Universal health coverage: As I understand it

Dr KK Aggarwal

Universal health coverage is the need of the hour. Two weeks back I was in Malaysia for the CMAAO Assembly, where the Malaysian Medical Association (MMA) spoke about their 40:40:20 scheme. The entire population of Malaysia has been divided into three income groups: Lower income group bracket 40%, middle income group bracket 40% and top 20 income bracket 20%. Their government has said that they would pay for and look after the lower 40% income group bracket.

That is what the Modi government has decided to do. 

Under Article 21 of the constitution of India, right to health is a fundamental right and under Article 467 state directive principles, it is the primary duty of the state government to provide this as per their means and if they cannot provide, they need to enlist the private health sector under PPP model.

Under Ayushman Bharat, the government is paying for the insurance premium of 50 crore people. Everybody has a criticism that the premium is too low for five lakh insurance. But the reality is it is not five lakh insurance, the insurance is of approximately one lac as the packages have been capped with the maximum cap being around one lakh for tertiary care procedures. For one lakh insurance, the premium calculation is correct. 

What is required is honesty at every level in running the scheme.

Being a capped reimbursement policy, chances of manipulations are lower except for billing one surgical procedure as two procedures. This loophole needs to be checked.

Once the government has divided the community into two segments the poor (under Ayushman Bharat) and non-poor (personal insurance), every hospital also can and invariably will have two categories in their establishments (general ward for Ayushman Bharat and private wards for others).

In my medical college, we were taught affordable health care under the subject low-cost healthcare and we all need to revise this topic. For example, why should I go for full hemogram in routine cases when the same information can be gathered by looking at the peripheral smear and ESR.

This scheme will promote the Make in India program of the Govt. Devices, consumables, drug, reagents and/or equipments will take precedence and their use will increase; we need to find out indigenous ways to manufacture these at low cost. Use of generics will increase, use of antiseptics may increase to cut down infection rates, which will bring down antimicrobial resistance (AMR).

The scheme will open doors for Jan Aushadhi drugs, only essential investigations, minimum cross referrals and promotion of day care procedures.  

Being a doctor means we are different and are considered demi Gods. Those who believe in it should do 10% subsidized charity by choice. The charitable rates can be reimbursed by the Ayushman Bharat schemes.

Universal health coverage is incomplete without disease prevention and harm reduction. The budgets for road safety, universal immunization, antenatal care, rural health, Swachh Bharat, environmental protection, skill development, drug development, safe water, safe soil etc. should be calculated as extension of health budget.

Harm reduction is already in the fray with elimination of mercury by 2020, sequential phasing out of Euro 4 vehicles with an aim to go for Euro 6, gradually reducing the air pollution parameters, phasing out trans fats in commercial restaurants.

A major mistake of the government is not banning tobacco from the country. The govt. is neither banning tobacco nor allowing comparatively safer electronic cigarettes in the market giving the message that conventional cigarettes are the best.

Among people who cannot afford, all those covered by ESIC, CGHS, Defence (BSF, CRPF, ITBP), PSUs, State health insurance, municipal corporations etc will automatically get excluded as they are already covered under respective schemes.  

Will casual or contractual laborers be covered under Ayushman Bharat? Another major challenge would be rare diseases.

Issues such as these will keep on coming up as the scheme is being implemented.

The success of the scheme will depend on the number of "no claims", amount of claims more than one lakh and percentage of disorders requiring recurrent hospitalization.  

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Early detection and timely treatment are the prerequisites to end TB by 2025

 The World Health Organization (WHO) has published its latest edition of the global TB report for this year. As per the report, globally, 10 million people developed TB disease in 2017; of these, 5.8 million were men, 3.2 million women and 1.0 million children. About 1.7 billion people, 23% of the world’s population, are estimated to have a latent TB infection, which puts them at risk of developing active TB disease. Also, drug-resistant TB continues to be a public health crisis. In 2017, 558 000 people developed rifampicin-resistant (RR)-TB); of these, 82% had multidrug-resistant TB (MDR-TB).

