Questioning Prevailing Paradigm in Public Health

Interruption : Legal clarification ............. Recently I have not given vaccine to my own children. Because I thought I will do better by keeping ? by known instructions in my country. So when I was talking of 80% people, I was talking about people into the program. Large number of people remain outside the programme and they have no way to come and enter the Program. And then we talk of holistic method and WHO, why there is no IFO education and information program is 30% because each minute a person is dying of it in India. We have lots of campaign and exposure on HIV AIDS but there is no campaign in totally as to how you can treat yourself from Tuberculosis. Because they told us a very low center rate. But we have very different rates of recipients and we do not have enough resources.

Speaker (New) : It is also a phenomenon of working in rural India with an ideal of having a docs. Strategy. It may conceptualise more with an ideal of that villages where people are working and living. So a health worker can go to a village and supervise and recommend. This is also that this program is only focusing on a part of this program.

Interruption : So until unless we trust the patient and we divide the strategy to provide him with the drugs which we provide instead of him coming to us after traveling ten kilometers a day.

Speaker from Finland/Europe : Now I find it very simplified way to present. I am not sure there is nobody to defame the Docs. program. And I am not going to do that because I am not working with W.H.O. But I think that is a slightly easy way because it is important to blame. No patient can walk 10 kms.

......... Translator : On the very conceptualisation of health. Thrust so much thrust. Away from the larger context. We are not talking of T.B. etc. and the society at large.

Translation / presentation in Hindi

Dr. Dev Dhar : The national program has very well documented that unless the nutrition is very very low the Anti dose of T.B. is ineffective. Another point which I think I want to clarify about Doc(?) Program is I think this program started in India about four years ago and it will take another four to five years before it will cover the entire country. Remember no communicable disease can be controlled in isolation. But what is important is the totality of the coverage. And unless we engage in totality it is unlikely that with our style of management or governance it is impossible to really assert or cover the entire area. So it may require another hundred years to maintain what we plan. And what is going to happen that most of our drugs are imported. We are dependent for our internal program to the supply and import of drugs. Therefore it will come to end and when that end comes then we have this real drama to face. Because we had developed the infrastructure, we had raised the expectations of the people and then we had no money for drugs.

Intervention: I am quite in agreement in what is said about difficulties in accessing T.B. drugs. But besides that I am not in agreement with the statement that a supervised an ideally speaking supervised controlled programm is the ideal program. Because the supervised program is in itself .................. irresponsible humanbeing. And the person is neither aware but is completely ignorant about his health problems. And this need supervision. So I am not convinced that Supervised Treatment is the Best Treatment. Ideally speaking, it passes strong messages pass on. And I think the entire failure of the programme is very nicely been potrayed under the talk of compliance and non-compliance and default rates which we really need to question. ....................

Dr. Dhar : You have made a very significant point. That people are interested in health. They do come for health. They diagnose the tuberculosis only six months after the ? Therefore people do go in time but they are not recognised.

Question : I have a suggestion. I think I would certainly agree to the Social Nature of Tuberculosis. And it does not get rid of Tuberculosis by Medical means. Ya ! that is very clear. But infact I think in the process the problem is that if you think about supervision not in a restricted way it is quite often executed. Then the problem with Tuberculosis treatment is that after two months if Tuberculosis treatment is working people feel better and we all know how difficult it is to continue the treatment if you are not feeling the pain if you are not going to treat with the drugs. So the supported structure that reminds you quite often or give you incentives of whatever possibilities you have in a decent way or a respectable way to work with a patient to see six months nine months whatever treatment period is needed. I think that is not the way to blame the concept of Tuberculosis control otherwise you led to adjust to social sector if people are willing or people are able organise their lives in such a way that they are able to take the drug correctly over such a long period especially if they are needy or they are poor if they have time scattered for the day. I think it is ask if you need support structure over a time period to treat tuberculosis.

Dr. D. Dhar : What the point he made is that many a times the National or International programs are taken as directive. They are not taken as guidelines to say what the objective and how to achieve it. As far as maharashtra is concerned, Maharashtra's policy is limited only to Doc. They are giving treatment also to those who are not coming. For one reason or for another because their difficulty is their difficulty. We have no right to say that this is not a difficulty. This is the first part. The second point they have also taken....... Please Wait ! Wait ! I am only responding to a question, I am not throwing open the discussion. please do not interrupt because we are only killing time. Please sit down. Please take the chair.

Interrupter : No ! I will not take the chair. You have to listen to us. you cannot put us down like this.

Dr. Dhar : I am not putting anyone done. Let me finish my point.

Speaker : No you have to respect him. We cannot wait till you finish upto 4'Oclock. This workshop is for people to say something.

Dr. Dhar : O.K. You want to say ! say !

Dr. Ritu Priya : No ! I will then make a point. I wanted to say that if look at doc ! Program, we need to look at number of issues involved with both sides. The plus point of it is on ground we look at experiences. If one than those who are getting treatment are the ones who are many more than the earlier in the district where it is actually been applied. To begin the exclusion which is happening and is talked about, therefore the one which have earlier been the defaulter are actually not on the register at all and therefore the success rate we see on terms because they have qued towards lot of default. Therefore this gives us later a positive picture then it is actually on the ground. But the positive is that whosoever is now on the register gets the full treatment because they have a whole box of drugs which is given to the health center from the beginning. So it is an assured move which was a major problem with the old T.B. Programme. So this is one part which is positive. I think the issue we need to deal at systematic level is how can we sustain that ? Even for those who are on our register. Because I think we need to look at both levels; one at longer term and terms of a larger issues of development of quality of life of people. That is what we gain at decreasing T.B. at Social level. But at the same time we cannot deny the fact of minimising the suffering of people who have T.B. today. And that where something like the health service does come in. The best implementation of that would be if we could do good coverage and cover the maximum number of vulnerable people. What it bothers is, it eliminates the most vulnerable and gives it only to those who would had been able to anyway get it. But it creates a Social Problem when it tells patient to come everyday. And yet it is the dimension of support to the defaulter so called defaulter on behalf of the old programme which has never been implemented. This is only on board that says it will be implemented. But how we are doing it, is through a structure which is much more expensive atleast five times more expensive then what we have been observing earlier. Therefore the unsustainability is not so much on the cost of drugs today but on structure which is done through contract workers and contract workers are those which are not going to get motivated to create a relationship with the community. This is what you require for a long term treatment and support those treatment. The structure for program does not allow for that because you are a contract worker who has atleast passed B.A. The minute he will get another job extra he will quit this and go. So for a moment you have a worker who can't build a relationship because he has been told the way it will be done. So the whole structure does not allow to fulfill the objective of the proposal. So that is the problem, I think we need to look at very centrally. The other problem is of technology. Why did we go to second line instead of first line. But it has many more issues. But as we have two very clear problems with continuing the programme. One is the sustainability of the program itself. It tomorrow the World Bank takes back the fund or decides to stop the fund the government cannot support because the cost is so much higher than the health budget. Now this is a very clear issue. And what we are doing will be done in process in terms of the mind set. it is said that if 'doc' is the first line treatment and your old program is a second third rate programme. But what we can afford on our own is only now what we consider or the third rate. So tomorrow I am not going to go for a third rate even if the government stops supporting it or an international body stops supporting it and I will therefore go to the private sector and buy my grudge. And therefore there will be a greater default and the rebound of T.B. will be much higher than we had before the programme started. And that is our concern. Not saying that drugs are not important.

Speaker (New) : Nutrition is not an operated factor as for the outcome of treatment is concerned. But as everybody knows; this is not something which is new. This is a very important factor as far as people with infection acquiring the disease is concerned. Infection is different from the disease and tuberculosis and for infection to be converted into a disease nutrition is an extremely important factor. All is well with all the diseases especially with tuberculosis and I think one can say and look at the impact of an improvement in nutrition on tuberculosis infection on tuberculosis disease aids then I think that will be made very clear. And we have colleagues working Bilaspur, Chattisgarh on this particular issue. Their initial findings do support the view that nutrition is a very critical factor in acquiring the disease. So may be in this context I would like to point out that Ayurveda one of the important treatments for tuberculosis is Ghee. Give Ghee to the patient to combat the situation. So I think this is an important issue which needs to be taken.

Dr. Dev Dhar : I think environment and nutrition are also important. He has also mentioned Ayurveda. now Ayurveda does not recognise diseases been caused by other reasons. It recognises that diseases are caused by the weakness in the body itself. There the Ayurveda treatment for T.B. in different individuals it varies. This is a very point to note. Therefore let us go to the next section called implementation. And fourth paper on implementation is about the dalit construction workers.

Dr. Ritu : Let us take on what is left on the First one Sir ! The eight part of the left one is about the utilisation part.

Dr. Dev Dhar : O.K. Let us take the utilisation part of the left one.

Dr. Ritu : Let us call Dr. Mittal to moderate this part.

Dr. Dev Dhar : Then who will talk, who will take now. I will conclude presentation only to encourage discussion and you have not taken that part at all. Otherwise I can go on for ever.

