Discuss the American Health Care System. Can we implement it in India? 2. What is DOTS? How will you organize and implement DOTs Programme at a district level? Discuss in detail.
3. Describe the National Health Policy of India. What goals are to be achieved by 2010? 4. Write notes on a. WHO b. UNICEF c. Health problems of Developing Nations.
5. Write notes on a. National Anti Malarial Programme b. National AIDS control programme 1. Discuss the American Health Care System. Can we implement it in India? Ans :American Health Care is the leading integrator of pharmacy benefit management (PBM), clinical pharmacy management (CPM), and disease and wellness management (DWM) in the nation: PBM services integrate medical, laboratory, and pharmacy information to provide a multi-faceted picture of a patient’s medical status, and there is a nationwide network of pharmacies contracted at rates that are competitive at the national level. American Health Care is committed to providing proactive CPM to positively impact the drug prescribing patterns of physicians and the drug utilization by plan members/patients.The by-products of such focused attention are improved health outcomes and decreased medical and pharmacy cost.
American Health Care is the champion of holistic patient care, aligning its internal and external resources to place what is best for the patient at the center of drug therapy decisions. DWM protocols or other therapeutic options must conform to the unique medical complexities of each patient. As a provider of unbiased pharmacotherapy information, American Health Care is known for its integrity, ethics, and dedication to science.In its passionate pursuit of excellence, American Health Care is a recognized innovator of products, processes, and tools that result in better care for patients through advanced data integration technologies, clinical pharmacy, and disease/health management. Health care in the United States is provided by many separate legal entities. Health care facilities are largely owned and operated by the private sector. Health insurance is primarily provided by the private sector, with the exception of programs such as Medicare, Medicaid, TRICARE, the Children’s Health Insurance Program and the Veterans Health Administration.At least 15.
3% of the population is completely uninsured and a substantial additional portion of the population (35%) is “underinsured”, or not able to cover the costs of their medical needs. More money per person is spent on health care in the United States than in any other nation in the world, and a greater percentage of total income in the nation is spent on health care in the U. S. than in any United Nations member state except for East Timor. Despite the fact that not all citizens are covered, the United States has the third highest public healthcare expenditure per capita.A 2001 study in five states found that medical debt contributed to 46. 2% of all personal bankruptcies and in 2007, 62.
1% of filers for bankruptcies claimed high medical expenses. Since then, health costs and the numbers of uninsured and underinsured have increased. The US pays twice as much yet lags behind other wealthy nations in such measures as infant mortality and life expectancy, though the relation between these statistics to the system itself is debated. Currently, the U. S. has a higher infant mortality rate than most of the world’s industrialized nations.The United States life expectancy lags 42nd in the world, after most rich nations, lagging last of the G5 (Japan, France, Germany, UK, USA) and just after Chile (35th) and Cuba (37th). The USA’s life expectancy is ranked 50th in the world after the European Union (40th).
The World Health Organization (WHO), in 2000, ranked the U. S. health care system as the highest in cost, first in responsiveness, 37th in overall performance, and 72nd by overall level of health (among 191 member nations included in the study). The Commonwealth Fund ranked the United States last in the quality of health care among similar countries and notes U.
S. care costs the most by far. According to the Institute of Medicine of the United States National Academies, the United States is the “only wealthy, industrialized nation that does not ensure that all citizens have coverage” (i. e. some kind of insurance). The same Institute of Medicine report notes that “Lack of health insurance causes roughly 18,000 unnecessary deaths every year in the United States.
” while a 2009 Harvard study published in the American Journal of Public Health found a much higher figure of more than 44,800 excess deaths annually in the United States due to Americans lacking health insurance.More broadly, the total number of people in the United States, whether insured or uninsured, who die because of lack of medical care was estimated in a 1997 analysis to be nearly 100,000 per year. On March 23, 2010, the Patient Protection and Affordable Care Act became law, providing for major changes in health-insurance procedures. Facilities In the United States, ownership of the health care system is mainly in private hands, though federal, state, county, and city governments also own certain facilities.
The non-profit hospitals share of total hospital capacity has remained elatively stable (about 70%) for decades. There are also privately owned for-profit hospitals as well as government hospitals in some locations, mainly owned by county and city governments. There is no nationwide system of government-owned medical facilities open to the general public but there are local government-owned medical facilities open to the general public. The federal Department of Defense operates field hospitals as well as permanent hospitals (the Military Health System), to provide military-funded care to active military personnel.The federal Veterans Health Administration operates VA hospitals open only to veterans, though veterans who seek medical care for conditions they did not receive while serving in the military are charged for services. The Indian Health Service operates facilities open only to Native Americans from recognized tribes.
These facilities, plus tribal facilities and privately contracted services funded by IHS to increase system capacity and capabilities, provide medical care to tribes people beyond what can be paid for by any private insurance or other government programs.Hospitals provide some outpatient care in their emergency rooms and specialty clinics, but primarily exist to provide inpatient care. Hospital emergency departments and urgent care centers are sources of sporadic problem-focused care. “Surgicenters” are examples of specialty clinics. Hospice services for the terminally ill who are expected to live six months or less are most commonly subsidized by charities and government.
Prenatal, family planning, and “dysplasia” clinics are government-funded obstetric and gynecologic specialty clinics respectively, and are usually staffed by nurse practitioners. Medical products, research and developmentAs in most other countries, the manufacture and production of pharmaceuticals and medical devices is carried out by private companies. The research and development of medical devices and pharmaceuticals is supported by both public and private sources of funding. In 2003, research and development expenditures were approximately $95 billion with $40 billion coming from public sources and $55 billion coming from private sources.
These investments into medical research have made the United States the leader in medical innovation, measured either in terms of revenue or the number of new drugs and devices introduced.In 2006, the United States accounted for three quarters of the world’s biotechnology revenues and 82% of world R;D spending in biotechnology. According to multiple international pharmaceutical trade groups, the high cost of patented drugs in the U. S. has encouraged substantial reinvestment in such research and development. Economist Dean Baker finds that the development of drugs relies heavily upon research funded by the public, and he suggests that savings to consumers would be immense if public funding increased to 100% of R;D, thus eliminating drug companies’ justifications for monopoly pricing rights.Health care spending In 2009, the United States federal, state and local governments, corporations and individuals, together spent $2. 5 trillion, $8,047 per person, on health care.
This amount represented 17. 3% of the GDP, up from 16. 2% in 2008. Health insurance costs are rising faster than wages or inflation, and medical causes were cited by about half of bankruptcy filers in the United States in 2001 One study by the Agency for Healthcare Research and Quality (AHRQ) found significant persistence in the level of health care spending from year to year.Of the 1% of the population with the highest health care spending in 2002, 24.
3% maintained their ranking in the top 1% in 2003. Of the 5% with the highest spending in 2002, 34% maintained that ranking in 2003. Individuals over age 45 were disproportionately represented among those who were in the top decile of spending for both years. Health care cost rise based on total expenditure on health as % of GDP. Countries are USA, Germany, Austria, Switzerland, United Kingdom and Canada. Seniors spend, on average, far more on health care costs than either working-age adults or children.The pattern of spending by age was stable for most ages from 1987 through 2004, with the exception of spending for seniors age 85 and over. Spending for this group grew less rapidly than that of other groups over this period.
Health care payment Doctors and hospitals are generally funded by payments from patients and insurance plans in return for services rendered. Around 84. 7% of citizens have some form of health insurance; either through their employer or the employer of their spouse or parent (59. 3%), purchased individually (8. 9%), or provided by government programs (27. %; there is some overlap in these figures). All government health care programs have restricted eligibility, and there is no government health insurance company which covers all citizens.
Americans without health insurance coverage at some time during 2007 totaled about 15. 3% of the population, or 45. 7 million people. Among those whose employer pays for health insurance, the employee may be required to contribute part of the cost of this insurance, while the employer usually chooses the insurance company and, for large groups, negotiates with the insurance company.
In 2004, private insurance paid for 36% of personal health expenditures, private out-of-pocket 15%, federal government 34%, state and local governments 11%, and other private funds 4%. Due to “a dishonest and inefficient system” that sometimes inflates bills to ten times the actual cost, even insured patients can be billed more than the real cost of their care. Insurance for dental and vision care (except for visits to ophthalmologists, which are covered by regular health insurance) is usually sold separately. Prescription drugs are often handled differently than medical services, including by the government programs.Major federal laws regulating the insurance industry include COBRA and HIPAA.
Individuals with private or government insurance are limited to medical facilities which accept the particular type of medical insurance they carry. Visits to facilities outside the insurance program’s “network” are usually either not covered or the patient must bear more of the cost. Hospitals negotiate with insurance programs to set reimbursement rates; some rates for government insurance programs are set by law. The sum paid to a doctor for a service rendered to an insured patient is generally less than that paid “out of pocket” by an uninsured patient.In return for this discount, the insurance company includes the doctor as part of their “network”, which means more patients are eligible for lowest-cost treatment there. The negotiated rate may not cover the cost of the service, but providers (hospitals and doctors) can refuse to accept a given type of insurance, including Medicare and Medicaid.
Low reimbursement rates have generated complaints from providers, and some patients with government insurance have difficulty finding nearby providers for certain types of medical services.Charity care for those who cannot pay is sometimes available, and is usually funded by non-profit foundations, religious orders, government subsidies, or services donated by the employees. Massachusetts and New Jersey have programs where the state will pay for health care when the patient cannot afford to do so. The City and County of San Francisco is also implementing a citywide health care program for all uninsured residents, limited to those whose incomes and net worth are below an eligibility threshold.Some cities and counties operate or provide subsidies to private facilities open to all regardless of the ability to pay, but even here patients who can afford to pay or who have insurance are generally charged for the services they use.
The Emergency Medical Treatment and Active Labor Act requires virtually all hospitals to accept all patients, regardless of the ability to pay, for emergency room care. The act does not provide access to non-emergency room care for patients who cannot afford to pay for health care, nor does it provide the benefit of preventive care and the continuity of a primary care physician.Emergency health care is generally more expensive than an urgent care clinic or a doctor’s office visit, especially if a condition has worsened due to putting off needed care.
