THE HINDU – CURRENT NOTE 19 March
Health policy wants public hospitals certified for quality
•The long awaited National Health Policy (NHP), announced a few days ago, proposes to raise public health expenditure as a percentage of the GDP from the current 1.15% to 2.5% by 2025. The resource allocation to individual States will be linked with their development indicators, absorptive capacity and financial indicators. “There will be higher weightage given to States with poor health indicators and they will receive more resources. The Policy aims to end inequity between States. But at the same time, States will be incentivised to increase public health expenditure,” says Manoj Jhalani, Joint Secretary — Policy, Ministry of Health and Family Welfare.
•While public health expenditure as a percentage of GDP will reach 2.5% only by 2025, many of the goals listed in the Policy have a deadline of 2025, some of them even sooner.
Preventive healthcare
•The policy stresses preventive healthcare by engaging with the private sector to offer healthcare services and drugs that are affordable to all. It wants to reduce out-of-pocket “catastrophic” health expenditure by households by 25% from current levels by 2025. It wants to increase the utilisation of public health facilities by 50% from the current levels by 2025.
•The Centre is working on introducing a health card — an electronic health record of individuals. “The health card will be for retrieving and sharing health data by lower [Primary Health Centre] and higher [secondary and tertiary] healthcare facilities,” says Mr. Jhalani. “It will be launched in six months to one year’s time in those States that show interest to roll it out in certain districts or across the State.”
•Like the Health Ministry’s national strategic plan for tuberculosis elimination 2017-2025 report, the Policy wants to reduce the incidence of new TB cases to reach elimination by 2025. In a similar vein, the policy has set 2017 as the deadline to eliminate kala-azar and lymphatic filariasis in endemic pockets, and 2018 in the case of leprosy. In the case of chronic diseases such as diabetes, cancer and cardiovascular diseases, it envisages a 25% reduction in premature mortality by 2025.
Challenging ambitions
•The policy “aspires” to provide secondary care right at the district level and reduce the number of patients reaching tertiary hospitals. For the first time, there is a mention of public hospitals and facilities being periodically measured and certified for quality.
•But the most ambitious target is providing access to safe water and sanitation by all by 2020. As per the January 2016 Ministry of Drinking Water and Sanitation’s country paper, sanitation coverage was only 48%.
•Other challenging targets set by the Policy include reducing the infant mortality rate to 28 per 1,000 live births by 2019 and under five mortality to 23 per 1,000 live births by 2025. According to the National Family Health Survey 4 (NFHS-4), IMR was 41 in 2015-16; it took 10 years to reduce IMR from 57 to 41.
•As against 62% children 12-23 months old, who were fully immunised in 2015-16 according to the NFHS-4 data, the Policy has set a target of 90% by 2025.
•The long awaited National Health Policy (NHP), announced a few days ago, proposes to raise public health expenditure as a percentage of the GDP from the current 1.15% to 2.5% by 2025. The resource allocation to individual States will be linked with their development indicators, absorptive capacity and financial indicators. “There will be higher weightage given to States with poor health indicators and they will receive more resources. The Policy aims to end inequity between States. But at the same time, States will be incentivised to increase public health expenditure,” says Manoj Jhalani, Joint Secretary — Policy, Ministry of Health and Family Welfare.
•While public health expenditure as a percentage of GDP will reach 2.5% only by 2025, many of the goals listed in the Policy have a deadline of 2025, some of them even sooner.
Preventive healthcare
•The policy stresses preventive healthcare by engaging with the private sector to offer healthcare services and drugs that are affordable to all. It wants to reduce out-of-pocket “catastrophic” health expenditure by households by 25% from current levels by 2025. It wants to increase the utilisation of public health facilities by 50% from the current levels by 2025.
•The Centre is working on introducing a health card — an electronic health record of individuals. “The health card will be for retrieving and sharing health data by lower [Primary Health Centre] and higher [secondary and tertiary] healthcare facilities,” says Mr. Jhalani. “It will be launched in six months to one year’s time in those States that show interest to roll it out in certain districts or across the State.”
•Like the Health Ministry’s national strategic plan for tuberculosis elimination 2017-2025 report, the Policy wants to reduce the incidence of new TB cases to reach elimination by 2025. In a similar vein, the policy has set 2017 as the deadline to eliminate kala-azar and lymphatic filariasis in endemic pockets, and 2018 in the case of leprosy. In the case of chronic diseases such as diabetes, cancer and cardiovascular diseases, it envisages a 25% reduction in premature mortality by 2025.
Challenging ambitions
•The policy “aspires” to provide secondary care right at the district level and reduce the number of patients reaching tertiary hospitals. For the first time, there is a mention of public hospitals and facilities being periodically measured and certified for quality.
•But the most ambitious target is providing access to safe water and sanitation by all by 2020. As per the January 2016 Ministry of Drinking Water and Sanitation’s country paper, sanitation coverage was only 48%.
•Other challenging targets set by the Policy include reducing the infant mortality rate to 28 per 1,000 live births by 2019 and under five mortality to 23 per 1,000 live births by 2025. According to the National Family Health Survey 4 (NFHS-4), IMR was 41 in 2015-16; it took 10 years to reduce IMR from 57 to 41.
•As against 62% children 12-23 months old, who were fully immunised in 2015-16 according to the NFHS-4 data, the Policy has set a target of 90% by 2025.
1.6-billion-year-old fossil find puts life into Indian geologist’s theories
•Fossils piece together the past, and sometimes — as in this case of a retired Indian geologist — can mend a reputation.
•On March 14, news agencies across the world reported the discovery of a group of fossils of a 1.6-billion-year-old red algae, a precursor to plant and animal life, from Chitrakoot in Uttar Pradesh. The findings were reported by a group led by Stefan Bengtson, Emeritus Professor, Swedish Museum of Natural History, in the peer-reviewed journal PLoS Biology.
•What has been eclipsed in the announcement is that one set of these fossils are called Rafatazmia chitrakootensis, named after Rafat Jamal Azmi, a Dehradun-based geologist at the Wadia Institute of Himalayan Geology, who was the first to report these unique fossils over two decades ago.
Textbook knowledge
•Then, however, Dr. Azmi’s findings were widely criticised by the Geological Society of India as the “small-shelly fossils” that he discovered seemed to suggest that animal forms evolved about 1.6 billion years ago, when the textbooks say that shelled creatures are thought to have first evolved at the beginning of the Cambrian “explosion of life”, around 550 million years ago.
•Moreover, Dr. Azmi interpreted the age of those fossils to bolster his long-standing but unorthodox thesis that the Vindhya mountain ranges, from where he sourced the fossils, were much younger than the Himalayas — only about 500-600 million years old.
•These are still matters of debate but Dr. Azmi was denied a promotion for two to three years because of these finds. Speaking to The Hindu over the phone, he said he had to “professionally suffer” for his finds and interpretations. “There were allegations in the media and even among the scientific community then that my findings were a fraud,” he said.
•Professor Bengtson, however, played a crucial role in exonerating Dr. Azmi. He came to Chitrakoot and accompanied the latter to the fossil site to assess his claims independently.
•“I found indeed the same fossils and was thus able to exonerate Dr. Azmi from the accusations of fraud in a Proceedings of the National Academy of Sciences (a top peer-reviewed journal) paper that we published in 2009,” Professor Bengtson told The Hindu in an e-mail.
•“... the filamentous form of red alga that we report is named Rafatazmia, in honour of Dr Azmi.”
•Professor Bengtson’s latest study, however, is based on collecting fossils from the same region in 2011, during an expedition in which Dr. Azmi wasn't involved.
•So far, the oldest known red algae was 1.2 billion years old, but the Rafatazmia predates them by 400 million years and though they are not skeletal animals of the kind Dr. Azmi believes them to be, they may represent an ancient form that could “rewrite the tree of life”, Professor Bengtson was quoted as saying in a news report.
‘Time of visible life’
•“The ‘time of visible life’ seems to have begun much earlier than we thought,” he said.
•The material structurally resembles red algae, embedded in fossil mats of cyanobacteria inside a 1.6-billion-year-old phosphorite, a kind of rock, found in the Chitrakoot region in Uttar Pradesh and Madhya Pradesh.
•“You cannot be a 100% sure about material this ancient, as there is no DNA remaining, but the characters agree quite well with the morphology and structure of red algae,” said Professor Bengtson.
•His group came to their conclusions using X-rays to observe regularly recurring platelets in each cell, which they believe are parts of chloroplasts, the organelles within plant cells where photosynthesis takes place.
Honour for Azmi
•While Dr. Azmi “accepted the honour” of lending his name for the oldest plant-like fossils, he disagrees with Professor Bengtson’s interpretation.
•Rather than being an ancient precursor to plant life, he suggests that it was more likely that they were algae-like organisms with a shell, that were widespread during the Cambrian era.
CCMB researchers control weight and fat gain in animals
•The two chains of clusterin protein, which are normally expressed in several tissues and can be found in several body fluids, when present together tend to lower lipid levels but administration of one of its chains — alpha or beta — results in completely different outcomes. Cells treated with a recombinant beta chain tend to accumulate fat while cells treated with an alpha chain showed no increase in lipid accumulation. Rabbits administered with a recombinant beta chain showed nearly 40% increase in weight while animals given an alpha chain showed no such increase. The results were published in the journal Scientific Reports.
•“Two chains of clusterin when present together tend to decrease body weight but one of the two chains (beta clusterin) increases body weight. This is quite unusual,” says Dr. Ch. Mohan Rao from the Centre for Cellular and Molecular Biology (CCMB), Hyderabad, and the corresponding author of the paper. “So the alpha chain should ideally be compensating for increase in body weight. But the alpha chain does not do that.”
Only lean mass, no fat
•“While excess energy gets accumulated in the form of fat when beta chain was injected into rats, we did not see this in the case of alpha chain. One possibility is that the alpha chain helps in the metabolism of food in such a way that fat does not accumulate,” he says. “Dissected rats that were given alpha chain showed increased levels of lean mass.”
•Apparently, there was no difference in the food intake between animals treated with alpha or beta chain. “It means that weight increase can happen even when there is no increase in food intake. It is the energy management by the body that is important. And alpha chain seems to modulate metabolism in such a way to promote energy expenditure and thus prevent fat accumulation,” he says.
•The effect of alpha and beta chains were tested on myoblast cells, fibroblast and cancer cells. The individual chains were injected into rabbits as well. “In my lab we study the effect of small heat shock protein on health and disease. To raise antibody for clusterin we injected the chains separately into rabbits. One set of rabbits was gaining weight while the other did not. That’s when we investigated the reasons. The animal-house in-charge noticed the change in the animals,” recalls Dr. Rao.
Rats too gained weight
•Though the effects of the two chains were seen in rabbits, the researchers turned to rats as more animals were required for investigating the effect of individual chains on animals.
•“We could see fat accumulation in cells from day two onwards. We observed for 10 days and fat accumulation continued for all the 10 days; we could study cells continuously only for 10 days,” says Suvarsha Rao Matukumalli from CCMB and the first author of the paper. “In the case of animals injected with beta chain, fat accumulation continued for four-five months. The controls and animals given alpha chain did not show weight or fat gain.”
•When cells were administered both the chains simultaneously, the cells did not accumulate fat for two-three days but started thereafter. “Fat accumulation was not as much as when only the beta chain was given but fat accumulation nevertheless continued,” says Ms. Matukumalli. But the effect of both the chains in animals was quite different. “When we introduced both alpha and beta chains together in animals we did not see any weight gain. The animals were very much like the controls,” she says. “Only large-scale, in-depth studies can reveal if alpha chain prevents weight gain.”
Need stents? Skip a beat no more
•On February 9, when 31-year-old Mumbai resident Augustine Chettiar underwent an angioplasty, a top-of-the-line drug-eluting stent called Alpine by Abbott cost him ₹1.2 lakh. He required two stents — tiny mesh-like devices that release measured doses of medication in the blocked artery — for two of his blockages. But during the procedure, a complication forced the doctor to use both stents in one single artery. Mr. Chettiar was advised to get the second blockage fixed after a few weeks.
•On February 14, the National Pharmaceutical Pricing Authority (NPPA) announced a ceiling on the prices of stents. The bare metal stent was capped at ₹7,260 while all drug-eluting stents were capped at ₹29,600.
•When Mr. Chettiar went for his second angioplasty on March 3, a high-end drug-eluting stent called Xpedition from Abbott cost him merely ₹29,600. And to top it, he also received a clear bill that marked out the stent price.
Hospitals under the scanner
•Hospitals across the country are closely being watched by the NPPA and the State Food and Drug Administration authorities on their pattern of billing after the capping of stent prices.
•The NPPA has directed all hospitals to issue detailed bills to the patients, specifically and separately mentioning the cost of the coronary stents, along with the brand name of the manufacturer, importer, batch number and other details. Those who fail to comply stand to be pulled up by drug controllers.
•“When we got the hospital bill after the second angioplasty, it was simple and understandable. More importantly, the price of the overall procedure reduced drastically,” says Mr. Chettiar’s wife Angela. “My husband had an insurance of ₹5 lakh. But the first procedure at Holy Spirit Hospital in Andheri cost us ₹4.5 lakh, of which ₹2.24 lakh was merely for the two stents. Fortunately, his company got the insurance firm to pass the additional amount for the second procedure that he underwent at Surana Hospital. It cost us merely ₹1.5 lakh,” she adds.
•While lakhs of patients have benefitted from the government’s decision, the NPPA continues to receive complaints from across the country of overcharging and lack of clarity in the bill.
•“Most of the complainants have got a refund from the hospitals. There are some others for whom we have asked for copies of the bill for better clarity,” says NPPA Chairman Bhupendra Singh, adding that they have asked the State drug controllers to re-audit all angioplasty cases from February 14, of hospitals that have complaints against them. A month since the price ceiling was introduced, the NPPA has received 37 cases of which five are fresh complaints.
Don’t miss the fine print
•Activists say that patients need to come forward and complain against any kind of non-compliance. “The government has set up a system in place. So it is now up to the patients and relatives to ensure that the bill they get is itemised,” says health activist Dr. Abhay Shukla.
•The new rule has drained out a major chunk of revenue for hospitals and thus there are chances of them trying to recover the money by inflating other costs. “The ideal way to compare is to get a bill of a patient who has undergone the procedure before February 14 and check if the hospital is overcharging in other aspects of the bill,” suggests Dr. Shukla.
•Hospital owners, however, see a new era of trust and greater volumes that will offset potential losses. “People who needed more stents and underwent cardiac surgeries can now afford angioplasties. The number of angioplasties will definitely see a rise now,” says Dr. Prince Surana, medical director of the Surana Group of Hospitals in Mumbai.
Why is the World Bank keen on resolving Indus divide?
•After her recent visit to India and Pakistan, World Bank Chief Executive Officer Kristalina Georgieva reiterated that the Bank was keen on resolving the disagreements between the two nations over the interpretation of the Indus Waters Treaty (IWT) following the construction by India of two hydroelectric power plants. Though the two nations have had no fresh conflict over the sharing of river waters for more than five decades, differences cropped up after Pakistan opposed the construction of the Kishenganga (330 MW) and Ratle (850 MW) power plants by India on the Jhelum and Chenab in Jammu and Kashmir, over which Pakistan has unrestricted rights under the treaty.
Why did the Bank intervene?
•Even before Partition, the Indus had created problems among the states of British India. The problems became international after the creation of two nations as the political boundary was drawn right across the Indus basin. The World Bank (then IBRD), under the presidency of Eugene Black, helped in 1952 to settle the dispute between the two nations on the sharing of the Indus river basin waters. He had said the escalation of the dispute would damage the economic development of the Indian subcontinent. After eight years of hard negotiations, Prime Minister Jawaharlal Nehru and President Ayub Khan signed the IWT on September 19, 1960. The Bank is also a signatory to the treaty. The IWT is a complex instrument, comprising 12 articles and eight annexures. It sets forth provisions of cooperation between the two countries in their use of the rivers, known as the Permanent Indus Commission (PIC).
Has there been any violation?
•According to the IWT, India has control over three eastern rivers of the Indus basin — the Beas, the Ravi and the Sutlej — and Pakistan has control over the three western rivers — the Indus, the Chenab and the Jhelum. All six rivers flow from India to Pakistan. Among other uses, India is permitted to construct power facilities on these rivers subject to regulations laid down in the treaty. India had asked the bank for appointment of a neutral expert following Pakistan’s objections to two projects, while Pakistan demanded the formation of a court of arbitration, alleging that India had violated the treaty. In December 2016, the Bank announced a ‘pause’ and asked both parties to resolve the issue amicably by the end of January 2017.
What stand did the Bank take?
•India welcomed the Bank’s neutral stand, while Pakistan sought intervention of the Bank after being unable to find an amicable solution to the dispute through the commission. Given that India has remained the Bank’s single largest borrower since its inception with cumulative borrowings from IBRD and IDA touching $103 billion, the bank did not perhaps want to upset it.
•With buoyancy in foreign exchange reserves, the Bank needs India more than the other way round and this has created some anxiety in the Bank circles about the future direction of their relationship.
Why is the Bank playing a role again?
•This is because India and Pakistan are important partners and clients of the Bank. In South Asia, Pakistan ($2,280 million) received the highest lending from the Bank after India ($3,845 million) during the fiscal 2016. Moreover, there are not too many borrowers with a credible record like India.
•The Bank maintained its aid could be effectively used if both nations kept the peace and ensured better management of the waters, on which lakhs of farmers depend. As both nations have failed to resolve the dispute amicably, the Bank CEO has initiated a dialogue. Changing its stance, India has agreed to attend a meeting of the commission in Lahore next week. Like in the 1950s, Bank officials are again playing the role of mediator.
