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Journal of the Academy of Hospital Administration

Notes, News and Journal Scan

Author(s): Sidhartha Satpathy*

Vol. 15, No. 2 (2003-07 - 2003-12)

Key Messages:

  • WHO's World Health Report 2003 - shaping the future depends on strengthening health care.
  • WHO steps up campaign on counterfeit drugs; India proposes legislation.
  • Inadequate regulations undermine India's health care.
  • Health tourism - where health care, ethics and state collide; Indian scenario.
  • Preserving today's scientific records for tomorrow.

1. WHO's World Health Report

Prof. Gill Walt states the overall message of this year's World Health Reports, "Shaping the Future," from the World Health Organization is clear. Strengthen health systems, otherwise there will be no progress in meeting a vast and growing array of health inequalities. Furthermore, the report says firmly that strengthened health systems must be based on primary health care. "Shaping the future" is actually about going back to basics.

Justice is seen as both a moral imperative and an aspect of wise security. The message of the new director general. Dr. Lee Jong-wook contrasts the injustice of parts of the world where there are expectations of longer and more comfortable lives, with other parts where there is despair over the failure to control disease, even though the means to do so exist. A child in Japan can not only expect to get reasonable access to health care throughout her life, but also to receive medicines worth, on average, $550 per year (and more if necessary). In contrast, a child in Sierra Leone-if she survives the diseases of childhood will have little access to treatment for illness and will receive, on average, medicines worth about $3 per year.

These inequalities must be confronted by strengthening health systems, building on the values and practices health care, the core principles of which remain as relevant in 2003 as they did at Alma Ata in 1978; universal access to care and coverage on the basis of need; commitment to health equity; community participation; and intersect oral collaboration.

The report is refreshing in its attempt to offer an integrated approach to improving health. Three chapters focus on particular diseases, but emphasis how health systems will play a part in meeting overall health goals. Although it does not evade the urgent need to confront the havoc caused by HIV/AIDS, and reminds readers of WHO's own "3 by 5" commitment (getting 3 million people onto antiretroviral therapy by the year 2005) the report keeps coming back to the health systems that will deliver the necessary prevention and treatment.

One chapter champions the polio eradication campaign as a disease oriented initiative, which has successfully brought together both public and private groups to immunize 575 million children against polio, reminding us that the encouraging success could be undermined if the last endemic areas of the world are not included, and the funding gap not bridged. And just one of the lessons form the SARS epidemic is that weaknesses in health systems, especially in infection control practices, play a key part in permitting emerging infections to spread.

While the 2003 report does not have health systems in its title it draws on notions of responsiveness and stewardship. It asks what need to be done in order to ensure heath systems are able to be responsive to the needs of populations, and how can stewardship steer towards pro-equity health systems.

How heartening it would be to see this World Health Report receiving the high level of attention it deserves-and moving the lens from specific diseases to supporting the health system which will deliver the interventions.

BMJ, Vol. 328, 3 Jan. 2004; p-6

2. WHO steps up campaign on counterfeit drugs - India proposes legislation

Helen Frankish states in the Lancet that WHO has launched an new initiative to tackle the growing problem of counterfeit and substandard drugs in six southeast Asian countries. The action plan was unveiled during a meeting in Hanoi, Vietnam (November 11-13), and will be implemented in Cambodia, China, Laos, Burma, Thailand, and Vietnam.

WHO's action plan will focus on efforts to combat counterfeiting in the region; to promote advocacy activities directed at key decision-makers, health professionals, and the public; and to strengthen inspection and post marketing surveillance in the region.

Up to 25% of all drugs consumed in poor countries are thought to be counterfeit or substandard, according to figures form the US Food and Drug Administration (FDA). Substandard drugs are estimated to account for 8.5% of medicines on the market in Thailand, 8% in Vietnam, and 16% in Burma. The drugs most commonly counterfeited in include antibiotics and medicines to treat HIV/AIDS, tuberculosis, and malaria.

The problem of counterfeit and substandard drugs is not just a concern for developing countries. In September this year, the FDA announced that it was increasing it s action on drug counterfeiting and importation, and that it had set up a task force to identify ways to prevent the trade in fake drugs.

The Lancet, Vol. 362, Nov. 22,2003; p1730

3. Inadequate regulations undermine India's health care

The private sector dominates health care in India, but inadequate legislation and failure to enforce regulations are contributing to poor quality medical services, says World Bank publication released in New Delhi recently. Eighty percent of spending on health in India is from personal funds, but existing laws do not ensure that private medical services maintain even minimum standards, says the report.

Powerful medical lobbies have opposed government efforts to regulate the private sector," it says, adding that India's medical councils are not enforcing laws relating to registration and licensing of medical practitioners.

In a section on private healthcare services the report acknowledges problems that consumer health organizations have long complained about; doctors over prescribing drug, recommending unnecessary investigations and treatment and failing to provide appropriate information for patients.

It says there are no laws regulating the geographical distribution of healthcare provides and the types of technology to be made available and it suggests that the influx of technology may have let to unreasonable use of equipment. Yet, despite such problems most people still choose the private sector, because of accessibility and shorter waiting times for diagnosis and treatment.

Health sector analysts say the private healthcare system in India should be segmented so that the relation between quality and prices of services can be examined.

The India Medical Association has consistently opposed any kind of regulation," said Ravi Duggal, coordinator of Mumbai's Centre for Enquiry into Health and Allied Themes, a non-governmental organization that has been long been campaigning for minimum standards.

BMJ, Vol. 328, 17 Jan. 2004; p-124

4. Health Tourism: Where Healthcare, Ethics and the State Collide

Edwin Borman reports in BMJ that after a consultation with concerned agencies to close perceived "loopholes that are open to abuse" by "Health tourists", the government has announced its response which raise some concerns regarding responsibilities of doctors. Questions have been raised regarding actual extent of "health tourism" in the absence of serious quantitative studies. The only figures available are anecdotal or based on extrapolation, and they vary considerably around the country. Further concerns relate to the applicability of suggested solutions and the public health implications of some of these.

Other than in the case of certain exemptions, specific regulations require NHS trusts to charge for health care that is provided to anyone who is "not ordinarily resident in the UK". While this should be performed by overseas patient managers, pursuit of payment seems variably to have been achieved, with anecdotal reports suggesting various forms of abuse. Some examples cited in the government's consultation involve free hospital care for the dependants of people exempt form charges and for visiting business people or their dependants.

Analysis of the responses to the government's consultation shows shows that respondents differed markedly on how certain key issues should be addressed. Though there is a risk of overgeneralising, these may be categorized according to their emphasis on costs or on the rights of the patient, thus providing another illustration of this dichotomy in a health service where both costs and rights are emphasized more than ever before.

Ethical problems regarding eligibility for treatment are most profoundly shown by the issue of the proposed withdrawal of free non-emergency hospital care for asylum seekers whose applications to the Home Office have been rejected. A group with understandably high healthcare needs they still may face long periods in the United Kingdom without financial support before being deported. The BMA cited ethical, clinical, and humanitarian grounds for not supporting this proposal. Similar considerations were felt to apply to the ongoing treatment of HIV positive patients (currently only testing is free), where as an added reason even cost effectiveness and be invoked. It is hoped that when legislation is prepared - it is scheduled to come into effect on 1 April 2004 - it will reflect a more compassionate side of British society than some public statements on these issues thus far suggest.

The government must be credited with maintaining free emergency treatment for visitor and for free continuing treatment for certain infectious diseases such as tuberculosis, thus reducing the public health risk and the chances of drug resistance. But the latter decision emphasises the questionable nature of its decision on "non-ordinary residents" who are infected with HIV.

In the final analysis, clearly there is an urgent need to address the gap in essential knowledge about the size and nature of the problem and to suggest more specific solutions. Good governance, like good medicine, should be evidence based and proportionate.

BMJ, Vol. 328, 10 Jan. 2004; p-60

Indian Scenario

The government of Maharashtra in collaboration with FICCI launched the Medical Tourism Council of Maharashtra (MTCM) in November, 2003. the council will project the state as a healthcare tourism destination and chalk out a strategy to improve domestic and international medical tourist traffic. To accomplish this goal, it would rope in both private and public hospitals and tourism sectors. At the inaugural function, the state government also launched a dedicated website for this project.

The Maharashtra government believes that by offering first world healthcare facilities at third world prices?, it can attract a lot of patients form the west to visit corporate hospitals in Mumbai. The state government also plans to spruce up public hospitals to cater to middle-class tourists from the West. For those wishing to combine their treatment with leisure, it would offer sightseeing tours of well-known tourist attractions. These customized packages would deliver the twin benefits of medical facilities along with a leisure holiday plan.

It seem Maharashtra is following the footsteps of Tamil Nadu where over 10,000 patients of foreign origin were treated by the Apollo hospital group (Chennai) in 2002. Other hospitals also get a large influx of foreign patients, mainly due to lower projection of Bady Naaz's cardiac surgery at Narayana Hridayalaya which in now termed as the Naaz factor. Riding in this wave the CB recently organized a symposium entitled "Healthcare:

5. Preserving today's scientific records for tomorrow

Information stored on paper can survive for millennia; information stored digitally today may not be recoverable this time next week. With seven million pages of new information added to the world wide web each day, the volatility of websites has emerged as an urgent problem, especially as websites are becoming the version of record for scientific journals. Three studies of links in peer reviewed journals all found their useful life to be a few years. For Stuart Brand, president of the Long Now Foundation, "This is not a good way to run a civilization." For librarians whose mission is to transmit today's intellectual, cultural and historical output to the future, it's fast becoming a nightmare. A project initiated by Stanford University Libraries is coming to their aid.

Called LOCKSS (for "Lots of Copies Keeps Stuff"), it aims to provide librarians with a cheap and easy way to collect, preserve, and provide access to their own, local copy of web published material ( The project has developed software that converts a personal computer into a digital preservation appliance. If a publisher gives permission, the appliance collects content by slowly crawling the publisher's site in the manner of a search engine. Access to the collected content is transparent; the appliance acts like a web cache to deliver requested pages form the publisher, or stored pages if the publisher fails to respond. In this way a library?s readers see the subscribed pages at their original location, even though the publisher may no longer provide them there.

These appliances do not stand alone but are linked via the internet. They continually audit each other's comparing their versions by voting on its digest (a unique value computed form the content). If an appliance finds its copy outvoted and thus probably damaged, it can repair the damage form the appliances that outvoted it. Lockss uses this process of mutual audit and repair as the alternative of careful backups and manual auditing of the backup copies is very expensive.

Initially using content provided by the BMJ and adding other titles at an increasing rate, beta testing of the LOCKSS system is under way at 80 libraries world-wide and should go into production in spring 2004. Some 50 publishers of academic journals are supporting the project.

BMJ, Vol. 328, 10 Jan. 2004; p-66

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