Approaches to Health care Delivery in India

Content:

Health care education:

• Medical schools in India produce the largest number of doctors than anywhere else in the world (30,408 from 271 medical schools)
• This has been possible due to the rapid proliferation of medical colleges in the last two decades, especially within the private sector. 
• The Medical Council of India (MCI), is the regulatory body which approves any significant reforms in medical curricula. 
• The accreditation process for medical schools focuses largely on the infrastructure and human resources required and little on the process and quality of education or outcomes.
•  The implementation of the recommendations of MCI regarding recognition or de-recognition of a medical college is governed by the Ministry of Health and Family Welfare, whilst individual universities also have variable sets of regulations for their affiliated medical schools. 
• As a result, there is no uniformity in the standard of medical education across the country.

Indian System of Medicine:

• The Ministry of AYUSH was formed on 9th November’ 2014. 
• It was created with a view to provide focused attention for  the development of Education and Research in Ayurveda, Yoga and Naturopathy, Unani,  Siddha and Homoeopathy.
• The objectives are as follows: 
  • To upgrade the educational standards  of Indian Systems of Medicines and Homoeopathy colleges in the country.
  • To strengthen existing research institutions and  to ensure a time-bound research programme on identified diseases for which these  systems have an effective treatment.
  • To draw up schemes for promotion, cultivation and  regeneration of medicinal plants used in these systems.
  • To evolve Pharmacopoeial standards for Indian Systems  of Medicine and Homoeopathy drugs.

Present Scenario:

• Though many institutions mushroomed, education quality has to be improved compared to the global perspective
• India is still a favorite destination for medical tourism, showcasing advances and expertise in the field
• The increasing population and the occurrence of diseases, demands Indian medical education and the training approach to be modified and ensure enhancing practical clinical skills, than just sticking with predominantly theoretical or classroom training
• India has one government doctor for 11526 people and overall 1:1600 which is a below-par from the recommendations of WHO 1:1000.

Challenges to overcome:

• Outdated Syllabus: 

• • The world is witnessing disruptions in the medical field and new domains of medical sciences.
  • However, the syllabus in India still remains the same.
  • There is a need to encourage case-based learning for students. This method of medical education gives a great difference in learning outcomes which is called competency-based, such methods will help the students have a holistic understanding of the subject.

• Teaching Methodology: 
  • The system has been following the teacher-centric pattern which does not deploy advanced technologies in medicine as much as developed countries. 
  • Indian medical education still lacks to teach the students a holistic understanding of the subject and does not focus more on Evidence-based and research-based education.

• Limited number of medical seats: 
  • Even now, India struggles to meet the demand and supply chain in medical education. 
  • With the growing population, more students choose medicine as a career but due to the limitations of medical seats in colleges they either need to pursue other opportunities or look out for foreign countries to their education.

• Retaining medical talent in India: 
  • According to WHO, Indian trained doctors constitute 9% of all registered doctors in the UK and about 50000 Indian doctors are serving half the UK population
  • There are over 100000 doctors trained in India employed overseas with the highest number in the US, followed by the UK, Canada and Australia. 
  • But India needs 20 lakh doctors to keep its population in the pink and unfortunately, we have only half the numbers. 
  • India produces 60000 medical graduates and these numbers are increasing.

Family planning:

• Family planning approach is meant to prevent population explosion.
• Population explosion is a social problem and it is deeply rooted in society. So efforts must be done to remove the social evils in the country.

India’s approach:

• Family planning in India is based on efforts largely sponsored by the Indian government. 
• India was the first country in the world to launch a national programme for family planning when it did so in 1952.
• The programme has undergone a massive transformation from its early days when the focus was in terms of a clinical approach to today when the focus is on reproductive health, and in the reduction of maternal and infant mortality rates, child mortality and morbidity.
• The National Population Policy (NPP) launched in 2000 has helped in the reduction of fertility.
• As part of the programme, the government established several clinics for reproductive health and family planning.
• There is also much awareness through various media propagating family planning, the need for spacing between children, and for having a lesser number of children per couple.
• The government adopted Two-Child Norm as a population stabilization measure and has popularized the slogan, “Hum Do, Humare Do”.
• There are also fines such as not providing government jobs if a person has more than two children, and so on. 
• But, these might have backfired in some places leading to more sex-selective abortions,  and skewed child sex ratio etc.
• Female sterilisations have become the main focus for India’s family planning programs (now called, ‘family welfare’).
• 96% of all sterilisations are the ones that women have undergone. 
• As per a report by the National Family Health Survey, most men believe that contraception is a woman’s business, and they have got to do nothing with it.

