Wednesday, March 14, 2012

Good Health at Low Cost (The Hindu | Book Review)

Note: Kerala and Tamilnadu are featured in this extension of a seminal research more than 25 years ago. The full text PDF of the book is available at http://bit.ly/GHLC-Book

Learning from others' policies

Arvind Sivaramakrishnan | March 12, 2012

http://www.thehindu.com/arts/books/article2988520.ece

GOOD HEALTH AT LOW COST, 25 YEARS ON: Edited by Dina Balabanova, Martin McKee, and Anne Mills; London School of Hygiene and Tropical Medicine, Department of Global Health and Development, 15-17 Tavistock Place, London WC1H9SH.

This is a welcome sequel to the seminal 1985 Rockefeller Foundation study Good Health at Low Cost, which investigated the determinants of good health care in countries which, despite other poor indicators, did better than many wealthier ones. The five chosen were China, Costa Rica, Cuba, the state of Kerala — treated as a country for the purpose — and Sri Lanka. This second Rockefeller-funded study, by the London School of Hygiene and Tropical Medicine with four other partner institutions, examines Bangladesh, Ethiopia, Kyrgyzstan, Tamil Nadu, and Thailand, and revisits the earlier four, but Cuba does not figure in either volume.

The work follows the World Health Organization by focusing on health systems, seeing them as institutions working with other institutions to promote well-being rather than simply providing treatment. In that sense, the aims the United Nations set out in the 1978 Alma-Ata Declaration have been retained, and the authors also note the significance of education and literacy programmes in improving maternal health and child survival rates. Countries have been chosen on the basis of national health system reforms, population and global region, and models of governance, among other factors, and the researchers analyse their findings in detail.

There is a wealth of material here. Bangladesh, one of the world's poorest countries, has made great advances in life expectancy, child health, and literacy, mainly as a result of strong emphases on community and household level health and family planning services. In South Asia, the country has among the highest life expectancy, together with the lowest total fertility rates and some of the lowest perinatal and maternal mortality rates, all of which have been achieved in under 30 years from a dauntingly bad start.

Infant mortality

Other countries are impressive in their own ways. Landlocked Ethiopia, a victim of vicious Cold War rivalry, terrible famines, and brutal civil war in which starvation was a weapon, has greatly reduced infant mortality with a national programme to distribute insecticidal bednets and improved prevention and treatment strategies. Substantial improvements have been made in the primary health care workforce based on districts and neighbourhoods, and in arrangements for doctors to travel to rural areas despite the poor transport infrastructure; the high incidence of HIV/AIDS has also been tackled with antiretrovirals and public education programmes.

Even the systems of the former Soviet Union are assets. Kyrgyzstan introduced compulsory health insurance after gaining independence in 1991, and has drawn upon pre-existing administrative experience as well as remarkable dedication on the part of ex-Soviet medical staff to maintain standards of care.

Tamil Nadu, for its part, has successfully ignored what is now a central government view of health policy as a matter of illness episodes and nothing else. The IIT Madras research team shows the state to be ‘unique' for its strong body of public health managers at district level, and for having trained and deployed village health nurses since the late 1970s; Tamil Nadu has better indices than most other states for fertility, and for perinatal and maternal mortality.

While the first four examples rely on a sometimes uneasy combination of public and private provision, Thailand, with a mainly public health care system, has outperformed many other countries; free antenatal care, skilled birth attendance, family planning, and immunisation, were all universal by the 1990s, and all Millennium Development Goals were met in the next decade.

Of course all is not rosy. In Ethiopia, out-of-pocket expenses account for 80 per cent of citizens' health spending, and tuberculosis is still widespread; India faces similar issues, including the airborne spread of resistant TB bacilli from the habit of spitting. Tamil Nadu has poor levels of nutrition, and high levels of maternal anaemia. In Kyrgyzstan, the collapse of the Soviet Union ended systems of support for young mothers.

The collection rightly avoids making easy statements of causal links between policy and results, though many of the patterns identified and the evidenced conclusions reached make very good sense. Secondly, in health policy around the world, documented questions still stand about, for example, the influence of the GAVI Alliance and pharmaceuticals manufacturers on health policy around the world.

