Capacity building for primary health care

A pluralistic and integrated medical system remains a solution worth exploring

A contentious element of the National Medical Commission (NMC) Bill 2017 — an attempt to revamp the medical education system in India to ensure an adequate supply of quality medical professionals — has been Section 49, Subsection 4 that proposes a joint sitting of the Commission, the Central Council of Homoeopathy and the Central Council of Indian Medicine. This sitting, referred to in Subsection 1, may “decide on approving specific bridge course that may be introduced for the practitioners of Homoeopathy and of Indian Systems of Medicine to enable them to prescribe such modern medicines at such level as may be prescribed.”

Missing the reality

The debates around this issue have been ranging from writing-off the ability of Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy (AYUSH) practitioners to cross-practise to highlighting current restrictions on allopathic practitioners from practising higher levels of caregiving. However, these debates miss the reality: which is a primary health system that is struggling with a below-par national physician-patient ratio (0.76 per 1,000 population, amongst the lowest in the world) due to a paucity of MBBS-trained primary-care physicians and the unwillingness of existing MBBS-trained physicians to serve remote/rural populations. Urban-rural disparities in physician availability in the face of an increasing burden of chronic diseases make health care in India both inequitable and expensive.

Therefore, there is an urgent need for a trained cadre to provide accessible primary-care services that cover minor ailments, health promotion services, risk screening for early disease detection and appropriate referral linkages, and ensure that people receive care at a community level when they need it.

Issue of cross-prescription

The issue of AYUSH cross-prescription has been a part of public health and policy discourse for over a decade, with the National Health Policy (NHP) 2017 calling for multi-dimensional mainstreaming of AYUSH physicians. There were 7.7 lakh registered AYUSH practitioners in 2016, according to National Health Profile 2017 data. Their current academic training also includes a conventional biomedical syllabus covering anatomy, physiology, pathology and biochemistry. Efforts to gather evidence on the capacity of licensed and bridge-trained AYUSH physicians to function as primary-care physicians have been under way in diverse field settings, and the call for a structured, capacity-building mechanism is merely the next logical step.

The 4th Common Review Mission Report 2010 of the National Health Mission reports the utilisation of AYUSH physicians as medical officers in primary health centres (PHCs) in Assam, Chhattisgarh, Maharashtra, Madhya Pradesh and Uttarakhand as a human resource rationalisation strategy. In some cases, it was noted that while the supply of AYUSH physicians was high, a lack of appropriate training in allopathic drug dispensation was a deterrent to their utilisation in primary-care settings. Similarly, the 2013 Shailaja Chandra report on the status of Indian medicine and folk healing, commissioned by the Ministry of Health and Family Welfare, noted several instances in States where National Rural Health Mission-recruited AYUSH physicians were the sole care providers in PHCs and called for the appropriate skilling of this cadre to meet the demand for acute and emergency care at the primary level.

Our own experience at the IKP Centre for Technologies in Public Health shows that there is hope. Here, the focus has been on deploying a capacity-building strategy using AYUSH physicians upskilled through a bridge-training programme, and the use of evidence-based protocols, supported by technology, to deliver quality, standardised primary health care to rural populations. Protocols cover minor acute ailments such as fever, upper respiratory tract infections, gastrointestinal conditions (diarrhoea, acidity), urological conditions, as well as proactive risk-screening. The Maharashtra government has led the way in implementing bridge training for capacity-building of licensed homoeopathy practitioners to cross-prescribe.

As anchors

Capacity-building of licensed AYUSH practitioners through bridge training to meet India’s primary care needs is only one of the multi-pronged efforts required to meet the objective of achieving universal health coverage set out in NHP 2017. Current capacity-building efforts include other non-MBBS personnel such as nurses, auxiliary nurse midwives and rural medical assistants, thereby creating a cadre of mid-level service providers as anchors for the provision of comprehensive primary-care services at the proposed health and wellness centres. Further, the existing practice of using AYUSH physicians as medical officers in guideline-based national health programmes, a location-specific availability of this cadre to ensure uninterrupted care provision in certain resource-limited settings, as well as their current academic training that has primed them for cross-disciplinary learning hold promise. These provide a sufficient basis to explore the proposal of bridging their training to “enable them to prescribe such modern medicines at such level as may be prescribed”.

