As reported by NDTV,  the couple had taken their son, Afroz, to a local hospital after he was diagnosed with high fever. The doctors advised them to take Afroz to Lucknow for better treatment, after which they requested for an ambulance. However, they were reportedly not provided with an ambulance, neither did they have any money. Helpless, the couple began walking, carrying their child, and he allegedly passed away while they were on the way home.

“We took our child to the hospital in the morning. The doctors told us to take him elsewhere for treatment. We asked them for a vehicle but they refused. There were three ambulances parked in the premises. I do not know why we were denied one,” the father alleged.

Predictably, the doctors have rebuffed the allegations.  The emergency medical officer, Anurag Parashar, said, “A child named Afroz came to the hospital at 8:10 pm. His condition was not well, so we directed the parents to take him to Lucknow for special treatment. They scoffed saying they will take him wherever they wish and left with the kid.”

While the allegations have not yet been proved, there is certainly an urgent need for a thorough investigation. It is also crucial to probe whether there is some communal angle associated with this untoward incident.

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The Ayushman Bharat National Health protection scheme (AB-NHPS) was announced amid a lot of hype and fanfare by PM Modi in Jharkhand on August 2018. It was launched in September, later that year. It was announced, in the usual grandiosity characteristic of literally everything that the PM announces, that the scheme will provide a health cover of Rs. 5 lakhs as compared to the modest cover provided by existing Rashtriya Swasthya Bima Yojana (RSBY) which provides a cover of Rs. 30,000. The Ayushman Bharat scheme is said to target over 10 crore Indian families comprising 8.03 crore rural families and 2.33 crore urban families.

The Ayushman Bharat scheme, later renamed as Prime Minister Jan Arogya Yojana (PMJAY) will subsume the existing RSBY. Some key aspects of the scheme are that there is no enrolment process and it is based on entitlement. Hospitals need to be empanelled in order to implement the scheme. Each empanelled hospital should have an “Ayushman Mitra” whose role will be to help those who visit the hospital navigate the facilities. Another component being access to Health and Wellness Center (HWCs) at primary level and financial protection.

However, the scheme missed the point at many levels. A Crisil report says that despite “sustained focus” on core health infrastructure, an overwhelming percentage of around 55 percent of country’s households don’t access government’s healthcare facilities because of perceived “poor quality of care.”

As rightly commented by a life sciences and healthcare expert Sheetal Ranganathan, this scheme which is pro-private insurance market, is overwhelmingly missing the voices of the people it intends to cater. In her essay titled “National Health Protection Scheme will not help its intended beneficiaries” she points out that majority in India, especially the rural areas don’t report sickness unless rendered inactive to work and earn, either by injury or the flare up of a chronic condition. This, in fact is common knowledge too. Going to a health center for minor treatments implies missing a day’s wage, a condition many in the rural parts of India can’t afford.

Moreover, that in rural India health is not a matter of choice. The scheme completely misses the point when it does not take into account the chronic conditions that people suffer from.

No matter which state the poor or deprived households may belong to, the epidemiological profile of the households will mirror each other At present, the top ailments that add the maximum burden of disease in the poorest states ( EAG or Empowered Action Group states ) include ischaemic heart diseases, lower respiratory tract infections such as bronchitis and asthma, chronic obstructive pulmonary disorder, tuberculosis and diarrhoea. Right now, these are the diseases adding the burden of maximum Out Of Pocket (OOP) expenditure to rural households. Hence in as many as 80 percent cases, the OOP expenditure of the patients within this strata depend on outpatient clinics, which require day to day diagnosis, and do not come under the ambit of NHPS.

The scheme includes hospitalization and surgical intervention, which though being an important aspect, is disconnected from this reality of the rural India.

The scheme demands that in order for its success or outreach, the reasons for the failure of RSBY should be carefully studied. For example, a study done in West Bengal’s five backward districts, Murshidabad, Malda, Dakshin Dinajpur, Uttar Dinajpur and Jalpaiguri reported that the preference for RSBY empanelled hospitals was low, the distribution of the empanelled hospitals uneven and there is a clear urban bias in the empanelment.