New Speaker : I am talking about the shifts in the utilisation pattern of the safe (?) treatment available both public and private. This is based on another data on National Survey Data in 1980s and 1990s. I classified according to classes based on the colony norms given by I.C. norms. These are twenty seven hundred - calorie for milk for poor. Often it twenty four hundred colony. This is the basic requirement to do secondary work. And based on this I classify the data in four groups which are very poor and four middle and high. During the classification of the data we showed that there are four groups which made into very poor. Almost all of the household. All members of these household do not get even a minimum family requirement. Most of the households do not get. Middle and high. Rest over the 80s and 90s the health zone of the very poor and the poor classes have actually have utilisation negative in the range of 15% to 20%. Earlier they were going lower number to public system. Now the number is further reduced and that number has been replaced for the middle and the higher class both in the public sector and the private sector. The paradigm of shift of the floor for the very poor has been to the unspecified sources and the charitable trust. But if we take the classes and their behaviour. Very poor we find are definite optium (?) of the system. Most of them still want to go to the Public Sector but since more from the middle and higher group are going to the Public Sector, the utilisation here has been negative. We are trying to access the reasons for this. One is the medical cost. For them if you see in 1980s and 1990s the hospital expenditure for all the classes have gone up. But it has gone up for the much higher quantum for the poor than the higher classes. I am not going into specific reasons. If I have questions, I can answer it. I also took some diseases like diahorrea fever related to child birth and pregnancy. ARI, T.B. and these common diseases. Suppose the poor still are going to the public sector but on the whole if I see the service system as a whole they are not been able to do that in the some number just because the most from the other classes which are and the service system which has increased is not compensating for their increase also. I think I have taken the IN-Patient CARE and the OUT-Patient Care. For the IN-Patient Care the further diseases the link goes to public sector for whatever the shift has been. The direction of shift goes to the charitable benevolent institution for the poorer classes. And I think, it is all the same thing, I reason been there has not been the choice left for themselves so they have to go to out- patient care for unspecified cases and for the IN-patient care they are going to the Charitable because the cost involved is so high that they cannot afford it. Thank you ! I think if there are any questions ?

Speaker new : I look at the changing, positioning patterns in the Secondary Level Care those at the District Hospital. So the main objective is to look at the changing pattern from the Service Positioning. And we look at the thirteen district hospitals shared over in thirteen districts. The district hospitals were selected purposefully for the qualitative study. Just like it shows the different hospitals been studied in different districts, our main finding was that in all the district hospitals the service provided was not free. But the targeted service. For APL there was a user charge. But for B.P.L. they had to produce a card. But from the case studies, from the patients we saw lots of abberations like even in the B.P.L. patients had to comply to user charges. Now we see in District Hospitals there are two kinds of things happening. One is privatisation of services to the implementation of user Fee and various kinds of Service which are identified further. It is like related registration, admission, bed food, diagnosis, Ambulance and if it will further go on to include operation charges also. But apart from user charges there we also see that these are bibs taking place and especially for surgical patients we see that doctors take from apart the stipulated charges they take it. And also some paramedical also take it. And on the other we also see there is a kind of Public and Private meets happening in district hospitals on behalf of Private entrepreneur in the public Sector hospital. And we see four kinds of changes taking place. Contracting at different categories of manpower and the contracting is not only limited to paramedical professionals but also going out to clinical services to the doctors, surgeons and General Practitioners. And then in outsourcing to non-clinical services like ranging to laundry, diet etc. Then there is ranking out of government land taking place especially for O.P.D. area given out. For cafeteria purposes, when renting out for various purposes like parking etc. Various links for the voluntary organisation is taking. Apart from these two kinds of thing there is a hospital development committee which is known by different links in different districts. The main function of different district and Hospital Development Committee is to collect user fees, maintain its account and utilise it for development hospital and it is comprising of these many officials. In some of the committee there is the facility of paid membership where we get different kinds of industrialists gradually involving themselves into the committee. Though we see that the main function for the collection of User Fee. We also see that they are maintaining these general kind of functions like general maintaince, contracting services, accounting and maintenance, accounting and maintenance of equipments, so we see that the kind of function is not properly laid out and then there is a overlap between the existing hospital administration function. This is further enhancing the private mix within the Public Sector. This hospital development committee which has been formally responsible for the independent government institutions within the public sector. And we finally see that services are provided free of cost by Public Sector and there is a split happening within the Service Positioning and there is a further engagement of counters and awareness in the Public Hospitals.

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