Emergency rooms are typically at, near, or over capacity. Long wait times have become a problem nationally, and in urban areas some ERs are put on “diversion” on a regular basis, meaning that ambulances are directed to bring patients elsewhere. Private Most Americans (59. 3%) receive their health insurance coverage through an employer (which includes both private as well as civilian public-sector employees) under group coverage, although this percentage is declining.Costs for employer-paid health insurance are rising rapidly: since 2001, premiums for family coverage have increased 78%, while wages have risen 19% and inflation has risen 17%, according to a 2007 study by the Kaiser Family Foundation. Workers with employer-sponsored insurance also contribute; in 2007, the average percentage of premium paid by covered workers is 16% for single coverage and 28% for family coverage. In addition to their premium contributions, most covered workers face additional payments when they use health care services, in the form of deductibles and payments.Just less than 9% of the population purchases individual health care insurance.
 Insurance payments are a form of cost-sharing and risk management where each individual or their employer pays predictable monthly premiums. This cost-spreading mechanism often picks up much of the cost of health care, but individuals must often pay up-front a minimum part of the total cost (a ‘’deductible’’), or a small part of the cost of every procedure (a payment). Private insurance accounts for 35% of total health spending in the United States, by far the largest share among OECD countries.Beside the United States, Canada and France are the two other OECD countries where private insurance represents more than 10% of total health spending Public Government programs directly cover 27. 8% of the population (83 million), including the elderly, disabled, children, veterans, and some of the poor, and federal law mandates public access to emergency services regardless of ability to pay. Public spending accounts for between 45% and 56. 1% of U.
S. health care spending. Per-capita spending on health care by the U. S. overnment placed it among the top ten highest spenders among United Nations member countries in 2004. Government funded programs include: * Medicare, generally covering citizens and long-term residents 65 years and older and the disabled. * Medicaid, generally covering low income people in certain categories, including children, pregnant women, and the disabled.
(Administered by the states. ) * State Children’s Health Insurance Program, which provides health insurance for low-income children who do not qualify for Medicaid. Administered by the states, with matching state funds. ) * Various programs for federal employees, including TRICARE for military personnel (for use in civilian facilities) * The Veterans Administration, which provides care to veterans, their families, and survivors through medical centers and clinics.  * National Institutes of Health treats patients who enroll in research for free. * Government run community clinics * Medical Corps of various branches of the military. * Certain county and state hospitals The uninsuredSome Americans do not qualify for government-provided health insurance, are not provided health insurance by an employer, and are unable to afford, cannot qualify for, or choose not to purchase, private health insurance. When charity or “uncompensated” care is not available, they sometimes simply go without needed medical treatment.
This problem has become a source of considerable political controversy on a national level. Healthcare in India Healthcare in India features a universal health care system run by the constituent states and territories of India.The Constitution charges every state with “raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties”. The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002. However, the government sector is understaffed and under financed poor services at state-run hospitals force many people to visit private medical practitioners. Government hospitals, some of which are among the best hospitals in India, provide treatment at taxpayer expense.Most essential drugs are offered free of charge in these hospitals.
Government hospitals provide treatment either free or at minimal charges. For example, an outpatient card at AIIMS (one of the best hospitals in India) costs a one-time fee of rupees 10 (around 20 cents US) and thereafter outpatient medical advice is free. In-hospital treatment costs depend on financial condition of the patient and facilities utilized by him but are usually much less than the private sector. For instance, a patient is waived treatment costs if he is below poverty line.Another patient may seek for an air-conditioned room if he is willing to pay extra for it. The charges for basic in-hospital treatment and investigations are much less compared to the private sector.
The cost for these subsidies comes from annual allocations from the central and state governments. Primary health care is provided by city and district hospitals and rural primary health centres (PHCs). These hospitals provide treatment free of cost. Primary care is focused on immunization, prevention of malnutrition, pregnancy, childbirth, postnatal care, and treatment of common illnesses.Patients who receive specialized care or have complicated illnesses are referred to secondary (often located in district and taluk headquarters) and tertiary care hospitals (located in district and state headquarters or those that are teaching hospitals). As far as American health care system is concerned it found difficult to implement in India all because of following point; 1. Lack of fund 2.
Lack of machinery 3. Over population 4. Infrastructure facilities 2. What is DOTS? How will you organize and implement DOTs Programme at a district level? Discuss in detail.Ans. STOP TB : IS DOTS THE ANSWER? INTRODUCTION Between 2. 00 and 3.
00 pm on 28th October 1998, 230 people around the world shared a common death : 228 of them died in developing countries; the other two died in he industrialised countries of the west. Most of them died in poverty, many in misery. Few of them will be remembered by anybody else other than their immediate family. The contrast between these two very different groups of people is immense. One group wealthy, healthy and middle aged. The other poor, sick, and dying long before the age of retirement.They live worlds apart, and surely never met.
Yet, there is a link between these two profoundly different groups of people. That link is tuberculosis. Between 2 and 3 million people die from tuberculosis every year, that’s between 5,500 and 8,200 people every day, 230-340 every hour, about 5 people every minute. And the six people who gathered at the White House in October were there to talk about tuberculosis.
The president’s wife had invited them to discuss the global tuberculosis epidemic and a new initiative to STOP TB.Faced with growing awareness that the global tuberculosis epidemic progresses unchecked, that millions of people suffer and die from a potentially curable disease, and that HIV and drug resistance threaten to turn a angerous epidemic into a global disaster, Around the same time, six people gathered in Washington, USA. Between them, they control a vast political and economic empire of government, business and banks.
They included the international financier, George Soros, James Wolfenson, who heads the World Bank, and Hillary Clinton, the first lady of the United States of America.These six people had gathered to call for action, and to put their resources behind the efforts. They called for intensified efforts to fight tuberculosis, based on the strategy of DOTS advocated by the World Health Organization. But will DOTS work? Many people have questioned whether DOTS will be able to turn back the tide of tuberculosis. They ask, does DOTS work; do we need it; can we afford it, and is it right? During this talk I will endeavour to answer some of these questions. The Global Tuberculosis SituationTuberculosis causes an enormous burden of disease and death around the world. One third of the world’s population – 2 billion people – have been infected with tubercle bacilli, and therefore, 9 million people develop tuberculosis every year, and 2-3 million people die of the disease.
200 million people alive today will suffer from tuberculosis at some time during their lives. The impact of tuberculosis is greatest on the poor; 99% of the deaths and 95% of all cases occur in the developing world. The majority of people affected by tuberculosis are in the economically active age groups.Families and communities are deprived of their parents and their work force. Tuberculosis and poverty go hand in hand – people who are poor get tuberculosis, and people who get tuberculosis become poor. Tuberculosis also shares a deadly synergism with HIV. People who have been infected with tubercle bacilli have a 10% lifetime risk of developing active tuberculous disease.
If they are also infected with HIV, the risk increases to nearly 10% per year. As a result, countries with a high prevalence of HIV are witnessing Definitions of DOTSDirectly observed treatment (DOT) or directly observed therapy is watching the patient take his/her medication to ensure medications are taken in the right combination and for the correct duration. It is used for diseases such as tuberculosis or HIV to assure compliance and avoid drug resistance. DOTS (Directly Observed Treatment, Short-course) has been identified by the World Bank as one of the most cost-effective health strategies available. DOTS costs only US $3 – $7 for every healthy year of life gained.
DOTS get people back to school, work and their families.The DOTS Strategy DOTS strategy combines appropriate diagnosis of TB and registration of each patient detected, followed by standardized multi-drug treatment, with a secure supply of high quality anti-TB drugs for all patients in treatment, individual patient outcome evaluation to ensure cure and cohort evaluation to monitor overall programme performance. DOTS is THE MOST EFFECTIVE STRATEGY available for controlling the worldwide TB epidemic today. DOTS is an inexpensive and highly effective means of treating patients already infected with TB and preventing new infections and the development of drug resistance.Between 1995 and 2003, more than 17. 1 million patients were treated under the DOTS strategy.
Worldwide, 182 countries were implementing the DOTS strategy by the end of 2003, and 77% of the world’s population was living in regions where DOTS was in place. DOTS programs reported 1. 8 million new TB cases through lab testing in 2003, a case detection rate of 45%, and the average success rate for DOTS treatment was 82%. WHO aims to achieve a 70% case detection rate of TB cases and cure 85% of those detected by 2005. The U. N.
Millennium Development Goals include targets to halve the 1990 TB prevalence and death rates by 2015.DOTS uses sound technology—the successful components of TB control—and packages it with good management practices for widespread use through the existing primary health care network. The technical, logistical, operational and political aspects of DOTS work together to ensure its success and applicability in a wide variety of contexts. Strengthening TB treatment How to implement DOTS Why is DOTS needed? Although health workers in many areas are working hard to diagnose and treat tuberculosis (TB), the number of people with TB is increasing rapidly.Some of the increase is due to the increasing HIV epidemic, but the number of TB cases is also increasing because of failures in existing treatment strategies for TB. People may be unable to access diagnosis and treatment for many different reasons (see below). Effective treatment of TB is important for individuals, their families and communities. People with active TB can spread TB to other members of their families or communities.
They become sick, are unable to work or fulfil family commitments, and will eventually die if their TB is left untreated.People who stop TB treatment before completing the course can continue to spread TB and may develop drug resistance. What is DOTS? DOTS (Directly Observed Treatment, Short course) is a new treatment strategy for TB that aims to address these challenges. This strategy is usually implemented The samples are collected over a 24 hour period: one when the person visits the health facility, one early next morning, and the next when the person with suspected TB returns to the health centre the following day.Samples are then sent to the diagnostic centre (or the person can travel to the diagnostic centre to provide samples). Who does it? Health worker at DOTS treatment centre or diagnostic centre. DOTS is based on the direct observation of people taking their TB drugs. However, the DOTS strategy includes much more than direct observation of treatment, as many factors are needed to ensure adequate and accessible TB care.