Ensuing discussions will be well served to focus on substantive aspects of this solution: design and scope of the programme, implementation, monitoring and audit mechanisms, technology support, and the legal and regulatory framework. In the long run, a pluralistic and integrated medical system for India remains a solution worth exploring for both effective primary-care delivery and prevention of chronic and infectious diseases.

Aparna Manoharan and Rajiv Lochan are involved with the IKP Centre for Technologies in Public Health;Rajiv Lochan is MD and CEO ofThe Hindu Group

Omission and commission

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The patient has been identified: It is India’s health care sector. The diagnosis has been made: It is a severe case of corruption, apathy and maladministration, mainly in the Medical Council of India (MCI), the apex body that regulates medical education, training and practice in the country.

The doctors—in this case, elected representatives, medical professionals and legal experts—all agree that immediate treatment is needed. But, they are still squabbling over the proposed cure, which is the National Medical Commission Bill, 2017, tabled in the Lok Sabha by Union Health Minister J.P. Nadda on December 29 last year.

The government says the bill will overhaul medical education by bringing in “transparency” and “accountability”, but the Indian Medical Association, an influential organisation that has around three lakh allopathic doctors as members, has opposed it. On January 2, the government was forced to refer the bill to a parliamentary standing committee, after the IMA began a 12-hour nationwide strike to prevent the bill from being passed.

The bill proposes to replace MCI with the National Medical Commission, a 25-member body comprising a chairperson, 12 ex-officio members, 11 part-time members, and an ex-officio member secretary. The chairperson and part-time members would be appointed on the recommendation of a “search committee”, headed by the cabinet secretary and comprising the chief executive officer of NITI Aayog, the Union health secretary and experts from the fields of law, management and public health.

Unlike in MCI, whose members are registered medical practitioners elected by ballot, the proposed commission would be constituted largely by the Union government. Only five part-time members would be elected by registered medical practitioners. A key provision in the bill is the setting up of four autonomous boards—one each to regulate undergraduate medical education, postgraduate education, medical assessment and rating, and ethics and medical registration.

The devolution of powers means that the commission will not be a regulatory monolith like MCI, which the community health expert Dr Rama Baru likened to a “medical mafia”—a nexus between corrupt doctors and politicians. Baru was part of MCI’s ethics committee, formed after its national president Ketan Desai was arrested for allegedly accepting Rs 2 crore as bribe to grant recognition to a medical college in Punjab. Baru said Desai had built a network of doctors across the country, and had tied up with politicians to sanction medical colleges in exchange for bribes of several crore rupees. “Those within the profession had lost trust in MCI,” said Baru.

In 2016, a parliamentary standing committee chaired by Ram Gopal Yadav, MP, found that there were “issues related to corruption” in MCI, and that it had failed to fulfil its responsibilities. “The quality of medical education is at its lowest ebb; the current model is not producing the right type of health professionals…,” said the report.

25-vikramgad-weekDoctors in demand: Patients waiting outside a rural hospital at Vikramgad in Maharashtra | Amey Mansabdar

 

Apart from replacing MCI with the decentralised commission, the bill also envisages a medical advisory council, which will help the commission shape policies and initiatives related to education and training. The council will have members nominated by states and Union territories.

“The idea is to shift from election to selection; and the search committee would select candidates through transparent processes. The professionals nominated by the government would be persons of high integrity,” said a NITI Aayog official who was involved in the drafting of the bill.

The move from election to nomination has been welcomed by doctors who feel that MCI elections were rigged. “Good doctors would also not vote, because they didn’t trust MCI,” said Dr Samiran Nundy, senior consultant at Sir Ganga Ram Hospital in Delhi.

The IMA, however, has sharply criticised the commission’s “bureaucrat-heavy” composition and its “inadequate representation” of medical professionals. “If the government had wanted a leaner body than MCI, it has not reflected in the bill,” said Dr K.K. Aggarwal, former IMA national president. “With a total of 150 members in the commission, the number exceeds that of MCI (130). Decision-making powers are now concentrated with the three members [each] of the four autonomous boards.”