The National Family Health Survey (NFHS), 2016 indicated that apart from the perceived poor level of care being the topmost reason for households not accessing government facilities, the second surmounting reason was that there was no nearby facility, which is the harsh reality of rural healthcare in India. This is to say that PMJAY is marred with both, problems of accessibility and uneven empanelment.

A Center for Policy Research (CPR) report argued that the fact of the scheme being oriented towards insurance, makes it more likely to suffer from either over or under treatment, citing the example that though the treatment may be obtained by inserting a stent, the medical experts can suggest a bypass because it will be more expensive, as has been the experience with RSBY. Moreover, if the hospitals sense that there is not much profit, they may not enrol in the scheme at all. Or they can turn patients away. When the price is too high, the hospital will try to convince the patients for unnecessary expenditure, a stark case in point being that of mass hysterectomies under RSBY following such erroneous pricing.

The report highlights that good medical care requires massive investments in adaptive price settings, legislation, third-party monitoring, quality improvements in public sector hospitals and ultimately significant investments in skilled capacity. It is only right to expect that there should be an increasing government intervention in these areas, rather than its withdrawal.

However, the scheme has no concrete mechanisms to ensure any form of accountability and places the burden of study or research on local NGOs. The success of a scheme that has been panned out at such a level with ambitious targets and shows the intention to benefit a large section of the poor and deprived, depends on rigorous and thorough monitoring, analysis and research. It requires that the government studies the failures of the previous schemes. It also requires that the trust of the rural people be won over through facilitation of access and advocacy. None of these has been done in the case. Increasingly, even during the course of the research for this article, it was found that the voices were mainly of private insurance companies which are promising to provide good and efficient services at cheap prices, there are barely any voices of people sharing their experiences with the scheme. Unfortunately this seems like another high soaring promise that’s likely to fall flat on its face.
 

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Image Courtesy: LiveMint

Indian has a shortage of an estimated 600,000 doctors and 2 million nurses, say the findings of a study by the Center for Disease Dynamic, Dynamics, Economic and Policy (CDDEP) in the US. This was reported by scientists who seemed to have found that the lack of proper training in administering antibiotics is preventing patients from accessing affordable life-saving drugs.
 
CDDEP produces “independent, multidisciplinary research to advance the health and wellbeing of human populations in the United States and around the world.”

Limited government spending for health services contribute to high medical costs for patients, reported the study by the CDDEP.

The health expenditure in India is largely out of pocket, as much as a staggering 65%, and such expenditures push more than 57 million people into poverty each year.

To identify key barriers in access to antibiotics in low and middle income countries, the researchers at CDDEP conducted stakeholder interviews in Uganda, India and Germany apart from literature reviews.

Gaps galore
There is a glaring gap in the international standards of health as defined by the World Health Organization (WHO) and as is practised in India. For example, though the WHO prescribes a doctor to patient ratio of 1:1000, in India, the study found that there is one doctor to every 10, 189 people. This implies a deficit of more than six lakh doctors. The nurse to patient ratio is 1:483 and has a glaring shortage of two million nurses!

Highlighting the accessibility or procurement of drugs as the primary challenge, Ramanan Laxminarayan, director at CDDEP said, “Lack of access to antibiotics kills more people currently than does antibiotic resistance, but we have not had a good handle on why these barriers are created.”

Recommendations of CDDEP study
The recommendations of the study say, “Interventions to improve access to antibiotics must take into account differences among countries. Healthcare institutions, both public and private, and regulatory, procurement, and supply chain systems need to meet users’ expectations and clinical best practices.”

It added that healthcare in many Low-Middle Income countries “requires fundamental changes, more government spending, and better regulation.” The study recommended that countries’ long-term visions should include plans to incorporate access to essential antibiotics into priority programs, such as infectious disease surveillance, HIV, Tuberculosis, malaria, and mother and child health programs, where efficient supply chains have already been established.

Emphasising the importance of National Health insurance schemes, it said, “National health insurance schemes can reduce out-of-pocket payments by patients, adequately fund health ministries, and dedicate funding for essential medicines, including antibiotics.”
“Ultimately, rising antibiotic resistance may be the biggest barrier of all. If resistance renders treatments ineffective, efforts to improve access to antibiotics will be futile, and the consequences will be felt worldwide. Antibiotic stewardship and infection prevention must therefore be pursued alongside improvements in access. All stakeholders—international bodies, government leaders, health and agriculture ministries, patients and medical practitioners, farmers and veterinarians, academia, and the pharmaceutical industry— must slow the emergence of resistance to existing antibiotics to ensure affordability and access everywhere,” the study concluded.