These include: * Political commitment ensuring adequate funding * Eucation for people with TB and their communities Reliable case detection using sputum smear microscopy to identify people with active TB * Standardised short course treatment for all people with smear positive TB * Direct observation and support for people taking drug treatment * A regular and reliable supply of freedrugs * Accurate record keeping to identifypeople who do not complete treatment * Effective monitoring both of people who are receiving treatment and of the performance of the DOTS programme as a whole.DOTS can be used to treat new TB cases, people who have relapsed, people who have previously had treatment, but not finished the course, and people who need retreatment. What makes DOTS different? Many people cannot access TB treatment or do not complete their TB treatment because of: * The need to take time off work or away from family * The cost of travel to the health facility or of drug treatment * A lack of available drugs * The belief that because they feel better they are cured and can top treatment * Having to take lots of different pills for a long time * a lack of user-friendly health services (e. .
unfriendly staff or unfriendly opening times) * Needing permission to travel or to see a health worker (e. g. in some cultures women may need their husband’s or father’s permission to travel or may need to be accompanied by a family member if they visit a health worker. Accessibility The DOTS strategy aims to improve access to TB treatment by: * Making treatment and diagnosis free * Using standardised courses of treatment People are more likely to seek diagnosis and treatment if treatment centres are close to where they live.People are also more likely to continue with treatment if it does not interfere with their work or family commitments.
DOTS is most likely to be effective in a community setting. By training community health workers or community volunteers as treatment supporters people can have their treatment in a way that does not disrupt their everyday lives. Support The person observing treatment is called the treatment supporter. Observing treatment is not the only role of a treatment supporter, they can also provide the support, encouragement and counseling necessary to help people complete their course of treatment.Currently, research confirms that the DOTS strategy works. However, it is unclear whether it is necessary to observe every dose of treatment or whether less frequent observation (e.
g. weekly) is equally effective. Either way, the treatment supporter needs to be someone who is accessible, reliable and concerned for the health of the person with TB. The treatment supporter provides encouragement, checks that the correct number of tablets has been taken, and follows up people who miss treatment. MonitoringThe recording and follow-up systems that are part of the DOTS strategy mean that both people taking treatment and the DOTS programme as a whole can be monitored effectively. People who stop treatment can be quickly identified and health workers or Community education What is it? The first step in encouraging people to seek treatment for TB is educating them about TB, its symptoms and its treatment, so people with symptoms will go to a health facility to seek diagnosis and treatment.
Community education plays an important role in this process.Helping people to understand the importance of completing treatment plays an important role in encouraging them to continue taking their TB drugs for the complete six to eight month course. Who does it? Health workers and community health workers. Case detection What is it? Screening people who come to health facilities who have had a cough for more than three weeks is seen by many health workers as the best way to identify people who have pulmonary TB. When the health worker suspects a person has TB and has discussed this with them, the person with suspected TB needs to provide three sputum samples. reatment supporters can work with them to understand their reasons for stopping treatment and try to find a solution.
At district level, the TB officer can use the records that are part of the DOTS programme to assess the programme and identify any problems, which can then be tackled effectively. Making a difference DOTS is not the final solution to the TB crisis – diagnosis and treatment still need to be made easier for health workers and people with TB. However, with the current resources available, DOTS is probably the most effective way of treating TB and ensuring people complete treatment.In resource poor countries, DOTS can improve the life of individuals with TB and the whole community. The samples are collected over a 24 hour period: one when the person visits the health facility, one early next morning, and the next when the person with suspected TB returns to the health centre the following day. Samples are then sent to the diagnostic centre (or the person can travel to the diagnostic centre to provide samples) Who does it? Health worker at DOTS treatment centre or diagnostic centre. Diagnosis of sputum smear positive TB What is it?Diagnosis of people with active TB is based on sputum smear microscopy The laboratory staff complete alaboratory register and return the results of the sputum smears to the treatment centre.
Who does it? Laboratory technician. Diagnosis of sputum smear positive TB Diagnosis of people with active TB is based on sputum smear microscopy. * Making treatment community based, so people do not need to take time off work or from domestic responsibilities to go for treatment Providing community education, so that people can recognise the symptoms of TB and go to a health worker for diagnosis and treatment.Treatment What is it? Treatment under the DOTS strategy consists of a combination of drugs taken over a six to eight month period. In the first two months (the initial phase), four drugs are taken together, while for the following four to six months (the continuation phase) fewer drugs are taken. If the treatment is carefully followed, a person with infectious pulmonary TB will stop being infectious within two to six weeks.
Doctors at the diagnostic center classify the person with TB and prescribe treatment according to national programme guidelines.Counselling for people with TB can focus on: * Treatment and its possible side effects _ the importance of continuing treatment until complete * How to tell family members and encourage them to be screened for TB. In some countries with a high burden of HIV, many people with TB will also be HIV-positive. People with TB can be counselled about this possibility, offered an HIV test, advised about the use of condoms and advised to consult a health worker if they become ill with chest or other illnesses. Who does it? Doctor at diagnostic centre.Direct observation What is it? Direct observation of tablet taking during the intensive phase (at least in people with smear positive TB) is currently recommended in the DOTS strategy. However, ongoing encouragement from the treatment supporter is the most important part, helping to ensure that people complete treatment and are cured Who does it? A treatment supporter — usually a community health worker or a communityvolunteer, but in some cases a health centre health worker or a work place supervisor, if this is more acceptable and convenient .
Support for people with TBWhat is it? Treatment support is one of the most important features of the DOTS strategy. TB treatment continues for eight months and people with TB often need encouragement to complete their course of treatment. This is one of the most important aspects of the DOTS strategy. Who does it? Treatment supporter. Identifying people who stop treatment What is it? It is important to identify people who stop treatment before their TB is cured.
People who stop treatment can continue to spread TB to others. Interrupting or stopping treatment can also lead to drug resistance.Treatment cards can help identify people who stop treatment quickly. These people can then be followed up and encouraged to continue with their treatment. People who interrupt treatment should be encouraged to re-start treatment, but the management of such cases depends on: * Type of person, e. g.
first TB treatment, multi-drug resistant TB, repeat treatment * Length of time the person took treatment * Length of interruption of treatment * Whether they are sputum smear negative or positive when returning to treatment.People who interrupt treatment should be referred to a trained TB nurse or doctor, who can assess them and prescribe appropriate treatment. Assessing the DOTS programme What is it? Monitoring and evaluation of the performance of the DOTS programme using the standard supervision and reporting forms .
This allows early identification of problems and improvement of the programme. Who does it? District TB officer. Resources needed for a DOTS programme The decision to introduce DOTS should be made jointly by the national TB programme and the district health or medical officer.The areas most suitable for first introducing DOTS are districts that are accessible, have a high TB burden and are already using standard short course treatment. A successful DOTS programme needs: physical resources (e. g. a laboratory, a treatment centre, a reliable drugs supply) and human resources (well-trained laboratory staff and health workers).
Physical resources DOTS diagnostic centre A diagnostic centre is the place where people with long standing cough and other respiratory symptoms are screened for TB and where people with TB can start their treatment.The centre should be easily accessible, well-equipped with a reliable supply of drugs and materials and have well-motivated and well-trained staff, so the DOTS programme is likely to be successful and can be a model for future programmes. What does a diagnostic centre do? * Screens people with TB symptoms. * Carries out sputum smear microscopy.
* Diagnoses TB. * Registers people with active TB for treatment. * Starts TB treatment. * Works with person with TB to identify DOTS supervisor.
* Traces people who stop treatment. Treatment centresMany people will live a long way from the diagnostic centre, so treatment centres should be set up. Treatment centres do not diagnose people or start treatment, but are places people can collect their month’s supply of drugs and have a monthly review meeting to check their progress.
Staff at treatment centres also supervise treatment supporters, refer people with respiratory symptoms or side effects to diagnostic centres and trace people who stop taking treatment. What does a treatment centre do? * Identifies and refers people with suspected TB to diagnostic centre. * Provides or arranges community-based treatment observation. Supplies TB drugs. * Maintains case records. * Traces people who stop treatment.
* Refers people with major side effects to diagnostic centre. * Maintains stock books for drugs and materials. * Supervises treatment supporters. The laboratory staff complete a laboratory register and return the results of the sputum smears to the treatment centre. Who does it? Laboratory technician.
organize and implement DOTs Programme at a district level: WHEN TO SUSPECT TB IN A PATIENT Pulmonary TB may be suspected in a person, who has persistent cough for 3 weeks or more with or without associated respiratory or constitutional symptoms.Such a person should have his sputum examined for acid-fast bacilli (AFB) on 3 consecutive days. Similarly, a person with extra-pulmonary TB may have organ-specific disease along with constitutional symptoms. Contacts of a smear-positive patient r wst also be examined for the presence of disease, f symptoms are suspected. SPUTUM MICROSCOPY Sputum examination for AFB ,he easiest and the most accurate method for diagnosis of pulmonary TB, but its collection should be done very meticulously in a labeled container after explaining the correct method of bring ng out the sputum.The method consists of 2-3 deep inhalations with an open mouth followed by a deep coughing from the chest. At least 3 sputum specimens should be collected for microscopic examination in a suspected case of pulmonary TB.
These include a SPOT specimen on the first day, followed by the EARLY MORNING and SPOT specimens on the second day. If a centre is not equipped with microscopy, DOTS STRATEGY IN INDIA, P:19-27. there is a need for the container to be transported to another centre with such laboratory facilities.In the case of a delay, it should be stored in a refrigerator and sent to the laboratory as soon as feasible, but definitely within a week. CLASSIFICATION AND CATEGORISATION OF TB CASES If at least 2 out of 3 sputum specimens are positive for AFB, the patient is classified as smear-positive and put on appropriate treatment. If one specimen is smear-positive for AFB and the radiographic abnormalities determined by an MO are consistent with the active pulmonary TB, the patient is still diagnosed as having smear-positive TB and put on appropriate treatment.
If all 3 sputum specimens are negative and the symptoms persist despite giving antibiotics for 1-2 weeks, an X-ray examination is carried out. If radiographic abnormalities are consistent with active pulmonary TB and the MO decides to treat the patient with ATT, a diagnosis of smear-negative TB is made and an appropriate treatment started. In either case, the patient’s TB Treatment and Identification Cards are prepared. He is given a thorough information about the various aspects of disease, the instituted treatment, the possible unpleasant effects and the need for a regular follow-up.DOTS STRATEGY The DOTS strategy has emerged as a possible solution to the rising number of TB cases Different parts of the world and has been incorporated in India’s Revised National Tuberculosis Control Programme as well. The strategy assures a compulsory and free availability of good quality drugs to all TB cases Necessitates drug administration under direct supervision, thereby ensuring the requisite regimen-compliance.
