It has been a slow shift but its effects are showing rapidly. As healthcare moves steadily from a crumbling public space into private hands, a disturbing, yet largely unrecognised, consequence has been an increased antimicrobial drug resistance within the community.
A study published in July in the medical journal Lancet had shown that the more people spend on treatment costs, especially medicines, the more antimicrobial resistance spreads in the community. The way it happens is that when a public health system makes patients share costs of services, such as a CT scan or a blood test or drugs, it shifts their loyalties to local private healthcare providers. Often, these are unqualified caregivers or chemists who provide patients lower quality or inappropriate dosage of antibiotics. This practice, the study explains, leads to increased drug resistance in the community.
The study results are particularly alarming in the light of the fact that the Narendra Modi government has slashed the already inadequate Union health budget allocations by 5.7%, to Rs 33,152 crore from Rs 35,163 crore in 2014-’15. Though state revenues have been simultaneously increased, it is yet to be seen how much money they will spend on the health sector.
Antibiotic resistance is a serious problem that compromises the ability to treat infectious diseases. It is the ability of microbes to flourish despite the presence of a drug that would normally limit its growth. Aiming to create awareness about the issue, the World Health Organisation has announced the first World Antibiotics Awareness Week from November 16 to November 22.
India got a bad name in antibiotic resistance in 2010, when British doctors announced the isolation of an enzyme, New Delhi Metallo-beta-lactamase-1 (dubbed a superbug), from a Swedish patient treated in India, which rendered the bacteria resistant to almost all antibiotics. Since then the level of bug resistance has been increasing. Another instance of the problem was the nearly incurable tuberculosis strain discovered in some patients of Mumbai’s PD Hinduja Hospital.
Incomplete treatment
“In the Indian context, among patients accessing public health sector, there is no regular supply for antibiotics, and the patients have to buy medicines on their own,” said Dr Nagamani Kammili, one of the authors of the Lancet paper and head of microbiology department at Gandhi Medical College in Secunderabad. “Many times they are not able to bear the cost or undergo incomplete treatment or take incomplete dosage, which increases drug resistance.”
Take the case of a 50-year-old diabetic in Govandi, an eastern Mumbai suburb dotted with slums, who was suffering from an abscess in the rectum. The local general practitioner treated him with meropenem injection, a "high antibiotic", for three days and the patient’s condition took a turn for the worse. He was first taken to a nursing home and then transferred to Joy Hospital in the eastern suburb of Chembur.
“The general practitioner prescribed him this antibiotic without taking a culture even,” said Dr Roy Patankar of Joy Hospital. “The abscess was not drained. Finally, he was brought to our hospital after his kidneys had shut down. He was in the ICU for about a fortnight. The antibiotic had suppressed his immunity, which was anyway compromised because of the diabetes. We could not prescribe him any drug, as he had already had meropenem. He died of septicaemia.”
Like that 50-year-old, most people in India visit private practitioners. The shift from public sector to private sector is also prompted by factors such as unwillingness to travel, wait time, and uncertainty about the quality of healthcare – all different kinds of out-of-pocket expense (for instance, a person could lose a day’s wage due to the travel and the wait at the public health centre).
“When a person is not able to access healthcare, his primary concern is not drug resistance,” said R Shrivatsan, who works in the area of public health in Hyderabad. “I feel the problem in India is that the treatment is ultimately palliative, and a fire-fighting mechanism. A patient takes medicine as long as he can manage. Getting food is more important. The question of drug resistance does not make sense, partly because everyday life is so precarious. An overcrowded hospital is one day’s wage. If the treatment lasts about 15-20 days, the patient has to go back every three days.”
Effective protocols
Recognising the anarchy in infection control and prescription practices, the central government formed a national taskforce to monitor antimicrobial resistance in the country in 2010 and also released a National Policy of Containment of Antimicrobial Resistance in 2011. This study noted that out-of-pocket expenditures is the most significant factor in predicting patterns of antimicrobial resistance, over and above factors such as poverty, antibiotic use in livestock, access to sanitation and hospitals.
The study explained that a robust public system has effective protocols which reduce the chances of misuse of antibiotics. Developed countries such as the United Kingdom, France, Germany, Canada and others have universal healthcare where national bodies issue standard protocols for various health problems.
Referring to the UK system, Pune-based Dr Abhay Shukla said “that is evidence-based medicine. Here, we give antibiotics for common cold and cough”. Dr Shukla, who is one of the national convenors of Jan Swasthya Abhiyaan, an umbrella network for organisations that work on public health, noted that even a country like Sri Lanka has an effective public health system.
The difference in the effectiveness of protocols shows in the way our National Aids Control Programme worked, Dr Shukla said. “A large majority of patients receive treatment from the public sector where most of the protocols are followed,” he observed. “If you have universal health care, the treatment automatically gets rationalised.”
An under-appreciated way to address the problem of antimicrobial resistance, as the Lancet study notes, would be to roll back the cost-sharing arrangements for drugs in the public sector. “The study strengthens the case for free medicines. If it tends to be regulated, the doctors in the public health sector prescribe rationally,” said Ravi Duggal, the country coordinator for the International Budget Partnership, which networks with organisations working on public budgeting. “Free medicines, however, cannot be granted without regulation.”
But instead of strengthening public health, both the central (Rashtriya Swasthya Bima Yojana) and some state governments such as Telangana (Rajiv Aarogyashri) and Maharashtra (Rajiv Gandhi Jeevandayee Arogya Yojana) have chosen to invest in health insurance cover schemes for poor families. These schemes have proven to be inadequate so far: many patients are paying for drugs, and there is gross misuse of the schemes in the private sector with unnecessary surgical procedures being performed on poor patients.
“Sometimes in a ward, we have two patients, one who is covered under the scheme and is pumped with antibiotics and some who are not covered under the scheme and cannot afford the antibiotics,” said Dr Kammili. “So, certain people get the privilege of high antibiotics and some do not. In such cases, the necessity of the use of high antibiotics is questionable.”
Bolstering the capacity of the public health sector to diagnose, prescribe and provide subsidised high quality medicines would, therefore, wean people off private care. “I have often wondered that instead of spending money on insurance, why the same budget can’t be used for boosting the overall infrastructure of our systems?” said Dr Kammili.
A study published in July in the medical journal Lancet had shown that the more people spend on treatment costs, especially medicines, the more antimicrobial resistance spreads in the community. The way it happens is that when a public health system makes patients share costs of services, such as a CT scan or a blood test or drugs, it shifts their loyalties to local private healthcare providers. Often, these are unqualified caregivers or chemists who provide patients lower quality or inappropriate dosage of antibiotics. This practice, the study explains, leads to increased drug resistance in the community.
The study results are particularly alarming in the light of the fact that the Narendra Modi government has slashed the already inadequate Union health budget allocations by 5.7%, to Rs 33,152 crore from Rs 35,163 crore in 2014-’15. Though state revenues have been simultaneously increased, it is yet to be seen how much money they will spend on the health sector.
Antibiotic resistance is a serious problem that compromises the ability to treat infectious diseases. It is the ability of microbes to flourish despite the presence of a drug that would normally limit its growth. Aiming to create awareness about the issue, the World Health Organisation has announced the first World Antibiotics Awareness Week from November 16 to November 22.
India got a bad name in antibiotic resistance in 2010, when British doctors announced the isolation of an enzyme, New Delhi Metallo-beta-lactamase-1 (dubbed a superbug), from a Swedish patient treated in India, which rendered the bacteria resistant to almost all antibiotics. Since then the level of bug resistance has been increasing. Another instance of the problem was the nearly incurable tuberculosis strain discovered in some patients of Mumbai’s PD Hinduja Hospital.
Incomplete treatment
“In the Indian context, among patients accessing public health sector, there is no regular supply for antibiotics, and the patients have to buy medicines on their own,” said Dr Nagamani Kammili, one of the authors of the Lancet paper and head of microbiology department at Gandhi Medical College in Secunderabad. “Many times they are not able to bear the cost or undergo incomplete treatment or take incomplete dosage, which increases drug resistance.”
Take the case of a 50-year-old diabetic in Govandi, an eastern Mumbai suburb dotted with slums, who was suffering from an abscess in the rectum. The local general practitioner treated him with meropenem injection, a "high antibiotic", for three days and the patient’s condition took a turn for the worse. He was first taken to a nursing home and then transferred to Joy Hospital in the eastern suburb of Chembur.
“The general practitioner prescribed him this antibiotic without taking a culture even,” said Dr Roy Patankar of Joy Hospital. “The abscess was not drained. Finally, he was brought to our hospital after his kidneys had shut down. He was in the ICU for about a fortnight. The antibiotic had suppressed his immunity, which was anyway compromised because of the diabetes. We could not prescribe him any drug, as he had already had meropenem. He died of septicaemia.”
Like that 50-year-old, most people in India visit private practitioners. The shift from public sector to private sector is also prompted by factors such as unwillingness to travel, wait time, and uncertainty about the quality of healthcare – all different kinds of out-of-pocket expense (for instance, a person could lose a day’s wage due to the travel and the wait at the public health centre).
“When a person is not able to access healthcare, his primary concern is not drug resistance,” said R Shrivatsan, who works in the area of public health in Hyderabad. “I feel the problem in India is that the treatment is ultimately palliative, and a fire-fighting mechanism. A patient takes medicine as long as he can manage. Getting food is more important. The question of drug resistance does not make sense, partly because everyday life is so precarious. An overcrowded hospital is one day’s wage. If the treatment lasts about 15-20 days, the patient has to go back every three days.”
Effective protocols
Recognising the anarchy in infection control and prescription practices, the central government formed a national taskforce to monitor antimicrobial resistance in the country in 2010 and also released a National Policy of Containment of Antimicrobial Resistance in 2011. This study noted that out-of-pocket expenditures is the most significant factor in predicting patterns of antimicrobial resistance, over and above factors such as poverty, antibiotic use in livestock, access to sanitation and hospitals.
The study explained that a robust public system has effective protocols which reduce the chances of misuse of antibiotics. Developed countries such as the United Kingdom, France, Germany, Canada and others have universal healthcare where national bodies issue standard protocols for various health problems.
Referring to the UK system, Pune-based Dr Abhay Shukla said “that is evidence-based medicine. Here, we give antibiotics for common cold and cough”. Dr Shukla, who is one of the national convenors of Jan Swasthya Abhiyaan, an umbrella network for organisations that work on public health, noted that even a country like Sri Lanka has an effective public health system.
The difference in the effectiveness of protocols shows in the way our National Aids Control Programme worked, Dr Shukla said. “A large majority of patients receive treatment from the public sector where most of the protocols are followed,” he observed. “If you have universal health care, the treatment automatically gets rationalised.”
An under-appreciated way to address the problem of antimicrobial resistance, as the Lancet study notes, would be to roll back the cost-sharing arrangements for drugs in the public sector. “The study strengthens the case for free medicines. If it tends to be regulated, the doctors in the public health sector prescribe rationally,” said Ravi Duggal, the country coordinator for the International Budget Partnership, which networks with organisations working on public budgeting. “Free medicines, however, cannot be granted without regulation.”
But instead of strengthening public health, both the central (Rashtriya Swasthya Bima Yojana) and some state governments such as Telangana (Rajiv Aarogyashri) and Maharashtra (Rajiv Gandhi Jeevandayee Arogya Yojana) have chosen to invest in health insurance cover schemes for poor families. These schemes have proven to be inadequate so far: many patients are paying for drugs, and there is gross misuse of the schemes in the private sector with unnecessary surgical procedures being performed on poor patients.
“Sometimes in a ward, we have two patients, one who is covered under the scheme and is pumped with antibiotics and some who are not covered under the scheme and cannot afford the antibiotics,” said Dr Kammili. “So, certain people get the privilege of high antibiotics and some do not. In such cases, the necessity of the use of high antibiotics is questionable.”
Bolstering the capacity of the public health sector to diagnose, prescribe and provide subsidised high quality medicines would, therefore, wean people off private care. “I have often wondered that instead of spending money on insurance, why the same budget can’t be used for boosting the overall infrastructure of our systems?” said Dr Kammili.
Buy an annual Scroll Membership to support independent journalism and get special benefits.
Our journalism is for everyone. But you can get special privileges by buying an annual Scroll Membership. Sign up today!