India’s spending
However, India’s public health expenditure is amongst the lowest in the world at 1.02% of its GDP in 2015 (a figure that has remained unchanged since 2009). This figure is lower than most low income countries.

The equivalent proportion of GDP spent on health in the Maldives is 9.4%, in Sri Lanka 1.6%, in Bhutan 2.5% and in Thailand 2.9% as per an IndiaSpend report.

Not surprisingly then, India has become the sixth biggest private spender on health among low-middle income countries. Out-of-pocket health expenditure pushed 55 million Indians into poverty in 2011-12.
 

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India will eliminate leprosy by 2018, Finance Minister Arun Jaitley told parliament in a budget speech on February 1, 2017, in an admission that the disease abounds. Activists working in the field say the target is impossible to achieve.

Of the new cases detected, nearly half (67,160) have been diagnosed at an advanced stage. And the number of new detections is high. For instance, in Telangana’s Adilabad district, a small village called Kushanpally with 250 houses (1,040 people) turned up 19 cases. “Pockets of high endemicity report thousands of new cases every year,” the World Health Organization (WHO) noted in 2016, adding that in 2015, India had accounted for 60% of the global total of new cases.

There is no reliable pan-India study or survey on the incidence of leprosy, and activists say the government is reluctant to record new cases for fear of losing its ‘elimination’ status.

Unwanted and neglected
Rachna Kumari was married at 18 and had two children by the time she was 21. Life was good in Munger, Bihar. Her world suddenly collapsed when she was diagnosed with leprosy. Her family disowned her and asked her to leave home.

Heartbroken, she fought with herself to find the courage to battle the disease and reclaim her life, alone. After being cured, she decided to dedicate her life to fighting discrimination in any form. Today, she sits on the panel of the International Federation of Anti-Leprosy Associations that works for leprosy patients. She works with Lepra Society’s Referral Centre in Munger, Bihar. “My dream is for the world to be leprosy-free. I tell every new leprosy patient not to feel ashamed but hold their head high and not have any fear,” she said, “If we all work together with sincerity, we can eradicate leprosy just as we did with polio.”

India has more than three million people with deformities caused by leprosy. They are relegated to the margins of society and feel neglected and unwanted, living mostly in 750-odd leprosy colonies. Society largely treats them as social outcasts.

Being infectious, leprosy can spread easily. If not detected in time, it spreads through skin and peripheral nerves, damaging the nerves of the hands and feet to render them dead to sensation. This naturally leads to disabling injuries. This is why leprosy is feared and stigmatised so much.

Most of us do not contract leprosy as our immune system is strong and we have built a resistance to mycobacterium leprae, the bacterium that causes the disease. It is those with weak immunity that fall prey to it. Invariably, it is the poor who are malnourished and do not have easy access to medical facilities.

Elimination is not eradication
Since India received funding from the WHO to tackle leprosy, it was under pressure to show progress, activists and experts say. The government hurriedly announced in 2005 that leprosy was eliminated–which implies that incidence is one case per 10,000 (0.01%). Some experts questioned the manner in which this elimination was achieved–for instance, by stopping active case-seeking (and counting on self-reporting, which invariably leads to under-reporting), and by not counting single-lesion cases (which are considered less serious).

Thanks to India’s vast population, even fewer than “1 in 10,000 cases” can number in the lakhs overall. Despite achieving elimination of leprosy as a public health problem in 2005, India had the largest number of leprosy patients in the world, the WHO noted in 2016.

Also, the ‘one in 10,000’ figure was arrived at by taking an average of all the states, disregarding the vast variations between states. For instance, large and underdeveloped Uttar Pradesh had a high incidence, while developed states such as Kerala had a low figure. Bunching all these together to achieve elimination status proved a costly mistake.