Baru said the bill did not address the issue of breaking the nexus between corrupt doctors and politicians. Rather, she said, by giving complete control to bureaucrats, the bill leaves the system even more vulnerable to “political interference, lobbying for posts and manipulation”. Baru, too, feels that the representation of those within the medical fraternity is inadequate.

The bill has also been criticised for proposing lax procedures in inspecting private medical colleges and regulating fees. Under MCI, a medical college would undergo “phase-wise” inspections before being granted recognition. MCI could debar colleges who repeatedly fail to meet the standards, and, in extreme cases, even de-recognise them.

One such case is that of Chintpurni Medical College at Pathankot in Punjab, which received permission to begin operations in 2011-12, and was later debarred after subsequent inspections revealed deficiencies related to faculty and facilities. Dr Sushil Garg, president of Chintpurni Medical College Parents’ Association, said the college continued to function even after being debarred. “During inspections, they [college authorities] would manage faculty requirements by bringing in ghost faculty [faculty that would only exist on paper],” said Garg. “Once, during an inspection, which was conducted on counting day [of an election], the management told MCI inspectors that no teachers were available because it was a government holiday. It was untrue. The holiday was on polling day, not counting day.”

Instead of improving on the existing regulatory framework, the bill proposes to do away with the “inspector raj” altogether. It says “third-party agency or persons” can be hired and authorised for inspecting, assessing and rating medical institutions, and proposes monetary penalties in case of any violation. Officials at the health ministry say the idea is to “open up” the sector, get more private players to set up medical colleges, and ensure that there is “greater supply” of quality medical professionals.

“MCI’s inspector raj had created fear among honest, genuine investors who wanted to set up medical colleges, and created a mechanism for blackmailing them in return for approvals,” said the NITI Aayog official. “This bill will allow honest people to set up colleges and address shortage of doctors.”

As per the bill, a key function of the commission will be to “frame guidelines for determination of fees in respect of such proportion of seats, not exceeding 40 per cent in private colleges and deemed universities”. Experts feel that it leaves room for market forces to commercialise medical education. “Why only 40 per cent? That, too, up to 40 per cent, which means zero to 40?” asked Sujatha K. Rao, former Union health secretary. “There are Supreme Court rulings directing states to constitute tariff committees to arrive at reasonable fees. Why is that being diluted? What if a private college charges 050 lakh a year? What is the oversight mechanism for overcharging and exploitation?”

She also disagrees with NITI Aayog’s argument that investors get returns through fees. “Why is medical education being treated as an investment, when the global view is for treating it as a public good? Why should one need 0400 crore to set up a medical college? This clause will only create inequity, restrict access to a large number of meritorious [students] who want to become doctors, and make availability of doctors in rural areas or for primary care impossible, and medical care expensive,” she said.

To solve the shortage of doctors in rural areas, the bill proposes a bridge course “for practitioners of homeopathy and of Indian systems of medicine to enable them to prescribe such modern medicines”. The IMA has bitterly opposed this clause, saying “unscientific mixing of systems… will only pave the way for substandard doctors and practices”.

“Since 2010, the government has been pursuing the idea of strengthening subcenters with a cadre of public health doctors trained for three years in medical colleges, much like the ‘licentiate in medicine and surgery’ in the British times,” said Rao. “This later spun into a bridge course of six months or so for AYUSH practitioners who are trained for five years, empowering them to prescribe a list of allopathic medicines.”

Rao feels that this provision, in its current form, can be abused, by way of legalising the current practice of AYUSH doctors prescribing allopathic medicines. “It will also enable them to pursue sham courses and work at any level, not just primary care,” she said.

Anupriya Patel, minister of state for health, told THE WEEK: “Any decision to allow bridge courses in modern medicine to AYUSH practitioners will be taken only by unanimous consent of all members present in the annual joint sitting of the NMC, and the councils for homeopathy and Indian system of medicines. Every single member will have a right to veto the proposal. Hence, there are strong safeguards provided. Detailed procedures and guidelines would be prescribed before any such decision is taken in the joint sitting.”

