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BSc (COMMUNITY HEALTH): PANACEA FOR RURAL HEALTH?

I came across an article by Dr Neeraj Nagpal ,(Convenor, Medicos Legal Action Group
Ex-President, IMA Chandigarh) on BSc Community Health.

I found it very thought provoking and informative, so sharing it in this page for you.

Dr Neeraj Nagpal

There is no dispute on the fact that rural healthcare in India is abysmal and drastic steps are needed to rectify the same. There is also no doubt that this involves a multipronged approach. A community health worker (Anganwadi worker, multipurpose health worker), a nurse practitioner, a pharmacist and a doctor available along with the infrastructure, medicine supply with improved connectivity (roads), electricity, safe water supply are all prerequisites to improved rural healthcare.

At different times in different states different schemes have been launched whereby the community health workers named differently in different states form the first line of community healthcare. Never however has an attempt been made to replace a doctor with a community health worker as is being done now under the garb of BSc (Community Health).

The fact of the matter being that though on paper we have rural dispensaries in every nook and corner of the state they fail to provide healthcare to our rural populace. The reasons are not far to seek. The buildings are in shambles with no resemblance of a hygienic healthcare facility as required under the Clinical Establishments Act. Rickety chairs and tables serve as infrastructure and even these are missing or broken. Electricity is mostly not available due to power cuts. There are no facilities of generator (how vaccination programmes are run without the cold chain is shrouded in mystery). Without proper autoclaving no procedures or surgeries are feasible in these dispensaries. Water supply even in dispensaries is from a hand pump if at all. Few of the dispensaries are approachable only by horse drawn vehicles, as buses do not travel to them.

Given the futile exercise of marking attendance in such dispensaries it is surprising that employees whether doctors, nurses or pharmacists come to work at all. This is a vicious cycle. Patients stop coming to these dispensaries as on previous visits their need at the time was not fulfilled whether because the doctor was absent, or medicines not available, or the procedure could not be done due to power cut etc. They then approach quacks, who thrive in this environment, for their daily medical needs. Also, disease does not seek to afflict a person only during office hours. To tackle patients in off duty hours appropriate residential arrangements for staff are sorely lacking.

In the Supreme Court, shortage of doctors in the country has been touted as a major problem. Government has shown statistics that India has 1 doctor for 1700 population. What has been glossed over in these statistics is that this figure is taken from the Medical Council of India (MCI), which concerns only with MBBS doctors. Are the doctors from the alternate system of medicine not doctors? BAMS (Bachelor of Ayurveda, Medicine and Surgery), BHMS (Bachelor of Homoeopathic Medicine and Surgery) and BUMS (Bachelor of Unani Medicine and Surgery) graduates all have four-and-half-years study of their systems of medicine including basic subjects like anatomy and physiology. Their number is any day more than that of MBBS doctors. If we include them in the statistics the ratio of doctor to patient in the country will be much less than 1 per 1000 recommended by the World Health Organization (WHO).

Either we consider them doctors or we do not consider them doctors for the statistical purposes. Even these doctors with 4-5 years of graduate study are labelled as quacks by the honourable Supreme Court if they dabble in modern medicine (Poonam Verma vs Dr Ashwin Patel). How then can a truncated study duration of 3 years equip someone with knowledge sufficient to practice modern medicine.

There is also the fact that for government health services in nearly all states there are many more MBBS applicants than seats available. All doctors in Government service have to do mandatory 3-5 years rural service as per different state norms. Punjab Govt managed to rope in about 1200 MBBS doctors to serve in rural areas on adhoc basis on consolidated salary of Rs 30,000 out of which they were also supposed to pay salary of two employees. These doctors were not given any service benefits and were appointed under the Zila Parishads. “Shortage of doctors” or that “MBBS doctors do not work in villages” is then a myth created by the powers that be to further their own ends. With unemployment and underemployment existent among MBBS doctors where is the need for a special cadre of rural doctors?