‘Elimination’ was confused with ‘eradication’–the latter refers to the complete and permanent reduction of new cases to zero–and the threat of leprosy was prematurely considered over. The government machinery that worked for leprosy elimination slackened, and its personnel were transferred to other health departments considered in more urgent need. Front-line workers stopped household visits to identify undetected cases.

Under-reporting of cases
Stoppage of active surveillance after the elimination announcement has led to severe under-reporting of cases in India, studies such as this one from Munger, Bihar, have pointed out.

Finding an increase in ‘heightened disability’ among the new cases detected, a midterm evaluation of the National Leprosy Eradication programme in late 2016 said that this indicated “that the cases are being detected late in the community and there may be several cases which are lying undetected or hidden”. These hidden cases are dangerous because untreated patients are “an active reservoir in the community which transmit the disease to [the] susceptible”, the review said. It also found a large number of children among those detected.

Yet, several activists and researchers who work with leprosy patients told IndiaSpend, while insisting they not be named, that the government is resisting documentation of new cases. They pointed out, for example, that for several years after 2005, the number of new leprosy cases detected hung around the figure of 130,000 annually as it was deliberately kept within the elimination range (0.01% of India’s 1.3 billion population).

The official number of new patients “is largely coming from passive reporting as there is no nationwide move to detect cases”, Ashim Chowla, chief executive of Lepra Society, Secunderabad, told IndiaSpend.

Places such as Delhi, Chandigarh, Dadra and Nagar Haveli, Odisha, West Bengal and Lakshadweep, which were at the forefront of elimination targets, are now among the worst affected. Kerala, for instance, which has the best health indicators in India and once had the lowest rates of leprosy, now has a large number of leprosy patients–probably because of the high number of migrant labour that comes in from Uttar Pradesh, Bihar, West Bengal and Odisha, where wages are lower.

Early detection and treatment
In case of leprosy, early detection and treatment before any disability sets in is important, as is rehabilitation of those who have been disabled so that they can live independently and carve out a dignified life. But society is rife with stigma and discrimination. Health activists have to fight numerous myths that have caught on because of poor understanding of the disease. One such myth is of leprosy being divine punishment for past sins.

Stigma prevents most patients from seeking medical treatment until it is too late, activist Vineeta Shanker, executive director of Sasakawa India Leprosy Foundation, points out. Nerve damage is irreversible and once disabilities set in, social rehabilitation becomes very challenging.
“We have to struggle even with the highly educated as well as opinion makers,” Chowla said. “Fairly recently, the Pope said that child abuse was like ‘leprosy in our house’. Because of the stigma involved, patients try to hide it. Changing attitudes takes time; even the government does not have the wherewithal to deal with something so complicated and produce quick results. This requires involvement of all stakeholders and drivers of change.”

Recently, parliament passed an amendment to remove discrimination against leprosy patients in various laws, especially those governing marriage and divorce, across faiths. There were 119 such laws, which blatantly discriminated against leprosy patients–for instance, by holding leprosy a valid reason for divorce, and considering leprosy an “incurable and virulent” disease. The government is also working on a draft bill to eliminate discrimination against persons affected by leprosy.

There are practical problems in detection, too. All parts of the patient’s body need to be examined, in good light, but most places where patients are examined are poorly lit. Male staff often shy away from asking women, especially in villages, to take off their clothes for examination. Many women refuse to do so. This means small diseased patches, of which even the patient is unaware, go undetected.

Once detected, the government treats leprosy patients for free. Patients are administered a multidrug therapy–a combination of different drugs–which is very effective and usually cures within six to 12 months.

As essential as early detection and treatment is post-treatment follow-up to detect relapse and identify drug-resistant strains.

The success of the anti-tobacco movement gives Chowla hope. “Leprosy needs something similar with corporate, private institutions and NGOs putting their commitment behind eradicating the disease,” he said. Since leprosy mainly affects the poor, it does not get the attention it deserves. The challenge is to end transmission by detecting cases and immediately putting them on multi-drug therapy, which should be made available even in the remotest parts of India. “There is no solid infrastructure at the moment that is geared to either detect and treat or end discrimination against patients,” he said.  
 

Earlier this year, the Supreme Court directed states and the central government to roll out awareness programmes about leprosy, something India should have proactively done seven years ago when it became a signatory to the United Nations resolution on the elimination of discrimination against persons affected by leprosy and their family members.