The bill also provides for conducting a licentiate exam, or an exit test for MBBS graduates to maintain standards. But experts have opposed this provision, too, saying the focus should now be on providing quality medical education.

“This test is desirable, but India is not ready for it, though a three-year period has been given for it to get operational,” said Rao. “For ensuring and maintaining a standard, the examination will have to be above average. This will mean that students from several backward states who cannot afford private tuitions may not be able to crack the examination. There will be a lot of problems in the interim, till such time that college standards do not improve.”

A poor prognosis: the National Medical Commission Bill

Dr George Thomas

There is no doubt that the Medical Council of India (MCI) has outlived its utility and should be reformed or replaced. The remit for the proposed new body, the National Medical Commission, should be clear, direct and workable. A regulatory body should be expected only to regulate and not to formulate policy, which is the function of Parliament and requires inputs from a number of sources, preferably with different points of view.

The fundamental flaw in the proposed Medical Commission is the lack of clarity on its function. Unfortunately, in the National Medical Commission Bill, 2017 in the chapter titled “powers and functions of the commission”, the phrase “lay down policy” occurs repeatedly. The Commission is also expected to “assess the requirements in healthcare, including human resources…” Such complex tasks, which require inputs from multiple agencies, will be done poorly, if at all, by the commission. The Commission should only be expected to monitor and regulate the training of health-care personnel and maintain professional standards.

Point of integration

What type of medical practitioners should the country train? This is a matter that the government should decide. It is poor policymaking to smuggle in clauses about interdisciplinary meetings between different medical systems and bridge courses into this Bill, under the omnibus “miscellaneous” section (item number 49). The failure of successive governments to promote scientific medicine and integrate the best of indigenous systems into one unified system has led to unhealthy competition among the various streams of medicine in India. It must be emphasised that modern medicine is wrongly labelled “Western”or “Allopathy”. Modern medicine takes all that is useful in therapy regardless of its source. It subjects every treatment protocol to the impartial tests of science. “Allopathy” is a term coined by Hahnemann, the founder of homoeopathy, and is seldom used in countries other than India. It would be great statesmanship to move to just one scientific system of medicine in India, combining all that is proven from different streams.

Who should the members of the Commission be? The present system of appointing members to the MCI has failed, resulting in rent-seekers repeatedly entering the Council. The present method of election, where potential candidates have to spend quite a large amount of money and time to get elected, has the unfortunate outcome of ensuring that mostly rent-seekers seek election. The election process should be reformed, not replaced. The proposal to have sections of society other than medical professionals in the commission is laudable. Having an almost entirely nominated commission, as the present Bill provides, is unhealthy. It will lead to a collection of ‘yes men and women’ whose chief qualification will be proximity to the existing government.

Medical education

Should private initiative be allowed in medical education? If the government is sincere in its objective of providing universal medical care, it is clear that high-cost private education will further exacerbate the problem of too many specialists in metropolitan areas chasing too few patients. Many ethical problems in India arise from this basic situation of too many doctors chasing too few paying patients. Issues such as unnecessary investigations and procedures, and too little time spent with each patient arise from the need to earn a reasonable amount and the need to do it from the small pool of paying patients. More importantly, such policy decisions should not be left to the Commission.

To start a medical college, State governments first issue a certificate of essentiality. The MCI then decides whether the proposed college has enough facilities to start the first year. Subsequently, inspections are done every year till the first batch of students has completed the final year. This has led to problems, as somewhere along the way, the Council finds that some colleges are unable to meet the requirements and withdraws recognition. This leaves students in a lurch and they then approach the judiciary to solve their unhappy situation. The proposed Commission has no mechanism to prevent this from happening. Merely shifting this responsibility to a medical assessment and rating board is no solution.

The present Bill is unlikely to provide a dynamic new thrust to medical care in India. It falls between the stools of excessively ambitious objectives and micro-management. On the one hand the Commission is expected to formulate policy, but on the other it is to decide fee structure. The government should exhibit statesmanship and form a parliamentary committee to draft a new Bill altogether with clear and workable objectives. In the end, policy decisions should be decided by policymakers, and not bureaucrats.