The reason why the political class is keen on BSc (Community Health) and of permitting them to practice modern medicine is to be seen in a different context.
Medical education has shifted from government medical colleges to private medical colleges in large numbers. Most private medical colleges are run by politicians or their relatives and henchmen. Lot of money is involved in medical education with an MD seat being sold for Rs 2 crore; even BSc (Nursing) and BAMS courses are fetching good premiums for these colleges. This puts a lot of pressure on the management of these colleges (politicians) to get more seats and medical colleges approved from the MCI. Resistance to the same has cost the MCI dearly. It has been disbanded; adhocism prevails in appointment and removal of the Board of Governors. The entire sequence bears a close scrutiny by an independent agency preferably the Central Bureau of Investigation (CBI).
If one (MCI) member Dr Ketan Desai was corrupt (not convicted) how does it justify the dissolution of an autonomous body with elected members? By the same argument the corruption of Mr Raja and Mr Kalmadi should lead to the dissolution of the parliament.

BSc (Community Health) is simply another way of selling medical seats without interference by the MCI. This would be possible only if the powers that be are able to get some legal sanctity to the BSc CH graduates practicing modern medicine. It was rightly pointed out by professional medical associations and legal luminaries that involvement of the MCI will need changes to be made in the Indian Medical Council Act. Govt has now cornered the National Board of Examination (NBE), a body which so far concerned with governing postgraduate medical courses Diplomate of National Board (recognized postgraduate teaching qualification even in medical colleges), to now award alternate of MBBS i.e. BSc (Community Health) degree.

Doing something new which would be marketable even if it were recycled goods has been the cornerstone of political gimmicks perpetrated in our country by our esteemed lawmakers. General elections being near there is a political compulsion for the government to have in its agenda schemes, which can be touted to voters as accomplishments. That it maybe illegal or harmful for the nation’s health is inconsequential to this breed of politicians and they are willing to tweak the law to meet their desired goals.

There is no magic wand to improve healthcare in rural areas. Posting a doctor in a rural dispensary of today with his hands tied for want of infrastructure, medicines and equipment is akin to hanging a photograph of a doctor in the dispensary. It serves no purpose except on paper. Because qualified doctors are demanding these facilities it is now prudent to replace them with hopefully a more pliable army of qualified quacks in the form of BSc (Community Health) graduates (Rural Doctors). Plus there is money to be made in starting these new courses for rural doctors.

Dr Neeraj Nagpal
Convenor, Medicos Legal Action Group
Ex-President, IMA Chandigarh                                             

SOME EPIDEMIOLOGICAL TERMS

Incidence is a number equal to the fraction of population that contracts a given disease during a given period of time. In other words, Incidence is the rate at which new cases of diseases occur within a population.

Prevalence of a disease is the fraction of the population that currently (or at some other particular time) has a given disease.

A sporadic disease is one that occurs only occasionally in a population (i.e., prevalence is zero).

An endemic disease is one that is always present in a population (i.e., never zero prevalence).

An epidemic disease is a disease that many people acquire over a short period (i.e., increasing incidence).

A pandemic disease is a world-wide epidemic disease (i.e., high world-wide incidence).

Common source outbreaks are some diseases arise from a single definable source, such as a common water supply. They are not propagated from individual-to-individual (e.g., person-to-person). Yet the disease continues to be endemic and perhaps epidemic as a consequence of contact with some typically geographically well-defined disease reservoir

Propagated epidemics are in contract, which are diseases spread not from some common, geographically well defined disease reservoir, but instead by individual-to-individual (e.g., person-to-person) contact.

INTEGRATING HEALTH CARE PROGRAMS FOR SUSTAINABILITY: PERSPECTIVE FOR HIV PROGRAM

National AIDS control organization was established under MoHFW in 1992 to address the program of HIV/AIDS.

The focus of NACP 1 (1992-1999): was mainly on HIV surveillance and related activities, screening of blood and blood products, and public education campaigns.

