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.

M-HEALTH: ENGINEERING THE HEALTH SYSTEMS

          The unprecedented spread of mobile technologies as well as advancements in their innovative application to address health priorities has evolved into a new field of e-Health, known as m-Health (WHO). According to the International Telecommunication Union there are now close to 5 billion mobile phone subscriptions in the world, with over 85% of the world’s population now covered by a commercial wireless signal. Recent advances in mobile technology have made it practical to automate some aspects of health care delivery in various health care settings.

        Evidence suggests mobile technology presents promising opportunities to improve the range and quality of services provided by community health workers. Various categories of mobile health technology (m-Health services) applications include health call centers, emergency toll-free telephone services, managing emergencies, mobile telemedicine, appointment reminders, community mobilization and health promotion, treatment compliance, mobile patient records, information access, patient monitoring, health surveys and data collection, surveillance, health awareness raising, and decision support systems. Therefore, mobile health technology (MHT) can be applied to develop any of these systems mentioned above.

         Mobile phones can simply be used to encourage patients to take their medication. Text short message service (SMS) messages, or other reminders like automatic call-backs can be used to communicate with patients, who are otherwise required to visit a TB clinic or to be monitored by a visiting health worker. Application features could include reminders, the app can remind patients to take their medication on time while being observed from an observer using the same application. Through video/telemedicine calling service, the observer will be able to monitor/diagnose his/her patients while taking their medication after receiving reminders and inquiring service in which patients can inquire about anything related to their case through the application.

        With the use of mobile phones, electronic data capture can potentially make it easier for health care personnel to collect and manage large volumes of data and shortens the time needed for analysis. This process streamlines the reporting of patient data to their respective national TB/HIV-AIDS/Cancer or many other programs. It will include streamlining of the reporting system in laboratories – connecting lab technicians, lab directors, physicians, field workers and, ultimately, patients – via text (SMS) and mobile or web interfaces. Projects can also integrate Global Positioning System (GPS) enabled phones to monitor the location of where field workers enter patient data, ensuring that fraudulent data is not entered from the field workers’ homes.

       In addition, GPS allows real-time mapping of disease outbreaks to accelerate the response time among governments and health workers alike.

       Therefore, we can say that mHealth tools enable CHWs to provide health services far from the clinical setting, in remote areas, and among hard to reach communities. Under this decentralized approach to service provision, health care can become more accessible to patients due to reduced time and expense of travel and due to the ability to seek out patients who are the targets of stigma and discrimination. These tools may help CHWs overcome many of the barriers they face in the field, including balancing multiple priorities, lacking appropriate tools to provide services and collect data, and limited access to training and supervision. As CHWs are generally the most frequent connectors of communities to formal health systems, the use of mobile tools to enhance health system performance requires further evidences. Assuring a successful roll-out of a mobile health application does not include only building the application. A comprehensive ‘cost effective analysis’ and ‘health impact assessment’ also needs to be done which should be done along with the groups of stakeholders who will determine the success or failure of the innovative technology.

Dr. Shikha Gupta (O.Th.), MHA (TISS)

THIRD PARTY ADMINISTRATOR: A MAJOR STAKEHOLDER OF THE HEALTH INSURANCE SEGMENT

              

           We have recently been hearing a lot about the health insurance industry in India- its growth and its dynamics. The insurers, healthcare providers, the policyholders and the third party administrators (TPAs) are the major stakeholders of this booming industry. Amidst the various headlines pertaining to this industry, we have also heard about accusations being made by the insurers about the inefficiencies introduced into the system due to the TPAs. Currently the four public sector units (PSUs) viz. National Insurance Company, The New India Assurance Co. Ltd., United India Insurance Co. Ltd. and Oriental insurance Co. Ltd. are the dominant players of the health insurance industry in India that accounted for almost 60% of the non-life insurance segment in 2011-12. After IRDA Act 1999, the private companies have been allowed to enter into the Indian insurance market and since then they have been steadily eating into the market share of these PSUs by the virtue of their aggressive marketing and impeccable customer service. However, the PSUs have not lost their niche and thankfully a lot of its credit goes to the TPAs.

The concept of TPAs was in fact the brainchild of the PSUs which were introduced in order to provide cashless services to the policyholders for multiple insurers. Hence, promoting cost efficiency by pooling the administrative costs in the then relatively small market. Since then the health insurance segment has continued to surge ahead registering an annual growth rate of 18.44% in 2011-2012 accounting for around 22% of the total non-life insurance segment as per the IRDA Annual Report 2011-12. And with that the TPA industry has flourished and grown considerably matured with the expertise to deal with both healthcare providers and the policyholders while being answerable to the insurers. There are as many as 16 TPAs licensed by the IRDA catering to both the PSUs and the private insurers. However, only a few of them are currently noteworthy given their vast experience and credibility. These include MD India Healthcare (TPA) Services Private Ltd., Medi Assist India TPA Private Ltd., Paramount Health Services (TPA) Private Ltd., Raksha TPA Private Ltd., E Meditek (TPA) Services Ltd. and TTK Healthcare TPA Private Ltd. to name a few.

Recently a few of the private sector insurers have resorted to developing their own in-house TPAs and this trend continues with more of the private insurers adopting this practice given the prospects of the expanding health portfolio. The urge for having in-house claim processing units rather than the TPAs comes from the fact that it would provide them better control over their processes and enable them to generate valuable data which can be utilized effectively to reduce the incurred claim ratio through various mechanisms and thus rescue this bleeding health portfolio.

Simply put the growth and sustainability of any insurer is based on three factors the number of new policies underwritten, the renewal of existing policies and the incurred claim ratio each year. For a customer who is the policyholder or the insured in this case, the prompt and hassle free services especially when they are undergoing the emotional trauma due to illness or hospitalizations is of utmost importance. This ensures customer satisfaction which in turn ensures renewal of policies and enables capturing new customers by word of mouth and reputation. An efficient customer relationship management (CRM) team makes all the difference in providing customers satisfaction and retaining clients especially considering that a huge chunk of health insurance business comes from the corporates buying group policies for their employees which makes them extremely demanding customers given the size of their premiums. If the PSUs were to do away with the TPAs, can they ever imagine serving such demanding customers which requires a great deal of professionalism which by the long standing history of any public sector institutions has most often been lacking. PSUs will not only fall short of performing without the TPAs but will also lose their customer base to the private players who at this point have built their capacities and are only waiting for an opportunity for the PSUs to falter.

The incurred claims ratio is a function of the policy terms and conditions and the provider management and control. The underwriting of the policy is exclusively done by the insurers and does not involve the TPAs. Designing policies which provide sufficient coverage to the insured and at the same time do not generate losses for the insurer is typically an art that insurers need to master. Introducing sublimit, capping and co pays into the policies is based on intricate analysis of the claims settled by the TPAs. The required data needs to be recorded and compiled by the TPA on the instructions of the insurers. Most front runners of the TPA industry have built their competency to capture and analyse all such data which can be effectively utilized to decrease the claims ratio by designing better policies.

As for the provider management, unfortunately in India, there is no regulation over the healthcare providers and hence price control is solely market driven. Tariff Rates and Packages are pre-decided by the TPAs by negotiations with network hospitals. Tripartite agreements by the insurers and practices such as investigations for the fraud management are a few mechanisms through which the healthcare providers can be better controlled if not completely regulated. Further the operations of the TPAs are well controlled by the PSUs through frequent audits for quality assurance purposes.

The disappointment of the PSUs has not germinated due to the inefficiency or underperformance of the TPAs but has in fact arisen out of insecurities mounting due to the threat from the private players. If only the PSUs consider for a moment the skills offered by the TPAs and their own capabilities in controlling the operations rather than indulging into the blame game, it might be an eye opener. Presently, the idea of doing away with the TPAs has been pushed to the back burner following the opposition by the TPAs, an industry which is the breadwinner for a huge human resource. But this chapter has not been closed yet. Sooner or later the PSUs will have to take a look at the big picture, which is in the best interest of their own sustainability in the long run.

-Aarati Nadkarni

B.Pharm, MHA (TISS)

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INDIA'S TB CONTROL - WHAT WENT WRONG?

Nowadays we find TB in news everywhere like shortage of drugs, increasing muti-drug and extensive drug resistance (MDR, XDR), making the treatment expensive and cumbersome. Total drug resistance (TDR) is now a death warrant, our popular serological tests for the diagnosis is declared as worse than useless, and a government order for mandatory case notification. In India, private practitioners are legally authorized to treat TB, but without quality check mechanisms often bypassing the prescribed treatment protocol leading to MDR, XDR and TDR. 

Among the developing nations, India pioneering TB control. A national TB control project was launched in 1962. BCG was used a main intervention with the expectancy of protecting against TB. Free TB treatment was included with public-private partnership (PPP). A fatal flaw in the TB control arouse when directly observed treatment short course (DOTS) because popular and PPP was neglected. In 2012, when India celebrated the golden jubilee year of TB control, the World Health Organization (WHO) named India the worst performer among the developing nations. 

India’s TB control pioneers introduced the mass BCG vaccinations in that hope that it would protect against infection by TB bacilli. In 1979, preliminary results of the 15 year long BCG trail showed no protection against TB bacilli infection. But this much debated results were ignored by then TB control leaders. In 1999, the final results confirmed that TB control project had lost the tool of primary prevention. BCG failed to protect against infection by TB bacilli, but protects against infection progressing to the childhood TB. In 2000, Indian Academy of Pediatrics called for major redesign of TB control, with alternative tactics to prevent and treat infection before it caused disease. DOTS saves life from mortality, but failed to control TB. 

TB bacilli spread through air we breathe making everyone at risk of infection. After infection, majority of us remain well, but the bacilli is alive, latent or dormant causing 10 % to develop TB disease sometime in adult life (In India, 15% are infected by 15 years of age; 40-60% by 40 years). Bacilli escapes easily to environment through spitting and coughing when the disease pathology is in lungs (pulmonary TB) making the lung TB a critical link in chain of transmission. This makes young children susceptible to infection causing a serious life threatening disease called childhood TB. Childhood TB is non infectious; so treating it with the universal neonatal BCG vaccination has no role in TB control. 

One way to control TB is by treating everyone with lung TB very early to break the transmission chain. But this is in theory only; a person with lung TB is infective for many weeks and by the time his sputum is tested positive he would have already infected children in contact. So, even if we attempt to treat all the infected we can bring down the infection rate. But, the target is to treat only 70% with DOTS!! And WHO estimates that only half of the lung TB gets DOTS. So, we have a target like this it’s not going to help India in controlling the TB. Moreover without PPP, it’s highly impractical to treat all the patients with protocol.

Our TB control pioneers designed for free treatment in public and private sectors. They designed a district TB treatment model under PPP. Interesting thing is, TB control is a Central government project whereas health care is State subject, so what happened? Private sector grown exponentially and the TB control project failed to address is huge gap. 

There are major factors predisposing the disease like HIV, poverty, nutritional deficiencies and the increasing Diabetes. In 1990, project review confirmed India’s failure to control TB. When WHO declared TB as global emergency in 1993, Revised National TB Control Programme (RNTCP) using DOTS was launched, but it took 13 years it national wide as government saw no TB emergency in India. So, all those fortunate who received DOTS the cure rate was high and the death rate declined. For those who had extra pulmonary TB, sputum test will not be of help in diagnosis and RNTCP is not interested in them as they do not spread TB bacilli. So, the project illustrates an incomplete health and incomplete public health.

In Epidemiology, “Control” is defined term – the disease burden should be reduced to a pre-stated level within a stipulated time period and prove it to be due to intervention and because of “secular trend”. TB should decline without specific interventions as the socio-economic status increases – that is “secular trend”. But what’s the situation is RNTCP has not set control targets in terms of time frame as well as disease burden. So, it’s not measuring secular trend then how can we say it’s a “control” in RNTCP?

The lesson from the other countries teaches us that to detect and treat infected children so that the latent bacilli are killed and children removed from the infected pool so, they will not develop pulmonary TB as an adult which is a feasible move in India. But this requires a redesigned TB control strategy. So for an effective control both interventions, DOTS, and treatment of latent infection must fit together tightly. 

Economically India loses $23.7 billion on an account of uncontrolled TB; to address this we have RNTCP with a budget of only $200 million. TB control is a human right entitlement and investment in socio-economic development. Poverty leads to TB and TB worsens poverty and poverty alleviation require TB control.