George Thomas is an orthopaedic surgeon at St. Isabel’s Hospital, Chennai

Cancer hits more women in India than men, but more men die of it

Image result for Cancer hits more women in India than men, but more men die of it

Estrogen, the female sex hormone that shields young women against cardiovascular diseases, plays a role in her battle with cancer as well. It not only increases her chances of getting the disease, but also increases her chances of survival, say doctors. Statistics prove this. The World Health Organisation-developed statistical tool Globocan 2012 shows the Big C has afflicted more Indian women than men. But more Indian men died due to cancer than women, said the World Cancer Report 2014.
Doctors in Chandigarh’s Postgraduate Institute of Medical Education and Research (PGI-MER) surmise women are subjected to more medical attention in their lifespan, allowing cancers to be picked at an early stage and hence improving life expectancy.

Image result for Cancer hits more women in India than men, but more men die of it

In all, 5.37 lakh Indian women got cancer in 2012 as against 4.77 lakh men, said the World Cancer Report. But 75% of the men affected with cancer have low life expectancy, while the mortality rate of cancer in women is 60%. In 2012, 3.56 lakh men died of the disease in comparison to 3.26 lakh women.

Among all cancers in both sexes, incidence of breast cancer is highest at 1,44,937, while the cervix uteri is the second most frequently occurring one with 1,22,844 cases. The third most common cancer is of the lip and oral cavity with 53,842 men affected.

This gender bias in cancer is noticeable. Dr Rakesh Kapoor, department of radiotherapy at PGIMER, Chandigarh, said, “Women are subjected to more medical attention in their lifespan as compared to men. From antenatal checkup, menopause problems and menstrual disorder, women get investigated and, by default, screened for cancer. Therefore, cancers are picked up at an earlier stage and mortality is less.” He said most national policies for screening are directed more towards cancers that hit women such as breast cancer and cervix cancer, as they are non-invasive. “Also, men have prolonged exposure to lifestyle risk factors that cause cancer such as tobacco use, substance abuse and alcohol consumption,” Dr Kapoor added.

Why is cancer mortality higher among men? Doctors say this could be because the lung and oral cavity cancers that are the leading cancers among men are usually detected at a late stage. “95% of these cancers are due to tobacco consumption, and 40% of all cancers in India are due to tobacco abuse. Mortality is high as it is hard to detect these cancers. We come across patients during an advanced stage of the disease, so they are tough to treat,” said Dr Ravi Mehrotra, director of ICMR-affiliated National Institute of Cancer Prevention and Research.

The World Cancer Report estimates that of the 1,589,925 lung cancer deaths worldwide in 2012, 30.90% were of women and 69.10% of men. “Breast cancer is detected early, particularly in the western world. There is no screening of cancers in men,” said Dr Rajesh Dixit, professor of epidemiology at the Centre for Cancer Epidemiology, Tata Memorial Centre, Mumbai. As per ICMR’s latest cancer registry, breast cancer, with an estimated 1.5 lakh (over 10% of all cancers) new cases during 2016, is the number one cancer.

Not just lifestyle, geography too plays crucial role in mapping of cancer incidences

cancer gfx

Over two decades back, doctors at Tata Memorial Hospital, Mumbai, noticed that most gall bladder cancer patients were from the Gangetic belt states of Bihar, Uttar Pradesh or West Bengal. This led to a series of studies that found high concentration of heavy metals in the soil and ground water in this belt — a likely factor for high incidence of gall bladder cancer.
It is now well known that the incidence of gall bladder cancer is highest in the country’s eastern side while south India registers the lowest.

Environment and lifestyle are among the leading risks. The incidence of lung cancer is registering a rise in metros, be it Bengaluru or Delhi. Women in urban India are more likely to get breast cancer than those in rural areas.

The Indian government’s Million Death Study released in 2012 for the first time showed that that the area an Indian lives in, his economic and educational status and religion contribute to the malady’s outcome. A youngster from India’s northeast is four times more likely to develop and succumb to cancer than one from Bihar.

“There is growing evidence that environment and lifestyle can cause cancer in younger people as well,” said former director-general of ICMR, Dr Vishwa Mohan Katoch. “While some cancers are common, others are specific to a region,” he said, adding that in the Gangetic plains the risk of gall bladder cancer is very high due to polluted water, sediments in water and high consumption of animal protein and fish.

Every day, 1,500 people die of cancer in India, making it the second most common cause of death in India after cardiovascular disease. And nearly 2,000 new cancer cases are detected in the country daily, according to National Institute of Cancer Prevention and Research. Projections put the number of new cases by 2020 at 17.3 lakh.

In eastern India, rise in tobacco use has led to an increase in lung cancer among men, and rapid changes in food habits have made women more vulnerable to breast cancer, said Kolkata-based oncologist Gautam Mukhopadhyay.
 Common cancers in the north-east are oesophagus, stomach and hypopharynx. Registries in the north-east have also recorded the country’s highest incidence of nasopharynx and gall bladder in Nagaland and Kamrup in Assam.
In Bengaluru and Chennai more than a quarter of the total number of cancers in women are of the breast. Bengaluru-based Dr PP Bapsy said mass screening is most important to detect cancer early. “We need low cost, accessible treatment,” Dr Bapsy said.

Most oncologists insist that lifestyle changes will by itself bring down incidence. “By some magic, if everyone stopped using tobacco in India, we will have at 50% lesser cancer cases,” said Dr Rakesh Jalali, medical director of Apollo Proton Cancer Centre.

India’s cancer cases far lower than those in the West, yet death rate higher

Image result for India’s cancer cases far lower than those in the West, yet death rate higher

India’s cancer graphs tell two distinct stories. The first holds out hope as India’s cancer incidence is far lower than developed nations such as Denmark and the US. If cancer strikes over 300 out of every 100,000 population in Denmark, the corresponding number in India hovers around 80. But the second Indian cancer story is worrisome: cancer manages to get the upper hand in almost 70% of cases in India. A study in medical journal, The Lancet, in 2014 indicated only 30% of India’s cancer patients survive for over five years.
So while India has lower cancer rates than many other countries, it has a high death rate. Check the World Health Organisation’s Globocan 2012 report’s analysis for breast cancer: only 1 out every 5 or 6 women newly diagnosed with breast cancer died in the US, but corresponding figures in India stood at 1out of every 2 patients.

Experts said early detection could go a long way in reducing the high death rate caused due to illiteracy, fear and taboos. “In India, almost 50% of all cancers are seen in late stages. This is the reason our death rate is higher than western countries,” said senior medical oncologist Shona Nag.

Maximum cancer patients succumb to lung, head and neck and breast cancers. “We lose almost 80% of all patients detected with lung cancer. The death rate due to breast cancer world over is 20%, but we lose over 50% of our breast cancer patients,” Nag said.

Almost 80% of cervical cancer patients are diagnosed in stage 3-4 in India, but the West has almost eradicated this cancer due to regular pap smear tests. Given India’s population, it is impossible to scan everybody. “Self-breast exams and clinical exams involving community workers or ancillary health professionals are hence crucial,” she added.

Lack of awareness is the main cause for late detection. “In the western world, the culture is openness and they are more aware. Though we have facilities, we cannot reach out to such a huge population. Almost all cancers are detected at late stage in India mainly because of lack of awareness and social stigma,” said medical oncologist Anantbhushan Ranade.

Cancer surgeon Anupama Mane said, “We have women with 10 cm lumps who come to us late because the lump didn’t hurt or cause pain so they did not think a check was needed.” Moreover, men don’t discuss women’s health. “So a blood stain or excessive bleeding is dismissed and not taken up as cause for worry,” Mane said. Early detection is key to reduce mortality. “It is important to diagnose cancer early because then you have a chance at curing it. The spread and extent of it make it harder to control,” said oncosurgeon Snita Sinukumar. Lack of a dedicated health care system is one of the big reasons for higher deaths. “Just like Aadhar, we need to make it compulsory to invest in one’s own healthcare,” Sinukumar added.

A red alert for women

It is common to think of heart disease as a ‘man’s problem,’ but you could be in for a surprise. The last two decades in India have seen a steady rise in incidences of heart attack among women, especially those in the reproductive age.

A recent study in the United Kingdom published in Heart, an international peer-reviewed cardiology journal, has shown that women who started menstruating at age 11 or earlier, or entered menopause before 47 had a higher risk of heart disease and stroke. The findings of the team, led by Sanne A.E. Peters a research fellow at the George Institute for Global Health, University of Oxford, suggest that women who have premature reproductive cycles or a history of adverse events should get themselves checked for heart problems.

While there are no studies of a similar kind in India, cardiologists say a low level of oestrogen — on account of changing lifestyle and other co-morbid conditions — is among the key reasons why younger women develop cardiovascular disease (CVD).

Indian survey

In 2013, a survey conducted by a team of senior doctors, titled “Visualising the Extent of Heart Disease in Indian Women” (VEDNA), mapped the trends of cardiovascular diseases among women based on interviews with 577 cardiologists from across the country. They found that 54% of doctors had observed a 16%-20% rise in CVDs among women since 2009. An estimated 65% of the doctors surveyed also showed that they had found insufficient oestrogen to be one of the main causes for younger women developing heart diseases.

Dr. C.N. Manjunath, Director, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, who was part of the survey, says, “The most worrying factor is that it is affecting more women in the reproductive age group now, unlike in the past when women got it mostly after menopause.”

This, along with risk factors such as a higher prevalence of diabetes, obesity and related ailments and physical inactivity, have worsened the problem, he adds.

Another study at the institute last November, which involved 750 patients below the age of 40 with premature coronary heart disease, found that 16% of them were women.

“At least three of the women patients (two were aged 25 and one was 26) did not have any conventional risk factors, indirectly indicating that low levels of oestrogen could be the cause,” says Dr. Manjunath.

Dr. K.K. Aggarwal, President of the Heart Care Foundation of India and immediate past national president of Indian Medical Association says what is worrying is that women exhibit atypical symptoms that delay diagnosis.

“The warning signs of this disease are different from those seen in men. For example, women do not have the characteristic chest pain but may have a jaw pain. This is one of the reasons why women do not get diagnosed in time, thus exacerbating the condition further,” he says.

Traditionally, heart disease has never been thought to be a woman’s disease. Thus, when a woman complains of symptoms such as breathlessness, it is very often mistaken to be some other problem, he adds.

“The classic pattern of angina with pain on the left side of the chest may be absent in women. They are more likely to have atypical angina, in which they could experience discomfort in the shoulders, back, and neck. Apart from this, shortness of breath is often the first and only presenting symptom. All of this can make the diagnosis tricky,” Dr. Aggarwal explains.

Risk factors

The risk factors for heart disease in women include the regular ones such as smoking, high cholesterol, high blood pressure, lack of physical activity, and an unhealthy diet. There are also some specific ones which include the use of birth control and other hormone pills.

Doctors say the need of the hour is to create awareness about the fact that heart diseases can affect anyone irrespective of age or gender. Only early and corrective lifestyle changes and preventive measures can help in combating the risk factors and avoiding heart diseases. Women in particular need to be aware of the signs and symptoms and take adequate care of their health.

Govt needs to increase healthcare outlay in budget: Report

Govt needs to increase healthcare outlay in budget: Report

Public sector accounts for only 30 per cent of the total healthcare expenditure in the country and investment in building and maintaining public health infrastructure needs priority in the forthcoming budget for FY 2018-19, a report says.

Public sector investment on healthcare accounts for less than 1.5 per cent of GDP, which is one of the lowest globally, and the government intends to increase the expenditure to 2.5 per cent of GDP by 2025.

The outlay on healthcare increased by a healthy 28 per cent in the last budget and the allocation is likely to see a similar increase in the forthcoming budget as well, according to a report by rating agency Icra.

In line with National Health Policy (NHP) 2017, the expenditure is expected to be directed towards setting up of new hospitals to increase the number of beds in the country, and for transformation of existing district and town level health centres to provide better healthcare facilities across geographies while using the existing infrastructure.

