AIR POLLUTION - THIRUVANANTHAPURAM CITY

Definition: Air pollution is the introduction of chemicals, particulate matter, or biological materials that cause harm or discomfort to humans or other living organisms, or cause damage to the natural environment or built environment, into the atmosphere.

Indoor air Pollution: A lack of ventilation results in concentration of pollutants inside houses or buildings resulting in “sick buildings”. These pollutants could be chemicals that emerge from building materials such as carpets and plywood (Emit formaldehyde), Volatile organic compounds emitted by paints, varnishes and solvents. Room fresheners, dust, degenerated lead paint dust etc are some of the other indoor pollutants. Tobacco smoke, smoke from cooking practices, indiscriminate use of pesticides, rearing pets inside house etc can also result in poor indoor air quality.

Outdoor air pollution: Chemical reactions between pollutants occur from different sources like automobile exhaust and industrial emissions. Smog is a type of large-scale outdoor pollution. Smog is seen even in Thiruvananthapuram city and the major source are vehicles and industries.

Driving force: Impact of vehicular pollution is widespread and contributes to the bulk of air pollution in the city while that of the industries are localized to the areas around it. There is an increase in use of fossil fuels in transportation and industries. The number of vehicles on road has increased enormously in the last decade resulting in an increase in air pollution. Decreased availability of electricity for both small and large scale industries has resulted in increased consumption of fossil fuels for generation of energy. Thiruvananthapuram is experiencing growth in urban spread as with other districts such as Cochin and Kozhikode. Most of the growth and spread is unplanned and resulting in degradation of air quality due to uncontrolled traffic, overcrowding, and improper waste management strategies. Increased use of fossil fuels for personal transport, poor automobile and road conditions, improper collection and disposal of domestic waste / garbage before it gets rotten, open incineration of wastes without segregation, improper sewage disposal resulting in frequent spillage and overflows etc are responsible for poor quality of air in the city. Frequent daily spillage of sewage from the medical college sewage pump house polluting the entire off medical campus points finger towards mere negligence. Coir wretting activities, even though are outside the city limits confined to the Kovalam lagoon in the TS Canal region, raise concerns. The main water bodies of Thiruvananthapuram such as Karamana River, Killi River and the Parvathy Puthanar, a man made canal are highly contaminated with coliforms and sewage matter causing significant air pollution.

State: Pollution Control Board monitor Ambient air for Suspended Particulate Matter (SPM), Respirable Suspended Particulate Matter (RSPM), Sulphur Dioxide (SO2 ) and Oxides of Nitrogen (NOX ) from stations located in industrial, residential and sensitive areas. There are 4 monitoring stations located in Thiruvananthapuram City. Reports from these stations show that SPM and RSPM regularly exceed allowable limits while that of SO 2 and NO X levels are maintained within the normal limits.

Air Pollution and Lung Diseases: Pollution can lead to several health hazards and the most significant among them is the respiratory illnesses resulting in significant losses in DALYs. Prevalence of various lung diseases can be taken as an indicator for control of air pollution. Several components in the polluted air play a role in activating lung diseases like asthma, bronchitis, COPD, and pneumoconiosis (a non-neoplastic condition), especially for those who are already asthmatic. Children are more susceptible to such pollutants than the adults as they spend more time outdoors especially during midday when air pollution levels tend to be higher as their oxygen demand is higher. Diameter of the airways is smaller and hence the inflammation caused by the particulate matters within the polluted air will be higher. Older persons are the other group that is adversely affected as their respiratory reserves are already lowered resulting in exacerbation of chronic lung diseases.

Determinants: There are several determinants to the effect of air pollution on individuals. As mentioned earlier, persons with poor immunological status, those with pre-existing diseases, older persons and children are most susceptible. Poor housing, unplanned nature of the city, poor building designs and improper waste disposal mechanisms are some of the environmental determinants. Traditional cooking practices using more of kerosene or fire wood, poverty, unavailability of LPG, unemployment, urban slums are some of the socio-economic determinants. Lack of awareness about pollution is one major reason where persons are unaware of the health hazards of such pollution, safety measures and means to prevent such hazards. Public are often not empowered to get the environment clean and curb air pollution. Rather the responsibility is fully shunted to the government as if there is no responsibility for the civil society.

Recommendations

1.      Strict enforcement of laws to aid fulfillment of vehicular and industrial emission standards.

2.      Easy available of LPG or CNG for production of energy and electricity for industry as needed. An effort has to be made to promote use of biogas, subsidized LPG or solar source for cooking in houses. Electric induction cookers are helpful in certain conditions and are cost effective.

3.      Design of buildings and industries, vehicles etc should be environment friendly.

4.      Regular ambient and source air quality monitoring and surveillance to be conducted. Such mobile units may continuously monitor air quality in the city and take action immediately such as diversion of traffic in case of traffic jams, issue of notice on the spot to polluting vehicles and check the standards of automobile pollution checking centers.

5.      Evaporative emissions from industries such as dry cleaners, printing, publishing, painting, and surface coatings can be recovered from being emitted to the atmosphere and this procedure has to be strictly implemented.

6.      Open burning of refuse should be banned and penalized. At the same time, activities such as composting should be incentivized.

7.      Create awareness about the hazards of excess use of cosmetics utilities such as air fresheners, hair sprays, deodorants, nail polish remover, shaving creams etc. and encourage them to minimize the use. Smoking tobacco in public spaces has to be banned.

8.      Establish more efficient public transport system such as metro rail so that personal use of scooters and cars may be minimized. Electric vehicles and bicycles have to be promoted.

9.      Proper sewage treatment has to be done and spillage of such drainage also has to be avoided. Special care has to be taken with the rivers, Parvathy Puthanar and Aakkulam lake that is causing both air pollution and water pollution.

10.  An inter-departmental cooperation is essential to address this serious public health issue and such a body has to be constituted under the auspices of Pollution control board with active participation of public health professionals to track the indicators, find appropriate remedial measures and provide recommendation for policy changes.

Status of Malaria in India

Introduction

During the British ruling in India, the period 1932 to 1941, fever accounted for 58% of the average annual deaths. Malaria was the largest single cause of fever deaths during this period. Morbidity directly due to the disease and also due to lowered immunity and mortality was recognized in the country. The annual mortality due to  Malaria was to the tune of  around 2.4million;  ie. 8 per 1000 population. This account for 37% of total mortality annually in India. Out of this, 1.25 to 1.50 million deaths was directly due to malaria. The infrastructural  developmental activities including building of roads, railways, and irrigation projects lacked design concepts that would prevent water logging whereby increasing chance for mosquito breeding.  

Distribution of the disease was depicted in 5 geographically as:

1.      Moderate to high intensity endemic area where malaria is prevalent and endemic but almost static. This include the coastal areas and Gangetic valleys.

2.      Forested hilly terrains of Sub-Himalayas, NorthEast & Western Ghats, the Chittagong Hill Tracts, in Assam, the Chota Nagpur Hills of the Central Provinces etc were considered as Hyperendemic areas.

3.      The relatively dry tract including the Sind, Rajputana, the south western portion of the United Provinces, a large part of Central India, Gujarat, Bombay, Hyderabad and Mysore with varying degrees of endemicity depending on irrigation.

4.      Areas such as Punjab, Delhi and North west were considered as prone to fulminant epidemic malaria.

5.      Areas such as Tanjore, spots in Orissa & Bengal were considered as non-hilly hyperendemic areas.

The Central Malaria Bureau and the Entomology Section of the Central Research Institute, Kasauli, that was found in 1926, was designated the task of Malaria Survey of India. This center was later changed to the Malaria Institute of India. In 1940, the Government of India took over this institute. The institute actively participated in public health works especially in investigating and preparing strategies for managing the disease. Training was provided for medical officers in the community, medical professionals in the defense including Army Navy and Air-force. This was mainly during the war that control of malaria became very important. Training for para-medical staff including sanitary inspectors and engineers, science graduates etc was also provided through the system. Through the provincial organizations, the central institute could also spread its activities including investigation, control etc through various ways in addition to the training and research activities.

Bhore Committee found that the provision for the treatment in the country quite inadequate. The distribution system of Quinine, the main drug of choice at that time was not enough to meet the requirement. It recognizes that the province’s effort of just managing epidemics would not suffice as far as malaria control is concerned. Poor organization structure, staffing, remuneration etc has made the program not a big success eventhough the disease was controlled to some extend in some areas. The dis-continuous efforts of the provinces also were the reason for the failure in spite of initiating research and training along with conducting field investigations and entomological studies etc. There were other external factors such as poor administration and war etc that was affecting the program. Thus Bhore committee identifies Malaria as an important disease that has to be taken care of actively.

Present status of Malaria in India

Presently, malaria control in India is implemented by the National Vector Borne Disease Control Programme (NVBDCP) by providing technical and operational support to the state and also sharing the cost. Implementation is through the PHCs with the participation of community and multi-purpose workers. Early detection & treatment, prophylaxis, behavior changes, integrated vector control, strengthening of MIS, multi-sectoral coordination etc are the key strategies. Drug distribution centers and fever treatment depots located in hard to reach areas to improve coverage. The program is receiving financial assistance from the World Bank and the Global Fund for AIDS, TB & Malaria (GFATM).

Around 70% of malaria in the South East Asian Region of WHO is contributed by India with an annual report of about two million cases and about 1000 deaths attributable to malaria. Currently in India, there is an increasing trend in malaria caused by plasmodium falciparum according to the available data from NVBDCP both in cases and in mortality in the post resurgence phase. This now account for 45% of the total reported cases. The clinical presentation pattern of severe malaria also has changed where multi-organ failure is more frequently seen with falciparum malaria. The ethnic tribes living in the forested pockets of the states like Orissa, Jharkhand, Madhya Pradesh, Chhattisgarh and the North Eastern states contribute to the bulk of mortality and morbidity attributable to malaria. 15% of the total malaria cases reported in India are in the urban areas which could be associated with construction activities and migration of people from endemic areas and the lower status of living. Majority of the malarial deaths reported in India are from Orissa and other forested areas occupied by ethnic tribes. As per the National Vector Borne Disease Control Program (NVBDCP), about 2 million parasite positive cases are seen in India in a year. Several independent studies suggest that the prevalence of malaria and the mortality is under reported. Studies by the Indian Council of Medical Research also prove that malaria incidence is hugely under-estimated. Considering the existing gaps in reported and estimated morbidity and mortality, need for estimation of true burden of malaria has been stressed. However, NVBDCP is providing all guidance to states for malaria control through implementing malaria drug policy, surveillance and research. The efforts of control of malaria are rather complicated by poverty and other adverse social determinants of health. To quote an example, in 2000, 88% of P. falciparum malaria was contributed by those states with population exceeding the national average of 26.1% population below poverty line (BPL). The Global Malaria Eradication Program of WHO that was launched in 1950s showed a big success where there was a significant decline in cases. From about 75 million cases and 8,00,000 deaths in 1947, it dropped to 49,151 cases (annual parasite incidence per thousand [API]: 0.13; slide positivity rate [SPR]: 0.38% and Plasmodium falciparum [Pf]: 34.9%) and no deaths in 1961. But there was a resurgence of the disease in different parts of the country which is attributed to contentment, administrative, operational and technical problems like resistance in vectors to commonly used insecticide DDT and resistance in parasites to chloroquine and overall low priority malaria enjoyed in the post control period. However, a modified plan of operation (MPO) was implemented in 1977 after which malaria cases declined and ranged between 2-3 million per annum in the subsequent years. There were further outbreaks in 1996 reporting an increase in cases to 30,35,588 and mortality of 2803. In 2006, the reported number of cases was 16,69,333 (API: 1.57; SPR: 1.63% and Pf:45.3%). As per the reports from WHO, presently, about 80.5% of the Indian population lives in malaria risk areas. Out of this, 4.2%, 32.5% and 43.8% live in areas of high, moderate and low risk to malaria respectively. However, preventive measures such as spraying of newer insecticides like synthetic pyrethroid, biological control measures through larvivorous fish like Gambusia and Guppy etc are being used recently along with mass awareness programs and extensive distribution of mosquito nets impregnated with insecticides in the risk areas.

Apart from income status and nutrition, individual vulnerabilities such as gender roles, aging, family size etc has made women as a more vulnerable group. Increased incidence of maternal mortality, still births, miscarriages, infant mortality etc in certain areas could also be attributed to the prevalence of malaria among these vulnerable women . Sensitization of the health services providers and policy makers is essential in this regard to further achieve the goals of malaria control and ensuring justice.

Drug resistance, insecticide resistance, lack of knowledge of actual disease burden along with new paradigms of malaria pose a challenge for malaria control in the country. Several social determinants of health are also playing their part as such as socio-economic, gender etc.  Administrative, financial, technical and operational challenges faced by the national programme has to be taken into account. Approaches and priorities that may be helpful in tackling serious issues confronting malaria programme has to be outlined.

The favourable changes in Malaria control that have occurred and the reasons for these changes.

Favorable changes were found with a reasonable control over the deaths due National Malaria Control Program (NMCP), a comprehensive program to control malaria was started in 1953 following endorsement of the Bhore Committee report by the Planning Commission. The broad objectives were to bring down malaria transmission to a level at which it would cease to be a major public health problem and to hold down the malaria transmission at low level indefinitely. A big success of NMCP after effectively covering a population of 165.6 million in 1957, urged the Government of India to change the strategy from control to eradication. Thus, in 1958, National Malaria Eradication Program (NMEP) was launched. Epidemiological surveillance was initiated in 1961 and by these efforts at the national and state level, many parts of the country were practically under control and entered into a technically maintenance phase by 1966. However, this was followed by outbreaks in several parts of the country. From 1968 onwards there were setbacks, 1976 recorded the highest ever post-eradication incidence of 6.47 million cases. 

A Modified Plan of Operation was implemented in 1977 with a good success to follow. The reasons for this were the change in strategy and approaches that included

i)                    Decreasing morbidity and mortality due to malaria

ii)                  To preserve the achievements of the country from green revolution etc

iii)                Fortnightly blood smear collection by domiciliary visits, from fever cases, their examination and treatment with antimalarial drugs.

iv)                Decentralisation of laboratory services to the PHC level.

v)                  Establishment of Drug Distribution Centres (DDCs)/ Fever Treatment Depots (FTDs).

vi)                Insecticidal spray with appropriate insecticide during the transmission period in rural areas recording Annual Parasite Incidence (API) 2 or above. In urban areas, through recurrent antilarval operations.

vii)              Health Education and Community Participation.

All these strategies of MPO helped to bring down the number of case significantly with a downward trend. The situation remained almost static for a decade from 1984 where the deaths due to malaria crossed the 500 mark. Malaria due to P.falciparum was also on the rise after 1994. Focal outbreaks were also found in some parts of the country from then onwards. 100% central assistance was provided to all the north-eastern states since December 1994. Other activities included

1.      Information, Education and Communication (IEC) components were Intensified by observing anti-malaria month throughout the country for increasing the awareness of malaria and its control among the community to ensure their participation.

2.      Accelerated urban malaria scheme was implemented in the problematic towns as urban malaria was seen on the increase due to developmental activities and migration.

3.      NMEP drug policy has been revised in view of rising incidence of P. falciparum malaria.

4.      An Enhanced Malaria Control Project with World Bank assistance was launched in 1997 to provide additional inputs for the control of malaria in the 100 identified hard-core tribal predominant districts of Andhra Pradesh, Bihar, Gujarat, Madhya Pradesh, Maharashtra, Orissa and Rajasthan. 19 problematic towns have also been included under this project. This Project, provided newer technologies like insecticidal spray with synthetic pyrethroids, bio-environmental methods for vector control including use of larvivorous fish and  biolarvicides, and rapid diagnostic methods for prompt detection of P. falciparum cases. Injectable artemisinine for the treatment of severe and  complicated malaria was made available.

The National Vector Borne Disease Control Programme (NVBDCP) was launched in 2004. where all the vector borne diseases were integrated under one umbrella to coordinate better implementation. Health being the state's responsibility, malaria control is carried out by the states, under the overall guidance of the NVBDCP. The program organizes interventions surveillance to monitor the impact and to detect malaria cases by examining fever cases in the entire country. In rural areas, blood smears are collected by multi-purpose workers at fortnightly intervals through Active Case Detection (ACD). Blood samples are also collected at the Primary Health Centres (PHCs) i.e. Passive Case Detection (PCD). In urban areas, PCD is carried out at the malaria clinics. Radical treatment is given, as per the policy of the NVBDCP to those found positive. The data thus obtained is used in calculating epidemiological indices at the various levels of health services. Assessing drug resistance using strict guidelines with support of monitoring teams, line of management is  decided at various levels and such information is passed on to the persons concerned.  Such thirteen NVBDCP teams routinely monitor P. falciparum drug sensitivity in the country. These teams are located in various regions so as to cover the entire country. Malaria Drug Policy (2007) of the NVBDCP provides treatment guidelines countrywide. It is understood that the vector causing malaria differs in different parts of the country and its susceptibility to larvicides etc also is not the same across the country. Hence, a recommendation has to be made for each state or regions which is done through the monitoring teams. Provision for presumptive treatment for fever cases in high risk areas to prevent mortality due to malaria was introduced. The new national drug policy was for malaria was  implemented in 2010. This has helped the country in bringing down the case load of malaria significantly and the resulting deaths. However the issue of drug resistance and increasing p.Falciparum malaria is posing new challenges.

Aspects of Malaria that have not undergone much change and the possible reasons for that.

There were several challenges that were faced during the effort of controlling the disease. There were hence many aspects that needed change in order to succeed in the mission. However, there were reasons for the flaws that could be rectified in the future. Some of these are,

Insecticide resistance in vectors

Resistance of vectors to insecticides and larvicides are increasing. This is also due to the injudicious use of insecticides and not identifying resistance in certain areas. There has been several insecticides that was found useful but later withdrawn due to ban. Latest used are the synthetic pyrethroids, but resistance has also been documented with them. There is also documented evidence of triple and quadruple resistance in certain parts of the country including the central part of India. Provision of nets impregnated with insecticide was a better option but there are still many pockets where awareness is not coupled well with distributing the nets resulting in under-utilisation of these expensive nets.

Drug Resistance

Chloroquine has been the mainstay of treatment of malaria for decades. This cost effective and safe drug has become resistant to most of the malarial cases in the country especially falciparum malaria. Quinine is effective but is reserved for treating complicated malaria owing to its adverse reactions and long duration of treatment. Mefloquine, eventhough useful in treating multidrug resistant falciparum malaria, due to its long duration of action, it is vulnerable for development of resistance. Artemisinin group of drugs are highly effective but safety in pregnancy, concern about neurological side effects due to short duration of action still debated. Drug resistance became an issue due to variety of reasons such as

1.      Incomplete treatment and non confirmation of diagnosis

2.      No standard guideline was been efficiently implemented especially in the lower socio economic regions

3.      Emperical and non-judicious use of medicines over the counter and by traditional healers

4.      lack of monitoring for drug resistance and network with researchers etc

Control of regular outbreaks

Proper control of regular outbreaks in some urban, rural and large project areas has not been possible as control of An. stephensi, the principal malaria vector in urban areas is becoming difficult. The vector is expanding its distribution southward that is resulting in the recent malaria outbreaks in Goa, Mangalore and recently in Kasargod district of Kerala state which is by and large free of malaria. This is also one of the reason for the observed under reporting of the cases mentioned elsewhere in this assignment. NGOs working in the field with their available limited knowledge are treating in the hard to reach areas of the country and lack proper guidance and monitoring.

Counterfeit drugs

Owing to the rapid development in the pharmaceutical manufacture sector along with relaxation of regulations and surveillance, counterfeit drugs are still in market. Counterfeit drugs are one of the major contributors for drug resistance. Currently since the medicines are more subsidized in india, counterfeiting has decreased but however, regulatory checks and pharmacovigilence has to be strengthened. Empowering drug controllers for regular monitoring could be a solution.

Effects of migration

Migration could be work work opportunity or could be due to famine, poverty or natural disasters etc. There is currently no action that is efficient to control of malaria through such migration. Those labourers migrating to non malaria endemic areas from endemic areas pose serious risk for spreading the disease. This is one of the reasons for the incidence of cases in certain project sites such as agriculture, construction projects etc. The migration of people to the forest fringes can result in something called as the forest malaria.

Socio-economic determinants

Social determinants of health have not been an agenda during discussions for controlling the disease. Unless such determinants such as poverty, marginalization, gender issues, faiths and local healer interactions, socio-cultural practices, living environment/ hygiene etc are taken into account, the aim of an effective control of malaria cannot be achieved. It is only recently that the social determinants of health are looked into as more public health professionals try to see through a non-medicalised lens.

School Absenteesm of Adolescent Girls due to Menstrual Problems

This report follows the enquiry into the school absenteeism by adolescent girls due to problems associated with menstruation. As of today, there are 12668 Schools in the state out of which there are around 2820 high schools including around 1001 government schools, many of them where adolescent girls attend. The enquiry throws light into a very serious issue where adolescent girls are forced to stay back home during their menstrual periods. There are also health problems prevailing among girls such as reproductory tract infections, skin infections and urinary tract infections. One of the studies conducted by a scholar from Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum also proves this as significant where the self reported morbidity is about 61% of the girls. It is of the opinion that menstrual hygiene should be stressed in schools in our state as it is been implemented in to some extend in some Tamilnadu. Menstruation, even though a natural process, it has been dealt with secrecy even at home due to taboo associated. Many girls from poor families cannot afford sanitary pads where they use rags, usually torn from old saris that are washed quickly inside the latrine and reused several times. Many of our schools do not have spaces with privacy and toilets are not girl friendly with adequate water supply. Rags that are unclean and the fact that there is no adequate wash facilities in school result in absenteeism and prevalence of infections in these girls. All these would not only reduce the reproductory health of a generation but also their overall development. Doctors say that during the period, girls may have to change napkins every 5 – 6 hours to prevent infections i.e. an average of 15 – 20 napkins during a period (per month). The following are the recommendations for consideration.

Recommendations
1. Girl-friendly toilets: In those schools where adolescent girls are studying, clean toilets with good lighting, privacy, adequate ventilation and clean running water should be made available. Dr. Bency Josephs study from Achutha Menon Center points out that reproductory tract infections is closely associated with erratic or absence of water supply in school toilets leading to absenteeism. This can be easily averted by this recommendation. Regular maintenance and cleaning to keep the toilets in good condition is paramount.
2. Sensitisation for teachers: As teachers are expected to be in good contact with students, they are more likely to identify key issues pertaining to reproductive health of their students and aid in early detection of problems and prevention of morbidity. Sensitising teachers in such schools will enable girls to access to information and clarification of doubts as well as advice to good health. This may also improve rapport between student and teacher in such matters.
3. Supply of sanitary napkins in School: As sanitary napkins are advised and owing to fact being unaffordable, provisions can be made to provide them in the school in adequate numbers and at a lower cost. It is recommended that such napkins may be provided free of cost or highly subsidised to those girls coming from poor socio economic background. Coin operated Sanitary napkin vending machines are available and are used in schools in other parts of the country – Tamilnadu is an example. This will significantly bring down the reproductory, urinary and skin infections among girls. However, the quality of the napkins supplied has to be strictly ensured. Cost escalation / manufacturing cost and shortage of napkins have to be thought of.
4. Ensure adequate water supply: Adequate clean running water in toilets is essential to keep clean during this period. Schools should be directed to make this provision as feasible. Where government water supply is not available, well water can be preferred provided it is kept clean; a bore well can also be thought of as required. Overhead water storage is ideal for providing a continuous stream of water.
5. Waste disposal: Safe disposal of used sanitary napkins is essential. All schools are expected to have a waste management system and this could be modified as needed. Waste basket should be provided inside girls toilets for disposing off used napkin. Provision of an incinerator can be thought of while burial of waste is economical.
6. Regular visits from health department: Being this also related to health, cooperation of health department maybe beneficial if regular visits can be done by doctors or health workers (ANM or ASHA of NRHM) of the respective PHC / CHC.

Implimentation
Effective implementation of the school sanitation and hygiene program would require an inter-sectoral effort. Health department can contribute by taking the lead in guiding the program, conducting the sensitisation programs for teachers and parents and health checks. Where ever possible especially with private and aided schools, PTA shall take the initiative in mobilising required resources to improve the conditions also taking help from professional bodies such as IMA. However, for such non-government schools, a subsidy for infrastructure development may be provided. Small scale industries may be promoted through self help groups to manufacture napkins with strict quality checks. Purchase from large scale manufacture at competitive price could be considered to bridge the huge demand. This would help in seeing sanitary napkins not as a luxury good and rather a healthy practice.

Monitoring and Indicators: Monitoring and evaluation will be carried out by regular inspections by the DEO, Health inspectors and reports from them and from the schools shall be submitted regularly to the department regarding status of infrastructure, attendance statistics with reason for absence from class etc in the provided data sheet to maintain uniformity in reporting during the evaluation period. Reported morbidity among students, status of school absenteesm due to menstrual problems, Improvements / comparisons between schools, percentage of teachers / schools sensitised to the issue, percentage of schools covered with infrastructure and availability of napkins etc can be of value as indicators for success of the program and evaluation.

Income Elasticity of health care demand

Introduction
The concept of ‘Elasticity’ has an important role in economics. The understanding of income elasticity of healthcare demand and expenditure is important to understand the health economics of the country and to guide policy making. United States and United Kingdom are the pioneers in research in health economics and it gained importance through many of their research only since the past two decades. The scope of studies is still been confined only to certain areas to cover a particular aspect scattered over a period of time in India. The World Development Report (WDR) of 1993 views health as a basic human right and stress the necessity of providing cost effective healthcare for the poor and that it can contribute towards alleviating poverty (11, 5). Hence understanding of health economics is essential for policy makers and for those guiding them.

Income elasticity – Definition
Elasticity in economics refer to the response in demand or supply in response to the price or income. The Income Elasticity of Demand measures the rate of response of quantity demanded due to an increase (or decrease) in consumer income(18) The higher income elasticity, the more sensitive demand for a good is to changes in income. High income elasticity suggests that when a consumer's income rises, consumers will purchase much more of that good. Negative income elasticity means that the good is inferior, and an increase/decrease in income would decrease/increase the demand for that good. Positive income elasticity means the good is normal, and an increase/decrease in income would increase/decrease the demand for that good.

Healthcare demand
The types of health care services offered vary widely and we expect that the elasticity of demand for specific service types would vary as well. There might be a differential demand for inpatient services, outpatient services, acute and preventive care, lab work, office visits, pharmaceuticals, x-rays, and a variety of other goods and services. This heterogeneity in healthcare demand suggests that it would we more informative if separate demand elasticities for each category of health services is estimated (3).

Healthcare is a luxury good?
The Economist magazine stated this as a conventional wisdom in 1993, writing: “As with luxury goods, health spending tends to rise disproportionately as countries become richer….´ (quoted in Blomqvist and Carter, 1997, p. 27) (19). Since the seminal papers by Kleiman (1974) and Newhouse(1977), much emphasis has been given to the role of income in determining health care expenditure (1, 4, 6, 26). The debate is still open on whether healthcare services should be considered as a necessity or a luxury good, namely, if income elasticity of expenditure is above or below unity (7, 19, 20, 21, 27, 25). However recent studies prove that it is not a luxury good after further analysis and considering biases (2)(28). A study reconsidering the economic relationship between healthcare expenditure and income on a long-run using a panel of 20 OECD countries observed health care as a necessity good over the period 1971-2004 (6) (9).

Income elasticity in Healthcare demand
Contrary to many earlier studies in rural India, as with studies in many other countries, demand for healthcare was found to be price and income inelastic(17). Products and services can be classified as necessity or discretionary. Necessity goods are expected to be relatively income inelastic, while that for discretionary goods is expected to be relatively responsive to income changes. However, it is difficult to classify health care services in general as necessity or discretionary (3). Because of the high income elasticity of demand for healthcare services in India, the demand increased disproportionately with the rise in income making the cost of operating such systems not sustainable (15). Such studies estimating elasticities of demand for healthcare services and that of health insurance are only very few (12). Elasticity can themselves vary with income. For example, a good that is a necessity for the rich can be a luxury for the poor. Yet another study with OECD countries showed income elasticities are higher at low-income levels and lower at higher income levels (16).

Income elasticity and health insurance
When consumers have the benefit of free access to healthcare, changes in their income does not have an effect on their ability to obtain such care (8). Two studies done by Marquis and Long (1995) and Marquis et al. (2004) shows that the all else being equal, the demand for health insurance does not significant change with personal or family income. The estimated income elasticities in the two studies were in the range of 0.01 to 0.15 and 0.03 to 0.04 respectively with health insurance (12, 22, 23). In both these studies, family income was measured relative to the federal poverty level.

Income elasticity and User fee
There are several studies to show that that the out-of pocket expenditure is quite large as people prefer to visit private facilities rather than public for curative care. (11, 24, 30). The utilization of healthcare services by the poorer and needy sections is affected by the implementation of user fees possibly due to its regressive nature. This argument presupposes that the poor are more price sensitive for health services than the rich are. And regarding the elasticities, the demand of these poorer section lies on the elastic segment of the demand curve of the community.

Income Elasticity and Ageing
The future cost of health care will increase in ageing societies with population ageing being a key driving force(13). Part of this is because of the fact that the forecasters assume that the health care cost will raise as fast as the GDP. But they do not consider that technological change will continue to push up health care expenses as societies adapt to newer treatment modalities. Elderly have a higher health care demand and are informed too. In most developed countries including Japan where it is an aged population, health care is heavily subsidized along with long-term care insurance(14). Because of this, an increase in household income would not increase the demand for healthcare. This is one reason for low income elasticity in developed countries including United states. However, in developing countries like India where the population of elderly are increasing in both proportion and absolute numbers, the scenario will be alarming. Besides GDP, some of the other factors contributing to the rise in healthcare expenditure include higher life expectancy, female labor participation and decreasing fertility rate (10).

Conclusion
It is of the view that the services that are highly sensitive to prices and income and that would generate large positive externalities and those life saving measures which are income sensitive should be provided free or at a subsidized price to those who deserve. More research on health economics is needed and if not taken into account, are likely to provide policy makers with misleading results.(6)

References

1. Acemoglu, Daron and Finkelstein, Amy and Notowidigdo, Matthew J; Income and Health Spending: Evidence from Oil Price Shocks; April 2009, C.E.P.R. Discussion Papers, Number 7255.
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9. B H Baltagi, F. Moscone; Health care expenditure and income in the OECD reconsidered: Evidence from panel data Economic Modelling Volume 27, Issue 4, July 2010, Pages 804-811 Special Issue on Health Econometrics
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12. Su Liu Deborah Chollet; Price and Income Elasticity of the Demand for Health Insurance and Health Care Services: A Critical Review of the Literature Final Report March 24, 2006 Submitted by: Mathematica Policy Research, Inc. 600 Maryland Ave. S.W., Suite 550 Washington, DC
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EVALUATION OF FAMILY PLANNING PROGRAM

Theoretical perspective
Historically, evolution of Family planning program in India from the immediate post-independence period was with the target of reducing birth rate and its consequences in the country. The proponents of Malthusian and neo-Malthusian theories in India influenced the policy makers during the initial days to take firm steps towards population control. The objective of the program in kerala too did not transcend beyond mere control over number of births and certain medical aspects of giving birth of a baby to a broader meaning of ‘planning a family’ keeping the inviolability of parenthood and other human values and needs. The program also concentrated more on the medical aspects of reproductive health, its consequences on economy, sustainability of other national programs and development of the nation as compared globally. The Kerala State policy driven by the Family planning program of the country also focused on the need for bringing down the population within a stipulated frame of time and this targeted program had specific indicators for outcome. Financial and other incentives for acceptors of family planning and health workers led to coercion to accept contraceptive measures. There are also instances of pressure tactics by the program on the health workers, even though not as bad as it happened in early days, to coerce people to undergo even a terminal contraception without adequate provision with information. Following the International Conference on Population and Development at Cairo in 1994, there was a shift of approach to a “Rights based”. However, though it reflected in the National Population Policy 2000, such recommendations remain un-implemented at large. Since the worth of the program was measured and determined only by its consequence without incorporating the social determinants, the state policy driven by the national program is Utilitarian in nature.

Benefits for Acceptors of Family Planning
Apart from the benefits for the nation as a whole, the following are the benefits for individual acceptor of family planning program –

Direct Benefits
• Reduced burden of repeated child bearing for women would help women to be in better health
• Enough spacing between children so that care of the mother and child is possible
• Terminal contraceptive measures prevent further pregnancies and associated morbidities which is of special mention in case of those women at risk
• Availability of safe Abortion locally and legally
• Sex Selective Abortions could be prevented if enforced properly
• Youth could also meet their sexual and reproductive needs
• Measures to plan and control family size is made available to women
• Reducing death of infant or mother

Indirect Benefits
• Reduced Reproductive Morbidity of both Men and Women
• Sexually transmitted diseases including HIV could be prevented
• Reduced instances of catastrophic expenses pushing to further poverty
• Early detection of treatable conditions preventing a larger burden
• High risk maternal and child care has started getting attention
• There is an opportunity to demand for sexual and reproductive rights as well as empowerment of women
Cost to the Acceptors

Direct costs:
• Hospitalization cost
• Cost of stay, medicines and materials
• Cost of transport to and from the institution in that case.
• Fee to be paid to birth attendants, nursing or for doctor if needed

Indirect costs:
• Productivity loss
• Wages lost during the period
• Time Costs incurred for tubectomy (takes upto 5 days hospitalization and upto 1 month of moderate rest at home) is much more than vasectomy (usually does not require hospitalization or rest)
• Wages lost by care takers or that has to be paid for bystanders
• During instances of hospitalization, such as in case of tubectomy, there is a cost to take care of children and other dependents at home.
• Cost of re-canalisation if at a future period in time, due to some reason the couple opts for another child.
• Loss of social/ family role for the period of hospitalisation and recuperation.
• Blame for failures usually on the women and she will have to bear the extra burden of maintaining family size.
• Value of the child unborn, following a terminal contraceptive measure such as Tubectomy or Vasectomy cannot be quantified if recanalisation fails.
• Risk of women being blamed of infidelity and resultant marital discord following failure of male contraception. This can happen when proper awareness of chance of pregnancy is given and if necessary care is not taken immediately after vasectomy.


Means to mitigate problems associated with the Costs
Ministry of Health and Family Welfare has introduced a Family Planning Insurance Scheme since 1981 and presently implemented through ICICI Lombard General Insurance Company to compensate the acceptors of sterilization for loss of wages. Central Government, under this scheme release fund to the state Government at a fixed rate such as Rs. 1100/- per Tubectomy, Rs. 600/- per Vasectomy, Rs 20 per IUCD Insertion etc. The package may vary from high focus states to low focus states. In addition to cash compensation for lost wages, food, medicines and materials etc, provisions are made to make a payment of ex-gratia to the acceptor of sterilization or nominee in case of an adverse event as follows. Rs. 200,000/- per case of death within 7 days of discharge, Rs. 50,000/- in case of death between 8 – 30 days of sterilisation, Rs. 25,000/- in case of failure of sterilization, and Rs. 25,000/- towards cost of treatment of serious post operative complication. Indemnity insurance of Rs. 200,000/- per case per doctor / facility but not more than 4 cases in a year is also provided in the program. However, there is a ceiling for the insurance company of Rs. 9 Crore to be paid in a year under each section. The amounts provided for sterilization would not be sufficient to meet all the costs of undergoing the procedure. It is unfortunate that there is no means at present to mitigate the costs involved in seeking Family Planning services. Medicines such as contraceptive pills and materials such as condoms and IUCDs are provided free of cost. Yet another fact to be noticed is that not all of the opportunity costs and incidental costs in terms of money and time are fully compensated.


Rights Provided within the program: Even though, the program highlights some of the rights, they are not fully fulfilled. However, these are,
• Right for controlling fertility
• Right for deciding size of the family
• Right to give proper care for family, especially children and spacing between two births

Rights being violated in the program

• Right to Reproduce: Even though, every individual has the right to take part in the process of reproduction, the Universal Declaration of Human Rights (UDHR), does not include the right to reproduce. It only declares that all humans “have the right to marry and to found a family” and that “motherhood and childhood are entitled to special care and assistance. The United Nations document that specifically upholds women’s right is the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), and it mandates reproductive freedom. Article 16(e) states that women and men must have the “same rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise their rights.” The clause of equal right is often violated as women has to compromise on the choices of contraception and the brunt of controlling family size is on her. Negotiating power of women is also pretty less in most of the Indian societies. There are also moves in different parts of the country to penalize couples and their children for not abiding to the norms prescribed by the Government.

• Right of women to decide on fertility is challenged by coercion and forceful tubectomy that is conducted as a ritual along with the delivery of second baby.

• As a result of lack of efforts from the health systems to create awareness about the effectiveness and ease of vasectomy, Tubectomy is preferred by men and the family where a comparatively more risky procedure is imposed on the weaker sex.

• Right to choose from available options is often hampered due to lack of availability or an overt projection of one method and lack of research and innovations in the field.

• Right of informed choice is violated because no information is provided on alternative choices.

• Right to refuse a method for women is usually denied as it would be the family or male partner who decides the method of contraception and size of family and the spacing.

• Coercion exists on grounds of incentives or penalties that take away the right to freedom of choice. Such exploitations exist to the extent that vasectomies are done on persons who are alcohol intoxicated by paying those incentives to consume more.

• Family planning programs also fail to maintain and promote existing families as it excludes the role and existence of members in a family as they become old. Programs view family’s function as just for taking generations forward and forget the values and positive transactions that are possible between generations. Encouraging such positive transactions may prove to be a better resource to foster identities and family values that is essential in care of older population and in bringing up of an ethically bound generation.

• Sexual self-determination of a woman forms an integral part of her dignity as a human being. Population policies and population control programs often are insensitive to this right and consider these “bodies” as mere instruments for procreation and hence consider that it could be easily manipulated to attain population control without providing provisions for respecting the identity.

Report on Elder Abuse & Crime in India, 2011

Report on Elder Abuse & Crime in India, 2011

SALIENT FINDINGS:

Reproduced with reference to the report published by helpage India

• Abuse by daughter-in-law was reported most in Delhi (100%) followed by Hyderabad (89%), and Bhopal (87%).

• Nationally Daughter-in-law emerged as the major abuser of the elderly (63.4%), followed by the son (44%) from the lower socio economic strata, as against the son (53.6%) last year in the higher socio economic strata.

• More than one fifth (22%) of the elderly have experienced any type of abuse with this being reported highest in Bangalore (44%) followed by Hyderabad (38%) and Bhopal (30%).

• Bangalore tops Elder abuse cases with a shocking 44%, it is closely followed by Hyderabad (38%), Bhopal (30%) and Kolkata (23%) the lowest being Chennai (2%).

• Verbal abuse is reported more in Delhi NCR, Mumbai, Hyderabad and Bangalore while emotional abuse seems to be more in Bangalore

• Half of the elderly from the lower socio economic strata reported facing abuse because of lack of emotional support. Last year among the elderly from higher socio economic strata, property issues emerged as the most common context for abuse

• More than two third (68%) of the elderly from the lower socio economic strata did not take any action when they faced abuse

• Most (98%) of the elderly reported not filing a complaint against abuse faced

• About 72% of the elderly stay with their sons while one fourth 39% stay alone with spouse Only.

• Chennai reported the highest percentage (38%) of elderly currently engaged in an economic activity while Delhi NCR the lowest (7%).

• Four fifth (81%) of the elderly are dependent on son, with the percentage being highest in Hyderabad (92%) followed by Kolkata (90%) and Bhopal (88%). The percentage of elderly dependent on spouse financially is highest in Patna (29%) followed by Hyderabad (22%).

• Two third (66%) of the elderly are financially dependent on others, with highest being reported in Ahmedabad (86%) and Mumbai (79%). Majority (85%) of the elderly reported being dependent for medical expenditure while three fourth (75%) for daily living expenditure


• Only one third (37%) said they would take any action in case of facing crime. Of those who said they wont, about half (46%) of such elderly reported that they were scared of facing further crime against them and there would not be any concrete action.



• The mean age of the elderly across the cities is 67 years. Nearly half (49%) of the elderly in Kolkata are of 70+ years

• Three fifth (60%) of the elderly are currently married, while more than one third (38%) are widow/ widower

• The mean number of children the elderly have is 4, with 2 sons and 2 daughters with highest being reported in Delhi NCR and Patna (5 each) and lowest in Hyderabad (3).

• More than two third (72%) of the elderly stay with son, while one fourth (23%) stay with spouse. More than one tenth (13%) are living with daughter

• More than half (52%) of the elderly are illiterate with one fourth (23%) having completed Primary levels and 15% having Middle level education

• Proportion of illiterate is highest in Patna (72%) and lowest in Hyderabad (27%)

• As regards the last main occupation, one third worked as unskilled workers and 26% were homemakers

• One fifth (21%) of the elderly are currently engaged in any economic activity with Chennai reporting the highest (38%) and Delhi NCR the lowest (7%)

• One fourth of the elderly in the age group of 60-69 years and less than one fifth (18%) in the age group of 70-79 years are currently engaged in any economic activity

• More than one fourth (29%) of the elderly currently economically active are petty traders and 13% are shop owners

• The average monthly household income of the elderly is Rs. 6269. About 30% of the elderly have a monthly household income in the range of Rs 2501-5000

• More than half (55%) of the elderly have remittance from children as the main source of income and more than one third (35%), pension

• More than two third (69%) of the elderly are living in their own house while 30% are living in a rented place

• More than two fifth (41%) of the elderly own property and this is highest in Delhi NCR (76%) and Bhopal (75%) and lowest in Ahmedabad (4%)

• One third (31%) of the elderly need assistance from anyone for daily routine activities with more than half (52%) are dependent on daughter-in-law

• Highest percentage of elderly needing assistance is among the oldest old (41%)


• More than four fifth (81%) of the elderly are financially dependent on their son and 14% on their daughter and 12% on daughter-in-law

• Three fifth (60%) of the elderly consider verbal abuse as elder abuse while more than two fifth (48%) feel physical abuse constitutes elder abuse


• More than one third each of the elderly feel that elder abuse constitutes emotional abuse (37%), showing disrespect (36%) and economic abuse (35%)

• Nearly one fifth (19%) of the elderly feel neglected with 20% of the elderly in the age group of 60-69 years feeling so

• More than two third (72%) of the elderly feel neglected sometimes while 17% feel neglected everyday

• Feeling of being neglected stems from the family related factors such as family members not interacting and being busy in their own lives/ work

• Verbal abuse is the most commonly reported abuse faced by the elderly from lower socio economic strata while it was ‘showing disrespect’ reported by the elderly from higher socio economic strata last year.

• It is observed that higher cases of elder abuse occur among elderly after 70 years. This trend was also observed among the higher socio economic strata last year

• In case of emotional abuse, mental torture was reported the most with Mumbai recording the highest (84%). ‘Speaking in loud voice’ is the highest percentage of abuse in case of verbal abuse

• One fourth of the elderly who took action (25%) reported discussing about the abuse faced with others in the family or in the neighbourhood or community

• Among the elderly who registered complaint, two fifth (40%) reported that nothing concrete came out of it. One fifth of the elderly reported that as a result of the complaint, the police carried out home visit

• More than one fourth (29%) of the elderly in the lower socio economic strata as compared to nearly half of the elderly (48%) last year (from the higher socio economic strata) expressed willingness to take concrete action

• Unwillingness to take any action against abuse stems from the perception among the elderly that - ‘it would lead to further abuse’ and ‘sense of shame in the community’

• Awareness about laws, policies and programmes against elder abuse is low among the elderly from lower socio economic strata

• One third (33%) of the elderly are aware of existing laws and programmes against elder abuse

• Among the elderly who are aware of the laws, policies and programmes, 18% are aware of the Maintenance and Welfare of Parents and Senior Citizen’s Act, 11% of the elderly are aware of the National Policy on Older Persons and 12% are aware of the Protection for Women against Domestic Violence Act

• Awareness of the law enforcing agencies is low as only 5% of the elderly are aware of these

• Two third (66%) of the elderly feel that role of police/ lawyers is supportive in controlling elder abuse


• More than two fifth (43%) of the elderly think that the police is equipped to handle such cases. The percentage of elderly from lower socio economic strata who are of the view that the Police Department is equipped to handle cases of elder abuse is higher as compared to the elderly from higher socio economic strata

• The major measures to be taken up by the law enforcing agencies suggested by the elderly include ‘giving protection’ (38%), ‘serving notice to the abuser’ and ‘carrying out home visits’ (33% each)

• ‘Having steady cash flow’ (51%), ‘having own property to reduce economic dependency’ (48%) and ‘making adjustments within family’ (35%) and are the major measures suggested by the elderly to control elder abuse

• Low percentage of elderly from lower socio economic strata reported ever facing crime. The highest percentage is reported by elderly in the age group of 70-79 years (3%)

• Among the major types of crime faced by the elderly, as reported are burglary, molestations and criminal acts with less than one tenth (8%) reporting intimidation

• Only one third (37%) are willing to take any concrete action for crime

• Unwillingness to take any concrete action stems from ‘being scared of facing further crime’ and ‘no concrete action’

• Half of the elderly feel that police is equipped to handle redressal of cases of crime

• Measures suggested for law enforcing agencies to tackle crime include ‘law enforcing agencies should provide protection to the elderly’, ‘serve notice to the person committing crime’ and ‘home visits to be made at regular intervals’

• The measures suggested by the elderly in controlling crime include ‘inform about the crime to the Police’, ‘contact counsellors to help deal with the crime, ‘procedure for legal aid should be simple and effective’, ‘contact Senior Citizen’s Association/ RWA for help and guidance and ‘simplify procedure for Police intervention’

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