Health

Context: A new set of operational guidelines of NP-NCD, issued by the government, limit the focus of palliative care in India to people with cancer.

About Palliative care

• It is the branch of medicine focusing on improving the quality of life and preventing suffering among those with life-limiting illnesses like heart failure, kidney failure, certain neurological diseases, cancer, etc.
• It aims to identify patients at risk of over-medicalisation at the expense of quality of life and financial burden on the family.
• It also aims to improve the quality of life by addressing the physical, psychological, spiritual, and social domains of the health of people suffering from life-limiting diseases
• It is often misinterpreted as end-of-life care.
• Beneficiaries are terminal cases of Cancer, AIDS etc.
• The goal is the availability and accessibility of rational, quality pain relief and palliative care to the needy, as an integral part of Health Care at all levels, in alignment with the community requirements.

Need for palliative care

• Palliative care in India has largely been available at tertiary healthcare facilities in urban areas. Due to this skewed availability of services, it is accessible to only 1-2% of the estimated 7-10 million people who require it in the country. 
• India has experienced a steep rise in the burden of lifestyle-related non-communicable diseases. Nearly 1.4 million people are diagnosed with cancer in India every year while diabetes, hypertension, and respiratory diseases are also on the rise. All these diseases need palliative care sooner or later in the disease trajectory.
• Post-independence India has made considerable efforts to improve the health of its people like the introduction of the three-tier health system, multiple national health programmes and schemes, and the Ayushman Bharat Health Insurance Scheme. But despite these efforts, 55 million people in India are pushed below the poverty line every year due to health-related expenditures. Over-medicalisation plays a significant role in this financial burden. 

Steps taken by the government:

• The National Programme for Prevention & Control of Non-Communicable Diseases (NP-NCD): In order to prevent and control major NCDs, it was launched in 2010 with a focus on strengthening infrastructure, human resource development, health promotion, early diagnosis, management and referral.
• The programme envisaged the provision of promotive, preventive, and curative care from the primary to tertiary institutes, thus providing health services delivery across the continuum of care.

• National Programme for Palliative Care (NPPC): It was launched in 2012, NCD Cells are being established at National, State and District levels for programme management, and NCD Clinics are being set up at District and CHC levels, to provide services for early diagnosis, treatment and follow-up for common NCDs. Provision has been made under the programme to provide free diagnostic facilities and drugs for patients attending the NCD clinics.
• National Programme for Health Care for the Elderly: To provide accessible, affordable, and high-quality long-term, comprehensive and dedicated care services to an Ageing population.
• NGOs like Pallium India, Karunashraya, and CanSupport are trying to fill the gap in palliative care in India.

Gaps in the guidelines

• Per the Global Atlas of Palliative Care, in 2020, the need for palliative care was higher for non-cancer illnesses. However, the revised NP-NCD operational guidelines, mention palliative care in synonymy with cancer only. Cancer is just one of 20 common health conditions that require palliative care. 
• Since most patients who need palliative care are suffering from debilitating diseases, home-based care forms the ideal mode of healthcare delivery. Previously, the programme guidelines mentioned providing support for home-based palliative care services. However, palliative care service delivery starts only from the district hospital in the revised guidelines, with no mention of home-based care.
• No mention of home-based palliative care services: Since most patients who need palliative care are suffering from debilitating diseases, home-based care forms the ideal mode of healthcare delivery.
• However, palliative care service delivery starts only from the district hospital in the revised guidelines.
• No mention of paediatric palliative care:  An estimated 98% of children facing moderate to severe suffering during their end of life reside in lower and middle-income countries like India.
• Linking of 11 programmes (including NPPC) to promote convergence: The mechanisms of the linkage with a programme (NPPC) that has not yet been fully implemented are unclear.

Way Forward:

• Access to palliative care will be assessed by estimating morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer. Including an indicator to assess morphine access is a welcome move, but an indicator focusing only on patients with cancer might lead to an inaccurate assessment of coverage of services.
• The recommendations of the World Health Assembly in 2014:

• Palliative care to be integrated into health systems at all levels. 
• Including palliative care along with curative treatment

It is high time for India to realise the ongoing pandemic of non-communicable diseases and strengthen its palliative care services.

Context: Recently the medical journal Lancet launched its study on Diabetes and Endocrinology that reveals that more than a tenth of the people in the country have diabetes, 35 per cent have hypertension and 28 per cent have high cholesterol levels.

What is a lifestyle disorder?

• Lifestyle diseases can be defined as diseases linked to one's lifestyle. These diseases are non-communicable diseases.

Causes of Lifestyle Disorder

• They are caused by lack of physical activity, unhealthy eating, alcohol, substance use disorders and smoking tobacco, which can lead to heart disease, stroke, obesity, type II diabetes and lung cancer.
• These studies have pointed out that lifestyle-related disease is aggravated by poor awareness, especially in rural areas.

 Who is more affected by Lifestyle disorders?

• Several studies have shown that close to 20 per cent of diabetics in the country are below the age of 45 and nearly 45 per cent of the people with the disease are not senior citizens.
• The burden of these disorders is higher in urban areas. But people in rural centres are increasingly becoming vulnerable to metabolic diseases, especially diabetes.
• There is, for instance, almost no rural-urban divide when it comes to pre-diabetes — more than 60 per cent of pre-diabetic people in India end up having the disease.
• The study’s warning that the country’s already serious diabetes burden could take a turn for the worst in the next five years should be taken seriously by the country’s healthcare sector.

Consequences of lifestyle disorder

• In 2005, the World Health Organization (WHO) estimated that 61 per cent of all deaths -35 million and 49 per cent of the global burden of disease were attributable to chronic diseases.
• By 2030, the proportion of total global deaths due to chronic diseases is expected to increase to 70 per cent and the global burden of disease to 56 per cent.
• The Havard School of public health estimated that NCDs are responsible for a loss of 6.2 trillion US dollars between the period 2012-30.

Context: Recently WHO said that piped potable water across India will avert 4,00,000 diarrhoea deaths.

Status of Water Accessibility in India

• As per UNICEF two-thirds of India’s 718 districts are affected by extreme water depletion.
• One of the challenges is the fast rate of groundwater depletion in India, which is known as the world’s highest user of this source due to the proliferation of drilling over the past few decades.
• Groundwater from over 30 million access points supplies 85 per cent of drinking water in rural areas and 48 per cent of water requirements in urban areas.
• Close to 54 per cent of rural women – as well as some adolescent girls - spend an estimated 35 minutes getting water every day, equivalent to the loss of 27 days’ wages over a year.
• Less than 49 per cent of the rural population is using safely managed drinking water (improved water supply located on-premises, available when needed and free of contamination)

Impacts of  Potable Water Accessibility

• It will help in reducing the number of deaths associated with water accessibility like diarrhoea etc.
• This would avoid 14 million DALYs (Disability Adjusted Life Years) from diarrhoea, save close to $101 billion and 66.6 million hours every day of time that would otherwise have been spent — predominantly by women — collecting water.
• A DALY represents the loss of the equivalent of one year of full health and is a way to account for the years of life lost due to premature mortality (YLLs) and the years lived with a disability (YLDs), due to prevalent cases of a disease or a health condition, in a population.
• It is estimated that waterborne diseases have an economic burden of approximately USD 600 million a year in India.
• School attendance in India decreases when children are required to spend hours collecting water. A 22 per cent increase in school dropout rates has been reported in drought-affected states.

Steps Taken for Potable Water Accessibility

• In 2019, the Ministry of Drinking Water and Sanitation (MDWS) was restructured and the Ministry of Jal Shakti (meaning “power of water”), was bifurcated into two key departments – the Department of Water Resources, River Development and Ganga Rejuvenation, and the Department of Drinking Water and Sanitation.
• In August 2019, the union Government launched the Jal Jeevan (Water for Life) Mission.
• The Centre says it will achieve 100% coverage under the Jal Jeevan Mission by 2024;
• So far five States, including Gujarat, Telangana, Haryana and Punjab, have reported full coverage. 
• Grassroots-level support is being prioritized, and communities play a pivotal role in the planning, implementation, operation and maintenance of their schemes. 
• Around 11,000 Implement Support Agencies (ISAs, mainly NGOs) are being  trained to support the implementation of the JJM, covering aspects such as

• community empowerment and engagement,
• water quality testing and surveillance,
• utility operation, water safety and security planning,
• source sustainability measures,
• such as recharge and reuse through grey water management,
• water conservation and rainwater harvesting.