RNTCP has already covered 450 million population of the country and has succeeded in achieving an overall cure rate of 80% for new Positive TB cases.Yet, there is an urgent need Widen the programme coverage not only for meeting the other challenges of programme-implementation but also to achieve RNTCP objectives at the national level. EVOLUTION OF RNTCF In India, the NTP had already been in place for 3 decades, and though created an infrastructure for TB control (comprising of 446 District TB Centres [DTCs], 330 TB Clinics, 16 State TB Training and Demonstration Centres [STDCs] and 47,000 TB beds), but remained a failure in terms of the case finding (around 30% only) and the treatment completion rates (between 35 and 40%).An Expert Committee, set up in 1992 by the Government of India to review the NTP, highlighted programme-deficiencies and recommended the corrective measures, based upon which, the Revised National Tuberculosis Control Programme (RNTCP) was framed for the entire country. Essentials of the RNTCP are as follows: 1. Cases should be detected by sputum microscopy than radiologically and atleast 3 sputum smears should be examined for diagnosis.
Sputum microscopy facilities should be strengthened by ensuring the availability of good quality equipments, training of the laboratory technicians, establishing sputum microscopy centres per one lakh population and creating appropriate cross-checking mechanisms for quality control assurance. 2. Highest priority should be accorded for treating smear positive patients with Short Course Chemotherapy (SCC) under the direct supervision in intensive phase and the appropriate supervision in continuation phase through the involvement of most peripheral health functionaries (such as multi-purpose workers, anganwadi workers, trained ais, village health guides, community volunteers etc. ) closest to the patient’s residence. 3. A regular and an uninterrupted supply of drugs should be assured right upto the periphery. 4. Training capabilities of all the health personnel should be improved.
5. Capabilities of the DTCs and the STDCs should be enhanced for an effective implementation, monitoring and evaluation of the programme. 6. Non-Governmental Organisations (NGOs) and private practitioners should be involved in RNTCP, in view of the fact that a large number of patients visit them. 7.
A sub-district supervisory level (termed as the Tuberculosis Unitf or TU) should be created for every 0. 5 million population for registration of cases at the unit instead of a district. The team should consist of one Senior Tuberculosis Supervisor (STS) and one Senior Tuberculosis Laboratory Technician (STLT), under the supervision of a medical officer designated as Medical Officer – TB Control (MO-TC). 8.
Recording and reporting system should be strengthened for ensuring the accountability and emphasis be laid on the monitoring of treatment outcomes. . Operational research should be encouraged for improvement of the programme efficiency.
10. Professionally designed Information, Education and Communication (IEC) activities should be established for supporting the programme. RNTCP OBJECTIVES Whereas, overall objectives of the revised TB programme are to reduce the morbidity and mortality from the disease and interrupt the chain of transmission of infection, the operational objectives are : (i) To provide SCC to all detected TB patients for the recommended duration of treatment till they are cured. ii) To treat annually on an average about 750 sputum positive cases per million population as against the existing rate of 375 per million population. (iii) To cure, atleast 85% of all newly detected cases of pulmonary tuberculosis.
(iv) To detect atleast 70% of the estimated incidence of smear-positive pulmonary cases. Efforts targeted at the case-detection should be made only after achieving 85% cure rates in the already detected cases, which is the prime target of RNTCP. PROGRAMME COVERAGEThe country saw an implementation of RNTCP in 1993 as a pilot-phase (Phase I) in 5 project areas (Delhi, Bombay, Calcutta, Bangalore and Mehsana district of Gujarat) covering a population of 2. 35 million.
Following its success, it was extended in 1995 (Phase II) to cover a 14 million population in 13 States. Again, the results were highly encouraging and led to the formal launching of RNTCP in the country (Phase III) in 1997. The programme has achieved atleast 80% of the cure rates, whereas certain areas have consistently achieved even higher cure rates.Following a rapid programme expansion in the late 1998 and early 1999, a population of 450 million was covered by the end of 2001. The Government plans to cover half of the country by 2002, 80% by 2004 and the entire country as soon as feasible. CHALLENGES IN IMPLEMENTATION Major challenges that stand in the implementation of RNTCP are as follows : 1.
Expansion: Achievement of National Targets is a great challenge in the programme- implementation, since the current overall cure rate of 80% for new smear-positive patients is still below the targeted cure rate of 85%.Further, the default rate at many centres continues to be high. 2. Private sector involvement: Involvement of the private practitioners, from whom 80% of the patients seek medical attention, constitutes a big challenge, as it would require them to cooperate with the programme guidelines and even possibly incur initial losses in the earnings. 3. IEC and health education: Religious practices of people, such as the Muslims keeping fasts during Roza days and the Hindus during festivals or on particular days of a week, largely hinder the drug administration to them.Active IEC campaigns and health education are necessary to remove superstitions prevalent in the society. 4.
Multiplicity of control programmes: It leads to a prevalence of confusion in the minds of treatment providers. Therefore, a uniform practice needs to be evolved with respect to the control programmes all over the country. 5. MDR-TB : Efforts are on to gradually introduce the ‘DOTS plus’, a complementary DOTS based therapy, comprising of the second line drugs, to tackle the MDR-TB problem.
6.Migratory population: Difficulties may be experienced in getting migratory population registered under the RNTCP. 7. Social stigma: Notions restricting the acceptance of TB patients, are still prevalent in the minds of people and require a propagation of frequent IEC campaigns to remove the superstitions amongst the people.
8. Integration: Priorities need to be instituted in respect of the TB control programme in minds of the health staff and doctors, so that RNTCP takes a higher status of execution from the present level, in comparison to the other diseases of national interest. . Involvement of medical colleges: The medical college fraternity needs to be integrally involved in the implementation of DOTS at the national level.
CLINICAL FOCUS Treating physicians should strictly follow the guidelines recommended by WHO in respect of the categorisation of TB cases, the institution of appropriate drug-regimens in correct dosages and the required protocol of sputum examination before treatment and during follow-up of patients. The patient should be adequately educated and motivated about the treatment, so as to ensure the requisite regimen-compliance.A clear message should be perceived by the patient that a non-compliance of therapy would be detrimental to his health and may result in making him a case of MDR-TB, which is much difficult to treat and requires a prolonged treatment with the costlier second-line drugs. Special situations, like diabetes, HIV-infection, pregnancy, renal and liver disease, demand modifications in the drug-regimens. CONCLUSION Acceptance of DOTS strategy in the Indian RNTCP has certainly brought encouraging success in the management of TB cases within the country.However, there are challenges to be met in the programme-implementation, before the RNTCP objectives are finally realized. Community involvement Community co-operation is essential for a successful DOTS programme. DOTS committees can serve as a link between health services and local communities.
DOTS committees should include motivated people including people with TB, health service managers, civic leaders, representatives of local organisations and local communities.Before DOTS is introduced, the district health officer can call a meeting with community members and leaders to introduce the DOTS programme and suggest forming a DOTS committee. The local community should be involved in the decision about who sits on the committee to ensure that the DOTS programme receives local support. It is important that the DOTS committee has a clear idea of the activities and involvement required from it. DOTS committees can: _ increase public awareness about TB in the ommunity through advocacy and education Support people in the community with TB by providing DOTS supervisors and people to followup those who stop treatment * Identify local problems in DOTS implementation and propose solutions at community level * Encourage co-operation between health institutions, health workers and NGOs * Protect health workers at treatment centres from undue political pressures. The best size for the committee is about 10-15 people, who will need to meet at least every four months in the first year of the DOTS programme and as necessary after that.DOTS committees should ideally include people from each of the groups discussed below.
1. District TB officers 2. Laboratory technicians 3. Health workers 4. Community health workers 5. Late patient tracers 6.
Community volunteers 3. Describe the National Health Policy of India. What goals are to be achieved by 2010? ANS : NATIONAL HEALTH POLICY National Health Policy Government Of India Ministry Of Health ; Family Welfare New Delhi 1983 Contents * INTRODUCTION * OUR HERITAGE PROGRAM ACHIEVED * THE EXESTING PICTURE * NEED FOR EVOLVING A HEALTH POLICY * POPULATION STABILISATION * MEDICAL ; HEALTH EDUCATION * NEED FOR PROVIDING PRIMARY HEALTH CARE * REORIENTATION OF EXISTING HEALTH PERSONNEL * PRACTIONERS ROLE IN HEALTH CARE * PROBLEMS REQUIRING URGENT ATTENTION * HEALTH EDUCATION * MANAGEMENT INFORMATION SYSTEM * HEALTH INSURANCE * HEALTH LEGISLATION * MEDICAL RESEARCH * INTER SECTORAL COOPERATION * MONITORING AND REVIEW OF PROGRESS Introduction 1.The Constitution of India envisages the establishment of a new social order based on equality, freedom, justice and the dignity of the individual.
It aims at the elimination of poverty, ignorance and ill-health and directs the State to regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties, securing the health and strength of workers, men and women, specially ensuring that children are given opportunities and facilities to develop in a healthy manner. . 2 Since the inception of the planning process in the country, the successive Five Year Plans have been providing the framework within which the States may develop their health services infrastructure, facilities for medical education, research, etc.
Similar guidance has sought to be provided through the discussions and conclusions arrived at in the Joint Conferences of the Central Councils of Health and Family.Welfare and the National Development Council. Besides, Central legislation has been enacted to regulate standards of medical education, prevention of food adulteration, maintenance of standards in the manufacture and sale of certified drugs, etc.
1. 3 While the broad approaches contained in the successive Plan documents and discussion in the forums referred to in para 1. 2 may have generally served the needs of the situation in the past, t is felt that an integrated, comprehensive approach towards the future development of medical education, research and health services requires to be established to serve the actual health needs and priorities of the country. It is in this context that the need has been felt to evolve a National Health Policy. Our heritage 2. India has a rich, centuries-old heritage of medical and health sciences. The philosophy of Ayurveda and the surgical skills enunciated by Charaka and Shusharuta bear testimony to our ancient tradition in the scientific health care of our people.The approach of our ancient medical systems was of a holistic nature, which took into account all aspects of human health and disease.