The court said campaigns should not use frightening images of leprosy affected people but utilise positive images and stories of those who had been cured. The judgment came as huge relief by focusing attention on the need to urgently deal with the disease, Nikita Sarah, Head of Advocacy, The Leprosy Mission Trust, India, said.

A good workable strategy in India may be to integrate leprosy care with other areas of healthcare so that the perception of it being a dreadful disease that has to be treated separately disappears.

One of the main challenges in the fight against leprosy is that there is no vaccine against it yet, Mary Verghese, Executive Director, The Leprosy Mission Trust India, told IndiaSpend. The only way to end transmission, she said, is to ensure that people know how to recognise early signs and symptoms of leprosy and come in immediately for treatment. Increased resource allocation towards leprosy control is imperative, she said.

(Ramesh Menon is an author, independent award-winning journalist, documentary film-maker and adjunct professor at Symbiosis Institute of Media and Communication.)

Courtesy: India Spend
 

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The NHM, launched in 2005, is India’s largest health programme aimed at providing universal access to healthcare. One of its primary missions is to improve maternal and child health and control communicable and non-communicable diseases.
 
Data show why it is critical that NHM funds be used optimally: India still accounts for 17% of global burden of maternal deaths, non-communicable diseases made for 61% of deaths in 2016, communicable diseases like leprosy and malaria are yet to be controlled and 55 million Indians slipped into poverty in 2011-12 because of health catastrophes they could not afford.
 
NHM also disburses funds to state health societies to help strengthen local health systems, institutions and capabilities. Rural health centres in India are short of human resources and infrastructure, as Indiaspend reported on January 30, 2018. Sub-centres were 20% short of human resources, 29% of them did not have regular water supply, 26% lacked electricity supply and 11% were not connected by all-weather roads.
 
India ranks lower than neighbouring Bangladesh and even sub-Saharan Sudan and Equatorial Guinea on healthcare access, we reported on May 23, 2018. And it spends 1.4% of its gross domestic product (GDP) on health, the least among BRICS nations.
 
In a two-part series, we look at the government auditor’s assessment of NHM’s functioning. In part one, we report on instances of financial mismanagement. The concluding part will detail the shortfalls in infrastructure and medical staff caused by this mismanagement.
 
The government has denied charges of financial irregularity. Funds were being released as soon as states fulfilled the requirements for their allocation, according to Manoj Jhalani, additional secretary and mission director, NHM.
 
“The diversion of NHM funds for non-NHM purposes/state government schemes is never supported by the ministry,” he said. “If any such instance comes to (our) notice, the same is recovered from the concerned state government, and states are directed to desist from such practice.”
 
Delayed transfers, misallocation and a growing balance
Our analysis of the CAG audit highlighted the following problems in the disbursement and usage of health funds:

18 states spent only 32% of allocation which was already 36% short
In 18 states, against a requirement of Rs 133 crore, reflected in the 2013-16 state programme implementation plans, only 64% was allocated, we found. But states were not able to utilise even the allocated amount, with no more than 32% or Rs 43 crore spent.
 
“There are a number of reasons for unspent funds, ranging from the lack of human resources to complicated procedures for procurement in construction-related activities,” said Avani Kapur, fellow at the Centre for Policy Research and Director of the Accountability Initiative. “Another key factor is the uncertainty in the timing and amount of funds received under the scheme. There is often a mismatch in the what the state/district administration demands and what is actually approved and received.”
 
NHM is funded by both the central government and the states, with the centre providing 60%. The ministry of health and family welfare used to release funds directly to the state health societies till 2013-14. The money is now sent to state governments, which then move it to the societies.
 
The state-level societies in turn, disburse the funds to district health societies for further release to blocks. From here, the money goes to various implementing units such as community and primary health centres and sub-centres and village health sanitation nutrition committees.
 
NHM funds are released in five parts: NRHM Reproductive and Child Health (RCH) Flexipool, National Urban Health Mission (NUHM) Flexipool and Flexipool for Communicable Diseases and Non-communicable Diseases, including injury and trauma and infrastructure maintenance.
 
“One of the reasons for the creation of these (state health) societies was that the unspent money gets carried over to the next year unlike the state treasury which has to return unutilised funds at the end of the financial year,” said Kapur.
 