NACP 2 (1999 – 2006): focus shifted to raise awareness and towards interventions focusing on promoting behavior change. ART was rolled out during this phase.

NACP 3 (2007- 2012): Focus was to halt and reverse the epidemic by 2012, by focusing on prevention efforts & integration of care, support and treatment strategies.

NACP 4 is currently being formulated with the objective to accelerate the process of reversal of HIV and further respond to epidemic through a well define integration process with increase in public-private partnerships.

Vertical Approach	Integrated Approach
Otherwise known as ‘stand – alone’ or parallel program. Interventions are provided through a separate administration, budget and operational integration with wider health system.	There is no separate administration or budget and interventions delivered through the existing healthcare facilities that provide routine or general health care services. Belief is to focus on the priorities of local people and tend to bring services together with minimum resource wastage. This create a single system where resources are shared and duplication is avoided

Basic questions to be asked while taking a major policy decision like planning for integrating with general health system are

Will integration add value? Is it the right time? Is it possible with existing infrastructure/human resource? Will it strengthen the health system? Is there a clear plan and clear outcome monitoring system?

As per WHO, 5 Basic competencies that apply to staffs working for patients with chronic diseases are

1. Patient-centered care

2. Partnering

3. Quality improvement

4. Information and communication technology and

5. Public health perspective.

Tanwar et.al (2013) researched the expert’s opinion on this regard and found that policies and policy makers were rigid with little flexibility for regional requirements and their felt need is to have flexibility guidelines. Experts felt that involvement of hospital superintendents or senior doctors in monitoring and day to day functioning of HIV care & treatment centres can make change in the attitudes of staff at the general hospital and improve ownership. A District AIDS officer from a general health system can play important role of coordinating with various HIV-related activities in a particular district and plan them in collaboration with the general health activities.

But concern is, integration will require utilization of multi-skilled workers and transfer duties from specialists to non specialists.

Keeping in mind, Experts felt that integration with general health system should happen in selected areas like department of PPTCT, STI, and ICTC. This integration should happen to make HIV-program sustainable leading to expansion of program activities and increased capacity of healthcare workers to meet the people’s needs. HIV programs should organize trainings like ‘pre-service’ followed by ‘In-service’  at staff level for interns, PG students and doctors working in private and government sector.

Link ART system could be a major step toward integration of HIV treatment with general system if closely monitored.

Vertical programs are justified where the general health systems are weak, fragile states or places where integration is not possible. Vertical programs should be time limited and integrated with general system to avoid spill over. Disease specific vertical program and general health system are working for the betterment of health of the people, and these programs would become more and far effective if they work in collaboration.

A Compilation of Central Government Orders for the Differently Abled Persons – (June 2013)

1. A Compliation of Central Government Orders for Differently Abled Persons

2. Policies and Schemes of Central and State Governments for People with Disabilities

APPROACHES OF ICDS AND NRHM IN ADDRESSING SEVERE ACUTE MALNUTRITION - A NEED FOR COHERENCE

Malnutrition is the term which is seen in almost all the newspapers and it is our countries attention too. In order to address malnutrition issue, there are 2 primary agencies i.e. NRHM and ICDS. However the management of severe malnutrition has huge gaps in the public policy of our country.

There is an inconsistency between the approaches of ICDS & NRHM leading to lack of clarity on the criteria for screening and identification, treatment protocols and the role of difference agencies for rehabilitation and follow up. Focus of intervention under NRHM is primarily on treatment of severe acute malnutrition (SAM) through nutrition rehabilitation centers (NRCs).

World Health Organization (WHO) definition of SAM is

•          Very low weight for height (Below -3Z score of median WHO standards)
•          Visible severe wasting
•          Presence of nutrition edema

Statistics at glance

         SAM children have a mortality risk higher than normally nourished children. The under 5 morality rate for SAM ranges from 30% - 50%. National Family Health Survey (NFHS) – 3 reveales that 6.4% of Indian children Under 5 years have weight for height scores less than -3SD which means at given point of time we have 8 million children who are SAM.