Over the centuries, with the intrusion of foreign influences and mingling of cultures, various systems of medicine evolved and have continued to be practised widely. However, the allopathic system of medicine has, in a relatively short period of time, made a major impact on the entire approach to health care and pattern of development of the health services infrastructure in the country.Progress achieved 3. During the last three decades and more, since the attainment of Independence, considerable progress has been achieved in the promotion of the health status of our people. Smallpox has been eliminated; plague is no longer a problem; mortality from cholera and related diseases has decreased and malaria brought under control to a considerable extent. The mortality rate per thousand of population has been reduced from 27. 4 to 14.
8 and the life expectancy at birth has increased from 32. 7 to over 52.A fairly extensive network of dispensaries, hospitals and institutions providing specialised curative care has developed and a large stock of medical and health personnel, of various levels, has become available. Significant indigenous capacity has been established for the production of drugs and pharmaceuticals, vaccines, sera, hospital equipments, etc. The existing picture 4. In spite of such impressive progress, the demographic and health picture of the country still constitutes a cause for serious and urgent concern.The high rate of population growth continues to have an adverse effect on the health of our people and the quality of their lives. The mortality rates for women and children are still dis- tressingly high; almost one third of the total deaths occur among children below the age of 5 years; infant mortality is around 129 per thousand live births.
Efforts at raising the nutritional levels of our people have still to bear fruit and the extent and severity of malnutrition continues to be exceptionally high.Communicable and non- communicable diseases have still to be brought under effective control and eradicated. Blindness, Leprosy and T. B. continue to have a high incidence. Only 31% of the rural population has access to potable water supply and 0. 5% enjoys basic sanitation.
4. 1. High incidence of diarrhoeal diseases and other preventive and infectious diseases, specially amongst infants and children, lack of safe drinking water and poor environmental sanitation, poverty and ignorance are among the major contributory causes of the high incidence of disease and mortality. .
2. The existing situation has been largely engendered by the almost wholesale adoption of health manpower development policies and the establishment of curative centres based on the Western models, which are inappropriate and irrelevant to the real needs of our people and the socio-economic conditions obtaining in the country. The hospital-based disease, and cure-oriented approach towards the establishment of medical services has provided benefits to the upper crusts, of society, specially those residing in the urban areas.The proliferation of this approach has been at the cost of providing comprehensive primary health care services to the entire population, whether residing in the urban or the rural areas. Furthermore, the continued high emphasis on the curative approach has led to the neglect of the preventive, promotive, public health and rehabilitative aspects of health care. The existing approach, instead of improving awareness and building up self-reliance, has tended to enhance dependency and weaken the community’s capacity to cope with its problems.
The prevailing policies in regard to the education and training of medical and health personnel, at various levels, has resulted in the development of a cultural gap between the people and the personnel providing care. The various health programmes have, by and large, failed to involve individuals and families in establishing a self-reliant community. Also, over the years, the planning process has become largely oblivious of the fact that the ultimate goal of achieving a satisfactory health status for all our people annot be secured without involving the community in the identification of their health needs and priorities as well as in the implementation and management of the various health and related programmes. Need for evolving a health policy – the revised 20-Point Programme 5. India is committed to attaining the goal of “Health for All by the Year 2000 A.
D. ” through the universal provision of comprehensive primary health care services. The attainment of this goal requires a thorough overhaul of the existing approaches to the education and training of medical and health personnel and the reorganisation of the health services infrastructure.Furthermore, considering the large variety of inputs into health, it is necessary to secure the complete integration of all plans for health and human development with the overall national socio-economic development process, specially in the more closely health related sectors, e. g. drugs and pharmaceu- ticals, agriculture and food production, rural development, education and social welfare, housing, water supply and sanitation, prevention of food adulteration, main- tenance of prescribed standards in the manufacture and sale of drugs and the conservation of the environment.In sum, the contours of the National Health Policy have to be evolved within a fully integrated planning framework which seeks to provide universal, comprehensive primary health care services, relevant to the actual needs and priorities of the community at a cost which the people can afford, ensuring that the planning and implementation of the various health programmes is through the organised involvement and participation of the community, adequately utilising the services being rendered by private voluntary organisations active in the Health sector. .
1. It is also necessary to ensure that the pattern of development of the health services infrastructure in the future fully takes into account the revised 20-Point Programme. The said Programme attributes very high priority to the promotion of family planning as a people’s programme, on a voluntary basis; substantial augmenta- tion and provision of primary health care facilities on a universal basis; control of Leprosy, T. B.
nd Blindness; acceleration of welfare programmes for women and children; nutrition programmes for pregnant women, nursing mothers and children, especially in the tribal, hill and backward areas. The Programme also places high emphasis on the supply of drinking water to all problem villages, improvements in the housing and environments of the weaker sections of society; increased production of essential food items; integrated rural developments; spread of universal elementary education; expansion of the public distribution system, etc.Population stabilisation 6. Irrespective of the changes, no matter how fundamental, that may be brought about in the over-all approach to health care and the restructuring of the health services, not much headway is likely to be achieved in improving the health status of the people unless success is achieved in securing the small family norm, through voluntary efforts, and moving towards the goal of population stabilisation.In view of the vital importance of securing the balanced growth of the population, it is neces- sary to enunciate, separately, a National Population Policy. Medical and Health Education 7. It is also necessary to appreciate that the effective delivery of health care services would depend very largely on the nature of education, training and appro- priate orientation towards community health of all categories of medical and health personnel and their capacity to function as an integrated team, each of its members performing given tasks within a coordinated action programme.It is, therefore, of crucial importance that the entire basis and approach towards medical and health education, at all levels, is reviewed in terms of national needs and priorities and the curricular and training programmes restructured to produce personnel of various grades of skill and competence, who are professionally equipped and socially moti- vated to effectively deal with day-to-day problems, within the existing constraints.
Towards this end, it is necessary to formulate, separately, a National Medical and Health Education Policy which (i) sets out the changes required to be brought about in the curricular contents and training programme of medical and health personnel, at various levels of functioning; (ii) takes into account the need for establishing the extremely essential inter-relations between functionaries of various grades; (iii) provides guidelines for the production of health personnel on the basis of realistically assessed manpower requirements; (iv) seeks to resolve the existing sharp regional imbalances in their availability; and (v) ensures hat personnel at all levels are socially motivated towards the rendering of community health services. Need for providing primary health care with special emphasis on the preventive, promotive and rehabilitative aspects 8. Presently, despite the constraint of resources, there is disproportionate emphasis on the establishment of curative centres—dispensaries, hospitals, institutions for specialist treatment—the large majority of which are located in the urban areas of the country.The vast majority of those seeking medical relief have to travel long distance to the nearest curative centre, seeking relief for ailments which could have been readily and effectively handled at the community level. Also, for want of a well established referral system, those seeking curative care have the tendency to to visit various specialist centres, thus further contributing to congestions, duplication of efforts and consequential waste of resources.To put an end to the existing all-round unsatisfactory situation, it is urgently necessary to restructure the health services within the following broad approach: (1) To provide, within a phased, time-bound programme a well dispersed network of comprehensive primary health care services, integrally linked with the extension and health education approach which takes into account the fact that a large majority of health functions can be effectively handled and resolved by the people themselves, with the organised support of volunteers, auxilliaries, para-medics and adequately trained multi-purpose workers of various grades of skill and competence, of both sexes. There are a large number of private, voluntary organisations active in the health field, all over the country. Their services and support would require to be utilised and intermeshed with the governmental efforts, in an integrated manner.
(2) To be effective, the establishment of the primary health care approach would involve large scale transter of knowledge, simple skill and techno- logies to Health Volunteers, selected by the communities and enjoying their confidence.The functioning of the front line workers, selected by the community would require to be related to definitive action plans for the translation of medical and health knowledge into practical action, involv- ing the use of simple and inexpensive interventions which can be readily implemented by persons who have undergone short periods of training. The quality of training of these health guides/workers would be of crucial importance to the success of this approach. The success of the decentralised primary health care system would depend vitally on the organised building up of individual self-reliance and effective community participation; on the provision of organised, back-up support of the secondary and tertiory levels of the health care services, providing adequate logistical and technical assistance. 4) The decentralisation of services would require the establishment of a well worked out referral system to provide adequate expertise at the various levels of the organisational set-up nearest to the community, depending upon the actual needs and problems of the area, and thus ensure against the continuation of the existing rush towards the curative centres in the urban areas. The effective establishment of the referral system would also ensure the optimal utilisation of expertise at the higher levels of the heirarchical structure.
This approach would not only lead to the progres- sive improvement of comprehensive health care services at the primary level but also provide for timely attention being available to those in need of urgent specialist care, whether they live in the rural or the urban areas. 5) To ensure that the approach to health care does not merely constitute a collection of disparate health interventions but consists of an integrated package of services seeking to tackle the entire range of poor health conditions, on a broad front, it is necessary to establish a nation-wide chain of sanitary-cum-epidemiological stations. The location and func- tioning of these stations may be between the primary and secondary levels of the heirarchical structure, depending upon the local situations and other relevant considerations. Each such station would require to have suitably trained staff equipped to identify, plan and provide preventive, promotive and mental health care services. It would be beneficial, depending upon the local situations, to establish such stations at the Primary Health Centres.The district health organisation should have, as an integral part of its set-up, a well organised epidemiological unit to coordinate and superintend the functioning of the field stations. These stations would participate in the integrated action plans to eradicate and control diseases, besides tackling specific local environmental health problems.
In the urban agglomerations, the municipal and local authorities should be equipped to perform similar functions, being supported with adequate resources and expertise, to effectively deal with the local preventable public health problems. The aforesaid approach should be implemented and extended through community participation and contributions, in whatever form possible, to achieve meaningful results within a time-bound programme. 6) The location of curative centres should be related to the populations they serve, keeping in view the densities of population, distances, topography, transport connections. These centres should function within the recom- mended referral system, the gamut of the general specialities required to deal with the local disease patterns being provided as near to the community as possible, at the secondary level of the hierarchical organi- sation. The concept of domiciliary care and the field-camps approach should be utilised to the fullest extent, to reduce the pressures on these centres, specially in efforts relating to the control and eradication of Blindness, Tuberculosis, Leprosy, etc.To maximise the utilisation of available resources, new and additional curative centres should be established only in exceptional cases, the basic attempt being towards the upgradation of existing facilities, at selected locations, the guiding principle being to provide specialist services as near to the beneficiaries as may be possible, within a well-planned network.