Outcomes of these measures:

• Economic Survey 2018-19 notes that India is set to witness a “sharp slowdown in population growth in the next two decades”. 
• The technological advances and improved quality and coverage of health care resulted in a rapid fall in Crude Death Rate (CDR) from 25.1 in 1951 to 6.2 in 2018.
•  In contrast, the reduction in Crude Birth Rate (CBR) has been less steep, declining from 40.8 in 1951 to 20 in 2018.
• Therefore demographic transition had resulted in the annual exponential population growth of over 2%

Immunization

• Immunization acts as a protective shield, keeping families and communities safe. 
• By vaccinating our children, we are also protecting the most vulnerable members of our community, including new-born babies.
• Immunization is one of the most effective and cost-effective ways to protect children’s lives and futures. 
• Immunization Programme in India was introduced in 1978 as Expanded Programme of Immunization (EPI)
• The programme gained momentum in 1985 and was expanded as Universal Immunization Programme (UIP) to be implemented in phased manner to cover all districts in the country by 1989-90.
• UIP become a part of Child Survival and Safe Motherhood Programme in 1992 Since, 1997, immunization activities have been an important component of National Reproductive and Child Health Programme and is currently one of the key areas under National Rural Health Mission (NRHM) since 2005
• Under the Universal Immunization Programme, Government of India is providing vaccination to prevent seven vaccine preventable diseases i.e. Diphtheria, Pertussis, Tetanus, Polio, Measles, severe form of Childhood Tuberculosis and Hepatitis B, Haemophilus influenzae type b (Hib) and Diarrhea 
• In the last two decades India has made significant progress in improving health indicators, particularly those related to child health. 
• India was certified polio-free in 2014 and eliminated maternal and neonatal tetanus in 2015.
• To accelerate full immunization coverage and to reach the unreached, the Government of India launched an ambitious programme called Mission Indradhanush, the largest immunization programme in the world in terms of the number of beneficiaries, geographical coverage and quantities of vaccine used, with nearly 27 million new-borns targeted for immunization annually.
• Ministry of Health and Family Welfare, Government of India provides several vaccines to infants, children and pregnant women through the Universal Immunisation Programme.
• Over nine million immunization sessions are held across India every year towards full immunization coverage. 
• The Programme introduced new vaccines, including the Pneumococcal Conjugate Vaccine (PCV) and Rotavirus Vaccine (RVV). 
• It is also rolling out a country-wide Measles-Rubella Campaign aiming to reach every child wherever they live.

Challenges:

• Despite the progress, infectious diseases continue to contribute to a significant proportion of child mortality and morbidity in India. 
• Nearly one million children die before their fifth birthday in India. 
• About one of every four of these deaths are caused by pneumonia and diarrhoea – two leading infectious causes of child deaths worldwide, even though many of them can be saved by interventions such as breastfeeding, immunization and access to treatment.
• Only 65 per cent of children in India receive full immunization during the first year of their life. 
• As per NFHS 4, 2015-16, in India the national average for full immunization is 62 per cent, DPT-3 coverage – 78.4 per cent and for measles first dose – 81.1 per cent. 
• Some of the newer challenges in achieving full immunization coverage include:
  •  limited capacities of staff, particularly in poor-performing states and at the field level, and 
  • gaps in key areas such as predicting demand, logistics and cold chain management, which result in high wastage rates.
  •  India also lacks a robust system to track vaccine-preventable diseases.