All the researchers here do, however, discover three factors central to good health policy and successful health care delivery. One is the strong involvement of women at all levels. Another is the honest evaluation of policies; this has, for example, made funding bodies see that the vertical interventions they favour cannot accommodate the complexities of health policy and health care delivery. The third is political will with, above all, a commitment to equitable access. This book will therefore be of great value to practitioners and policymakers.

http://www.thehindu.com/arts/books/article2988520.ece

© The Hindu

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Sunday, March 11, 2012

Odisha Couple spreads HIV awareness; Kerala Police and Public supports (Express News Service)

On a grueling cycling mission

http://expressbuzz.com/edition/print.aspx?artid=360886
By Express News Service | 07 Feb 2012

THIRUVANANTHAPURAM: The battered blue bicycle looks as if thieves have had a go at it. It has no seat, no chain, no bell or brakes. Laxmikhanta Maity, its wiry, sun-burnt owner, places his feet on the pedals and his chest on the cushioned handlebar. He reaches out with his hands and propels himself and the bicycle forward by rolling the front wheel along.

Surely, not a comfortable way to ride, but Maity - who has come all the way from Rajnagar village, Kendrapara district, Odisha (formerly Orissa) - is on a mission to warn of a more threatening danger - the danger of AIDS. And in this ambitious campaign, which hopes to cover the whole of India, the social worker is accompanied by his wife, Monorama Maity, a diminutive woman riding another battered, but normal bicycle.

‘’It has been eight months now since we left home. We’ve covered 16 districts in Odisha and 18 each in AP and Tamil Nadu. Thiruvananthapuram is the first in Kerala, we hope to cover many more districts before crossing over to Karnataka,’’ Maity eagerly explains his plans. Both bicycles sport the national flag and Monorama’s are also laden with small bags carrying their meagre possessions. The couple spends the night at police stations and travels by day. Maity says he launched the campaign after two men in his village died of HIV/AIDS. Maity dabbles in Ayurveda back home, but no amount of treatment at various hospitals could save them.

The couple meets people, hands out pamphlets and info on how HIV/AIDS is spread. ‘’There’s practical difficulty for me talking about these things to women. My wife does that,’’ Maity explains why he brought his wife along on the difficult and potentially dangerous trip.

Maity does not have much of an opinion of the Kerala State AIDS Control Society which, he says, did not offer him much help. ‘’But the people of Kerala and the police too are very good. We met the Police Commissioner and the Chief Secretary. We also hope to meet the Chief Minister,’’ he said, before cycling away to the nearest school with his wife for another awareness programme.

http://expressbuzz.com/edition/print.aspx?artid=360886

Wednesday, February 29, 2012

Honor Killing and Killing of the Honor in Kerala

Dear Forum,

In Kodiyathur near Mukkom in Calicut district in Kerala 27 year old man was tied to a post and beaten to death by a moral brigade of 15 men. It seems, the victim, despite warning from the culprits, was accused of continuing an affair with a married woman.

The issue to be noted here is not the magnitude or the extra judicial nature of the punishment or that the victim did not break the law of the land since the woman's husband did not complain (IPC 497-adultery) etc.

This incident is only a tip of the iceberg of the ongoing sexuality related Human Rights violations regularly occurring in Kerala with institutionalized impunity since the victims are most often Sex Workers or MSMs.

In the late eighties a street sex worker was murdered in the police lock up in Calicut but the perpetrators escaped punishment and recently a boy in Calicut killed himself due to severe police harassment for supporting his brother to elope and marry his girlfriend despite severe obstructions from the police department.

Young people sitting on the beach get arrested regularly here.

Recently a prominent politician was man handled by the public in the full glare of the media, got arrested and charged for having caught travelling in a car with a lady who is not his wife.

The MP's car was stopped by a large group of moral public for been seen with a strange lady.

One of the earliest splits in Congress party in India took place - as the culmination of events triggered from an incident of a prominent congress politician caught with a strange lady in his car when it met with a minor accident-the product the Kerala Congress party which is a decisive ally in the UDF Govt.

These are only the signs of the continuations of ever prevailing intolerance towards sex in Kerala society and the major brunt of all this is taken by the Sex Workers and MSMs.

Cultural leaders, politicians, leftist groups and feminists are all guilty of silence on this matter.

Demanding sexual freedom and sexual excesses are not same.

Revolution in the attitude to sexuality should be inseparable from the agenda of social revolution itself and the social reform movements which caused marked improvements in Kerala society have completely failed to address the politics of sexuality.

The extremely conservative leftist groups have added to this failure by holding the ridiculous view that sexuality itself is an import of imperialism!

Tragically most of the feminists in Kerala belong to leftist groups and fails to discern that feminism should be more oriented to Human Rights than culture.