Role of ICDS

           Anganwadi worker’s (AWWs) are responsible for the regular growth monitoring of children Under 6 years of age, they identify the children for malnourishment and provide follow up care including referrals. AWW are suppose to refer children who are severely underweight as per WHO standards of Weight for Age.

Management of Malnutrition at NRC

           Currently there are no central guidelines available for the management of SAM. Under NRHM different states have now set up NRCs and the broad programmatic interventions are more or less similar.

At NRC, the child is screened for SAM by

1.     Weight for height/length
2.    Mid upper arm circumference (MUAC)
3.   Presence of edema

What happens at NRC is the children who are referred to the NRC by the AWW based on the weight for age are screened for SAM. Children who fit the criteria are only admitted and rest all sent back.

Data set from NFHS and Integrated Nutrition Health Program (INHP) reveals that this approach has 2 errors

• It misses identifying a substantial proportion of SAM cases
•  The numbers of referred cases by AWW are not the actual SAM cases. By this approach the recent acute weight loss are not referred because they are not yet below the cut-off to actually qualify as severe underweight.

Simple relying on weight for age measure would leave around 36%-44% of SAM children because they fall under moderate or normal weight for age. Thus screening for severely underweight done at Anganwadi centre (AWC) is simply not a sensitive test for identifying SAM

And, among the referred children to NRC (58% - 75%) are not SAM to fit the entry criteria for NRC’s admission. Thus, the specificity of severe underweight cut-off scores test in identifying SAM cases is very poor.

Gap in the entry criteria

·                          There is lack of consistency between the referral criteria of AWW (weight for age) and the entry criteria of NRC. Many children are needlessly referred to and sent back. This could create a poor impression on the AWW at the village level demotivating her as well as parents of the children.

·         Entry criteria also does not include appetite test. Children who has appetite can be treated at community level.

Gap in exit criteria and follow up

·                        As per WHO and Indian Association of Pediatrics (IAP) guidelines, a child are discharged from NRC when weight for height/length is more than -1 SD. SAM is treated institutional based with therapeutic foods of F-100 formula.

·        Children who are admitted in NRC are kept for 14 days for nutritional rehabilitation, medical treatment and nutritional counseling unless physician extends the stay.

·         Approximately Rs.50/day is sent on the SAM child for food and drugs + Rs. 6/day worth food from AWC after discharge. 

·         Due to non availability of community based management (CBM) this whole exercise of treatment goes in Vain. International experiences say that NRC has limited role for this reason making it just a one side link of this ‘conveyor belt’ approach.

Stunting an issue to be addressed

·         Stunting is an indicator of long neglected inadequate growth. A focus of SAM has no direct impact on stunting but a focus on stunting will help in preventing SAM by reducing low birth weight.

·         Also instead of waiting for weight for age to reach the cut-off of NRC, it’s better to refer cases based on percentage of weight loss.

Conclusion and Recommendations

        Ready to use therapeutic drugs (RUTFs) can be used in the community as an effective SAM management. As it is estimated from international experiences that 80% SAM can be treated at community level, freeing the scare resources to treat for more intensive sick SAM children at the NRC.

• AWW to asses child on weight for height/length and train her to identify & screen children who are SAM affected for entry of NRC.
•  AWW to be trained on conducting appetite test for SAM for proper case referrals.
• CBM of SAM children can be effectively done by ICDS with their huge network of AWC. A strategy to manage them at community level would be to combine providing 
• ü  Therapeutic foods                                                    presently done at NRC 
  ü  Nutrition counseling                                                presently done at NRC 
  ü  Regular growth monitoring and                              presently done at AWC 
  ü  Community mobilization                                         presently done at AWC 
  ü  Facilitate intensive breast feeding practices            presently done at AWC

Thus there is an urgent need to bring the ICDS of malnutrition in coherence NRC of malnutrition.