Expenditure should be reduced through the fullest possible use of cheap locally available building materials, resort to appropriate architectural designs and engineering concepts and by economical investment in the purchase of machineries and equipments, ensuring against avoidable duplication of such acquisitions. It is also necessary to devise effective mechanisms for the repair, main- tenance and proper upkeep of all bio-medical equipments to secure their maximum utilisation. 7) With a view to reducing governmental expenditure and fully utilising untapped resources, planned programmes may be devised, related to the local requirements and potentials, to encourage the establishment of practice by private medical professional, increased investment by non- governmental agencies in establishing curative centres and by offering organised logistical, financial and technical support to voluntary agencies active in the health field. (8) While the major focus of attention in restructuring the existing govern- mental health organisations would relate to establishing comprehensive primary health care and public health services, within an integrated referral system, planned attention would also require to be devoted to the establishment of centres equipped to provide speciality and super-speciality services, through a well dispersed network of centres, to ensure that the present and future requirements of specialist treatment are adequately available within the country.To reduce governmental expenditures involved in the establishment of such centres, planned efforts should be made to encourage private investments in such fields so that the majority of such centres, within the governmental set-up, can provide adequate care and treatment to those entitled to free care, the affluent sectors being looked after by the paying clinics.
Care would also require to be taken to ensure the appropriate dispersal of such centres, to remove the existing regional imbalances and to provide services within the reach of all, whether residing in the rural or the urban areas. (9) Special, well-coordinated programmes should be launched to provide mental health care as well as medical care and the physical and social rehabilitation of those who are mentally retarded, deaf, dumb, blind, physically disabled, infirm and the aged. Also, suitably organised of various disabilities. 10) In the establishment of the re-organised services, the first priority should be accorded to provide services to those residing in the tribal, hill and back- ward areas as well as to endemic disease affected populations and the vulnerable sections of the society.
(11) In the re-organised health services scheme, efforts should be made to ensure adequate mobility of personnel, at all level of functioning. (12) In the various approaches, set out in (1) to (11) above, organised efforts would require to be made to fully utilise and assist in the enlargement of the services being provided by private voluntary organisations active in the health field.In this context, planning encouragement and support would also require to be afforded to fresh voluntary efforts, specially those which seek to serve the needs of the rural areas and the urban slums. Re-orientation of the existing health personnel 9. A dynamic process of changes and innovation is required to be brought about in the entire approach to health manpower development, ensuring the emergence of fully integrated bands of workers functioning within the “Health Team” approach. Private practice by governmental functionaries 10. It is desirable for the States to take steps to phase out of system of private practice by medical personnel in government service, providing at the same tome for payment of appropriate compensatory no-practising allowance.
The States would require to carefully review the existing situation, with special reference to the availability and dispersal of private practitioners, and take timely decisions in regard to this vital issue. Practitioners of indigenous and other systems of medicine and their role in health care 11. The country has a large stock of health manpower comprising of private practitioners in various systems, for example, Ayurveda, Uncanny, Side, Homeopathy, yoga, Naturopathy, etc. This resource has not so for been adequately utilized. The practitioners of these various systems enjoy high local acceptance and respect and consequently exert considerable influence on health beliefs and practise.
It is, therefore, necessary to initiate organised measures to enable each of these various systems of medicine and health care to develop in accordance wit its genius. Simultaneously, planned efforts should be made to dovetail the functioning of the practitioners of these various systems and integrate their service, at the appropriate levels, within specified areas of responsibility and functioning, in the over-all health care delivery system, specially in regard to the preventive, primitive and public health objectives. Well considered steps would also require to be launched to move towards a meaningful phased integration of the indigenous and the modern systems. NATIONAL HEALTH POLICY – 2002 1. INTRODUCTORY 1. A National Health Policy was last formulated in 1983, and since then there have been marked changes in the determinant factors relating to the health sector. Some of the policy initiatives outlined in the NHP-1983 have yielded results, while, in several other areas, the outcome has not been as expected.
1. 2 The NHP-1983 gave a general exposition of the policies which required recommendation in the circumstances then prevailing in the health sector. The noteworthy initiatives under that policy were:- (i) A phased, time-bound programme for setting up a well-dispersed network of comprehensive primary health care services, linked with extension and health education, designed in the context of the ground reality that elementary health problems can be resolved by the people themselves; ii) Intermediation through ‘Health volunteers’ having appropriate knowledge, simple skills and requisite technologies; (iii) Establishment of a well-worked out referral system to ensure that patient load at the higher levels of the hierarchy is not needlessly burdened by those who can be treated at the decentralized level; (iv) An integrated net-work of evenly spread speciality and super-speciality services; encouragement of such facilities through private investments for patients who can pay, so that the draw on the Government’s facilities is limited to those entitled to free use. 1. 3 Government initiatives in the pubic health sector have recorded some noteworthy successes over time.
Smallpox and Guinea Worm Disease have been eradicated from the country; Polio is on the verge of being eradicated; Leprosy, Kala Azar, and Filariasis can be expected to be eliminated in the foreseeable future. There has been a substantial drop in the Total Fertility Rate and Infant Mortality Rate. The success of the initiatives taken in the public health field are reflected in the progressive improvement of many demographic / epidemiological / infrastructural indicators over time – (Box-I). Box-1 : Achievements Through The Years – 1951-2000 Indicator| 1951| 1981| 2000| Demographic Changes| | | | Life Expectancy| 36.
7| 54| 64. 6(RGI)| Crude Birth Rate| 40. 8| 33. 9(SRS)| 26. 1(99 SRS)|Crude Death Rate| 25| 12.
5(SRS)| 8. 7(99 SRS)| IMR| 146| 110| 70 (99 SRS)| Epidemiological Shifts| | | | Malaria (cases in million)| 75| 2. 7| 2. 2| Leprosy cases per 10,000 population | 38. 1| 57. 3| 3. 74| Small Pox (no of cases) | ;gt;44,887| Eradicated| | Guineaworm ( no. of cases)| | ;gt;39,792| Eradicated| Polio | | 29709| 265| Infrastructure| | | | SC/PHC/CHC | 725| 57,363| 1,63,181 (99-RHS)| Dispensaries ;Hospitals( all)| 9209| 23,555| 43,322 (95–96-CBHI)| Beds (Pvt ; Public)| 117,198| 569,495| 8,70,161 (95-96-CBHI)| Doctors(Allopathy)| 61,800| 2,68,700| 5,03,900 (98-99-MCI)| Nursing Personnel| 18,054| 1,43,887| 7,37,000 (99-INC)| 1. While noting that the public health initiatives over the years have contributed significantly to the improvement of these health indicators, it is to be acknowledged that public health indicators / disease-burden statistics are the outcome of several complementary initiatives under the wider umbrella of the developmental sector, covering Rural Development, Agriculture, Food Production, Sanitation, Drinking Water Supply, Education, etc. Despite the impressive public health gains as revealed in the statistics in Box-I, there is no gainsaying the fact that the morbidity and mortality levels in the country are still unacceptably high. These unsatisfactory health indices are, in turn, an indication of the limited success of the public health system in meeting the preventive and curative requirements of the general population. 1. 5 Out of the communicable diseases which have persisted over time, the incidence of Malaria staged a resurgence in the1980s before stabilising at a fairly high prevalence level during the 1990s.Over the years, an increasing level of insecticide-resistance has developed in the malarial vectors in many parts of the country, while the incidence of the more deadly P-Falciparum Malaria has risen to about 50 percent in the country as a whole. In respect of TB, the public health scenario has not shown any significant decline in the pool of infection amongst the community, and there has been a distressing trend in the increase of drug resistance to the type of infection prevailing in the country. A new and extremely virulent communicable disease – HIV/AIDS – has emerged on the health scene since the declaration of the NHP-1983. As there is no existing therapeutic cure or vaccine for this infection, the disease constitutes a serious threat, not merely to public health but to economic development in the country.The common water-borne infections – Gastroenteritis, Cholera, and some forms of Hepatitis – continue to contribute to a high level of morbidity in the population, even though the mortality rate may have been somewhat moderated. 1. 6 The period after the announcement of NHP-83 has also seen an increase in mortality through ‘life-style’ diseases- diabetes, cancer and cardiovascular diseases. The increase in life expectancy has increased the requirement for geriatric care. Similarly, the increasing burden of trauma cases is also a significant public health problem. 1. 7 Another area of grave concern in the public health domain is the persistent incidence of macro and micro nutrient deficiencies, especially among women and children.In the vulnerable sub-category of women and the girl child, this has the multiplier effect through the birth of low birth weight babies and serious ramifications of the consequential mental and physical retarded growth. 1. 8 NHP-1983, in a spirit of optimistic empathy for the health needs of the people, particularly the poor and under-privileged, had hoped to provide ‘Health for All by the year 2000 AD’, through the universal provision of comprehensive primary health care services. In retrospect, it is observed that the financial resources and public health administrative capacity which it was possible to marshal, was far short of that necessary to achieve such an ambitious and holistic goal.Against this backdrop, it is felt that it would be appropriate to pitch NHP-2002 at a level consistent with our realistic expectations about financial resources, and about the likely increase in Public Health administrative capacity. The recommendations of NHP-2002 will, therefore, attempt to maximize the broad-based availability of health services to the citizenry of the country on the basis of realistic considerations of capacity. The changed circumstances relating to the health sector of the country since 1983 have generated a situation in which it is now necessary to review the field, and to formulate a new policy framework as the National Health Policy-2002.NHP-2002 will attempt to set out a new policy framework for the accelerated achievement of Public health goals in the socio-economic circumstances currently prevailing in the country. OBJECTIVES The main objective of this policy is to achieve an acceptable standard of good health amongst the general population of the country. The approach would be to increase access to the decentralized public health system by establishing new infrastructure in deficient areas, and by upgrading the infrastructure in the existing institutions. Overriding importance would be given to ensuring a more equitable access to health services across the social and geographical expanse of the country. Emphasis will be given to increasing the aggregate public health investment through a substantially increased contribution by the Central Government.It is expected that this initiative will strengthen the capacity of the public health administration at the State level to render effective service delivery. The contribution of the private sector in providing health services would be much enhanced, particularly for the population group which can afford to pay for services. Primacy will be given to preventive and first-line curative initiatives at the primary health level through increased sectoral share of allocation. Emphasis will be laid on rational use of drugs within the allopathic system. Increased access to tried and tested systems of traditional medicine will be ensured. Within these broad objectives, NHP-2002 will endeavour to achieve the time-bound goals mentioned in Box-IV.Box-IV: Goals to be achieved by 2000-2015 Eradicate Polio and Yaws| 2005| Eliminate Leprosy| 2005| Eliminate Kala Azar | 2010| Eliminate Lymphatic Filariasis| 2015| Achieve Zero level growth of HIV/AIDS| 2007| Reduce Mortality by 50% on account of TB, Malaria and Other Vector and Water Borne diseases | 2010| Reduce Prevalence of Blindness to 0. 5%| 2010| Reduce IMR to 30/1000 And MMR to 100/Lakh| 2010| Increase utilization of public health facilities from current Level of 75%| 2010| Establish an integrated system of surveillance, National Health Accounts and Health Statistics. | 2005| Increase health expenditure by Government as a % of GDP from the existing 0. 9 % to 2. % | 2010| Increase share of Central grants to Constitute at least 25% of total health spending| 2010| Increase State Sector Health spending from 5. 5% to 7% of the budgetFurther increase to 8% | 2005 2010| 4. Write notes on a. WHO b. UNICEF c. Health problems of Developing Nations. ANS : a. WHO World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations (UN) that acts as a coordinating authority on international public health. Established on April 7, 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health Organization, which had been an agency of the League of Nations. BackgroundThe notion of establishing an international authority to overlook issues of public health began with the formulation of rules of international law during late 19th and early 20th century. Already on December 9, 1907, a convention was concluded in Rome for the establishment of an International Office of Public Health by the governments of the United Kingdom, Belgium, Brazil, Spain, the United States of America, France, Italy, the Netherlands, Portugal, Russia, Switzerland and Egypt. This organization consisted of representatives of the signatory parties. Constitution and history The WHO’s constitution states that its objective “is the attainment by all people of the highest possible level of health . Its major task is to combat disease, especially key infectious diseases, and to promote the general health of the people of the world. The World Health Organization (WHO) is one of the original agencies of the United Nations, its constitution formally coming into force on the first World Health Day, (April 7, 1948), when it was ratified by the 26th member state. Jawarharlal Nehru, a major freedom fighter of India had given an opinion to start WHO. Prior to this its operations, as well as the remaining activities of the League of Nations Health Organization, were under the control of an Interim Commission following an International Health Conference in the summer of 1946. The transfer was authorized by a Resolution of the General Assembly.The epidemiological service of the French Office International d’Hygiene Publique was incorporated into the Interim Commission of the World Health Organization on January 1, 1947. Activities Apart from coordinating international efforts to control outbreaks of infectious diseases, such as SARS, malaria, Tuberculosis, swine flu, and AIDS the WHO also sponsors programmes to prevent and treat such diseases. The WHO supports the development and distribution of safe and effective vaccines, pharmaceutical diagnostics, and drugs. After over two decades of fighting smallpox, the WHO declared in 1980 that the disease had been eradicated – the first disease in history to be eliminated by human effort. The WHO aims to eradicate polio within the next few years.The organization has already endorsed the world’s first official HIV/AIDS Toolkit for Zimbabwe (from 3 October 2006), making it an international standard. In addition to its work in eradicating disease, the WHO also carries out various health-related campaigns — for example, to boost the consumption of fruits and vegetables worldwide and to discourage tobacco use. Experts met at the WHO headquarters in Geneva in February, 2007, and reported that their work on pandemic influenza vaccine development had achieved encouraging progress. More than 40 clinical trials have been completed or are ongoing. Most have focused on healthy adults. Some companies, after completing safety analysis in adults, have initiated clinical trials in the elderly and in children.All vaccines so far appear to be safe and well-tolerated in all age groups tested. The WHO also promotes the development of capacities in Member States to use and produce research that addresses national needs, by bolstering national health research systems and promoting knowledge translation platforms such as the Evidence Informed Policy Network -EVIPNet. WHO and its regional offices are working to develop regional policies on research for health -the first one being the Regional Office for the Americas PAHO/AMRO that had its Policy on Research for Health approved in September 2009 by its 49th Directing Council WHO also conducts health research in communicable diseases, non-communicable conditions and injuries; or example, longitudinal studies on aging to determine if the additional years we live are in good or poor health, and, whether the electromagnetic field surrounding cell phones has an impact on health. Some of this work can be controversial, as illustrated by the April, 2003, joint WHO/FAO report, which recommended that sugar should form no more than 10% of a healthy diet. This report led to lobbying by the sugar industry against the recommendation, to which the WHO/FAO responded by including in the report the statement “The Consultation recognized that a population goal for free sugars of less than 10% of total energy is controversial”, but also stood by its recommendation based upon its own analysis of scientific studies.The World Health Organization’s suite of health studies is working to provide the needed health and well-being evidence through a variety of data collection platforms, including the World Health Survey covering 308,000 respondents aged 18+ years and 81,000 aged 50+ years from 70 countries and the Study on Global Aging and Adult Health (SAGE) covering over 50,000 persons aged 50+ across almost 23 countries. The World Mental Health Surveys, WHO Quality of Life Instrument, WHO Disability Assessment Scales provides guidance for data collection in other health and health-related areas. Collaborative efforts between WHO and other agencies, such as the Health Metrics Network and the International Household Surveys Network, serve the normative functions of setting high research standards. Publishing * International Classification of Diseases (ICD) is a widely followed publication. The tenth revision of the ICD, also known as ICD-10, was released in 1992 and a searchable version is available online on the WHO website.Later revisions are indexed and available in hard-copy versions. The WHO does not permit simultaneous classification in two separate areas. * The annual World Health Report, first published in 1995, is the WHO’s leading publication. Each year the report combines an expert assessment of global health, including statistics relating to all countries, with a focus on a specific subject. The World Health Report 2007 – A safer future: global public health security in the 21st century was published on August 23, 2006. * Bulletin of the World Health Organization A Monthly journal published by WHO since 1947. * A model list of essential medicines that ll countries’ health-care systems should make available and affordable to the general population. * Global plan of action on workers’ health is a draft to protect and promote health in the workplace, to improve the performance of and access to occupational health services, and to incorporate workers’ health into other policies. The WHO has emphasized the effort because, despite the availability of effective interventions to prevent occupational hazards, large gaps exist between and within countries with regard to the health status of workers and their exposure to occupational risks. According to the WHO, only a small minority of the global workforce has access to occupational health services.The action plan deals with aspects of workers’ health, including primary prevention of occupational hazards, protection and promotion of health at work, employment conditions, and a better response from health systems to workers’ health.  * Health Sciences Online is a non-profit online health information resource from the World Health Organization. The WHO website A guide to statistical information at WHO has an online version of the most recent WHO health statistics. According to The WHO Programme on Health Statistics: The production and dissemination of health statistics for health action at country, regional and global levels is a core WHO activity mandated to WHO by its Member States in its Constitution.WHO produced figures carry great weight in national and international resource allocation, policy making and programming, based on its reputation as “unbiased” (impartial and fair), global (not belonging to any camp), and technically competent (consulting leading research and policy institutions and individuals). Programmes and projects * African Programme for Onchocerciasis Control (APOC) * Yellow Card or Carte Jaune, is an international certificate of vaccination (ICV) issued by the WHO. It is recognised internationally and may be required for entering certain countries where there are more health risks for travellers. The Yellow Card should be kept in the holder’s passport as it is a medical passport of sorts. * Collaborating centres are institutions designated by the director-general that work to support WHO rogrammes.  * Global Burden of Disease project (GBD) * Global Initiative for Emergency and Essential Surgical Care * Global Malaria Programme (GMP) * Household Water Treatment and Safe Storage (HWTS) * Prequalification of Medicines Programme (PMP page) * Integrated Management of Childhood Illness * International Programme on Chemical Safety (IPCS), with ILO and UNEP * International Radon Project * World Health Day is celebrated every year on 7 April. Conventions * Single Convention on Narcotic Drugs * Convention on Psychotropic Substances * World Health Organization Framework Convention on Tobacco Control Private sector partnerships Aeras: Aeras Global TB Vaccine Foundation * DNDi: Drugs for Neglected Diseases Initiative * FIND: Foundation for Innovative New Diagnostics * IASP: International Association for Suicide Prevention * IAVI: International AIDS Vaccine Initiative * IDRI: Infectious Disease Research Institute * IOWH: Institute for Oe World Health * IPM: International Partnership for Microbicides * MMV: Medicines for Malaria Venture * MVI: Malaria Vaccine Initiative * PATH: Program for Appropriate Technology in Health * PDVI: Pediatric Dengue Vaccine Initiative * TB Alliance: Global Alliance for TB Drug Development * GAVI Alliance: Global alliance for vaccines WHO Headquarters in GenevaMembers of the WHO are 191 of the UN members, the Cook Islands and Niue. Non-state territories of UN Member States may join as Associate Members (with full information but limited participation and voting rights) if approved by an Assembly vote: Puerto Rico and Tokelau are Associate Members.  