Patriarchal normativity in sex is one of the root causes of sexual violence and despite elaborate discourse on patriarchy many feminists fails to take note of the reality that sexuality itself is a social construct that rest on the structures built around a gendered society.

In the current Kerala society sexuality is an important arena of struggle more than any other where all need to fight for their rights but the tragedy is that the feminists are on the other side of the table since they cannot think of rights like sexual freedoms beyond cultural and matrimonial confines.

This attitude to sexuality is the greatest tragedy as well as the challenges of feminism in Kerala and unless and until the feminists in Kerala start accepting sexual freedom including sex work as work all these sex related atrocities here will continue unabated.

Tito Thomas (Advocate),
Director,
CSRD,Calicut

[Source: AIDS-INDIA eFORUM]

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Epi Updates (Times of India and Deccan Chronicle)

‘AIDS under control in Kerala’

TNN | Feb 12, 2012
http://timesofindia.indiatimes.com/city/kochi/AIDS-under-control-in-Kerala/articleshow/11854899.cms?prtpage=1

KOCHI: Kerala had managed to control HIV/AIDS and the number of affected persons was less compared to other states, said Dr M Prasannakumar of the Kerala State AIDS Control Society at the public health conference at IMA House on Saturday. He said that 2,200 new cases were being reported every year in the state but the number was minimal. He said that nearly 60% of HIV positive persons in Kerala were employed outside the state. Of the 10,000 pregnant women in the state, seven were tested positive. "We could trace 86 HIV positive pregnant women last year," Dr Prasannakumar said.

A total of 6,000 persons are undergoing treatment for HIV/AIDS in the state. The number of HIV-affected persons is high in districts that are closer to the Tamil Nadu border. Dr K Suresh, epidemiologist and public health consultant of the World Bank in India, said that the standard of public health education in the country was declining. "Even universities are not following a uniform syllabus on public health," he said. Health experts discussed a variety of topics including vector management, community-based palliative care and maternal health interventions. The conference will conclude on Sunday with a session on developing standardized competency framework for public health professionals in India. The valedictory function will have B Ekbal, former vice-chancellor of Kerala University, as the chief guest.

http://timesofindia.indiatimes.com/city/kochi/AIDS-under-control-in-Kerala/articleshow/11854899.cms?prtpage=1

Palakkad tops in HIV/AIDS cases

February 12, 2012 By Vinod Nedumudy DC Kochi

http://www.deccanchronicle.com/print/94301

Don’t be surprised to know that the district that cares the most for the bed-ridden is also the district having the most number of HIV/AIDS patients in the state. Palakkad has reported the highest number of HIV/AIDS patients in the state, 2,825 persons, according to the latest statistics released by the Kerala AIDS Control Society. In another key finding, the society has detected that 2,200 persons are detected with HIV every year in the state. Of 10,000 pregnant women, seven are being detected with HIV/AIDS, while in 2011 alone 86 pregnant women were detected with the deadly disease. The total number of people identified with the infection across the state is 15,000 While four in every 1,000 sex workers in other districts are found infected with HIV, 36 sex workers in Palakkad contracted the disease. “The sex workers in other districts are better paid than those in Palakkad and hence the number of clients per each sex worker a day in other districts is 1 to 2 while in Palakkad it is 5 to 6 per day. Hence the chances of contracting the disease are on the upper side in Palakkad,” according to Dr M. Prasanna Kumar, team leader and head of technical support unit for Kerala State AIDS Control Society.

The maximum cases are reported from Chittur, Alathur and Palakkad taluks. Another interesting fact is that even agriculture labourers are found infected with the disease in Palakkad while it is nil in other districts. The proximity of Palakkad to Coimbatore in Tamil Nadu where the prevalence rate of AIDS is over one percent, is cited as the main reason for the high incidence. The illicit liquor trade flourishing in the district is another reason. Close on the heels is Thrissur, with 2,012 registered cases and Thiruvanathapuram follows suit with 1,700 HIV cases. The least affected is Wayanad with 200 cases, while in Ernakulam the numbers rests at 1,000. Low prevalence is also reported from Alappuzha, Idukki and Kottayam. The society is yet to study the reasons for the high prevalence in Thrissur.

http://www.deccanchronicle.com/print/94301

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Monday, February 27, 2012

Palliative Care: NEJM Article mentions how Kerala's prohibitive rules have changed

Painful Inequities — Palliative Care in Developing Countries

Daniela Lamas, M.D., and Lisa Rosenbaum, M.D.