 The disease burden caused by TB is declining in most countries, but not fast enough to reach the first (2020) milestones of the End TB Strategy.

 By 2020, the TB incidence rate needs to be falling at 4–5% per year, and the proportion of people with TB who die from the disease (the case fatality ratio, CFR) needs to fall to 10%. But, worldwide, the TB incidence rate is falling at about 2% per year and the TB mortality rate is falling at about 3% per year.

 So, clearly much more needs to be done if the goal of ending the TB epidemic by 2030 is to be met with.

 TB remains the leading cause of death from a single infectious agent (above HIV/AIDS).

 Specific targets for 2030 are a 90% reduction in the absolute number of TB deaths and an 80% reduction in TB incidence (new cases per 100 000 population per year), compared with levels in 2015. Underreporting of detected cases and underdiagnosis remain major challenges to achieving these targets.

In 2017, India accounted for highest number of TB cases globally at 27%; India along with China and the Russian Federation accounted for almost half of the world’s cases of MDR/RR-TB: India (24%), China (13%) and the Russian Federation (10%).

India (26%) was the top country accounting for the global gap in diagnosis and treatment followed by Indonesia (11%) and Nigeria (9%).

India has not fared well as is evident from this latest global TB report. TB is a preventable and curable disease. Despite advances in TB care, India continues to have the highest burden of both TB and MDR TB patients globally.

India has set an ambitious target for itself – to be free of TB by 2025 - five years before the global target in the Delhi End TB Summit held in March this year. To achieve these targets, the Government has rolled out new “National Strategic Plan (NSP) to end TB by 2025”.

Control of TB should therefore be of immediate priority for all stakeholders including health care providers and policy makers.

When I was president of IMA, we had started a campaign “IMA TB Initiative: GTN”. The latest TB statistics for India bring this strategy to the forefront in the battle against TB.

l G: GeneXpert test (diagnose)

l T: Treat (patients) & Trace (contacts)

l N: Notify (mandatory)

Early diagnosis translating to early treatment is the basis of controlling TB. All household and close contacts of patients with infectious TB should be traced, screened and treated with a full course of ATT if found to have TB. Contact tracing interrupts the chain of transmission of the disease by early detection and timely and complete treatment. TB is a notifiable disease. Every case of TB has to be notified to the concerned authorities.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Ayushman Bharat to roll out today across the country

Today onwards, nobody will be poor in India, from the health point of view. Now, all needy people will have an insurance of Rs 5 lakh with the premium paid by the government. 

The Prime Minister, Shri Narendra Modi, will launch the Ayushman Bharat scheme, officially known as the Pradhan Mantri Jan Arogya Yojana (PM-JAY) today in Ranchi, Jharkhand.

The scheme will provide insurance cover of up to Rs 5 lakh per family per year at any government or empanelled private hospital all over India, for secondary and tertiary care hospitalization. More than 10 crore poor and economically deprived families and more than 50 crore people will benefit. There is no restriction on family size, age or gender. All pre-existing conditions are covered from day one of the  policy. The benefit cover includes both pre and post hospitalization expenses.

All workers in India, who earn less than 21,000 INR per month are already covered under the Employees’ State Insurance (ESI) Scheme. 

Getting the insurance premium paid by the government will now be a fundamental right for those who are eligible for the scheme.

All hospitals and health care establishments, who have committed 10% free work for the economically weaker section (EWS) of the society will now get paid under the scheme; also, all government hospitals will start getting some reimbursements under the scheme. So, more and more people will now opt for private wards in government hospitals. 

Health is already a fundamental right under Article 21 of the constitution of India and improvement of the public health is a primary duty of the government under Article 47, under the Directive Principles of State Policy, based on the means available, which mandates the government “to raise the level of nutrition and the standard of living and to improve public health”. And, if the required means are not available, the state government can then mandate all private hospitals to enroll under this scheme.

Because all emergent health conditions will be paid for under the insurance scheme for the poor and the needy, hospitals will no more have an excuse to refuse treatment and 100% hospitals will have to comply. 

Time has come for universal health coverage and to make quality health care “available”, “accessible”, “affordable” to all and also “accountable”. The Ayushman Bharat scheme is one step towards this end.

For those who can pay, it must be mandatory to get an insurance for at least Rs 5 lakh, which will become a minimum benchmark for health insurance in India.

Once 100% people are insured, health care will become affordable over time to everyone. Treatment costs will automatically reduce.

The two types of insurance (Ayushman and non Ayushman), two types of premiums, two types of packages and two types of treatment will also invariable undergo auto correction. 

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Diphtheria Update

Diphtheria kills 12 children in 13 days in two Delhi govt hospitals

At least 12 children have died of diphtheria in 13 days, between September 6 and 19, in two government hospitals in Delhi, as reported in HT, Sept. 21, 2018. Eleven children have died in the North Delhi Municipal Corporation-run Maharishi Valmiki Infectious Diseases Hospital and one child died in the Delhi government-run Lok Nayak Hospital. Of the 300 cases reported so far this year, 85 people were admitted with the bacterial infection at the Valmiki Hospital from September 1 to September 19, hospital authorities said.

Here is a recap of diphtheria, the disease.

· Diphtheria is an infectious disease caused by the gram-positive bacteria Corynebacterium diphtheriae.

·         The infection is transmitted via close contact with infectious material from respiratory secretions (direct or via airborne droplet from coughing or sneezing) or from skin lesions or clothes of the infected person or by touching contaminated objects such as toys.

·         Humans are the only known reservoir for C. diphtheriae. Immunity, either via natural infection or vaccine-induced does not prevent carriage. Hence, asymptomatic carriers play an important role in disease transmission.

·         Diphtheria is fatal in 5-10% of cases. Mortality rate is higher in young children.

·         Clinically, diphtheria presents as respiratory diphtheria or cutaneous diphtheria or an asymptomatic carrier state.

·         Respiratory diphtheria is caused by toxigenic strains of C. diphtheria. It mainly involves the pharynx (throat) and upper airways. Symptoms include sore throat, malaise, cervical lymphadenopathy and low grade fever. In some patients, toxin induces the formation of a thick grey coating “pseudomembrane” over the throat and tonsils making it difficult for the patient to breathe and swallow. The membrane is composed of necrotic fibrin, leukocytes, erythrocytes, epithelial cells and organisms. This membrane adheres tightly to the underlying tissue and bleeds with scraping.

·         Complications include blocking of airway, myocarditis, peripheral neuropathy, paralysis, pneumonia or respiratory failure.

·         A form of malignant diphtheria is associated with extensive "membranous pharyngitis" along with massive swelling of the tonsils, uvula, cervical lymph nodes, submandibular region and anterior neck ("bull neck" of toxic diphtheria). Respiratory stridor may ensue, leading to respiratory insufficiency and death. Aspiration of the membrane can also cause suffocation in these patients.

·         Cutaneous diphtheria is usually a mild disease and presents as cutaneous sores or shallow ulcers. Complications are uncommon in cutaneous diphtheria.

·         Diagnosis is usually clinical. Definitive diagnosis requires culture of a throat swab or swab from the skin lesion to isolate the bacteria. However, if clinical suspicion for diphtheria is high, then treatment must be started immediately without waiting for lab confirmation.

·         Treatment: Administration of diphtheria antitoxin and antibiotics. Antitoxin is usually not required in cutaneous disease due to the lack of pseudomembranes or cardiac involvement

·         Antibiotic of choice: Erythromycin (500 mg four times daily x 14 days) or procaine penicillin G (300,000 units every 12 hours for patients ≤10 kg and 600,000 units every 12 hours for patients >10 kg IM). When the patient is able to take orally, give oral penicillin V (250 mg four times daily) x 14 days.

