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Tag Archives | public health

Smart or dumb: Cities should be safe

Bhubaneswar emerged as the top candidate among the 20 cities chosen to be part of the Government of India’s Smart Cities Mission. One hopes that the plans of turning the city into a smart one will include strengthening risk resilience, particularly in places that are supposed to ensure safety and health of the citizens.

By Nidhi Gupta (@nidhi1902)

Image credits: NAVFAC (Monthly Safety Stand Down) [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

Image credits: NAVFAC (Monthly Safety Stand Down), via Wikimedia Commons

A major fire that broke out earlier this week in the SUM Hospital in Bhubaneswar took lives of over 20 people and caused injuries to over 100. The fatalities caused were mostly patients who were on ventilator support in the ICU ward. One was immediately reminded of the fire that broke out at Murshidabad Medical College and Hospital in August this year and the one at the AMRI Hospital in Kolkata in 2011. Given the large number of hospitals that the country has, these incidents of fire may seem statistically insignificant. However, some places of safety (like the hospitals, police stations, etc.) are expected to not only have zero tolerance for human negligence and errors, but also a foolproof disaster management plan. Incidents such as these point to our society’s stubbornness to not learn from history and to our Government’s callous attitude towards loss of life and property.

A healthcare facility in Odisha is governed by the Odisha Clinical Establishments (Control and Regulation) Act, 1990, which lays down standards relating to fire safety. However, it has been reported that only 3 hospitals out of the 568 in Odisha currently have the clearance from fire department and most of the hospitals lack the basic fire-fighting equipment. Moreover, SUM Hospital did not follow fire safety norms and overlooked an advisory that was issued to them by the fire department in 2013. While the hospital management at the SUM Hospital has asserted that owing to diligence shown by its staff the casualty number was low, it can be argued that there should have been no casualties in the first place.

Passing the buck around or offering some monetary compensation does little to console the victims’ grieving families. Reactionary measures like suspending hospital staff (as in the case of SUM Hospital) or board of directors (as in the case of AMRI hospital) cannot be substitutes for ensuring the structural and operational resilience of hospitals. It is of utmost importance that the healthcare facilities in our country are regularly audited for compliance with safety standards and that the staff is periodically trained on safety and evacuation. It is also imperative that the management of facilities found with dubious certificates are heavily penalised. The National Disaster Management Authority (NDMA) of India has issued very comprehensive guidelines for hospital safety, including those for fire safety in hospitals. While these guidelines are not binding, it is expected that hospitals implement these in earnest and be prepared to handle any disasters and be optimally functional immediately afterwards in order to respond to the medical requirements of the affected community.

Bhubaneswar was ranked first in the Smart City Challenge competition held by the Government of India earlier this year and is one of the 20 cities each of which will receive Rs 1000 crore of funding from the Centre and the State Governments. One sincerely hopes that the emphasis being laid to improve “quality of life” for the citizens will also include measures that ensure that the lives of the said citizens are first protected.

Nidhi Gupta is Head, Post-Graduate Programmes at the Takshashila Institution and tweets at @nidhi1902

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Using behavioural economics insights for vector-borne diseases

Aiming for better health outcomes without addressing the behavioural roots of health problems is bound to be unsuccessful.



A recent public health issue that has made global headlines and has caught the imagination of public health practitioners the world over has been the spread of Zika– a virus that spreads through mosquitoes. While it hasn’t yet been conclusively established, there’s increasing evidence of the connection between the virus and microcephaly – a birth defect that causes brain damage in foetuses. This possible link between the virus and microcephaly has sent alarm bells ringing. The virus has infected people in more than 20 countries in Central and South America and the Caribbean and has the potential for further international spread. With the World Health Organisation (WHO) declaring the spread of Zika virus as an international public health emergency, countries around the world are announcing a slew of policy measures to tackle the outbreak and spread of the virus.

The WHO estimates that more than half the world’s population is at risk from vector-borne diseases (spread through mosquitoes) and that more than one million people die every year from such diseases. Low- and middle-income countries with high incidence of poverty, tropical weather – in which mosquitoes thrive and fragile public health systems are normally at a higher risk for spread of vector-borne illnesses. Clearly, vector control is the most important tool in preventing the outbreak and controlling the spread of such diseases. Indeed, as has been in the case of Zika, fumigation, distribution of mosquito repellant and vaccine development are the immediate measures that various countries adopt. Other solutions promulgated range from the benign travel advisories to the more controversial ones advising women to not get pregnant until the crisis has passed.

However, it is important that any policies for vector control do not just rely on traditional methods but also include insights from the recent advances in behavioural economics. This branch of economics, which has made inroads into public policies (at least in the US and the UK), counters neo-classical economics in that it does not assume (and rightly so) human beings to be fully rational agents when it comes to making decisions and choices. Various research studies in this area have shown how humans tend to consistently make sub-optimal choices. One of the insights is that of present bias, wherein the human mind disproportionately weighs present costs over future benefits and hence makes people deviate from their own desired behaviour. For instance, the cost (time and money) of getting a vaccination today outweighs the unseen future benefits and hence many people (especially the poor) delay getting the vaccinations. The researchers have also studied and proposed how policies – often termed as “nudges” can be designed that match people’s actual psychology. Typical health ailments that have been targeted through nudge approaches are obesity and smoking. However, the concept has not yet found currency to fight the diseases of the global South.