Prevention and control of epidemic:

India’s response to the coronavirus disease (Covid-19) pandemic is predominantly based on three different laws –

• the Epidemic Diseases Act, 1897 (EDA); 
• the Disaster Management Act, 2005 (DMA); and 
• the Indian Penal Code, 1860 (IPC). 

After the declaration of the pandemic as a “notified disaster”, the National Executive Committee of the National Disaster Management Authority (NDMA), set up under the DMA, imposed the graded lockdowns and issuing periodic guidelines to states for enforcing the lockdowns.

Integrated Disease Surveillance Programme: 

• National Centre for Disease Control working under the Ministry of Health and Family Welfare (MoHFW) implements and monitors disease surveillance in India.
•  It has established a decentralized state based surveillance system  (laboratory based and IT enabled) for epidemic prone diseases to detect the early warning signals.
• This enables initiation of timely and effective public health actions in response to health challenges in the country at the districts, state and national level.

The Integrated Health Information Platform (IHIP):

•  a web-enabled near-real-time electronic information system is also incorporated for disease surveillance and for managing disease outbreaks since November 2018 in selected districts of 7 States (Karnataka, Andhra Pradesh, Himachal Pradesh, Odisha, Uttar Pradesh, Telangana & Kerala) in its first phase. 
• Division of Emergency Medical Relief, under MoHFW, is also supporting states/ districts in outbreak investigation and response that requires action at national level and other public health emergencies of international/ national concern.

Issues related to epidemic Control in India

• The use of an ad-hoc legal architecture with a multiplicity of statues has resulted in a patchwork response against the epidemic in several areas.
• The archaic three-page-and-four-section EDA does not define what constitutes a “dangerous epidemic disease”. 
• It confers unbridled power to the executive to respond to the disease by the way of promulgating ordinances or regulations, but without due care to the social and reputational standing of the people affected due to the pandemic.
• A new and robust epidemic law must take into account the experiences and lessons learnt from the current crisis.

Essential drugs

• As per the World Health Organisation (WHO), Essential Medicines are those that satisfy the priority health care needs of the population. 
• The list is made with consideration to disease prevalence, efficacy, safety and comparative cost-effectiveness of the medicines. 
• Such medicines are intended to be available in adequate amounts, in appropriate dosage forms and strengths with assured quality. 
• They should be available in such a way that an individual or community can afford.
• Drawing an essential medicines list (EML) is expected to result in better quality of medical care, better management of medicines and cost-effective use of health care resources. 
• This is especially important for a resource limited country like India. The list of essential medicines is intended to have a positive impact on the availability and rational use of medicines

National List of Essential Medicines (NLEM)

• Ministry of Health and Family Welfare, Government of India hence prepared and released the first National List of Essential Medicines of India in 1996 consisting of 279 medicines. This list was subsequently revised.
• Till June 2018, 851 medicines (including 4 medical devices i.e. Cardiac stents, drug eluting stents, condoms and intrauterine devices) are regulated under Revised Schedule – I based on the National List of Essential Medicines, 2015 (NLEM, 2015).
• The list is prepared based on the country’s disease burden, priority health concerns, affordability concerns etc.
• In order to make medicines affordable, Government of India promulgated the National Pharmaceutical Pricing Policy, 2012 bringing all medicines with specified dosage and strength included in NLEM under price control. 
• Accordingly, Drug Price Control Order, 2013 was issued by Department of Pharmaceuticals under the Ministry of Chemicals and Fertilizers for fixing the ceiling price of medicines included in NLEM, 2011.

Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP)

• It is a well-known fact that branded medicines are sold at significantly higher prices in India.
•  Given the widespread poverty across the country, making available reasonably priced quality medicines in the market would benefit everyone, especially the poor and the disadvantaged.
• “Jan Aushadhi” is the novel project launched by Government of India in the year 2008 for the noble cause – Quality Medicines At Affordable Prices for All.
• The Campaign was undertaken through sale of generic medicines through exclusive outlets namely “Pradhan Mantri Janaushadhi Kendra” in various districts of the country.
• Bureau of Pharma PSUs of India (BPPI) is the implementing agency of Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP).