War and health: designing a debris

This article reveals the extent to which people's lives get mutilated - symbolically and otherwise - in the aftermath of a war. In an era when internal wars and those waged by an outside nation are defining the lives of several nations, this article might convince people to take the situation more seriously. The subject of the article is Iraq, a nation that back in the 1980s had some of the best health indicators. Today, courtesy of decades of war, political infighting and factionalism, people in the country struggle for survival. A study found that in 2010, the average life expectancy in Iraq was just 58 years. The infant mortality rate was 84 deaths per 100,000 live births, and the maternal mortality rate was twice as high as that of Jordan. According to World Health Organisation reports, diseases like diabetes, hypertension and cancer are also on the rise. The other overwhelming concern that has been pushed under the carpet pertains to the unmet mental health needs of the Iraqi population. A household survey revealed that one in every three households reported that one or more of its members has been subjected to violence. The problem has been aggravated by the migration of most senior psychiatrists to safer countries. Further, mental health problems still attract stigma. Critics have blamed the ongoing internal violence, overt corruption and pilferage of funds for the extremely slow pace at which money is pumped in by international agencies deployed to address the health needs of the population.

Paul WC. Iraq's health system yet to heal from ravages of war. Lancet. 2011 Sep 3; 378(9794): 863-66.

Working towards medicines for all in India

Universal access to healthcare is high on the agenda for government and policy makers who envision a healthy India. The author of this paper argues that providing free healthcare of the same standard to everyone irrespective of their economic status is one way to ensure that there is no discrimination. This will also improve the quality of public health services.

However, for universal access to healthcare to become a reality, we must tackle the issue of access to medicines. Expenditure on drugs accounts for 50-80% of total medical expenses in India. The Indian pharmaceutical industry is viewed as an international success story and a saviour of the poor in many parts of the world for providing drugs at low prices. But the so-called 'messiah' has failed to provide millions of Indians affordable access to medicines. It is estimated that the government will have to incur an additional expenditure of Rs 3,000 crore if medicines are to be provided free of cost from the primary to the tertiary level of care. Professional associations will have to work together towards the goal of regulating and tackling unethical practices prevalent in the pharmacy and health sectors in India. The experiences of the Tamil Nadu Medical Services Corporation and of the Chittorgarh and Nagaur districts show that access to medicines for all can indeed be achieved even in the Indian scenario. Price control for a list of essential medicines and a strong and rational national vaccine policy are two steps that the author suggests for regulating the pharmaceutical sector. He also proposes a better use of the trade related intellectual property rights clauses, including compulsory licensing for highly priced patented drugs. Finally, there is a need to safeguard against multinational companies taking over Indian pharmaceutical companies; such takeovers will adversely affect the "pharma self sufficiency" of India and of those countries who see India as their low cost and efficient pharmacy.

Srinivasan S. 'Medicines for all', the pharma industry and the Indian state. Econ Polit Wkly. 2011 Jun11;46 (24):48-50.

The mammoth('s) challenge

This editorial discusses the trials facing China, a country that is on its way to becoming a global economic power house. The country also faces a mammoth challenge in the form of non communicable diseases (NCDs) which account for 80% of annual deaths and 70% of its total disease burden. 90% of the burden of NCDs is caused by related morbidities and can have adverse effects on the economic and social growth of the country, a World Bank report on the Chinese health sector suggests. Increasing treatment costs and loss of productivity will cast a cloud over the country's economic growth. The editorial also points out that with China's one-child policy, family support which is crucial in disease conditions will also become scarce and individuals will have to shoulder the burden of such care without other help. China, in spite of its extraordinary achievements in the economic sector, has failed to extend this success to the population health sector. There are initiatives to strengthen the health sector, and the first step in the direction has been to train more doctors, especially those in primary healthcare. There is also a move to improve the professional status of doctors, thereby making their influence felt at the policy level, influencing related industries like food, tobacco and alcohol. The investment made will result not only in a healthy China, but will yield benefits like increased productivity and a booming economy.

Editorial. China's major health challenge: control of chronic disease. Lancet. 2011 Aug; 378 (9790):457.

How do doctors choose their specialisation?

There is a need to look at the preferences for specialisation among undergraduate medical students. This will indirectly help in regulating the supply of specialised doctors, ensuring that there is an adequate supply of doctors in all fields and resulting in efficient utilisation of human resources.

This paper looks at the preferences of medical students through the course of their studies. Students in the final and pre-final years were exposed to clinical subjects, which in turn helped them to decide their specialisation. Medicine and surgery were the favoured choices of most of the students. Nonclinical subjects do not attract students. This may lead to a dearth of teachers in these fields. Students chose orthopaedics over radiology, paediatrics and dermatology. Anaesthesia was low in the list of choices. Few male students opted for gynaecology. Factors promoting the choice of subjects are the individual's interest, the potential for career advancement, the earning potential and the prestige associated with the specialisation. Students are also influenced by their teachers. Some students also wanted to migrate to the USA for their post-graduate studies as they thought it would lead to a better lifestyle and financial security, besides exposing them to the latest medical technologies

Kumar R, Dhaliwal U. Career choices of undergraduate medical students. Natl Med J India. 2011 May-Jun;24(3):166-9

Women prisoners: in a sorry state

Healthcare services for prisoners, especially women prisoners, worldwide, are well below the minimum requirement to be provided by the public healthcare systems of their respective countries. Despite the considerable rise in the number of women prisoners in the recent past, services for them fall short of human rights recommendations.

