcare management center,

The business leaders will invest either in their individual capacities or through their companies. The campus will include four centres—for healthcare management, public policy , manufacturing sciences and infrastructure . The healthcare management centre will be named after Max India, public policy centre after the Bharti Group, manufacturing centre after the Hero Group and infrastructure centre after Punj Lloyd.[link]

With corporatization of hospital sector picking up pace, India will need more healthcare managers in future.

In response to an article Economist, Policy Wise has previously argued that banning quacks is not a viable solution to urban health crisis. Quacks exist because of the poor quality government dispensaries and primary health centers even in large cities.

A new survey conducted in a Delhi slum shows exactly that,

The study, conducted by doctors from the All India Institute of Medical Sciences (AIIMS) during 2004-08 in a South Delhi slum, found that of the 207 households, only two preferred to visit the government dispensary located four kilometres from the settlement. The others felt that non-qualified medical practitioners are more humane, more communicative and offer more payment options for daily wage workers[link] (emphasis added)

This is the state of affairs in South Delhi where apart from numerous government dispensaries, two of India’s premier medical facilities, All India institute of Medical Sciences (A.I.I.M.S0 and Safdarjung Hospital are located. The service delivery mechanism in case of quacks is simply more attuned to local needs.

The need of the hour is not give in to pressure of organized medicine and ban quacks–rather, attempts should be made to co-opt them into the primary health system by means of proper training and constant monitoring and education.

Gujarat government has launched a new tele-medicine scheme to provide healthcare in villages,

“Through video conferencing, doctors at a distant hospital will be able to diagnose the villagers for basic ailments and prescribe medicines online. The printout of the prescription will be available at the community service centres set up by the department,” said Vyas.

[link]

With broadband connectivity slated to reach every village in Gujarat within the next two years, this wonderful initiative can help address one of the most important public health problems in India: Addressing shortage of trained physicians in rural India.

A new report by Save the Children has placed India alongside Ghana in providing healthcare to the children, with more than half of children lacking access to basic healthcare.

More than half of Indian children under the age of five do not get the health care they need, according to a report by Save the Children.

It ranks India alongside Ghana when it comes to providing basic health care to its children under five years of age.

The full report (PDF) has two interesting conclusions,

a) Maternal health is intrinsically linked with child mortality rates. India has the dubious distinction of topping the numbers for both under five mortality as well as maternal mortality.

b) Most of the deaths are preventable by low cost solutions like measles vaccines, deliveries by trained professionals e.t.c.

At the risk of making an obvious point, it is not shiny new A.I.IM.S which India or at least her poor need but investment in public health.

Based on the Conditional Cash Transfer model, a new anti-AIDS program in Tanzania will offer people money to practice safe sex,

The $1.8m trial – to be launched this year – will counsel 3,000 men and women aged 15-30 in southern rural Tanzania over three years, paying them on condition that periodic laboratory test results prove they have not contracted sexually transmitted infections.

[link]

Will it work? Possibly but a lot will depend upon the adequacy of laboratory facilities for periodic testing and training of staff e.t.c. It is also essential that an educational component be part of the entire program.

In a fine column in the Indian Express, Saubhik Chakravarti argues that respecting patent regimes does not necessarily sacrifice lives,

They should also see that the question of affordable access to drugs is a matter of public policy, not patents per se. India spends 1 per cent of its GDP on public health — that’s a scandal bigger than anything an MNC can cook up. And of every rupee spent on public hospitals, only 15 paise are spent on buying drugs that are given free to patients. Surely this calls for furious activist action?

Of course, lifesaving drugs like Tarceva, priced as they are, will pose questions even in a vastly better public health system. There are sensible ways to tackle this.

First, there are provisions in the Indian patent law on local manufacturing. Typically, local manufacturing will bring down prices. These provisions however can’t be applied immediately after a patent is granted.

Second, suppose the price of a patented lifesaving drug is “too high”. Drug price control authorities can impose controls only on essential drugs — those most commonly used and for common ailments. But competition authorities can investigate the pharma company’s pricing structure. The WTO’s intellectual property rules explicitly allow for this. And under domestic law, competition authorities have suo motu powers to investigate pricing in any sector.[link]

The emphasis on patents, as this blog has argued in the past is taking the easy way out for the ”pro-poor” activists. A well-thought patent policy can simultaneously can achieve both aims: protect and promote innovation while ensuring that drugs remain affordable for those who can’t afford them. And ensuring cheaper drug prices is not the business of Pharmaceutical companies only; as Chakravarti points out why is public health spending in India only 1% of the G.DP?

The Scientist has a wonderful article on the need for proper monitoring and evaluation of public health pro grammes. While billions have been invested in recent years in public health, outcome measurement remains poor. ”The evaluation gap” leads to a situation where there is little accounting of the moneys spent or the benefit of the pro gramme. The article examines a few important reasons for that anomaly,

Why have even well-intentioned public health programs given the evaluation of outcomes short shrift? The reasons are complex and touch on every aspect of health program planning, from the economics of fund allocation to ingrained modes of thinking about large-scale public health interventions. Public health program administrators “really don’t like to talk about technical issues – whether the programs they’re designing are working or not,” says David Sack, a professor at Johns Hopkins Bloomberg School of Public Health. Sack says that administrators tend to place emphasis on the immediate amelioration of public health concerns and view tracking the impact of interventions as a secondary consideration. “If you call something ‘research,’ then it may seem irrelevant or an ivory tower type of thing,” says Sack, who is also the director of the Center for Health and Population Research in Bangladesh.

Then there’s the aspect of devoting already scarce funding to evaluation in global health programs. Johanna Daily, an infectious disease doctor and professor at Harvard Medical School, says that thorough evaluations may cost less than purchasing drugs, hiring health workers, and other implementation costs, they still cost something. “When people are criticized for not measuring, you have to understand that they are making that decision,” she says. “There’s a cost to measurement that has to be balanced with rational decisions.”

Daily says that public health funding is so hard to come by in the developing world, that money is spent on treatments and interventions that are known or suspected to work, while funding for evaluation of the impact is often ignored. “There’s so much work to be done and there’s so little money,” she says. Given the paucity of resources, says Daily, who also works on malaria projects with a Boston-based aid organization, Partners in Health, this disconnection is understandable. “If I had $100,000 I guess I would buy $100,000 worth of vaccines.”[link]

There are a couple of other important reasons: One, lack of trained evaluators in most developing countries. Evaluation is a specialist business and requires specific skills. Second, many such projects are mired in corruption and it is best for all concerned that there is no monitoring and evaluation. Also, many gigantic public health interventions are guilt assuaging trips for rich Western donors rather than well thought out public policy interventions. In such a scenario, evaluation does not occupy an important place in the entire equation.

The best approach to solve this problem is for donors to insist that monitoring and evaluation must be part of program planning with a separate budget allocated to it. It is heartening to note that USAID has taken this approach.

Despite the most strenuous efforts,polio has become impossible to eradicate. Now in a more worrying trend, the latest outbreak in U.P is due to the P3 strain,

As a result, no fresh cases of P1 have been reported in the last one year. But the neglect of other polio viruses has led to an unprecedented outbreak of P3. Eighty-two cases of P3 have been reported since January 2008 – 69 in UP, Bihar (12) and Haryana (1) and the virus is replacing P1.

Health ministry officials agreed that P3 cases were on a sharp rise due to the singular focus on P1, but said that since the latter was more virulent it needed to be checked first.

“We had almost lost hope on P1. Hence, the focus was shifted to tackling it. Today we are close to eradicating P1 from India,” an official said.[link]

In the latest India budget, 950 crores have been allocated to polio eradication. The question which policy makers in India need to ask is this: Is it time to give up the dream of polio eradication?

The Economist has an article on the quacks practicing in Delhi,

Ten years ago Delhi’s state government drew up an “Anti-Quackery Bill” of which nothing more was heard. But the real problem is less the quacks themselves than the health-care vacuum in which they flourish. India’s private health business is booming, importing flashy technology to serve a growing middle class and foreign “medical tourists”. But the public health system remains skeletal. There are only 60 doctors for every 100,000 people in India, compared with 257 per 100,000 in America. In slums, sick poor people go to quacks because government-run clinics are too far away and the queues too long. In many rural areas, there are no clinics. [link]

Public policy has largely been driven by the medical profession which sees quacks as a financial threat. It is in its interest to introduce strong licensing laws to curtail the number of physicians. The key is not to punish the quacks by passing even more stringent (and unimplementable laws) but to train the quacks so they can serve as outposts of the public health system.

In an op-ed in Economic Times, Arvind Panagariya tells the story of Indian rural health crisis. He then provides some policy prescriptions,

This can be best accomplished by providing the poor cash transfers for out-patient care and insurance for in-patient care. Once this is done, a competitive price must be charged for services provided at public facilities as well. The government should invest in public facilities only in hard to reach regions where private providers may not emerge.

Second, the government must introduce up to one-year long training courses for practitioners engaged in treating routine illnesses. This would be in line with the National Health Policy 2002, which envisages a role for paramedics along the lines of nurse practitioners in the United States.

The existing RMPs may be given priority in the provision of such training with the goal being replacement of all RMPs by qualified nurse practitioners.

Finally, there is urgent need for accelerating the growth of MBBS graduates to replace unqualified “doctors” who operate in both urban and rural areas. Taking into account the evolution of medical colleges and assuming that doctors remain active for 30 years after receiving their degrees, there are at the most 650,000 doctors in India today. [link]

Many of these recommendations have been advocated by this blogger previously. (Here and here). Nevertheless, Pangariya’s claim that the increased number of M.B.B.S graduates would help solve the rural health crisis is not quite correct. As Policy Wise had argued,

Currently, around 600,000 doctors are registered with the Medical Council of India. The physician-population ratio of 56 per 100,000 is inadequate and below the levels recommend by the World Health Organization. However, the distribution is heavily skewed and the physician-population ratio in urban areas has been estimated to approach 200 per 100,000 which approximates the physician concentration in developed countries. In other words, India faces a severe shortage of physicians in rural areas, a problem which is not amenable merely to increased number of physicians[link]

Considering the extremely poor infrastructure in most of India’s rural areas, it is unlikely that fresh M.B.B.S graduates would be able to give up the lure of practicing in cities. The issue here is not of renumeration; doctors in rural areas are not necessarily poor. In fact, an average M.B.B.S is more likely to make money in a remote rural area than in an urban setting. (Higher prevalence of disease, low competition e.t.c.) It is the abysmal infrastructure (electricity and water, no educational facilities for children) which prevents even the struggling city physician from considering the option of migrating to rural areas. Therefore, state’s focus should be directed on training the current health professionals in rural areas to ensure that they can provide a minimum level of care. It is not to argue medical education should not be freed from the stranglehold of the government but the ameliorative effect of such a policy change on rural health–at least in the short term–is questionable.