INDIA IS BATTING WELL*

Without fanfare, polio may have been defeated in India.  January 12th 2012 marked the anniversary of the last diagnosed case. Polio remains endemic in Afghanistan, Nigeria and Pakistan and so India is at risk of the reintroduction of the virus unless everyone is immunised.

When I visited Delhi four years ago as a member of a group advising the Indian government, a task force of 300,000 immunisers were converging on the north-east quadrant of the country where several hundred residual polio cases occurred each year.  Consuming half the world’s polio vaccine, India, as reported by the World Health Organisation, requires nearly a billion doses of oral polio vaccine annually to vaccinate more than 170 million children under the age of 5. By this means it is possible to achieve what the epidemiologists call, rather infelicitously, herd immunity. If the vast majority of the population or ‘herd’ are immune, even an isolated case will cause no great damage because it cannot spread to non-immune people.

Three other mighty achievements impressed me when I revisited Delhi in February as part of the same advisory panel reviewing progress with improvement in maternal and child survival.  They made up for a dismal season of cricket.

First, while the all-India death rate of mothers in childbirth remains at the tragic level of 212 per 100,000 births, and infant mortality is about 47 per 1000 births, there are marked improvements.  The statistics have limited accuracy, especially when collected in poorer regions, but most states have progressed in the past five years albeit with stasis or even regress in the poorer north-east, such as in Assam and Uttar Pradesh. 

Five years ago, the concept was gaining currency for the deployment of unpaid married women of standing in rural villages to be trained as social health workers. http://mohfw.nic.in/NRHM/asha.htmTheir task was to help young pregnant women seek care for obstetric problems and to encourage them to deliver in or near a health care facility capable of saving life from post-partum haemorrhage.  Each social health worker would receive two weeks of very basic training and be given a mobile phone for calls for help to be received and sent.  No big deal, the phone, as there are about 900 million of them in use in India today compared with next to none in 1996.

Training social health workers in Chittagong

There are now 800,000 of these women at work.  Of course there are the tongue-clickers who wish to see these women paid, trained in primary care and generally promoted, and in time that career pathway may develop.  But for the moment, in a country where 300 million people live in poverty and where the government spends less than 2% of GDP on health, this service is much better than nothing, especially where no medical help is available locally and emergency transport is erratic.  The women gain kudos and some skills they can build on and maternal and infant mortality falls.

Second, and equally amazing, is that serious plans are afoot to provide universal health insurance.  As with Mexico, Thailand, China and Brazil, India is well on the way to government-funded universal cover.  A distinguished medical friend and former colleague, Dr Srinath Reddy, a cardiologist who cares for the heart of the prime minister, was appointed chair of a group to formulate the proposal. Already several of the more affluent states are removing the financial and political barriers to basic and essential care for over one billion Indians would be an astounding achievement.  Read more at http://www.lancet.com/journals/lancet/article/PIIS0140-6736(10)61960-5/abstract

The third astonishing I learned this year is that India now has an electronic data base for more than 100 million of its citizens and is moving rapidly to expand. Finger and retinal prints are computerised.  A person is assigned a 12-digit number, the first official proof that he or she exists. As The New York Times reported, each citizen ‘can use his or her 12-digit identity number, along with a thumbprint, to identify him or herself anywhere in the country. It will allow him or her to gain access to welfare benefits, open a bank account or get a cellphone far from his or her home village, something that is still impossible for many people in India.’ See

http://www.nytimes.com/2011/09/02/world/asia/02india.html?pagewanted=all

A migrant farm worker has fingerprints photographed and peers into an iris scanner in New Delhi in the first effort to officially record each Indian's identity as an individual.

  

Employers looking for cheap labour must now identify their employees thus reducing the likelihood of them claiming for people on their payrolls who do not exist. 

The capacity to link this massive data base through India’s ever-expanding sophisticated ITC network to assess changing health status in the country is exciting.

Mr. Tendulka may have to wait to score his 100th century, but his nation is heading steadily against immense odds towards a very healthy score.

*Previously published in AusMed

A transatlantic review of the NHS at 60

BMJ 2008; 337 doi: 10.1136/bmj.a838 (Published 17 July 2008)

Cite this as: BMJ 2008;337:a838

Author Affiliations

1.     ¹Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138, USA

1.     dberwick@ihi.org

At the NHS Live conference celebrating 60 years of the NHS at the beginning of July, Donald Berwick explained why he admires the UK health system and how it could be even better

Cynics beware, I am romantic about the National Health Service; I love it. All I need to do to rediscover the romance is to look at health care in my own country.

