Sewagram, 9th-10th July, 2005.

Participants: Anant Phadke, C. Sathyamala, Ulhas Jajoo, S.P.Klantri, Binayak Sen, Dhruv Mankad, Jyoti Gupta, Ravi D'Souza, Ritu Priya.

At the outset it was collectively decided to begin the MAM with the two substantive campaign issues, the proposed universal ban on iodised salt and the polio eradication initiative, and the theme for the annual meet 2006, then to discuss the thematic cells and finally other organizational issues. Despite the small number, the discussion on all subjects was as lively as always.

Iodine D efficiency Disorders (IDD) and Universal Iodisation of Salt

 The e-group discussion on the subject had been consolidated and a print out was available for reference. Anant, Dhruv and Ritu led the discussion, with queries and comments from all others. The issues raised can be summarized as follows:

I. The Epidemiology of IDDs and impact of universal salt iodisation
" Magnitude of the problem ?
" Evidence of positive impact ?
" Evidence of negative consequences ?

II. The Political Economy of salt and its iodisation

III. Choice/rights of citizens vs. compulsory consumption of iodised salt.

 Available information and technical data related to (I.) was discussed and, even after consideration of opinions to the contrary by MFC members on the e-groups, led to questioning of the scientific basis of such a public health intervention.

For II, the information supplied (on the e-group) by Dhruv of the available US and Indian production processes available for Potassium iodate and then using it to iodate common salt was found very useful. Small scale iodation plants had become feasible with the Indian technology; the US one being much more expensive.

The issue of Choice/rights of citizens Vs. compulsory consumption of iodised salt (III) was discussed at some length and two views were expressed- (i) that compulsion by the state was not acceptable at all and (ii) that compulsion was not acceptable for measures of individual protection but justified if the freedom to choose was likely to violate other's rights or harm others.  It was thought that the second statement is open to abuse and "a 100 questions need to be asked before any such step is taken".  Ulhas pointed to the need to differentiate ethics, morality and spirituality. The consensus formulation reached after discussion was " We question the use of compulsion in any public health intervention."

In view of the intensive discussion, it was thought that Dhruv would formulate the objection to the ban from MFC, in a manner that it accommodated all views and would be acceptable to all MFC members. The request to Sridhar to do a review on the subject for MFC was to be repeated.

Theme and Structure of Annual Meet 2006

The theme decided at the GBM, Jan. 2005 was 'Quality and Costs of Health Care: Social Regulation in the context of Universal Access'. Ritu briefly presented the main points of the background note circulated by her on the e-group (and published in the bulletin). A long session of brainstorming followed through the second half of the first day and on to the second morning.  Recapturing the whole discussion is difficult, however to give a sense of it, the major issues are given below :

I. That diverse perspectives exist on the issue:

 i. The issue of Quality and cost as reflected in the National Health Policy was brought up by Anant.

 ii. The CII statements were pointed out by Ritu.

           iii. The Management approach was articulated by Dhruv:
" Minimum infrastructure standards Patient satisfaction.
" Incremental upgradation

iv. The views of communities and peripheral level workers were considered important to incorporate

II Formulating the Minimum standards:
" Ulhas started the discussion on this from his experience of a community health programme - For a Primary Health Care Hospital, focusing on the personnel and specialities required.
" S.P. Kalantri spoke of 122 criteria set for a rural hospital by the Maharashtra Health Systems Development Project, which included criteria for infrastructure, referral, safety mechanisms levels of technology and personnel.
" Ravi D'Souza suggested that we should not think of personnel by specialities but by the minimum services needed and what all one doctor can provide. The issue of standards for the private sector was raised.

III Public/Private Sector and Regulatory Mechanisms

" Ritu suggested that we think of criteria for public health services as first priority and then how they can be met by all kinds of private sector services as well.
" Sathya emphasised the need to look at the issue systemically, e.g. how can we envisage doctors coming to work in public health services when medical education is to involve high fees and medical tourism affects the orientation of medical institutions?
" Anant brought in the issue of primary level care providers in both sectors, the CHW and the private practitioners. The public system standards are available, so we can start with them. The issue of universal access will have to be addressed for the private sector.
" Sathya added the importance of setting criteria for use of diagnostics e.g. ultrasound in pregnancies.
" Dhruv pointed out that, with public hospitals becoming corporations, same criteria and mechanisms as for the private sector will have to be applied.
" Ulhas brought up the role of the community in controlling quality and cost. One model could be that the government provides the infrastructure and the doctor is paid by the community. The Gram Sabha should be involved in tariff negotiations.
" Anant pointed to the Canadian model of social insurance with the municipal body and communities playing a role.

For Public Health Programmes
" Anant wanted discussion on the issue of standards for public health programmes, as raised in the background paper. He raised the issue of defining the 'desirable' standard and the simultaneous need to compromise on them due to economic constraints, for instance, even with .0001% cretinism, he thought it desirable to do screening of all neonates, but would not consider it a priority for our health services at this stage.
" Ritu questioned whether this is a 'desirable'. We need to think at what point of prevalence do we let nature take its course.  Magnitude of the problem, level of technology needed and optional measures available to tackle each problem as well as cost at societal level - not only financial but in the Illichian sense- have to be taken into consideration.
" Binayak posed the question - how do we address the issue of dealing with epidemics and the endemic conditions that lead to mass ill-health e.g. improving water supply? In this context, Ritu pointed to the importance of recognising the role of the public health system in highlighting the causality of disease in society, through surveillance, monitoring and initiation of societal action.

 Finally, the following tentative structure was worked out for the Meet :-
 

Session I
Role of the Health Care System from a Public Health Perspective

[One or Two Overview Papers as Backgrounders with brief presentation of main points.
  +
Open Discussion ]

Session II
Quality of Public Health Care

a) Surveillance / monitoring at district level  - content
   - inputs required (costing, expertise etc.)

b) Programmes  - priorities selling
   - criteria for quality
   - wasteful expenditure

Background papers + in-depth discussion on one/two control programme(s) (e.g. IDD control and Polio Eradication which are already under discussion within MFC).

Session III
Quality Standards for Community Level, Primary Level, Secondary & Tertiary Level Service Delivery

  - Services required at each level
- Criteria/parameters for quality [for professional medical care, Paramedics and
  community providers,  Institutions (Public and private), teams ]
- Inputs needed to reach those levels (finances, technology, human) for public
 health system & for private sector.

Backgrounders of specific experiments and experiences should form the basis for discussion, e.g.:

Low Cost Effective Care Centre, Vellore
Community-based Palliative Care Network, Manjeri, Kerala
Arvind Eye Care Centre, Hyderabad,
Jan Swasthya Sahyog, Bilaspur
Trauma Centres
Drug Procurement System - Tamil Nadu.
Glass vs. Disposable Syringes,
Dais vs. Institutional Deliveries
Mitanin Programme, Chhatisgarh.
 

Session IV
Structures Required for Social Regulation
" Accreditation and rating systems?
" Social insurance systems?
" Community structures
" Lessons drawn from the experience of case studies discussed in the previous session.

(All the examples given were illustrative and not exhaustive)
 
 

Date & Venue

The two dates proposed at the GBM (21st-22nd Jan & 27th - 28th Jan.) were discussed and the second preferred since it gave people the day of 26th to travel.

Venue : The convener informed others of the communication with Dr. Ekbal about organizing the 2006 meet in Kerala. It was felt that another option should also be explored. Vellore was proposed, and Ravi D'Souza and Binayak volunteered to contact Anand Zachariah and other friends to sound them out about the possibility.

Vellore was thought to be a good option because of the medical setting and possibility of interaction with 'socially conscious people' interested in the theme outside MFC. It has several experiments with developing quality of care suited to local context, and there are several possible venues there - CHAD/ Karigiri/ the main college campus……..
 

The Polio Eradication Initiative

Sathya initiated the discussion by tracing the sequence of events of how the issue got taken up: a letter sent to WHO by her and Dr. O. Mittal asking questions about the polio eradication initiative, a memorandum sent to the mohfw/UNICEF/WHO in April 2003, MFC members endorsement of the memo, still waiting for response from these bodies.  The decision not to go to public in the World Health Assembly media was so as not to cause confusion in the public mind. Subsequently, an article co-authored by Sathyamala, O. Mittal, R.Dasgupta and R. Priya has been published in the IJHS, as also a response to an article in the EPW on the subject. So now it is time to think of going into campaign mode. In the ensuing discussion, additional points were raised and some others corroborating the critique were cited.

" Dhruv provided information of an estimated cost worked out to Rs.30,000 / per child protected, with a lot spent on the advertising.

" Anant reported Dr. Deodhar's critique that eradication is technically not feasible since sub-clinical infections persist and water supply safety is not being dealt with.
Anant also reported Dr. Kale & Dow's point that reversion of virus is possible and vaccine associated paralytic polio (VAPP) is 25% of all cases in India today.

" He quoted Dr. Jacob John in Jan. 2004, Ind. J. of Paediatrics, acknowledging the limitations of the present strategy and advocating for injectable polio vaccine (which is 150 times the price of the oral one).

It was generally felt that a campaign should now be undertaken and a sequence of steps planned for it. Several different approaches to the campaign were proposed, including mobilization/networking with existing critics, larger mobilization and information dissemination, demanding compensation for children who get paralysis despite having been immunised, demanding full information etc.

Everyone volunteered varying degrees of input in the campaign. Existing papers could be used for going to academics but briefs and other documents would have to be prepared for the larger campaign. Further discussion for the campaign was left till the annual meet.

Organisational Issues

1. MFC brochure-Decision taken that the convener will get the brochure printed, after updating information and life-subscriber charges etc.

2. Thematic Cells- No one was sure whether they were in suspended animation or dead! It was proposed to check with the conveners of each cells if they wished to revive them or saw the possibility of that. The following thematic cells and their convenors as per memory of those present:
  Theme                                Convenor
  Women & Health Cell -         Neha Madhiwala
  Health Policy Cell -               Abhay Shukla
  Primary Health Care Cell -     Shyam Ashtakar
  Infectious Diseases Cell -     Yogesh Jain
 [Any others?]

3.  MFC Books & Reports - In Search of Diagnosis, the Medical Education Anthology, Under the Lens, Depo-Provera, Bhopal, Gujarat.
" We need to collect complete information about the present stock of each one- from previous conveners, the registered office, Cehat Mumbai, CHC, Sathyamala.
" An earlier proposal to upload them on the website was repeated and welcomed by all. Anant remembered that Amar had offered to get it done. It was proposed that this be followed up. It was also proposed that members with the competence could be asked to volunteer time to do the uploading. Nobhojit Roy has been doing it for the MFC bulletins, but it is too much work for one person.

4. Functioning of the MFC e-group was discussed and it was felt that some rules decided upon earlier need to be reiterated -
" Introduction of all new members must be given by the introducer.
" The ground rules need to be sent on the e-group every month to remind them periodically.
" The detailed discussion at the Bhopal GBM was recalled and it was felt that the issues spelt out there need to be taken up.

5. Follow-up on Gujarat and the Togadia case- The convener reported her communication with the Amnesty International Asia desk, whose network had also represented to the MCI on the need for investigating the role of doctors during the post Godhra carnage. The MFC report had been used for this. Exchange of information of our respective cases with the MCI had been decided upon.

" It was decided to discuss the case at the annual meet when more people involved were present.

" Members recalled that at the Gujarat meet it had been decided that MFC would develop a curriculum on Communalism for doctors and a curriculum on Health and Violence. A workshop was organised in 2003 at Pune. No one had any information about further follow-up of either curricula.

" Anant reported that Cehat (Sunita, Neha, Abhay and Jaya Velankar) had done on analysis of the post-mortem reports. The analysis may be available with Sunita??

6. It was pointed out that minutes of the Gujarat meet and the last 2 meets had not been published in the MFC bulletin. Neither had the audited statement been published for the past 2 years.  It was felt that this should be rectified.

7. Sathya reported that she had been appointed by the Supreme Court as advisor to the Committee on the Bhopal case, chaired by Prof. Ganguli, Director ICMR. Unfortunately, the issues raised by her and others in the Committee in favour of the surviving victims were misrepresented in the minutes. Despite bringing this to the Chair's notice corrections were not made. So an affidavit had to be filed in the SC against him.
Recent publications on the Bhopal Gas Tragedy had completely blacked out the MFC reports - eg. Seminar's special issue and a publication co-authored by Sathyu & Ward Morehouse.

These issues brought the discussion around to two perennial question (i) members' sustained interest and time commitment to MFC, and (ii) marginalisation of MFC perspectives by the mainstream trends and the need to articulate and disseminate these more effectively. It was thought important that attempts be made to address these issues when planning the forthcoming annual meet and other activities.