Social Justice in Health Sector

Actions of Regulatory Authorities

• National Pharmaceutical Pricing Authority (NPPA) had recently regulated the price of cardiac stents
• NPPA now aims to define an upper limit on orthopaedic implants as they constitute huge margins with many opting to stay away from surgery due its expensive nature for patients and insurers
• Regulation of prices by NPPA can have the negative effect on research activities in areas associated with the medical product
• Price capping will improve affordability for patients and will initiate a competition as demand for implants rise
• Different body parts will have implants priced at different rates and hence arriving at a price cap would be a challenge

Telemedicine Project

• Central government has adopted Odisha’s successful telemedicine project model
• Has enabled to eliminate regional disparity and provides access to treatment for patients particularly in rural and underserved communities
• E-medicine platforms are set up in government run Primary Healthcare Centres(PHCs), community health centres and sub-divisional hospitals
• Telemedicine projects have created employment opportunities for local youth as they are trained in e-health assistance after which they receive loans to start e-health centres in PHCs
• These centres have electronic database storing records of patients for future use

Generic Drug Prices Deflation

• Price reduction improves affordability of medicines for patients
• Effect of increased competition among drug manufacturers to improve efficiency of production and cut prices of their drugs
• Concurrent to decreasing demand for drugs hence can be interpreted as a sign of a society that is becoming more healthy
• Reduces profitability of generic drug manufacturing companies
• Can be discouraging for researchers in the field of drug production

Kala-Azar

• Vector-borne disease that India has not been successful in reduction (only 30% reduction)
• India accounts for half the global burden of Kala-Azar 
• Endemic to Bihar, Jharkhand, U.P and West Bengal
• Parasitic disease transmitted by carrier called Sand Fly
• Being a disease of the poor, adequate sanitation facilities need to be provided to eradicate Kala-Azar
• Use of malarial insecticide DDT was found to be efficient in controlling the disease
• Built up drug resistance to SSb injection meant that fatality rates increased and stopped India’s efforts at eliminating the disease
• NVBDCP has issued directives to ASHA workers for local surveillance in endemic regions to look for patients with visible symptoms of Kala-Azar for identification and early treatment
• A rapid diagnostic test called rK39can and new drugs have aided the fight against Kala-Azar
• PKDL refers to dormant parasite within patients even after cure of the disease that can be a future source for transmission of the disease

Mental Health Sector Challenges

India adopted a National Mental Health policy in 2014 and passed the National Mental health Act in 2017. Although these acts and policies are forward looking and progressive, the challenges in mental health sector remain reflective of the main challenge in the rest of the health sector – financing

• Other than Gujarat and Kerala, no other states have a standalone mental health policy
• Financing of mental health sector is very low in most states resigned to less than 1
• Under National Health Mission, the states are entitled to receive funds for mental health sector under Non-Communicable Diseases- but states have largely refrained from making productive use of such a provision from a centrally sponsored scheme
• Overall lack of state level action plans- defining activities for implementation, budgetary allocation, timelines, lack of monitoring agencies and indicators for gauging outcomes

Mental Healthcare Act, 2017

• Aims to provide mental healthcare and services for persons with mental illness
• Seeks to ensure that mental patients lead a life of dignity without being discriminated against or harassed

Definition of Mental illness

A substantial disorder of thinking, mood, perception and orientation of memory which impairs judgement, behaviour, capacity to recognize reality or ability to meet ordinary demands of life + Mental Conditions associated with alcohol or drug abuse.

It does not recognise mental conditions that are a result of underdevelopment of the brain or sub-normality of intelligence

Features of the Bill

• Ensures that all individuals would have the right to treatment for mental illnesses in hospitals or clinics run or funded by the government
• Guarantees free treatment to BPL and homeless even if they do not possess BPL card
• Recognizes the right of the individual to live with dignity and to not be discriminated against
• Right to confidentiality of the person with respect to mental health, mental healthcare and treatment vetted out to him
• Photograph of the person cannot be released to the media without his consent

Treatment

• The individual can choose his preferred mode of treatment and a nominal representative with the care giver given the option to deviate from the chosen mode of treatment after making an application to Mental Health Board to review/cancel the advance directive.
• A medical practitioner following the advanced directive of the patient shall not be held liable on any unforeseen circumstance
• Electro-convulsion shall not be done without administering anaesthesia or muscle relaxation. It shall strictly not be performed on minors
• Patients shall not be chained and physical restraint may be used only if necessary

Mental Health Authority

The Bill empowers the government to set up Central and State Mental health Authorities. These bodies are responsible for:

• Registration, Supervision and Maintenance of all mental healthcare establishments in the state
• Registering all mental healthcare practitioners
• Standardisation of quality norms for provision of mental health care services
• Making the practitioners aware of the provisions of the Act
• Receive complaints with respect to provision of services and appropriately take action after enquiry
• Advice state governments on matters of mental health

Decriminalizing Suicide

• A person who attempts suicide shall be considered to be a patient suffering from mental illness and shall not face punitive action under IPC
• The state shall in such a case would be liable to provide care and treatment to such a person to reduce the risk of recurrence of attempt to suicide

Drawbacks of the Act

• Definition of Mental Health Professional: The definition of a mental health professional does not include psychotherapists and psychoanalysts
• Lack of clarity on Advance Directive: The Act fails to provide for full list of treatment options which enables individuals to take a decision without information asymmetry. The advance directive is not subject to approval by a competent authority
• Expert Committee Clarity: Neither act or rules define constitution, procedure and terms of reference of the expert committee mandated to review and effective implementation of the Act. Greater transparency is required for such a body.

Swachch Bharat Abhiyan Gramin

• Implementing individual household latrines to improve sanitation and achieve open defication free coverage – IHHL and ODF are pillars of the programme
• Verification and implementation of SBM(G) parameters using geo-tagging and capturing Aadhar details

Swachh Bharat Gramin

Positive Outcomes of the Mission

• Increased toilet construction within households (individual household latrines) and schools and its usage
• It enhanced sanitation facilities for rural people thus reducing vulnerability to health hazards like diarrhoea, encephalitis and other water borne diseases by progressing towards the eventual aim of open defecation free villages
• Emancipated dignity of women within households and also encouraged attendance of girl students in schools

QCI’S Empirical Evidence

• QCI carried out Swachh Survekshan Gramin Survey, 2017 to monitor construction and usage of toilets in households with geo-tagging of households
• QCI survey provided evidence to a dramatic improvement in construction and usage of toilets evidence of a discernible behavioral change among rural people
• The survey found that toilet coverage has doubled and in comparison to 2011 census, households without toilets constitute only 32% down from 69%
• 9 in 10 rural households that have access to toilets are actually using it evidence for the behavioral turnaround

Swachh bharat has created a healthy competition between villages, states, cities and districts with public health and hygiene being the ultimate victor. A palpable change is visible in rural areas as evidence collected by QCI suggests. We should continue the combination of infrastructure readiness with impact measurement and people’s movements to achieve maximum potential of the mission.

The costs of public health crisises far outweigh the cost of fixing it and hence it is imperative that Swachh bharat powers on reducing vulnerabilities by enhancing public health and hygiene.

Possible Question

Swachh Bharat Gramin has been successful in overcoming the behavioral aversion among rural population in using sanitation facilities. Evaluate.