The NHS is one of the astounding human endeavours of modern times. Because you use a nation as the scale and taxation as the funding, the NHS is highly political. It is a stage for the polarising debates of modern social theory: debates between market theorists and social planning; enlightenment science and post-modern sceptics of science; utilitarianism and individualism; the premise that we are all responsible for each other and the premise that we are each responsible for ourselves; those for whom government is a source of hope and those for whom government is hopeless. But, even in these debates, you are unified by your nation’s promise to make health care a human right.

No one in their right mind would expect that to be easy. No wonder that, even at age 60, the NHS seems still immature, adolescent, searching.

You could have chosen an easier route. My nation did. It’s easier in the United States because we do not promise health care as a human right. In America, people ask, “How can health care be a human right? We can’t afford it.” As a result, almost 50 million Americans, one in seven, do not have health insurance. Here, you make it harder for yourselves, because you don’t make that excuse. You cap your healthcare budget, and you make the political and economic choices you need to make to keep affordability within reach. And, you leave no one out.

Full Article

Mr Magoo strikes the NHS

I am old enough to remember cartoons of Mr Magoo, the endearing short-sighted and well-intentioned buffoon who (if it had been possible) would have driven his car over the arch of the Sydney Harbour Bridge rather than use the roadway.  Always his adventures ended with him chortling in mock triumph, “You’ve done it again, Magoo!”

There is a story of an older man driving on the wrong side of a freeway, observed by a news helicopter that transmitted the message to radio and, freakishly, the man’s wife heard it and phoned him. “There’s a person driving down the wrong side of the freeway!” she told him. “That’s true!” he replied, “But there’s more than one of them!”

The British prime minister, Mr David Cameron, ably assisted by his health secretary  Mr Andrew Lansley, are of the Magoo mould. They have proposed legislation radically changing the English (not Welsh, Northern Ireland or Scottish) NHS.

The Bill, which emphasises enhanced privatised competition in the search for efficiency, is now ringing alarm bells everywhere.  Most of the royal colleges are up in arms about it, calling for its rejection in the House of Lords.

“In spite of being offered £60bn of public funds, GPs have voted against the reforms,” writes Philip Stephens in the Financial Times.

The enabling document runs to several hundred pages and many able minds have wilted trying to understand it, including that of the notable commentator Martin McKee from the London School of Hygiene.  On balance, McKee thinks the legislation is a disaster.  The politics are convoluted. Mr Cameron and his minister appear to driving on, despite the flow of oncoming traffic.

More from the 13 February edition of the Financial Times (hardly a Fabian tract):

“Good policy can make for bad politics. Useful reforms often invite short-term unpopularity. Sometimes the dynamics are the other way round. Bad policy courts instant popular acclaim…David Cameron and Nick Clegg have pulled off a rare feat. The coalition government’s National Health Service reforms unite bad policy with worse politics. They foreshadow a costly bureaucratic upheaval and the fragmentation of health provision. They also promise to bury Mr Cameron’s political ambition to prove the Tories can be trusted with the NHS.

When Mr Lansley first unveiled his plan he failed to address a basic question: what was the problem this bureaucratic convulsion was designed to solve? The question still remains unanswered. The health secretary admits he could have achieved 90 per cent of his objectives without any legislation.

During the next few weeks the legislation will suffer a mauling in the House of Lords. Andrew Lansley [the health minister] has been obliged to submit more than 100 amendments to his own bill. Many more changes will be voted through against the health secretary’s wishes. Mr Cameron, though, is battening down the hatches. Downing Street’s calculation is that once the bill becomes law – albeit in emasculated form – the fuss will die down. The prime minister is making a mistake. The real problems will start with implementation.

The NHS needs modernising. A bigger say for clinicians, local accountability and more choice are among the things that would make it more responsive to patients. Britain should be spending more on primary care and less on hospital beds. It needs fewer general hospitals and more centres of specialist excellence. Health and social provision require seamless integration. There is a place for competition.

Some of these elements are found in Mr Lansley’s blueprint. They are buried, though, in the organisational upheaval.”

What a mess, Magoo!  As Hillary Clinton discovered, and Barack Obama rediscovered, it is easy to stir the bees with serious health reform proposals.  Stings are plentiful and the honey is scarce.

Read More at Croakey