The following states and entities was granted observer status: Palestine (a UN observer), Vatican City (UN observer), Order of Malta (UN observer) and Chinese Taipei (an invited delegation). Non-members of the WHO are Liechtenstein and the rest of states with limited recognition. WHO Member States appoint delegations to the World Health Assembly, WHO’s supreme decision-making body.All UN member states are eligible for WHO membership, and, according to the WHO web site, “Other countries may be admitted as members when their application has been approved by a simple majority vote of the World Health Assembly. ” The WHO Assembly generally meets in May each year. In addition to appointing the Director-General every five years, the Assembly considers the financial policies of the Organization and reviews and approves the proposed programme budget. The Assembly elects 34 members, technically qualified in the field of health, to the Executive Board for three-year terms. The main functions of the Board are to carry out the decisions and policies of the Assembly, to advise it and to facilitate its work in general.The WHO is financed by contributions from member states and from donors. In recent years, the WHO’s work has involved increasing collaboration with external bodies; there are currently around 80 partnerships with NGOs and the pharmaceutical industry, as well as with foundations such as the Bill and Melinda Gates Foundation and the Rockefeller Foundation. Voluntary contributions to the WHO from national and local governments, foundations and NGOs, other UN organizations, and the private sector, now exceed that of assessed contributions (dues) from the 193 member nations. Regional offices Uncharacteristically for a UN Agency, the six Regional Offices of the WHO enjoy remarkable autonomy.Each Regional Office is headed by a Regional Director (RD), who is elected by the Regional Committee for a once-renewable five-year term. The name of the RD-elect is transmitted to the WHO Executive Board in Geneva, which proceeds to confirm the appointment. It is rare that an elected Regional Director is not confirmed. Each Regional Committee of the WHO consists of all the Health Department heads, in all the governments of the countries that constitute the Region. Aside from electing the Regional Director, the Regional Committee is also in charge of setting the guidelines for the implementation, within the region, of the Health and other policies adopted by the World Health Assembly.The Regional Committee also serves as a progress review board for the actions of the WHO within the Region. The Regional Director is effectively the head of the WHO for his or her Region. The RD manages and/or supervises a staff of health and other experts at the regional headquarters and in specialized centers. The RD is also the direct supervising authority—concomitantly with the WHO Director General—of all the heads of WHO country offices, known as WHO Representatives, within the Region. WHO liaison and other offices WHO has a number of specialist offices/agencies, as well as liaison offices at the most important international institutions. IARC, International Agency for Research on Cancer (Lyon, France) * WHO Centre for Health Development – WHO Kobe Center (Kobe, Japan) * WHO Lyon Office for National Epidemic Preparedness and Response (LYO) (Lyon, France) * WHO Mediterranean Centre for Vulnerability Reduction (Tunisia) * WHO Office at the African Union and the Economic Commission for Africa (Addis Ababa, Ethiopia) * WHO Liaison Office in Washington (USA) * WHO Office at the European Union (Brussels, Belgium) * WHO Office at the United Nations (New York, USA) * WHO Office at the World Bank and the International Monetary Fund (Washington, USA) Country offices The World Health Organization operates 147 country and liaison offices in all its regions. The presence of a country office is generally motivated by a need, stated by the member country. There will generally be one WHO country office in the capital, occasionally accompanied by satellite-offices in the provinces or sub-regions of the country in question.The country office is headed by a WHO Representative (WR), who is a trained physician, not a national of that country, who holds diplomatic rank and is due privileges and immunities similar to those of an Ambassador Extraordinary and Plenipotentiary. In most countries, the WR (like Representatives of other UN agencies) is de facto and/or de jure treated like an Ambassador – the distinction here being that instead of being an Ambassador of one sovereign country to another, the WR is a senior UN civil servant, who serves as the “Ambassador” of the WHO to the country to which he or she is accredited. Hence, the title of Resident Represaentative, or simply Representative. The WR is member of the UN system country Team which is coordinated by the UN system resident Coordinator.The country office consists of the WR, and several health and other experts, both foreign and local, as well as the necessary support staff. The main functions of WHO country offices include being the primary adviser of that country’s government in matters of health and pharmaceutical policies. International liaison offices serve largely the same purpose as country offices, but generally on a smaller scale. These are often found in countries that want WHO presence and cooperation, but do not have the major health system flaws that require the presence of a full-blown country office. Liaison offices are headed by a liaison officer, who is a national from that particular country, without diplomatic immunity. StaffingThe World Health Organization is an agency of the United Nations and as such shares a core of common personnel policy with other agencies. The World Health Organization has recently banned the recruitment of cigarette smokers, to promote the principle of a tobacco-free work environment. The World Health Organization(WHO) successfully rallied 168 countries to sign the Framework Convention on Tobacco Control in 2003.  The Convention is designed to push for effective legislation and its enforcement in all countries to reduce the harmful effects of tobacco. On August 28, 2005, the National People’s Congress of China signed the Convention. Controversies Condoms and the Roman Catholic ChurchIn 2003, the WHO denounced statements by the Roman Curia’s health department, saying: “These incorrect statements about condoms and HIV are dangerous when we are facing a global pandemic which has already killed more than 20 million people, and currently affects at least 42 million. ” Intermittent Preventive Therapy The aggressive support of the Bill & Melinda Gates Foundation for intermittent preventive therapy which included the commissioning a report from the Institute of Medicine triggered a memo from the former WHO malaria chief Dr. Akira Kochi. Dr. Kochi wrote, “although it was less and less straightforward that the health agency should recommend IPTi, the agency’s objections were met with intense and aggressive opposition from Gates-backed scientists and the foundation”. b. UNICEF UNICEF United Nations Children’s Fund (or UNICEF; pronounced /? ju? n? s? /) was created by the United Nations General Assembly on December 11, 1946, to provide emergency food and healthcare to children in countries that had been devastated by World War II. In 1953, UNICEF became a permanent part of the United Nations System and its name was shortened from the original United Nations International Children’s Emergency Fund but it has continued to be known by the popular acronym based on this old name. Headquartered in New York City, UNICEF provides long-term humanitarian and developmental assistance to children and mothers in developing countries. UNICEF relies on contributions from governments and private donors and UNICEF’s total income for 2006 was $2,781,000,000.Governments contribute two thirds of the organization’s resources; private groups and some 6 million individuals contribute the rest through the National Committees. UNICEF’s programs emphasize developing community-level services to promote the health and well-being of children. UNICEF was awarded the Nobel Peace Prize in 1965 and the Prince of Asturias Award of Concord in 2006. Structure of the organization and staff The heart of UNICEF’s work is in the field, with staff in over 190 countries and territories. More than 200 country offices carry out UNICEF’s mission through a unique program of cooperation developed with host governments. Seven regional offices guide their work and provide technical assistance to country offices as needed.Overall management and administration of the organization takes place at its headquarters in New York. UNICEF’s Supply Division is based in Copenhagen and serves as the primary point of distribution for such essential items as lifesaving vaccines, antiretroviral medicines for children and mothers with HIV, nutritional supplements, emergency shelters, educational supplies, and more. Guiding and monitoring all of UNICEF’s work is a 36-member Executive Board which establishes policies, approves programs and oversees administrative and financial plans. The Executive Board is made up of government representatives who are elected by the United Nations Economic and Social Council, usually for three-year terms.Following the reaching of term limits by Executive Director of UNICEF Carol Bellamy, former United States Secretary of Agriculture Ann Veneman became executive director of the organization in May 2005 with an agenda to increase the organization’s focus on the Millennium Development Goals. She was succeeded in May 2010 by Anthony Lake. Unlike NGOs, UNICEF is an inter-governmental organization and this is accountable to governments. This gives it unique reach and access in every country in the world, but may also sometimes hamper its ability to speak out publicly on rights violations, or to openly criticise the policies and actions of governments. UNICEF National Committees There are National Committees in 36 industrialized countries worldwide, each established as an independent local non-governmental organization.The National Committees serve as the public face and dedicated voice of UNICEF, raising funds from the private sector, promoting children’s rights, and securing worldwide visibility for children threatened by poverty, disasters, armed conflict, abuse and exploitation. UNICEF is funded exclusively by voluntary contributions, and the National Committee, collectively raise around one-third of UNICEF’s annual income. This comes through contributions from corporations, civil society organizations and more than 6 million individual donors worldwide. They also rally many different partners – including the media, national and local government officials, NGOs, specialists such as doctors and lawyers, corporations, schools, young people and the general public – on issues related to children’s rights. Promotion and fundraisingIn the United States, Canada and some other countries, UNICEF is known for its “Trick-Or-Treat for UNICEF” program in which children collect money for UNICEF from the houses they trick-or-treat on Halloween night, sometimes instead of candy. UNICEF is present in 190 countries and territories around the world. UNICEF designated 1979 as the “Year of the Child”, and many celebrities including David Gordon, David Essex, Alun Davies and Cat Stevens gave a performance at a benefit concert celebrating the Year of the Child Concert in December 1979. Many people in developed countries first hear about UNICEF’s work through the activities of 36 National Committees for UNICEF.These non-governmental organizations (NGO) are primarily responsible for fundraising, selling UNICEF greeting cards and products, creating private and public partnerships, advocating for children’s rights, and providing other invaluable support. The U. S. Fund for UNICEF is the oldest of the National Committees, founded in 1947.  New Zealand appointed, in 2005, 18-year-old Hayley Westenra, a talented, world famous opera / pop singer as their Ambassador to UNICEF, in an effort to enlist the youth of the world in supporting UNICEF. Westenra has made several trips to visit underprivileged children in third world countries on behalf of UNICEF, in an effort to publicize their plight, and has engaged in fund-raising activities in support of the UNICEF mission, as well.In 2009, the British retailer Tesco used “Change for Good” as advertising, which is trade marked by Unicef for charity usage but is not trademarked for commercial or retail use. This prompted the agency to say, “it is the first time in Unicef’s history that a commercial entity has purposely set out to capitalise on one of our campaigns and subsequently damage an income stream which several of our programmes for children are dependent on”. They went on to call on the public “who have children’s welfare at heart, to consider carefully who they support when making consumer choices”.   Sponsorship Recently, UNICEF has begun partnerships with world-class athletes and teams to promote the organization’s work and to raise funds.On 7 September 2006, an agreement between UNICEF and the Spanish association football club FC Barcelona was reached whereby the club would donate 1. 5 million euros per year to the organization for five years. As part of the agreement, FC Barcelona will wear the UNICEF logo on the front of their shirts, which will be the first time a football club sponsored an organization rather than the other way around. It is also the first time in FC Barcelona’s history that they have had another organization’s name across the front of their shirts. In January 2007, UNICEF struck a partnership with Canada’s national tent pegging team. The team was officially re-flagged as “UNICEF Team Canada”, its riders wear UNICEF’s logo in competition, and team members