Women prisoners normally come from socially and economically backward communities and have little education. Many are addicted to alcohol, drugs and smoking. This also makes them prone to various diseases. These issues should be addressed by the healthcare system.

Instead, women are often held in the same prison as male prisoners and their special needs are not considered. Due to the paucity of space assigned for women's prisons, women prisoners may be kept under high security even when they have not been assigned to this category. Their mental health problems and reproductive health problems are not addressed. There are many other human rights violations in women's prison cells. The government and policymakers must be sensitised on these issues and take corrective steps.

van den Bergh BJ, Gatherer A, Fraser A, Moller L. Imprisonment and women's health: concerns about gender sensitivity, human rights and public health. Bull World Health Organ. 2011 Sep 1;89(9):688-94 | doi:10.2471/BLT.10.082842

The Aadhaar number is the foundation for better health

The author discusses the advantages of the Aadhaar identification project in the context of the programme for "better health for all". The identification number being issued by the Unique Identification Authority of India under the Planning Commission, Government of India is denoted by the word "Aadhaar" which means foundation. This will help governments in developing nations struggling to build a proper healthcare system, and requires the cooperation of health service providers.

Aadhaar will give each holder a unique personal identification number. It will incorporate information on treatment sought by the holder with different healthcare providers. In the case of children it will maintain a record for the number of immunisations received and the health checkups carried out at the appropriate age. In case of an emergency, the Aadhaar number will provide the individual identity and medical history of the patient. The Aadhaar number will be beneficial to people who qualify for various government schemes such as the National Rural Health Mission and Janani Suraksha Yojna. The data thus gathered will also provide health statistics for researchers, enabling preventive measures to be taken for populations with specific health problems. Adhaar will protect sensitive data like biometrics to avoid any possibility of misuse. The government will grant access to data only to authorised personnel. It is hoped that Aadhaar will form the basis for a system to provide better healthcare facilities catering to individual needs.

Nilekani N. Building a foundation for better health: the role of the Aadhaar number. Natl Med J India. 2011 May-Jun; 24(3): 133-5.

Reforming regulations governing research with human subjects

In 1981, recommendations made by the United States National Commission for the Protection of Human Subjects of Biomedical and Behavioural Research formed the basis for the Code of Federal Regulations. A section of this code extended to other federal departments, and became the common rule in the USA in 1991. The author notes that even after 30 years, the rule has not changed substantially, despite advances in research. Critics opine that these regulations consume substantial resources and frame burdensome bureaucratic procedures even as they are insufficient to protect research participants. An Advance Notice of Proposed Rulemaking (ANPRM) was drafted by the working group of the Office of Management and Budget which coincides with the US President's order to critically examine all regulations. The Department of Health and Human Services coordinated with the Office of Science and Technology Policy in issuing an ANPRM: "Human Subjects Research Protections: Enhancing Protections for Research Subjects and Reducing Burden, Delay, and Ambiguity for Investigators".

The key issues mentioned in the ANPRM are: prioritisation of resources for continuing Institutional Review Board (IRB) review for studies posing "more than minimal" risks while expediting IRB review for studies involving "minimal risks" (risks faced in everyday life, routine physical or psychological examination), and reducing the burden on researchers by simplifying concerned processes. It was asked whether research posing only informational harm to the research subjects could be "excused" from IRB review and be subjected to the standards for data security and confidentiality based on the Health Insurance Portability and Accountability Act (HIPAA). The suitability of having only one IRB of record for all domestic sites in multisite studies, protection of research subjects before attaining IRB review, and the burden of HIPAA information protection standards were discussed. The need for consistent guidance, a harmonised adverse events electronic reporting system, a simplified and explicit informed consent process, and a one-time consent procedure for all further research on biological specimens collected, were also expressed. The ANPRM acknowledges that the proposed changes won't be agreeable to everyone despite being in accordance with the President's mandate.

Emanuel EJ, Menikoff J. Reforming the regulations governing research with human subjects. N Engl J Med. 2011 Jul 25. [Epub ahead of print]. PMID: 21787202.

Role of social science in health policy and systems research

This article is the fourth in a series of policy forum articles examining the challenges of strengthening health policy and systems research (HPSR). The present article focuses on the importance of social sciences in HPSR. HPSR usually considers biomedical, clinical and epidemiological knowledge, building on measurable facts through statistical analysis and often with a cause-and-effect focus on HPS issues. Social sciences which may be qualitative in nature focus on the elucidation and arrive at different interpretations of the same experience. However, both approaches have the same focus on health and policy systems and concern about strengthening the health system. The authors refer to a middle range theory which falls between the positivism of quantitative research and the relativism of qualitative research. There is more scope to enrich HPSR by multi- and interdisciplinary work and analytic generalisations which also help to develop general conclusions on the basis of which further research can be done. The authors have come up with suggestions for this rigorous investigation in HPSR. The first step in a research project is to plan an effective questionnaire, asking "how and why" questions, which should be followed by a deep understanding of the experience. Conceptualisation and re-conceptualisation is very important to develop an understanding of the research area. Next is the interpretation on the basis of the evidence and the background. Negative case analysis plays a significant role in interpretation to refine the explanations and theories. It is very important for a researcher to be explicit about his/her own assumptions. The authors reiterate the importance of triangulation across the methods and knowledge paradigm to conduct a successful HPSR.

Gilson L, Hanson K, Sheikh K, Agyepong IA, Ssengooba F, Bennett S. Building the field of health policy and systems research: social science matters. PLoS Med. 2011 Aug;8(8): 1-6.

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