As human beings are at the centre of all policies that are aimed at improving public health, achieving improved health outcomes is nearly impossible without addressing the behavioural roots of health problems. It is therefore critical that developing countries’ large-scale public health policies to contain the spread of vector-borne diseases must utilize the insights from behavioural economics.

Nidhi Gupta is a Programme Manager at the Takshashila Institution and tweets at @nidhi1902


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Privatisation in the Universal Health Coverage (UHC)

Salil Kalianpur

Recently, the Indian government announced plans to offer Universal Health Coverage (UHC) to Indian citizens. This is not new. India had embraced this vision at the time of its independence. But, over the 65 years since then, India’s public spending on health — currently around 0.9-1.2 percent of GDP — is among the lowest in the world.

The result is that public health facilities are funded almost negligently. Apathy by successive governments led to faulty planning and combined that with inefficient management of public health over the decades. Schemes like the National Rural Health Mission (NRHM) and the several government-funded health insurance schemes provide merely a partial response. Out-of-pocket expenditure still remains at 71 percent of all spending, without coverage for outpatient care, medicines and basic diagnostic tests. This effectively leaves the sick and the ailing – especially the poor – out in the cold.

India’s future lies in its demographic dividend – the advantage of having a young, healthy and productive work force. And to reap the benefits of this work force that is expected to form the foundation of India’s growth in the coming decades, it must reform its public health system. It is impossible that the system, in its present form, can ever meet the future needs of the population at large.

To address this socio-economic problem, the government simply decided to throw more money at it and hope for a solution. It announced that it would triple its spending in the health sector in the 12th Five Year Plan and increase spending from an average 0.9 percent of GDP to 2.5 percent of GDP by 2017. Amongst other things, it announced a $5.4 billion plan to distribute medicines free of cost to its citizens. The question is, can it?

A very obvious analogy lies in the Right To Food (RTF) Act. The imbalance between the expansive vision expressed by the Act and the narrow means it seeks to achieve it is uncannily like the state of public health care. Huge quantities of food grain are produced every year yet millions of Indians starve to death or are malnourished because of the government’s shocking inability to get that produce from “farm to fork”. The infrastructure is simply inadequate. Similarly, just by procuring medicines in bulk and offering it for free, the disease burden in India will not miraculously decrease.

India simply does not have the medical infrastructure required to provide health care to all its citizens by itself. It currently has one of the most privatised medical systems in the world where the government meets only 17 percent of the total healthcare costs compared to 46 percent in the United States and almost 92 percent in Britain.  This might lead the average person to perceive that India is woefully under-resourced in the health sector. On the contrary, India has the largest number of medical colleges in the world producing among the largest numbers of doctors in the developing world. India gets “medical tourists” from many developed countries reflecting the high standard of medical skill and expertise here. They seek care in its state-of-the-art, high-tech hospitals which compare with the best in the world. India is the fourth largest producer of drugs by volume in the world and is among the largest exporters of drugs in the world.

Leaving aside a few government run institutions such as AIIMS and PGI, all the noteworthy achievements listed above, were made possible by the private sector. While India has the capability and the resources (less but surely present), the government has woefully failed to create equitable distribution of the services that are produced. The statistics are staggering. A decade old report by the World Bank estimated that 93 percent of all hospitals, 64 percent of beds, 80-85 percent of doctors, 80 percent of out-patients and 57 percent of in-patients are in the private sector. At Independence, the private sector provided only 8 percent of health care facilities.

It is obvious that the private sector is well entrenched in delivering health care. Instead of discouraging it, strategic encouragement can help build UHC more quickly. For example, in rural India, the public health facilities are inefficient and marked by chronic absenteeism. The private sector considers rural India unprofitable since affordability is very low in the population. Through direct cash transfers or health vouchers, the government can create affordability in rural India. This will encourage private sector entry, create competition and improve overall health delivery in the region. Slowly but surely doctors who avoid rural practice may find it lucrative to return. Alongside the government must also focus on finding solutions that will decrease the need to seek health services. It must encourage its citizens to lead healthier lifestyles by creating the environment for increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventative care.

Today, India does not have enough doctors or nurses. The government can chip in here by using all the capacity that the country has.  It can train hundreds of “community health workers” across the country to diagnose communicable diseases and direct patients to hospitals. At present, it is doing so but not in a systematic or an effective manner. India has rarely, if ever used radio broadcasts and text messaging allowing rural citizens faster access to vaccinations, examinations, and treatment.  In a country with the highest television-density in the world, it can effectively use cell phones to send and receive information about disease outbreaks and health updates. These steps maybe small but the impact on health outcomes can be immense.

The good news is that the government seems to have realised that it must relinquish its role as a provider of primary healthcare, making way for private companies and individual medical practitioners to take the lead in offering clinical services, and focus its energies and resources on preventive interventions such as immunization and HIV testing. Whether or not the government will follow through on allowing the private sector to deliver, while it focuses on ensuring that the distribution is equitable, remains to be seen.

Salil Kallianpur is a health care marketing professional with experience in the pharmaceuticals and medical device industry. He blogs at “My Pharma Reviews” (salilkallianpur.wordpress.com). Views expressed are his own and not those of his employer

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