Public sector accounts for only 30 per cent of the total healthcare expenditure in the country, as compared to 42-58 per cent in Brazil, 58 per cent in China, 52 per cent in Russia, 50 per cent in South Africa, 48 per cent in USA and 83 per cent in UK as per the WHO reports.

ICRA believes that investing in building and maintaining public health infrastructure should be given priority in the budget as these facilities are lagging and vast majority of the population has to bear their own healthcare costs due to low penetration of health insurance.

Besides, along with the setting up of new hospitals, the report recommends setting up of medical colleges and nursing academies to address the shortage of beds and skilled medical professionals in the country, it said.

The budget is also likely to increase the allocation for addressing the increasing burden of non-communicable diseases (NCDs) such as diabetes, cardiovascular diseases, hypertension and to increase the outlay for providing free drugs, diagnostics and emergency services across all public hospitals, in line with NHP 2017.

Icra suggested that new infrastructure developed through incentives can also be utilised for catering to the growing medical tourism in the country, which is expected to continue to grow by 20 per cent over the next five years generating export revenues and employment.

New medical bill will affect quality of healthcare in Karnataka: Doctors

Image result for karnataka

The Karnataka Private Medical Establishments (Amendment) Bill 2017, which proposes to regulate private medical services by fixing prices for services and prescribing punishment for doctors in case of irregularities in pricing-related matters, has put the Karnataka chapter of Indian Medical Association (IMA) and the state government at loggerheads. The bill is scheduled to be tabled in the assembly next week.Private doctors have termed the bill draconian and are protesting three clauses – setting up of a grievance redressal cell as a supervisory body with powers to act against doctors up to the extent of jailing them, exclusion of government hospitals and price-capping on treatment in private hospitals.

The IMA and private practitioners want the government to consider recommendations made by the committee headed by former Chief Justice of Karnataka high court Vikramajit Sen. “Justice Sen had said there cannot be two sets of rules for private and government hospitals. However, this bill leaves government hospitals out of the ambit of legislation meant to ensure efficient and timely treatment for patients and curb malpractices,” said Rajshekar S Bellary, president, IMA Karnataka.

The government must bring all government-run hospitals under the ambit of KPME Act to ensure quality healthcare, said Madan S Gaekwad, president of the Private Hospitals and Nursing Homes Association (PHANA). “We don’t want any price control by the government. The patient charter should be included as a guideline for all doctors and not as a law,” he added.

According to H Nagendra Swamy, senior president at Manipal Hospitals, none of the proposals made by the Justice Vikramajit Sen Committee has been considered.”Following our protest in June, a joint select committee was formed. However, the government still came up with a bill that will neither benefit patients nor any other stakeholder,” he said.

“It is necessary that we take this extreme step (protest) as our survival is at stake,” a statement by the Surgeons’ Association said.

Govt begins ranking district hospitals to improve services

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Aiming to foster competition and nudge government hospitals to improve health services, Niti Aayog, along with the health ministry, has started ranking district hospitals on the basis of their performance on health indicators.

There are around 734 district hospitals across the country which provide secondary healthcare facilities to people. In addition, around 300 other hospitals, such as women’s hospitals at the district level, will also be rated. The decision to track the performance of district hospitals came as the Modi dispensation believed that despite large amounts pf money being allocated to these hospitals which have a critical role in providing healthcare, there was no comprehensive system to assess their performance based on measurable health outcomes.

The rating will create an environment to nudge hospitals towards improvement. The entire exercise will also provide an evidence base and help identify hospitals that need to be incentivised.

The indicators on which performance will be measured include OPD per doctor, number of laboratory tests per technician, stock out rate of essential drugs, bed occupancy rate, C-section rate, blood bank replacement rate and post-surgical infection rate. Number of functional hospital beds per 1,00,000 population, ratio of doctors, nurses and paramedical staff are other factors which will be taken into account while accessing the performance of district hospitals.

The index will also capture, for the first time, feedback from patients as high weightage has been assigned for patient satisfaction score.