Planned progress for health

Is the failure to achieve a target a real failure, and does it call for abandonment of the target itself? In some situations the answer to this hypothetical question may be yes, but in case of health, it is a firm no. There were a number of targets in terms of health indices planned for the tenth Five-Year Plan, which have not been achieved, we can spend some time in analyzing why, but a more prudent course of action is to make a firmer resolve to achieve them in the coming five-year plan.

The Planning Commission is the apex body advising how the resources and efforts of the government should be channeled in the coming years. A strong and far-sighted commission provides the government of the day with inputs to focus its efforts on problems that really confront the nation. Planning Commission has constituted a High Level Expert Group (HLEG) to formulate a comprehensive strategy for development of the health sector in the next 10 years. The HLEG undertook a situational analysis of each of the key elements of the existing health system and developed recommendations for reconfiguring and strengthening the health system, identified gaps and meeting the projected health needs of the people of India over the next decade. Earlier, editorial did offer few suggestions on priority for the 12^th Five-Year Plan.[1]

The principal issues that face the country are maternal and infant mortality, malnutrition among children, anemia among women and girls, fertility, and raising the sex ratio (female to male ratio). There has been progress on all fronts except the sex ratio. The government needs to look at the sex ratio more carefully and adopt strategies to reverse the trend. While the aforesaid issues are medical in nature, sex ratio is a social problem. Pure medicine or technology is not going to help us reverse the sex ratio, however, the steps that are being taken appear to be in the right direction. The decisions of the Central and State governments and the stand of the High Courts have all supported the ban on the misuse of sonography machines. With time it is hoped that good sense will prevail among people at large and that will lead to an improvement. The Commission has reaffirmed its commitment to bettering these indices while casting its eye elsewhere too. The Commission has set a target regarding the out-of-pocket expenses towards health care. Presently, 79% of the national health expenditure is out of pocket and of this 50% is on drugs and medicines. This is planned to be reduced to 50%. Incidentally it is because of the high out-of-pocket expenses that the Indian Health Systems is ranked lowly by the World Health Organization.

The 12^th plan has AYUSH in its focus. That the country has rich resources in so far as traditional medicine needs to be considered. There are about 7.87 lakh registered AYUSH doctors, 489 recognized AYUSH Colleges with an annual admission capacity of about 28,000 undergraduate and postgraduate students. There are 3277 AYUSH hospitals with bed strength of 62649, 24289, AYUSH dispensaries. There were 8644 manufacturing units 7494 Ayurvedic units, 414 Unani units, 338 Siddha units, and 398 Homoeopathic units in the country as on 1.4.2010, engaged in manufacturing the AYUSH drugs. Can we as a country afford to ignore these resources, freely available for the health system, yet sparingly used. The doctor to population ratio, excluding AYUSH doctors from Indian healthcare sector is 1:1624. However, with AYUSH doctors, it becomes 1:780. Professor JS Bajaj, an eminent medical scientist and former member of Planning Commission recently emphasized that acute shortage of MBBS doctors in health sector in general and PHCs in particular can be filled by AYUSH doctors if we give them additional one year training. This will enable AYUSH doctors tackle communicable diseases, NCD and emergency conditions more effectively, especially in rural areas where they are already practicing. No doubt, AYUSH doctors can add much more value with their specialized knowledge in respective systems and should not be looked only as substitutes of MBBS doctors in rural areas. This strategic change will be an important step for affordable and accessible healthcare in India. If the Planning Commission is also suggesting the integration of AYUSH systems into the mainstream national health delivery system, AYUSH practitioners need to be trained in emergency medicine and family medicine to utilize this human resource more effectively. Further, AYUSH medicines should be made available at all levels and AYUSH research need to be integrated with other research streams.

Another area that has been identified is validation of AYUSH therapies in areas of their strength and national relevance. In this context it would not be out of place to point out the recommendations made by Shailaja Chandra (former Secretary AYUSH) in her report on Status of Indian Medicine and Folk Healing.[2] The report has been reviewed in this issue.

For the last 40 years, a drug-based approach has been adopted in research on ASU treatments, and has predictably met with limited success. What needs to be done is to adopt a multidisciplinary approach towards AYUSH treatments in comparison with conventional treatments. The people would thus have an authentic idea of the degree of effectiveness of the AYUSH treatments.

Such comparative studies need to be planned and funded by a joint committee comprising eminent scientists, professionals, and secretaries along with representation from bodies, such as ICMR, DBT, DST, and CSIR. It is noted that a large number of projects on overlapping themes are funded by different agencies. This results in small initiatives, which do not yield any substantial outcome from the public point of view. An institutionalized critical review of research funded by public money is necessary. This would discourage repetitive research and ensure that research is focused on outcomes of direct advantage to the public—in true sense a translational research.

A thrust area proposed by the working group of the health division of the commission is promoting quality research to validate the efficacy and safety of AYUSH remedies; this would obviously include -Ensuring availability and conservation of medicinal plants; Accelerating Pharmacopeial work; Ensuring availability of quality drugs; Positioning AYUSH national institutes as leaders in SAARC region and propagation of AYUSH for global acceptance as systems of medicine.

There is a growing concern among Ayurveda fraternity about the disproportionate allocation of health funds among mainstream healthcare and AYUSH systems. This has been happening since independence. Department of AYUSH should be allocated at least 10% of total health budget, and appropriate programs on cross-cutting themes need to be initiated. This will boost the morale of the AYUSH community and will bring about sweeping changes in the sector. Progress in the number of rigorous and whole system–integrated protocol-driven Preclinical and Clinical studies completed under AYUSH has been negligible over the 11^th Plan. High priority must be accorded for validated classical drugs listed in respective formularies through appropriately designed clinical studies. Clinical Research should precede every other type of research. Unless this activity is taken up with all seriousness, the allocation of public money for AYUSH will be difficult to justify. There is need to define costs of efficacious protocols. AYUSH and respective councils must align research areas to national priorities to strengthen primary health care, treatments for difficult-to-treat conditions, palliative care, health promotion, and disease prevention.

Over this background, J-AIM wishes to congratulate Dr Sayeeda Hamid, Member Health, Planning Commission, for taking a historical decision to integrate contemporary medicine and AYUSH together so that the health of India is better secured. It is clear that attempting to use AYUSH treatments for diseases where modern medicine is successful may not be the focus. The effective and affordable medicines from Ayurveda, Unani, Siddha, and Homeopathy and preventive and promotive role of Yoga are extremely valuable for India. The aim should be to integrate the best available solutions and treatments to complement conventional medicine with the advantages of AYUSH. All systems of medicine should complement each other and not replace them. Actually, this so-called diverse group of pathy or systems should integrate in such a way that there is only one medicine, which is in the best interest of people. This is clearly the future of medicine.