There are significant delays in the receipt of funds as CAG reported too, she said. “Given that states/districts have to prioritise routine activities such as salaries and Janani Suraksha Yojana payouts, there is an incentive to not spend money till the funds reach specifically (for certain projects),” she said. “Our research has thus shown that a lot of the softer expenses such as IEC (information, education, communication) or training often remained neglected.”
 
There are other problems with central sponsorship of schemes like NHM. Item-wise budgeting means that states do not have the flexibility to spend as per need, said Kapur. “I have heard the case of Himachal Pradesh where ASHAs (accredited social health activists) were not needed at one time but had to be hired because of NHM norms,” she said. “Under the new norms of the 14th finance commission, there is a provision wherein 25% of the funding is completely untied. (I) haven’t yet seen how states have operationalised this though.”
 
Unspent funds ranged from 40% to 76%, Meghalaya spent least
 
State health societies had spent only Rs 1,06,180 crore ($ 20.7 billion) of the Rs 1,10,930 crore ($ 17.1 billion) available during 2011-16. In some states the unspent balance ranged between 40% to 76% — for example, in 2015-16, in Meghalaya it was 76% and in UP, 52%.

 
Source: Comptroller and Auditor General of India
 
The table above shows the unspent balance without interest and with interest (as mandated by the NRHM guidelines). In 2011-12, the unspent balance available with 27 state health societies without interest was Rs 5253 crore ($ 1.02 billion) which came down to Rs 3686 crore ($ 555 million) in 2015-16. However, over the same period, the unspent balance, including interest, with 27 states increased from Rs 7375 crore ($1.44 billion) to Rs 9509 crore($1.43 billion) .
 
Defaulting state are not being penalised, as procedure requires
States that do not spend the money given to them must be penalised, according to procedure laid out by the Union Cabinet and applicable from 2014-15.
 
State governments had to release the money to state health societies within 15 days of receiving it, and if they failed to do so state governments were liable to pay interest — 5.75% to 7.25%, depending on the going bank deposit rate.
 
The audit observed that Rs 49 crore released during 2014-15 and Rs 450 crore released during 2015-16 under Mission Flexipool and RCH Flexipool to state treasuries were not transferred to state health societies as of May 2016.
 
When asked to explain, the ministry told CAG that from time to time states had been asked to ensure timely release of funds to health societies. However, the CAG observed that the ministry had no answer when it was asked about action taken against defaulting states.
 
Operational guidelines for the funds also provide for money to be used for only specific targets. In six states (Andhra Pradesh, Gujarat, Jammu and Kashmir, Rajasthan, Telangana and Tripura), Rs 36 crore was diverted to other schemes as mentioned earlier. The ministry admitted to CAG that it had not acted properly in diverting NRHM funds for non-NRHM purposes.
 
For the period 2011-15, utilisation certificates (UCs) of Rs 4,283crore, under Mission Flexipool, were pending in 22 states/UTs. Under RCH Flexipool, UCs of Rs 3,175 crore were pending from 21 states/UTs as of May 2016.
 
‘Poor data management’
“Data management processes are under NHM are very poor, we have also found that data is often poorly maintained,” said Kapur who has authored the budget study on the NHM. “The inability to maintain data management systems has a consequence on planning for the next year as well as implementation. UCs need to show utilisation and the failure to submit it has implications for future rounds of fund release.”
 
Lack of staff and high vacancies mean that frontline functionaries have to produce and maintain most records without any clarity on how and when it will be used, Kapur said.
 
In its response to our questions, the ministry of health and family welfare has said that it has already put in place a slew of measures to deal with these problems: regulation of fresh funds, the use of the Public Financial Management System which provides a digital platform for fund management in real time, audit of state funds, training and review of state finance staff and the immediate transfer of funds between state health societies and state treasuries.
 
The central government is also advocating the use of single bank account in state operations so that in order to keep track of unspent funds, according to Jhalani.
 
(This is the first of a two-part series.)
 
Next: Upto 38% Shortfall In Medical Staff At Health Facilities Across India
 
(Salve is an analyst with IndiaSpend.)

Courtesy: India Spend
 

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