According to the Joint Malnutrition Estimates released by the UNICEF, the WHO and the World Bank, India has shown a significant improvement in various indices of Nutrition.

• Stunting among children under five years in India dropped from a prevalence rate of 41.6% in 2012 to 31.7% in 2022. This was accompanied by India’s share of the global burden of stunting declining from 30% to 25% in the past decade.
• The overall prevalence of wasting in 2022 was 18.7% in India, with a share of 49% in the global burden.
• The prevalence of obesity marginally increased in a decade from 2.2% in 2012 to 2.8% in 2022.

The decline in stunting in India is commensurate with National Family Health Survey (NFHS)-5 (2019-2021) data which estimated its prevalence at 35.5% as against 38% in NFHS-4 (2016) and 48% in NFHS-3 (2006).

Despite improvement in the stunting and wasting, significant number of children are still reeling under the problem of Malnutrition.

Reasons for prevalence of widespread Hunger in India:

• Inappropriate child feeding practices: The WHO and UNICEF recommend that breastfeeding should be initiated within the first hour of birth and infants should be exclusively breastfed for the first six months. NFHS-5 says that only 42% of infants are breastfed within one hour of birth and only 64% of infants are exclusively breastfed for first 6 months. 
• Low Female literacy: Nutrition levels are majorly affected by the education level of women. It increases awareness about nutrient-rich diet, personal hygiene, good feeding practices etc. Educating women also help in containing the family size in poor, malnourished families. But female literacy in India is only 65% and the rate is much lower for the states like Bihar and Rajasthan that recorded high levels of malnutrition in children. 
• Poor Sanitation:  Repeated infection with diarrhoeal diseases due to poor sanitation contributes to chronic malnutrition by inhibiting intestinal absorption of nutrients and is strongly correlated with stunting. The proportion of people with access to improved sanitation facilities in India is only 49% as per NHFS-4. 
• Micro nutrient deficiency:  According to studies, more than 80 per cent of the Indian population suffers from micronutrient deficiencies, contributing to compromised immunity. This is mainly due to lack of dietary diversification, changed dietary habits, food processing resulting in plant micronutrient loss, crop homogenisation. 
• Food inflation: With rising food inflation families become less able to buy and eat nutritious food. According to a report of ADB, 1 per cent increase in food inflation leads to an increase of 0.3 per cent in both infant and child mortalities, and 0.5 per cent in undernourishment. 

Limitations of existing schemes:

• The ICDS program, while successful in many ways, has not made a significant dent in child malnutrition. This is mostly due to the priority that the program has placed on food supplementation, targeting mostly children after the age of three when malnutrition has already set in.
• Stringent conditions to avail the benefits of Pradhan Mantri Matru Vandana Yojana has led to the exclusion of teenage mothers and poor women who birth more than one child, thereby abetting the intergenerational cycle of undernutrition.
• Exclusion errors, non-inclusion of nutritious items such as pulses and edible oil in the PDS basket failed to improve the nutritional status of poor households.

Measures taken by the Government: 

• POSHAN Abhiyaan is an overarching umbrella scheme to improve the nutritional outcomes for children, pregnant women and lactating mothers by holistically addressing the multiple determinants of malnutrition. It involves convergence of multiple programs and schemes: ICDS, PMMVY, NHM (with its sub components such as JSY, MCP card, Anaemia Mukt Bharat, RBSK, IDCF, HBNC, HBYC, Take Home Rations), Swachh Bharat Mission, National Drinking water Mission, NRLM etc.
• Pradhan Mantri Poshan Shakti Nirman (PM POSHAN) for providing one hot cooked meal in Government and Government – aided Schools.
• Food fortification: 
  • Fortification of wheat is being implemented in 12 states on pilot basis.
  • Fortification of edible oil, too, was made compulsory across the country by FSSAI in 2018.
  • Fortification of milk was started in 2017 under which the National Dairy Development Board of India (NDDB) is pushing companies to add vitamin D.
  • States have been scaling up the use of double-fortified salt in an effort to combat iron and iodine deficiencies.
• Price stabilisation fund to regulate the price volatility of important agri-horticultural commodities like onion, potatoes and pulses.