N Engl J Med 2012; 366:199-201 January 19, 2012

http://www.nejm.org/doi/full/10.1056/NEJMp1113622

Excerpts:

In many countries, physicians learn only about opiates' side effects, not their potential benefits, said Dr. M.R. Rajagopal, a palliative care physician in India. “Modern principles of pain relief and palliative care still aren't taught to medical students in 80% of the world,” he said, noting that many physicians in India finish training without ever seeing a morphine tablet.

Rajagopal recalled treating a patient with nasopharyngeal cancer whose pain was eventually controlled with morphine. The patient was also undergoing radiation therapy, and when his primary care doctor saw his morphine prescription, he tore it up, saying, “Never let me catch you with that again. That will destroy you.” Like many physicians, he feared opioid addiction and refused to believe that radiation alone was inadequate to treat the pain.

In Kerala, India, the opportunities for treating pain were similarly restricted until a few years ago. Physicians had to secure five licenses from different government bodies before they could prescribe a milligram of morphine. Often, one license expired before another was obtained, and the physician would have to start the process again without having administered a dose. In response to the efforts of Rajagopal, the palliative care physician, Kerala's rules have changed, but in most Indian states prohibitive hurdles remain (see Table).

For the full text, please visit http://www.nejm.org/doi/full/10.1056/NEJMp1113622

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Saturday, February 25, 2012

Kerala's Social Determinants and Tamil Nadu's Health System

Affordable Southern remedies for better health

K Srinath Reddy

http://ibnlive.in.com/news/affordable-southern-remedies-for-better-health/224911-55.html

Forbes India | Jan 28, 2012

When can a baby girl born in Madhya Pradesh expect to live as long and healthy as a baby girl born in Kerala, overcoming the six-fold higher risk of dying before her first birthday? When will a rural Indian have the same level of satisfaction about the healthcare he or she receives, as a foreign medical tourist featured in the brochures of corporate hospitals? Will the 40 million Indians, who are annually pushed into poverty because of unaffordable healthcare costs, be relieved of the crushing burden of catastrophic health expenditures in a country where private, out-of-pocket spending accounts for 71 per cent of all health financing?

While the Indian media is currently concerned over the fluctuating growth rates of the economy, it is the health indicators which should cause considerable concern.

Our infant and maternal mortality rates (presently 47 and 210 respectively) do not compare with those of Sri Lanka (11 and 47, respectively, a few years ago). While 42 per cent of our children below three years are undernourished, 15 per cent of urban adolescents are overweight, calling for nutrition policies that provide adequate and appropriate nutrition at each stage of life. India is home to a third of the world's measles cases as well as 61 million persons with diabetes. Smoking claims a million lives each year, with chewing tobacco adding to the world's highest load of oral cancer. In 2000, India lost 9.2 million potentially productive years of life due to early cardiovascular deaths occurring in the 35-64 years age range. This loss is projected to rise to 17.9 million years in 2030. We need a health system that can deal with the unfinished agenda of underdevelopment as well as the maladies of maladapted modernity.

With the emergence of new infectious diseases and a rapid rise in heart diseases, stroke, diabetes, cancers, mental illness and injuries, the health system has to respond to new challenges through creation of capability for prevention, early detection and cost-effective treatment. All this while continuing to emphasise maternal and child health, and traditional infections like tuberculosis, malaria and AIDS as the prime public health priorities. India's poor health indicators reflect the cumulative consequences of neglecting primary healthcare in all its dimensions.

Good health is inconceivable without an assurance of safe water, domestic and public sanitation, adequate nutrition and clean environment to all segments of the population. Easy access to dependable health services which can avert or ameliorate common ailments, an expected feature of good primary healthcare, is mostly unavailable in both rural and urban areas.

The National Rural Health Mission (NRHM) has attempted to strengthen primary healthcare, with focus on maternal and child health. While some success has been recorded in recent years, evidenced by a steady, but not speedy decline in infant and maternal mortality rates, much greater investment is needed in infrastructure, health workforce, management systems, community empowerment and governance. Urban primary healthcare too needs attention, with well dispersed community health centres forming the base of a three-tier network of healthcare facilities.For this challenging agenda to be successfully addressed over the next decade, we need to increase the level of public financing in health from around 1.2 per cent of the GDP at present to at least 3 per cent, to make it comparable to China (2.3 per cent) and Thailand (3.3 per cent). India spends $132 per capita on health, compared to $193 in Sri Lanka, $309 in China and $345 in Thailand. More public funding helps to reduce out-of-pocket spending.

The increased funding should be spent on strengthening primary healthcare infrastructure and district hospitals; scaling up the size and quality of the health workforce (ranging from community health workers to nurses and doctors); free supply of essential drugs and vaccines; and creation of a tax-funded system of universal health coverage wherein an essential health package of primary, secondary and tertiary services will be available, free of charge, to every Indian citizen. Such a system would be based on a single payer system rather than a fragmented system of multiple insurance providers. The government will be the guarantor of universal health coverage, even if it is not the sole provider. Health services will be provided by a network of public facilities and contracted in private providers.

This wish list cannot even be partially fulfilled, without system reform, innovation and political will. To ensure reforms in pooled drug procurement, supply chain management, healthcare facility accreditation, programme evaluation, human resource development and portability of health financing, new regulatory and facilitatory structures and systems are needed.

Competency-linked cadres for public health and health management should be created, to improve the design and delivery of health programmes. Information technology-enabled service delivery models, e-health, m-health and telemedicine can enhance outreach and effectiveness of healthcare. The complementary roles of Central and state governments need to be clarified and collective commitment to the creation of a robust and corruption-free health system must be generated across the political spectrum.

Even as the health system is progressively strengthened, policies and programmes in other sectors, which impact health, need to become sensitive and responsive to public health concerns. From agriculture and food processing to urban design and transport, there are many actors who can contribute to better health of our people. While convergence of services is needed at the frontlines, co-ordination of policies is required at the central level. Social determinants like education, employment, income and gender equality are also important enablers of good health.

I do not have a simple prescription for transforming health in India. In a complex system like health, a package of interventions is needed for successful, speedy and sustainable change. If I were permitted only one wish, I would like to see the whole of India having a health system like that of Tamil Nadu and social determinants like Kerala. Both states are now being cited internationally as examples of good health at low cost. The compass clearly points to southern models, if we wish to travel towards good health.

http://ibnlive.in.com/news/affordable-southern-remedies-for-better-health/224911-55.html

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ToI Report on Swanthanatheeram

Sex workers chart out a new career path

TNN | Jan 31, 2012

http://timesofindia.indiatimes.com/city/kochi/Sex-workers-chart-out-a-new-career-path/articleshow/11693624.cms

ALAPPUZHA: Swanthanatheeram, the self-help groups (SHGs) of women sex workers in the district, instituted by the Kerala State Aids Control Society (KSACS), is proving to be a big success with around 40 erstwhile sex workers taking up alternative jobs to make a living.

No one exemplifies Swanthanatheeram's success than 50-year-old Santha (name changed) a former sex worker who now plays the chenda (a percussion instrument) to make a living.

"I became a sex worker after my husband deserted me and my three daughters 14 years ago as I had to educate my children and also marry them off. But after I joined Swanthanatheeram in 2007 after much persuasion, I learned to play sinkari melam (chenda ensemble) along with 12 members of my SHG. Now we perform in temples, churches and houses during all kinds of festivities," she told TOI.

"Now we are busy and have a lot of programmes as it is the festival season. I earn Rs 800 for a performance and we have at least three programmes a week," she says.

SHGs also have other success stories to tell. Five sex workers learnt to drive the auto rickshaw and bought auto rickshaws with SHGs help and are now leading a decent life; 10 sex workers, trained as hospital helpers, have found jobs in various hospitals; and another group of 12 women are all set to learn sinkari melam.

It was in September 2007 that KSACS constituted SHGs of sex workers in the district as part of its Suraksha project, which aimed to reduce the rate of HIV transmission among sex workers, and drug users.

Paulose Kuriakose, district manager, Suraksha, told TOI that initially the SHGs had only 11 members. Now there are 35 SHGs, and of the 1,821 commercial sex workers identified by the KSACS in the district, 1,002 have joined the SHGs. And as many as 40 have completely abandoned sex work and are making a living through the activities of their SHGs.

Dr Nisha R S, a councillor with KSACS in Alappuzha, said many of the sex workers had left the field after they realized they could earn a decent income through their SHGs.

Five sex workers learnt to drive autorickshaw, 10 trained as hospital helpers and another group of 12 women are all set to learn sinkari melam.

-- Sajimon P S

http://timesofindia.indiatimes.com/city/kochi/Sex-workers-chart-out-a-new-career-path/articleshow/11693624.cms

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