·         Diphtheria antitoxin, to neutralize the effects of the toxin, is administered intravenously over 60 minutes for rapid inactivation of the toxin. But, it must be administered early because once the toxin enters the cell, it is ineffective. A hypersensitivity test must be done prior to administration.

o    The American Academy of Pediatrics (AAP) recommends 20,000 to 40,000 units for pharyngeal/laryngeal disease of <48 hours duration, 40,000 to 60,000 units for nasopharyngeal disease, and 80,000 to 120,000 units for >3 days of illness or diffuse neck swelling (bull neck).

·         Patients should be kept in isolation until two consecutive cultures taken at least 24 hours apart are negative.

·         All close contacts of the patients including the health care workers should be administered diphtheria toxoid (DT) vaccine, if vaccination status is not updated. After cultures have been obtained, contacts should receive antimicrobial prophylaxis with a single dose of penicillin G benzathine (600,000 units IM for persons <6 years of age and 1.2 million units IM for persons ≥6 years of age) or oral erythromycin (500 mg four times daily x 7-10 days).

·         Prevention is via a 3-dose primary vaccination series with diphtheria containing vaccine (DTwP/DTaP vaccine or pentavalent vaccine) followed by 3 booster doses. Vaccination should begin as early as 6-week of age with subsequent doses given at an interval of 4 weeks between doses. The 3 booster doses should preferably be given during 12-23 months, at 4-7 years and at 9-15 years of age. Ideally, there should be at least 4 years between booster doses.

(Source: Uptodate, CDC, WHO)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Fake it to make it

We all aspire to be successful, be happy always, or project confidence and put our best foot forwards…each one of us wants to be a person of sterling qualities. But, this is not always so. Not everybody is successful, our definitions of happiness vary and confidence often takes a long time to develop. So, if I am none of the above, then how can I be what I am not?

There is saying “Fake it till you make it”, it suggests that by imitating confidence, competence, and an optimistic mindset, a person can realize those qualities in their real life. It is similar in meaning to the idiom “act as if” (Wikipedia).

Here are some ways how you can do it:

·  If you want to feel happy, practice faking a smile. Hold a pen in your mouth and force a smile. This is what happy people do.

·  Adopt power postures, even when you don't feel so confident. Compared to a low-power pose (sitting hunched over with arms and legs crossed), a high-power pose (expansive posture) has been shown to be associated with increase in testosterone and decrease in the levels of the stress hormone cortisol. Testosterone is related to dominance and confidence.

·  Join a laughter club.

·  Dress the part. How you dress will affect how others see you. Clothes make a strong visual statement about your self-image.

·  Model yourself after a person who is successful. Mimic their actions.

Faking it does not mean that you should be insincere. Behaving like the person you want to become is an effective way to positively change your life.

“Fake till you become it. Do it enough until you actually become it and internalize.” 

Whatever you do, practice it over a period of time (japa), till it is deeply etched in your consciousness.

“As one thinks, so he becomes”. The human mind is very powerful and has unlimited potential. It can influence behavior. Repeated actions change to habits, which ultimately shape your personality.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Decriminalization of section 377: Much more needs to be done

In a historic and unanimous judgment delivered this month on 7th Sept, the Supreme Court of India decriminalized section 377 of the Indian Penal Code (IPC), as per which homosexuality is a punishable offence, stating that “Section 377 is irrational, arbitrary and incomprehensible” and termed “sexual orientation as biological phenomenon, says any discrimination on this grounds is violative of fundamental rights”.

Homosexuality has mostly been perceived in terms of sexuality and sexual relationship with a same sex partner. But, this is not the only or its most relevant aspect. There are several related issues, which need to be dealt with to bring the LGBT community into the mainstream.

While the Supreme Court has protected their sexual rights, there is still a long road ahead before they can enjoy other civil rights as do the heterosexuals including the right to equality (under Article 14 of the constitution of India), right to live with dignity without discrimination (under Article 15), right to life and liberty (under Article 21), right to privacy (under Article 21) and right to freedom of expression (under Article 19).

Right to health and access to healthcare (under Article 21), right to reputation (under Article 21), right to education (under Article 21), right to marriage, right to shelter, right to inherit property, right to form associations, right to adoption, protection from domestic violence, right to employment, right to insurance are some other challenges that also need to be addressed.

Limited or lack of access to basic health care, negative encounters with hospital staff and inadequately trained health care providers are barriers to care for the LGBT community. It’s difficult for them to get health insurance. These barriers must to be overcome.

All health care providers must be educated and trained in LGBT patient-centered care to ensure that the LGBT individuals do not receive substandard care and services, and also that their health issues are taken care of with sensitivity and without any discrimination or bias. Not only doctors and paramedical staff, other hospital staff members such as security guard, receptionist, office clerks etc. should be trained in verbal and nonverbal communication.

Communicating without being judgmental is the first step towards building trust and respect.

Some health-related issues pertaining to LGBT are:

·         Disparities and improving healthcare and services for older LGBT populations

·         Health-related behaviors and outcomes in chronic conditions among transgender Medicare beneficiaries

·         Health indicators for older sexual minority individuals

·         Need to improve measures of sexual orientation and gender identity to identify LGBT older adults

·         Sexual orientation differences in risk factors for cardiovascular disease in men

·         Prevalence of diabetes by sexual orientation

·         A complex case of a trans-feminine youth with a BRCA1 mutation

·         Victimization and suicidality among transgender individuals

·         Co-occurrence of gender dysphoria and autism spectrum disorder symptoms in adults

·         Perceived stress and depressive symptoms among sexual minority young adults

·         Prevalence and correlates of prescription drug misuse among sexual minority men

·         Identifying and counting individuals with differences of sex development in population health research

·         Disaggregation of data by sexual orientation, gender identity, and sex assigned at birth

·         Chronic conditions disparities

·         Health outcomes of gender-affirming interventions

·         Self-harm and suicide prevention for sexual and gender minority (SGM) youth

·         Assessment of and appropriate responses to gender incongruence

·         Preventive health care and screenings

·         Protective influence of families and schools

·         Minority stress and resilience factors

·         Racial and ethnic disparities

·         Substance use among SGM youth

·         HIV prevention, including Pre-exposure prophylaxis uptake and adherence

·         Methodological and ethical issues in conducting research with SGM youth

·         Improving LGBT clinical and cultural competency.

·         Changes to laws and policies that affect the health of SGM populations, as well as issues related to healthcare coverage and access

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Thanking IMA

Dear Friends,

A new team of CMAAO leaders took office at the 33rd Assembly of CMAAO held in Penang, Malaysia from 12th-14th September.

Dr Ravindran Naidu, President Malaysia Medical Association was elected President for this year.

I was elected as the President-elect and will be taking over as President CMAAO on 5th September in 2019 in Goa.

CMAAO or the Confederation of Medical Associations in Asia and Oceania currently has 18 member National Medical Associations (NMAs): India, Australia, Bangladesh, Cambodia, Hong Kong, Indonesia, Japan, Korea, Macau, Malaysia, Myanmar, Nepal, New Zealand, Pakistan, Phillipines, Singapore, Sri Lanka, Taiwan and Thailand.

The credit for bringing IMA on the global map goes to Dr Ketan Desai, Former President World Medical Association (WMA), Dr Ajay Kumar Council Member WMA, Dr Vinay Aggarwal Past President CMAAO and Dr Ravi Wankhedkar National President IMA.

Since its establishment in 1956, the objective of CMAAO has been to promote academic exchange of information on health issues and also to cultivate ties of friendship between member medical associations. In the event of any epidemic or outbreak or public health crisis, various countries can share their health models besides knowledge and experiences of a similar situation.

For example, in the IMA-CMAAO meet on combating air pollution held in New Delhi last year, the Korean Medical Association presented its model of tackling air pollution in their country. Similarly, the Sri Lanka NMA should be able to showcase their model for achieving control of malaria to their government.

I am thankful to IMA for electing me as an office bearer of CMAAO, first as 2^nd Vice President, then 1^st Vice President and now President-elect and finally as President.

I will strive to fulfill my responsibilities with the support of all my colleagues in IMA and CMAAO.

Dr KK Aggarwal

Padma Shri Awardee

President-elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA