जन स्वास्थ्य घोषणा पत्र के मुख्य सूचक:

1. स्वास्थ्य के अधिकार को देश के हर व्यक्ति के लिए न्यायोचित अधिकार बनाया जाए , केंद्र और राज्य स्तर पर उपयुक्त कानून सुनिश्चित करके ।
2. एक सार्वभौमिक स्वास्थ्य प्रणाली (यूनिवर्सल हेल्थ केयर) की स्थापना हो जो ना केवल स्वास्थ्य सेवाओं को व्यापित करे बल्कि सरकारी स्वास्थ्य सेवाओं को सभी स्तरों पर विस्तृत और सशक्त किया जाए । अंतरिम तंत्र के रूप में निजी प्रदाताओं को कुछ जिम्मेदारियां दी जाएं ताकि स्वास्थ्य रक्षा में वर्तमान कमियों को भरा जा सके । यह सार्वभौमिक स्वास्थ्य प्रणाली (यूनिवर्सल हेल्थ केयर ) लोगों को पूर्ण रूप से निशुल्क और गुणवत्तापूर्ण स्वास्थ्य सेवाएं प्रदान करेगी, बिना किसी निजी जेब खर्च के के।
3. स्वास्थ्य प्रणाली के लिए आवश्यक बजट आवंटन, मानव संसाधन और इंफ्रास्ट्रक्चर सुनिश्चित किया जाए :
सामान्य कराधान के जरिए वित्त पोषण से स्वास्थ्य पर सरकारी व्यय में भारी वृद्धि की जाए , जो तुरंत जीडीपी के 3.5% के बराबर हो। (यह वर्तमान दरों पर पर वार्षिक रूप से प्रति व्यक्ति ₹4000 हो, जैसा कि 2017 की राष्ट्रीय स्वास्थ्य नीति में सिफारिश की गई है ) और कुछ वर्षों में में में जीडीपी के 5% के बराबर हो। और यह स्वास्थ्य के कुल व्यय का का एक चौथाई से भी कम किया जाए। 
4.. हर व्यक्ति के लिए यह अधिकार सुनिश्चित किया जाए कि वह सभी आवश्यक औषधियों एवम जांच सेवाओं को निशुल्क किसी भी सरकारी अस्पतालों से प्राप्त कर पाए। इसकी व्यापकता दूसरे राज्यों जैसे तमिल नाडू , दिल्ली एवम राजस्थान में चल रही योजनाओं समान होंगी, जिससे लोगों को पूर्ण रूप से निशुल्क आवश्यक औषधियां एवं सरकारी स्वास्थ्य सेवाओं के सभी स्तरों पर मिलें।
5. आयुष्मान भारत के तहत ' प्रधानमंत्री जन आरोग्य योजना ' या 'राष्ट्रीय स्वास्थ्य रक्षा मिशन ' की योजना को त्याग दिया जाए , जो बदनाम बीमा मॉडल पर आधारित है। इसके बजाय वर्तमान सरकारी स्वास्थ्य बीमा योजनाओं को एक विस्तारित और मजबूत सार्व जनिक प्रणाली में समाहित किया जाए।
6. स्वास्थ्य सेवाओं का परिचालन इस प्रकार होना चाहिए कि कुछ चुनिंदा सेवाओं के लिए ही निजी स्वास्थ्य प्रदय कर्ताओं का उपयोग किया जाए ताकि सार्वजनिक प्रणाली को मजबूत किया जाए । परंतु इसकी दिशा प्रस्तावित आयुष्मान भारत कार्यक्रम की रणनीति जैसी नहीं होगी, जिसमें सार्व जणिक संसाधनों को अंधाधुंध तरीके से निजी स्वास्थ्य क्षेत्र को सौंपा जा रहा है । 
7. जन स्वास्थ्य सेवाओं के निजीकरण के सभी रूपों को रोका जाएगा और विभिन्न प्रकार के सरकारी निजी -साझेदारियों ( पब्लिक प्राइवेट पार्टनरसिप )- जो सार्वजनिक प्रणाली को कमजोर कर रही है, उसे खारिज किया जाएगा। जो संसाधन निजी संस्थाओं को मजबूत करने के लिए प्रयोग किए जा रहे हैं , उन्हें सार्वजनिक सेवाओं को बढ़ाने और स्थाई रूप से सार्वजनिक पूंजी का निर्माण करने के लिए इस्तेमाल किया जाएगा। 
-- सार्वजनिक सेवाओं को कमजोर बनाने वाली सरकारी -निजी भागीदारी यों को समाप्त किया जाए । ऐसी योजनाओं में खर्च होने वाले पैसों को सरकारी स्वास्थ्य तंत्र के विस्तार और स्थाई सार्वजनिक सं पती के सृजन में निवेश किया जाए, जिससे इन पैसों का बेहतर उपयोग होगा। 
8. निजी मेडिकल क्षेत्र और कारपोरेट अस्पताल का नियंत्रण और राष्ट्रीय नैदानिक प्रतिष्ठान अधिनियम ( किलिनिकल 
एसटाबिलिस्मेंट एक्ट ) के द्वारा किया जाए , ताकि मरीजों के अधिकारों का अनुपालन हो सके , विभिन्न सेवाओं की दरों एवं उनकी गुणवत्ता के विनियमन हों , डाक्टरों द्वारा निदानन और रेफरल में घूसखोरी को रोकने और मरीजों की शिकायतों का निपटारा सुनिश्चित किया जाए । सभी राज्यों द्वारा राष्ट्रीय अधिनियम या राज्य विशेष अधिनियम को अपनाया जाए।
9. सार्वजनिक स्वास्थ्य सेवाओं के समुदाय आधारित नियोजन - एवं निगरानी :
सार्वजनिक स्वास्थ्य सेवाओं की जवाबदेही और अनुकूलता को सुनिश्चित करने के लिए सभी स्तरों पर सार्वजनिक स्वास्थ्य सेवाओं के समुदाय आधारित नियोजन -एवं निगरानी को सार्वभौमिक बनाया जाए , जिससे एक लोकतंत्रिकृत , समुदाय संचालित स्वास्थ्य प्रणाली और एक स्वास्थ्य देखभाल की रूपरेखा की तरफ कदम बढ़ाया जाए।
10. सार्वजनिक स्वास्थ्य प्रणाली में भ्रष्टाचार की समाप्ति के लिए पारदर्शिता अधिनियम के जरिए नियुक्ति, पदोन्नति , स्थानांतरण , वस्तुओं एवं सेवाओं की खरीद और इंफ्रास्ट्रक्चर के विकास किए जाएं । 
11. सभी कर्मचारियों को जो ठेके (कांट्रेक्ट ) पर कार्यरत हैं जैसे कि आशा , आंगनवाड़ी कार्यकर्ता एवं सहायिका सहित सभी कर्मचारियों को नियमित किया जाए और सुनिश्चित किया जाए कि उन्हें श्रम कानूनों से संरक्षण प्राप्त हो । सरकार द्वारा संचालित कालेजों में क्षमता निर्माण के लिए सभी तरह के स्वास्थ्यकर्मियों की शिक्षा और प्रशिक्षण में सार्वजनिक निवेश की वृद्धि सुनिश्चित की जाए । पर्याप्त संख्या में स्थाई पदों का सृजन कर सुप्रशासित और पर्याप्त जन स्वास्थ्य कर्मियों का बल स्थापित किया जाए। सार्वजनिक स्वास्थ्य प्रणाली के सभी स्तरों के स्टाफ को पर्याप्त कौशल प्रशिक्षण , समुचित वेतन और स्थान नियोजन देने की व्यवस्था की जाए एवं कार्यस्थल में समुचित परिस्थितियां उपलब्ध हों।
12. सरकार को वैज्ञानिक रूप से जन हितैषी औषधीय नीति अपनानी होगी जिसमें औषधियों , टीकों, निदानों और मेडिकल उपकरण शामिल होंगे , इसमें निर्माण लागत पर आधारित मूल्य निर्धारण प्रणाली के जरिए सभी आवश्यक औषधियों और उनके अनुरूप पों ( एनोलोग्स) के साथ मेडिकल उपकरणों को मूल्य नियंत्रण के अन्तर्गत लाया जाएगा। सभी युक्तिसंगत हीन औषधियों और युक्तिसंगत हीन नियत खुराक औषधि सम्मिश्रर्णों ( फिक्स्ड डोज ड्रग कॉम्बिनेशन ) पर प्रतिबन्ध लगाना , अनैतिक मार्केटिंग को असरदार ढ़ंग से विनियमित और उन्मूलन करना जिसके लिए औषधीय मार्केटिंग के तौर तरीकों के बारे में समान कानू नी आचार संहिता (युनिफोर्म कोड़ फॉर फार्मास्युटिकल मार्केटिंग प्रैक्टिसेस) को अपनाया जाएगा ।सरकार को एक जेनेरिक औषधि नीति तैयार करनी चाहिए और जेनेरिक औषधियों की आसान उपलब्धता सुनिश्चित करते हुए डाक्टरी नुस्खे में जेनेरिक नाम लिखने को अनिवार्य बनाना होगा, औषधियों तक पहुंच को बढ़ावा देने के लिए भारतीय पेटेंट अधिनियम में सार्वजनिक स्वास्थ्य सम्बन्धी उपायों को स्थान देना। पेटेंट के दुरूपयोग के खिलाफ सुरक्षा प्रदान की जानी चाहिए और आवश्यक औषधियों के निर्माण के लिए स्थानीय निर्माताओं को अनिवार्य लाइसेंस दिए जाएं ।
13. कमजोर वर्गों और विशेष जरूरतों वाले समूहों के लिए स्वास्थ्य तक पहुंच में विशेष उपाय किए जाएं :
इन वर्गों की कमजोरी का कारण सामाजिक स्थिति ( जैसे महिलाएं, दलित, आदिवासी) , स्वास्थ्य स्थिति (जैसे एच आई वी से पीड़ित), पेशा( शारीरिक रूप से मैला ढोने वाले), सक्षमता, उम्र या कोई अन्य हो सकता है । सभी महिलाओं , बेघरों , सड़कों पर भटकने वाले बच्चों , विशेषकर कमजोर आदिवासी समूहों, शरणार्थियों , प्रवासी लोगों तथा ट्रांसजेंडर व्यक्तियों को स्वास्थ्य सम्बन्धी आवश्यकताओं की पूर्ति की गारंटी दी जाए । जाति और समुदाय /धर्म -आधारित भेदभाव के सभी रूपों का उन्मूलन किया जाए। स्वास्थ्य सेवाओं या स्वास्थ्य से सम्बन्धित सार्वजनिक किसी भी सेवा या योजना तक पहुंच के लिए आधार लिंक की अनिवार्यता को समाप्त किया जाए । 
14. जेंडर आधारित हिंसा को एक जन स्वास्थ्य सम्बन्धी मुद्दा माना जाए और आवश्यकता पड़ने पर शीघ्र बचाव एवं स्वास्थ्य देखभाल, व्यापक मेडिकल देखभाल और पीड़ितों को लगातार सहायता सुनिश्चित की जाए ।
15. सभी गर्भवती और धात्री माताओं के लिए मातृत्व भत्ता सार्वभौमिक बनाया जाएगा।
16. आई. सी. डी. एस. कार्यक्रम को सार्वभौमिक बनाया जाए और इसमें तीन साल से कम उम्र के बच्चों को खास तौर से असरदार ढ़ंग से शामिल किया जाए , जिसमें कुपोषण का समुदाय आधारित प्रबन्धन और दिन में देखभाल करने की सेवाएं हों।
17. व्यवसायिक स्वास्थ्य और सुरक्षा पर व्यापक नीति निर्माण और अमल हो एवं असंगठित एवं कृषि क्षेत्रों में कार्यरत कर्मियों के लिए कर्मचारी राज्य बीमा अधिनियम (ई. एस.आई . ),1948 को विस्तारित और सशक्त किया जाए ।
18. राष्ट्रीय स्वास्थ्य मिशन में संशोधित जिला कार्यक्रम और समुचित कार्यान्वयन के जरिए मानसिक स्वास्थ्य के मसलों से सम्बन्धित व्यक्तियों के व्यापक इलाज और देखभाल को सुनिश्चित किया जाए । 
19. मेडिकल बहुलता को समर्थन हो ताकि लोगों के पास गैर एलोपैथिक चिकित्सा का विकल्प उपलब्ध रहे , जिसमें घर प्रसूति सम्बन्धी सुरक्षित तरीका भी शामिल है । गैर एलोपैथिक प्रणालियों से सम्बन्धित अनुसंधान और दस्तावेजीकरण को भारी बढ़ावा दिया जाए ।
20. बहुपक्षीय और द्विपक्षीय वितपोषण एजेंसियों तथा कारपोरेट कंसलटेंसी संगठनों
( जैसे-विश्व बैंक, यू. एस. ए.आई . डी.,गेट्स फाउंडेशन , डिलोइट और मैकिंजी आदि) का सभी राष्ट्रीय स्वास्थ्य नीति निर्माण और रणनीति विकास में हस्तक्षेप समाप्त किया जाए ।
21. नैदानिक परीक्षणों के अनुमोदन और आयोजन के लिए कड़े विनियमन पर अमल किया जाए , जिसमें निष्पक्ष और परीक्षण के उन प्रतिभागियों को समय पर प्रतिपूर्ति सुनिश्चित की जाए जो प्रतिकूल प्रभावों से पीड़ित होते हैं एवं परीक्षण स्थलों पर नैदानिक परीक्षणों के आयोजन पर सी. डी. एस.सी.ओ.(CDSCO) कड़ी निगरानी रखे ।
22. सभी के लिए स्वास्थ्य का अधिकार की पूर्ति की ओर बढ़ने के लिए स्वास्थ्य के सामाजिक कारकों को व्यवस्थित ढंग से संबोधित करना जिसमें खाद्य सुरक्षा , पोषण एवं स्वच्छता के साथ पर्यावरणीय प्रदूषण , तनावपूर्ण कार्य परिस्थितियों , सड़क सुरक्षा की अपेक्षा , तम्बाकू, अल्कोहल आदि जैसे व्यसंकारी पदार्थों और जेंडर आधारित हिंसा सहित अन्य प्रकार की हिंसा पर ध्यान दिया जाए। जन स्वास्थ्य के कार्यों का एकीकरण सभी स्तरों पर लोकतांत्रिक समावेशन , धर्मनिरपेक्षता , मानवता एवं क्षेत्रीय स्तर पर शांति के साथ किया जाए। 
जन स्वास्थ्य अभियान, जन स्वास्थ्य आंदोलन का भारतीय इकाई है, जो व्यापक प्राथमिक स्वास्थ्य सुरक्षा एवं स्वास्थ्य के सामाजिक निर्धारकों पर कार्य करते हुए स्वास्थ्य और न्याय संगत विकास को सर्वोच्च प्राथमिकता ओंं के रूप में स्थापित करने के लिए एक विश्वव्यापी आंदोलन है और इसमें 20 से अधिक नेटवर्क और 1000 संगठन और बड़ी संख्या में व्यक्ति भी शामिल हैं 
जन स्वास्थ्य अभियान की ओर से 
अभय शुक्ला
सरोजिनी नदिंपल्ली 
सुलक्षणा नंदी

CLINICAL TRIALS

Parliamentary Committee Indicts Clinical Trial Industry

Amit Sengupta 12th September, 2013 � THE Seventy-Second Report of the Parliamentary Standing Committee on Health marks a strong indictment of the way in which clinical trials are being conducted in India. Before discussing the report, it is important to understand the underlying reasons for the present state of affairs. Open Invitation for Foreign Companies to Conduct Clinical Trials in India The story dates back to 2005 when the Indian government revised a very crucial section of the Drugs and Cosmetics Act, which governs the use of medicines, vaccines and other products that are used to improve human health. The amendments in 2005 pertained to the section on clinical trials, ie, research done to prove that a product is safe and effective. All medical products, before being allowed to be marketed, need to pass through different phases of clinical trials. The 2005 amendments made it easier for drug companies to do research that involved Indian participants. The government�s rationale for easing conditions under which research could be done by foreign companies were that it would bring in foreign investment (the abiding mantra of neo-liberal policies!), that it would help Indian science by drawing more research activities into the country, and it would help Indian patients by promoting early introduction of new drugs. Within a year, the number of clinical trials being conducted jumped to over 500 per year , from less than 100 per year in the pre-2005 era. What followed was a virtual free for all � unscrupulous trial sponsors and contract research organisations (CROs) milked the system and patients suffered. The regulatory systems did not have the capacity to deal with the sudden rise in the number of trials.� The resulting confusion could well have been termed a �comedy of errors�, except for the fact that the consequences were tragic, and in several instances, fatal. Shift of Clinical Trial Locations to Developing Countries Traditionally the United States has been the major centre for conducting clinical trials. A vast majority of clinical trials used to be conducted in the United States and Western Europe. While even today a majority of trials are conducted in these two regions, the situation has started changing quite rapidly in recent years. Given that most pharmaceutical companies that develop new medical products are based in the US and Western Europe, it was logical that trials to validate these products would be conducted in these regions. The shift of clinical trials to other countries has been driven by several factors. One major factor that has contributed to the globalisation of clinical trials is the rise of contract research organisations and the accompanying outsourcing of clinical trials. Unlike a few decades earlier, drug companies often prefer not to directly conduct trials but outsource them to CROs. The CRO industry has grown phenomenally � its turnover grew from $1 billion in 1995, to $7 billion in 2005, and to an estimated $21.4 billion in 2010. CROs prefer non-traditional sites to conduct clinical trials because they are cheaper in countries such as India as compared to the developed world. What is left unsaid is that the cost of human lives is also cheaper. Most European countries have regulations that mandate compulsory insurance for human trial subjects that includes �no fault liability� � ie, insurance coverage that covers the possibility that the research may result in adverse effects on subjects even if the trials were properly designed and executed. In India, we are just starting to discuss the issue of compensation for trial subjects who suffer adverse effects. Also left unsaid is that CROs prefer countries such as India because regulatory capacity is weak and laws and rules are yet not commensurate with requirements. There is clear evidence that trials are moving to places outside the US and Western Europe. This is clear from data from the European Medicines Agency (EMA) regarding number of trial participants involved in Phase III trials (the largest final phase of trials before regulatory approval) for which data was submitted for regulatory approval of different drugs in the EU. In 2005, 79.8% of trial subjects lived in the EU or the US, but by 2011 this had declined to 62.7%. The largest increase was in Asia � from 2.0% to 12.8%. Exploiting the Vulnerability of Poor Patients There is another very important reason why it is easy to enroll �volunteers� for clinical trials in a country like India. Theoretically all trial participants are volunteers, and choose to participate after they are clearly explained about the risks involved. It is important to recognise that all trials are experiments, and hence carry a theoretical risk. That is why there is a huge premium put on the �informed consent� process of clinical trials. In countries such as India the entire process of procuring informed consent from trial participants has been converted into a sham in a very large number of cases. First, a bulk of trial participants are drawn from underprivileged sections, many of who do not have the capacity to understand the consequences of participating in a clinical trial. Second, and perhaps most importantly, trial subjects are vulnerable because they are at the mercy of a non-functioning health system. They are vulnerable to pressure from their treating physicians � who could also be the investigator in a clinical trial � because participation in a trial can often be the only way in which a poor patient is able to afford treatment for a chronic or life threatening conditions. CROs exploit the vulnerability of patients to recruit trial patients and the tag of a �volunteer� means very little. We discussed earlier that it was believed that by changing the regulatory norms in favour of less restrictions on clinical trials by foreign companies, Indian patients and Indian science will benefit. Neither has happened. Indian patients rarely benefit as trials conducted by foreign companies are used to generate data that allows them to get marketing approval in their home countries. These drugs are patented and sold in the global market at exorbitant prices, well out of the reach of virtually all Indian patients, and definitely not available to poor patients who form the bulk of trial participants in India. Nor has Indian science benefited. CROs today recruit both patients to participate in trials and doctors or scientists who conduct the trials. The latter are not involved in designing the trial, or in using the data to further their own research. The data generated flows back to the parent company and Indian scientists are used as mere conduits to generate and transmit data. The horror story of the Indian clinical trial industry has now started unfolding and the evidence has been so compelling that the Supreme Court, in early 2013, stepped in to put severe restrictions on approvals to clinical trials. The Supreme Court, in an interim order that responded to a Public Interest Litigation (PIL) by Swashya Adhikar Manch and others, directed that the Drug Controller General of India (DCGI) would have to consult the health industry before allowing any clinical trial in the country. There are extensive reports of ethical violations and of multiplying severe adverse effects involving trial subjects. The Gory History of Clinical Trials The gross and repeated rights violation of trial subjects in India are grim reminder that when private capital stands to benefit, and when public scrutiny is muted, rights violations are the norm rather than an aberration. The history of trials on human subjects, has in the past, thrown up several such instances.� Two of the worst instances of such violation relate to the Auschwitz trials in Nazi Germany and decades of violations of human rights among the prison population and among people of African origin in the United States, who were coerced into participating in clinical trials. A particularly horrendous tale in the US (among several others) unfolded with revelations in 1972 surrounding the �Tuskegee Study of Untreated�Syphilis�in the Negro Male�, which was begun in the 1930�s and lasted 40 years. In it, several hundred mostly illiterate men with syphilis in rural Alabama were left untreated, even after a cure was discovered, so that researchers could study the disease. In the late 1970s, other horror stories emerged. In 1979, the Philadelphia Inquirer reported that inmates in Holmesburg (Philadelphia Detention centre) had been used as guinea pigs to test whether mind-altering drugs were useful as Army weapons. In 1981, the paper reported that inmates had been dosed with dioxin to test the herbicide's effects on human health. The centre was later to gain further notoriety as it became known that for twenty years, tests involving toothpaste, deodorant, shampoo, skin creams, detergents, liquid diets, eye drops, foot powders and hair dye were conducted on the prison inmates, all accompanied by constant biopsies and frequently painful procedures. Finally in 1978, public opinion forced Congress to adopt legislation that severely restricted the use of prison populations for clinical trials. It has been conjectured that the move of clinical trials to developing countries found its early impetus in this change in the US law. The HPV Trial in India The story of the HPV trials in India, sponsored by a US based NGO called Program for Appropriate Technology in Health (PATH), appears to be a throwback to the dark ages of the Auschwitz, Tuskegee and Holmesburg trials. Instead of concentration camp, jail inmates, or African Americans, here the trial subjects were thousands of young pre-adolescent girls, many of them living in hostels, in rural areas of Andhra Pradesh and Gujarat. PATH was given approval for a trial that they called a �demonstration project�. PATH�s so called demonstration project was funded by the Bill and Melinda Gates Foundation and the vaccines were provided free of cost by the two giant vaccine manufacturers � Merck and Glaxo Smith Kline (GSK). The trial involved vaccinating girls with a vaccine that would protect them against the Human Papilloma Virus (HPV). It is believed that infection by the HPV virus predisposes to the development of cancer of cervix (the last portion of the uterus). While only a fraction of patients infected by the HPV virus develop cervical cancer, almost all cervical cancer patients are found to harbour the virus. The two vaccines developed by GSK (Cervarix) and Merck (Gardasil), are available in many countries (including the United States where it has been extensively used since 2006) and is also approved for marketing in India. However the issue we pick up here is not the efficacy and safety of the vaccine (regarding which there are several questions, which we are not elaborating here) but of the way in which the trial was designed and executed. There were gross ethical violations in which trial participants were recruited. In Andhra Pradesh, consent was not taken either from the girls or from their parents or guardians. Hostel wardens signed up to give consent for hundreds of girls in their charge. The district health systems were in no position to monitor the health of the trial subjects or to follow up on possible adverse effects. The story broke when four deaths were reported among trial subjects in Khammam. Till this day the cause of death and its possible link with the vaccine has not been established or disproved for the simple reason that there were no systems in place to follow up trial participants. When the issue was raised by several health and women�s organisations and was also raised in parliament, the ministry of health and family welfare promised to conduct an enquiry. The enquiry report agreed with the contention that there had been several violations of rights and of regulatory procedures, but remained silent as regards apportioning of blame and recommendation of punishment for those involved in allowing and in conducting such a trial. PATH tried to hide behind its fa�ade of being a non-commercial NGO and a self proclaimed philanthropy. It repeatedly tried to obfuscate the issue by claiming that it had conducted a �demonstration project� and not a clinical trial, and hence rules governing clinical trials did not apply to their project. This is a blatant lie as clearly any experiment conducted on human subjects (especially one where a medical product was administered), irrespective of the nomenclature, is a clinical trial. The DCGI provided approval for the trail when the trail design was flawed as it did not have proper protocols in place to record informed consent, or systems in place to effectively monitor the vaccinated children. The ICMR, the apex body in the country that develops guidelines on clinical trial ethics, was complicit participant and collaborator. In fact the Project Advisory Group (PAG), set up for the project, included representatives from ICMR, PATH, AIIMS, governments of Gujarat and Andhra Pradesh, and the World Health Organisation (WHO). Scathing Criticism of the Indian Regulatory System Given this context, the recent report of the Parliamentary Standing Committee on Health, comes as a timely corrective. The report has been scathing in its criticism of all those who were involved � PATH, DCGI, ICMR, and the inquiry committee. In its report the Standing Committee has remarked: �It is apparent the PATH has exploited with impunity the loopholes in our system as also the absence of a nodal point or a single window for maintaining a data bank of foreign entities entering the Country for setting up their offices�. It further goes on to say: �Coming to the instant case, it is established that PATH by carrying out the clinical trials for HPV vaccines in Andhra Pradesh and Gujarat under the pretext of observation/demonstration project has violated all laws and regulations laid down for clinical trials by the Government. While doing so, its sole aim has been to promote the commercial interests of HPV vaccine manufacturers who would have reaped windfall profits had PATH been successful in getting the HPV vaccine included in the UIP of the Country. This is a serious breach of trust by any entity as the project involved life and safety of girl children and adolescents who were mostly unaware of the implications of vaccination. The violation is also a serious breach of medical ethics. This act of PATH is a clear cut violation of the human rights of these girl children and adolescents. It also deems it an established case of child abuse. The Committee, therefore, recommends action by the Government against PATH. The Committee also desires that the National Human Rights Commission and National Commission for Protection of Children Rights may take up this matter from the point of view of the violation of human rights and child abuse�. It is hoped that the government and concerned agencies will act on the parliamentary committee report expeditiously. At stake is not just the immediate case of the HPV trials but the entire perversity that now permeates the clinical trials industry in the country. Clinical trials are necessary if safe and effective medicines are to be developed. But by allowing the conversion of the clinical trials industry into the worst kind of profit making enterprise, we are doing gross disservice to both experimental science and health care.

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Generic Prescribing of Medicines: Diktats are Not a Substitute for Sound Public Policy

Amit Sengupta 25th April 2017 In a recent public meeting Prime Minister Narendra Modi announced that the government would take steps to reduce costs incurred on purchase of medicines by making it mandatory for doctors to prescribe medicines in generic name. In itself such a step by the government would be welcome. Unfortunately past experience shows that such pronouncements are mere empty promises that have no relation to the situation on the ground. The government, through the Medical Council of India (MCI), had in a Gazette notification dated September 28, 2016, notified that “every physician should prescribe drugs with generic names legibly and preferably in capital letters and he/she shall ensure that there is a rational prescription and use of drugs.”  Till date not a single prescription audit has been conducted to either check or ensure that doctors are following this government order passed six months back. Experience on the ground indicates that an overwhelming majority of doctors continue to flout the directive. Given this it is not unreasonable to conclude that the recent pronouncement is just another empty promise. COMPANIES MANIPULATE MEDICINE PRICES It is important to first examine all the issues involved that determine the burden on patients incurred through purchase of medicines.  Expenditure on medicines is the single largest contribution to out-of-pocket expenses (expenses directly incurred by patients) while receiving treatment for illnesses. The primary reason for this is that patients are forced to access healthcare from private providers in the absence of public facilities. Currently only 20 percent of hospital care and 40 percent of out-patient care is provided in government facilities. Patients also need to purchase medicines while receiving care in government facilities as in large parts of the country a bulk of medicines are not available in public facilities. As a result 50-70 percent of out-of-pocket expenses incurred on healthcare is accounted for by expenses on medicines. Healthcare costs are a major source of indebtedness in India and various studies show that 5-7 crore Indians are pushed below the poverty line every year because of unaffordable healthcare costs. The pharmaceutical industry plays a very important role in keeping medicine prices high in order to maximize profits. The final price of medicines in the market that patients pay for has no relation to the actual manufacturing and distribution costs of medicines. There is a large volume of evidence which shows that the selling price of a medicine can be 10 to 20 times (or even more in some cases) that of the actual manufacturing cost. Further, there is a large variation in the cost of the same medicine when marketed by different companies. Typically the top selling brand of a medicine is more expensive than brands that have lower market shares. The obvious question is, if a cheaper brand is available why do people buy the more expensive brand? They do so because patients do not make a choice about the brand to be bought – they are led by the advice of doctors or chemists. Pharmaceutical companies ensure a market for their drugs by promoting their brand of medicines with doctors and chemists. The larger the company the higher is its ability to promote its medicines by providing incentives to doctors and chemists. The net result is that the products of larger companies tend to be more expensive and yet sell more in the market. Companies have been known to use a number of strategies to promote their medicines to doctors. Incentives provided include gifts, sponsored trips to exotic locations, sponsorships to doctors’ associations to organise conferences, etc. In the past few years there have some attempts to curb this practice and the Medical Council of India now bars doctors from accepting gifts and sponsorships from drug companies. However this measure has not been followed up by punitive punishments to those who continue with this grossly unethical practice. Further loopholes in the MCI’s directive are being used with impunity by both drug companies and a section of doctors. Thus, for example, companies show doctors they wish to favour as ‘consultants’ and continue to pay them large sums of money in exchange for the loyalty of such doctors towards the company’s brands. Drug companies also provide incentives to chemists in the form of discounts that they offer. Thus, for example, a pack with an MRP (maximum retail price) of Rs100 may be offered to a chemist for Rs 50. While the patient ends up paying Rs 100, the chemist is able to retain Rs 50 of that amount. This practice is rampant and drug companies continue to lobby that they be allowed to pay large discounts to chemists, so they are able to manipulate the market. GENERIC PRESCRIBING IS SCIENTIFIC AND RATIONAL The logic of lowering cost to patients by insisting on generic prescriptions is related to the above. Every drug that is sold has an International Non-proprietary Name (INN) that is decided upon by a global authority. The INN of a drug is also called its generic name. In addition, in India, most companies also have a brand name for the drug. For example, the INN for a common drug used to treat fever and pain is Paracetamol. Different companies sell the same drug (Paracetamol) under their chosen brand names – Crocin, Calpol, Paracip, etc. In the case of some popular drugs in India, the same drug may be marketed by hundreds of companies, each with a different brand name. The brand identity of a drug is crucial for a company as it is this identity which allows it to differentiate its product from that of other companies. If drugs were only allowed to be sold by its INN, ie, generic name, companies would not be able to induce a larger number of prescriptions for its own product. This in turn would curb the ability of large companies to overprice their products by bribing doctors and chemists. The Drugs and Cosmetics Act was amended a few years back and it now specifies that the generic name of a drug should be displayed more prominently than the brand name. While this is being followed, companies have found innovative solutions to get around this stipulation. Almost invariably the generic name is shown in faint, almost invisible colours, while the brand name is always displayed in bold bright colours. There is another very key reason why prescription in generic names should be encouraged. Medical students are taught about drugs only through their generic names and even experienced doctors often find the large number of brand names used for the same drug extremely confusing.  Prescription in generic names is more scientific and rational. WHY AN ADMINISTRATIVE FIAT CANNOT WORK However, an administrative fiat to prescribe drugs in generic names just will not work unless various measures are put in place. We have mentioned about the nexus between doctors, chemists and the drug industry earlier and unless this nexus is broken by clear laws and punitive actions against violations, the practice of prescriptions by brand names will continue. Further, there is no mechanism of systematic prescription audit that can track compliance with a system of mandated generic prescription. As past experience shows, in the absence of such a mechanism, directives will continue to be flouted. Prescribing doctors are also likely to encounter practical issues if asked to strictly comply with the directive to prescribe only in generic names. Most drugs sold at retail outlets in India have brand names and very few are sold only in generic names. So when a doctor prescribes in a generic name the discretion moves to the chemists, who will be required to sell one out of several brands that he stocks of the same medicines. In such a situation, unless there is cap on discounts that companies are allowed to provide to chemists, the chemist would be likely to choose the more expensive brand for which he receives a higher discount from the company. Currently, in fact, under Indian law, chemists cannot substitute a drug written by a doctor. So if the prescribed drug is not available in its generic name (which is usually the case) he is not legally allowed to sell another drug that has a brand name specified. Further compounding the problem is the fact that there is a huge shortage of trained pharmacists in India, and most chemists work without the services of a full time pharmacist. So not only is substitution not legally tenable, most outlets do not have the technical ability to make such substitutions. MEASURES THAT GOVT IS LOATHE TO CONSIDER Mere diktats do not make good public policy unless accompanied by enabling mechanisms that allow a new policy, however good it may be, to be implemented. The hallmark of the current government has been a penchant for making grandiose announcements, without a modicum of seriousness in actual implementation. The prime minister’s statement on prescription in generic names is likely to end up as one more such instance. If the government is really serious about curbing expenditures on medicines, there are some obvious steps it can initiate. First would be a concerted effort to make available all essential drugs free of cost in public facilities. Wherever this has been done, for example in Tamil Nadu and Rajasthan, the benefits to patients have been remarkable. Interestingly the free drug scheme in Rajasthan predates the installation of the current BJP government in the state and the BJP during the assembly elections had campaigned saying that the incumbent (Congress) government was feeding poison to patients in the name of generic medicines! The government also has the choice to overturn the Drug Price Control order of 2012, where drug prices were delinked from their manufacturing costs and pegged to existing market rates. A reversal to the earlier manufacturing cost based pricing, where drug prices in the controlled category were determined by providing a 100 percent mark-up over manufacturing costs, would automatically bring down drug prices, in many cases by an order of magnitude. We, of course, understand why the current government would not be inclined to institute such policy changes. These desirable changes involve increased public investment on healthcare and clear intent at curbing profiteering by industry. Both are anathema to a government that puts corporate interest above public health.

NFHS-4

As per NFHS-4 conducted for the period of 2015-16, the performance of rich states(Maharastra,Tamilnadu,Hrayana) and Poor states(Bihar,Madhya Pradesh) in terms of key health indicators are as follows-

(1) Under 5 Mortality Rate – Declined across all the states.

(2) Total Fertility Rate – reached near or below replacement level (2.1) except Bihar.

(3) Incidence of Stunting(Height for age) and Underweight has fallen significantly.

(4) per cent of literacy amongst women has increased significantly in all states.

(5) Number of births assisted by health personal & Child immunization has increased across all states.

There are some disturbing facts as well-

(1) proportion of young children fully immunised has, somewhat surprisingly, declined in the rich states of Maharashtra and Haryana.

(2) proportion of anemic women aged 15-49, has remained surprisingly high and unchanged in Maharashtra, Tamil Nadu and West Bengal, while it has actually increased significantly in Haryana.

(3) Tamil Nadu shows a high and almost unchanged proportion (around 40 percent) of married women who have experienced spousal violence. In Haryana, the proportion has increased over the decade from 27 percent to 32 percent. Contrast with the major declines in Bihar, Madhya Pradesh and Maharashtra.

The national and state health programmes like NHM, Mission Indradhanush, ICDS etc. seems to be well implemened throughout countery making the achievement in terms of U5MR,TFR, recdution in malnutrition etc. louder.

While the trend seems to be encouraging across all states there is still a far way to go ahead compared to the absolute value of these indicators. India is lagging behind Asian nations as well in terms of Healthy Life expectancy, Underweight child & stunted child under 5, leaving scope for further improvement.

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KayDee • 5 months ago

Comparison of data of NFHS-4 and NFHS-3 between the rich and poor states:

Child health: decline in U5MR and total fertility rate, improvement in new-born immunization, decrease in stunting and underweight percentages and positive attitude towards assisted institutional child births can be seen in all states irrespective of economical status in comparison to last collected data. But, immunization among young children and sex ratio varies from state to state and it is noted that very poor states and states with rich economy lack in these factors e.g. Haryana, Maharashtra, WB and Karnataka.

Maternal health: access to healthcare centres has improved overall but anemic problems remains serious problem in all states.

From these indicators it can be analyzed that:

Information dissemination and institutional support to fulfil claims made in schemes, whose information has been circulated among public, got success in targets e.g. family planning, institutional deliveries, immunization drives etc. Similarly, women health, especially pregnant women, remains poor due to lack of information and weak support from govt. authorities to women health schemes.

Economy of state doesn’t matter when schemes are funded by the central pool and in addition, political will matters most than any other factor to do constructive works in healthcare sector.

Thus, NFHS-4 can be treated as pat on the back and emergency alarm to improve performance in some fields at the same time.

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The NFHS-4 when compared to the NFHS-3 reports shows a marked improvement in various fields:

>The percentage of women literacy has increased in all states.

>There has been an increase in financial access to women due to Jan Dhan yojana.

>Household electricity has increased in all states.

>In Bihar and MP, most of the indicators increased.

There are some worrying signs too:

>Cases of domestic violence have remained the same in Tamil nadu but increased in Haryana.

FINDINGS ON HEALTH:

>Under 5 mortality, child mortality have fallen along with an increase in health personnel assisted births.

>Total fertility rate has fallen in all states. The proportion of stunting and underweight children has declined.

>Sex ratio in Karnataka, MP and West Bengal has declined.

>Immunization has declined in richer states but has increased in others.

>The proportion of anaemic women between 15-49 years has remained the same in Maharshtra, tamil nadu and west Bengal and increased in Haryana.

The improvement in various indicators like IMR, U5MR, FR shows, health personnel shows an increase in reach of various government schemes lie NRHM (National rural health mission) and their success in combating health issues. The decline in stunted and underweight children shows betterment of food security through various government programmes like Mid day meal scheme.

There are some worrying signs like declining sex ratio, increase in anaemic women that still need to be addressed by reducing female infanticide, more focus on women health. Moreover, inspite of improvements, India’s Healthy Life Expectancy(HALE) at Birth is lower than most neighboring countries indicating room for improvement.

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xyz • 5 months ago

National faimily health survey conducted by National institute of population science Mubai on behalf of GOI. There is an improvement in the health and human development indicator in the NFHS 4 compared to NFHS 3. Following are the finding of report:

1) infant mortality, child immunization, percent of birth assisted by the health personel , spouse violence against married women and financial inclusion of women have shown improvement in case of poor states such as Bihar, MP,..

2) the sex ratio at birth has fallen in states like MP, WB and KN.

3) proportion of children immunized has declined in HARYANA AND MH.

4) The The proportion of women aged 15-49, who are anaemic, has remained high and unchanged in MH, TN and WB, while it has actually increased significantly in Haryana,.

5) iNDIA'S life expectancy at birth is lower than Bangladesh, vietnam and china. Child mortality and stunted children rate is higher than these countries. .India is doing better than Pakistan

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shubh  xyz • 4 months ago

It's "International Institute for Population Sciences"....keep writing...you are good..

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Arvind Kumar  xyz • 5 months ago

u hv written only ist part of the ques..bt u hv mentioned all valuable points

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xyz  Arvind Kumar • 5 months ago

Thanks for reviewing ..will include other pa

Haryana Health

April 22, 2014 at 5:49pm

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हरयाणा में लोगों के स्वास्थ्य के बारे में व् स्वास्थ्य सेवाओं के बारे में तरह तरह के विचार प्रकट किये जाते हैं इस विषय को आम नागरिक की नजर से भी समझने की आवश्यकता है | स्वास्थ्य का मतलब शरीर  मेंबीमारी का न होना ही नहीं है बल्कि इसका मतलब शारीरिक , मानसिक तथा सामाजिक रूप से ठीक रहने की अवस्था है | स्वस्थ मानव जीवन के लिए स्वास्थ्य के अंतर खंडीय  कारकों जैसे अच्छा भोजन , सुरक्षितसाफ पीने के योग्य पानी , बेहतर सफाई व् शौचालय व्यवस्था , बेहतर रहन सहन व् खान पान , रोजगार , प्रदूषण रहित वातावरण , लिंग समानता ,सभी के लिए स्तरीय शिक्षा ,सामाजिक न्याय तथा वर्तमान बेहतरस्वास्थ्य सेवाओं की सभी के लिए उपलब्धता अदि की बहुत ही महत्त्व पूर्ण भूमिका है| दुःख की बात यह है की इन सब मानकों की अनदेखी होती रही है |महज डाक्टरों , बीमारियों तथा दवाओं के पैमाने से स्वास्थ्य के मुद्देको नहीं देखा जाना चाहिए |और न ही इसे बाजार व्यवस्था में मुनाफा कमाने के क्षेत्र के रूप में देखा जाना चाहिए | निति निर्धारकों को भी इसे तुरंत लाभ हानि की नजर से नहीं देखना चाहिए | मूल भूत कारक  जो मनुष्यके स्वास्थ्य को वास्तव में प्रभावित करते हैं , पर ज्यादा ध्यान दिया जाने की जरूरत है | हरयाणा का सामाजिक  विकास यहाँ के आर्थिक  विकास की संगति में नहीं हुआ जिसके चलते सामाजिक सूचकांक कई क्षेत्रों मेंनिराशाजनक हैं | हरयाणा ज्ञान विज्ञानं समिति द्वारा किये गए खरल गाँव के सर्वे में भी एक बात साफ़ तौर पर उभर कर ई की लोगों का विश्वास सरकारी स्वास्थ्य सेवाओं में कम हुआ है जिसके कई कारण हो सकते हैं जिनको और ज्यादाव्याख्यायित करने की आवश्यकता है | उस गाँव में बीमारियों के इलाज के लिए एक वर्ष में तक़रीबन 30 लाख रूपये खर्च किये | दवाओं की कीमतें भी उसके बाद काफी बढ़ी हैं | इसी प्रकार एक बात और साफ तौर परउभर कर आयी  की गाँव में रात के वक्त  कोई स्वास्थ्य सुविधा गाँव वासीयों को उपलब्ध नहीं होती क्योंकि आर ऍम पी भी अपने गाँव में प्रैक्टिस न करके पडौस के गाँव में प्रैक्टिस करते हैं और श्याम को अपने गाँव आजाते हैं | भिन्न भिन्न  जगह स्वास्थ्य कैम्पों  मसलन दनौन्दा ,दुबलधन माजरा , बहु अकबरपुर ,जाब भराण आदि गाँव में मरीजों को देखने पर अंदाजा हुआ की अलर्जी के बहुत मरीज हैं , दमे के मरीज बढ़ रहे हैं , बुखार, पेट में गैस का बनना , जोड़ों के दर्द अदि के मरीज काफी हैं | पी जी आई ऍम एस के आंकड़े बताते हैं कि कैंसर के मरीजों का प्रतिशत बढ़ा है  और इसी प्रकार जामनू बीमारियों का प्रतिशत भी बढ़ा है |एक खास बात औरहै कि हर मरज कि एक दवा "सटीरायडज "का बड़े पैमाने पर अवांछित इस्तेमाल किया जा रहा है |इनमें से अलर्जी की बीमारी वहीँ पर वातावरण में मौजूद अलर्जन के कारण हो सकती है | कीट नाशकों के बेइन्तहा  व्अवांछित इस्तेमाल के चलते पानी और खाने कि चीजों में इनकी मात्रा ज्यादा होने के कारण इनका प्रत्यक्ष  या परोक्ष रूप से  इन बीमारियों की बढ़ोतरी में योगदान नजर आता है |                                 
              पी जी आई एम् एस में 2006 में कैंसर के रोगियों  की संख्या 5333 थी जबकि 2010 में यह बढ़कर 7685 हो गयी | भैंस का  दूध  निकालने  वाला औक्शीटोसीन का टीका भी स्वास्थ्य के लिए हानिकारक हो सकता है |सब्जियों पर बेइन्तहा कीट नाशकों के स्प्रे का इस्तेमाल तथा दूसरे कैमिकल्ज का प्रयोग हमारे खाने को बड़े पैमाने पर प्रदूषित कर रहा है|बचाव का पक्ष हमारे बीच से गायब सा ही होता जा रहा है | इसी प्रकार पुत्र लालसा के चलते लड़का पैदा करने के लिएइस्तेमाल की जाने वाली दवाओं के कारण होने वाले जामनू विकारों की बढ़ोतरी से इंकार नहीं किया जा सकता |माईग्रेशन बढ़ा है , लायफ़ स्टायल में बदलाव आया है जिनके चलते ब्लड प्रेशर , डायबटीज, मानसिकतनाव ,व् कैंसर की बीमारियाँ बढ़ रही हैं | सड़क हादसे बढे है और चोट के कारण मौतों का अनुपात भी बढ़ा   है |  यद्दपि  हरयाणा उन्नत अर्थ व्यवस्था वाला राज्य है तथापि सामाजिक सूचकांक वांछित (अपेक्षित ) से कम हैं | ऐसा क्यों है ?  यह एक गंभीर विचारणीय व् विश्लेषण का मुद्दा है |2011की जन गणना के अनुसार :हरयाणा की कुल जनसँख्या = 2.5353081  करोड़ पुरुष =1.3505130 करोड़ महिला =1.1847951   करोड़ लिट्रेसी प्रतिशत =76.64 पुरुष =85.38 महिला=66.77 दलित महिला = ?लिंग अनुपात =877 ( राष्ट्रिय औसत =940)0-6 लिंग अनुपात हरयाणा (830)  (राष्ट्रिय औसत =(914)नैशनल फॅमिली हैल्थ सर्वे तीन (NFHS III)के हरयाणा के कुछ आंकड़े उत्साहवर्धक हैं तो कुछ आंकड़े चिंता बढ़ाने वाले भी हैं | *3 साल से कम उम्र के उन बच्चों का प्रतिशत जिनको जन्म  के 1 घंटे के अन्दर माँ का दूध पिलाया गया = 22.3 प्रतिशत *0-5 महीने के बच्चों का प्रतिशत जो सिर्फ माँ  के दूध पर थे =16.9 *3 साल से कम उम्र के बच्चों का प्रतिशत जो ( STUNTED) थे =43.3  (NFHS-2-55.6 %)*3 साल से कम उम्र के बच्चों का प्रतिशत जो (WASTED) थे =22.4 (NFHS-2-7.8%)*3 साल से कम उम्र के बच्चों का प्रतिशत जो (UNDERWEIGHT) थे =38.2(NFHS-2-29.9%)*6-35 महीनों के बच्चों का प्रतिशत जो खून की कमी का शिकार थे =82.3%*शादी शुदा 15-49 के बीच की महिलाओं  का प्रतिहत जो खून की कमी का शिकार थी =56.3 %15-49 साल की गर्भवती महिलाओं  का प्रतिशत जो खून की कमी का शिकार थी = 69.7 %वर्तमान में शादी शुदा महिलाओं का प्रतिशत जो घर के फैंसले लेने में शामिल होती हैं = 41.7 %शादी शुदा महिलाएं जो कभी न कभी अपने पति की हिंसा  का शिकार हुई =27.3 %हालाँकि INFANT MORTALITY दो के मुकाबले ५७ से घटकर ४२ पर आ गयी है | 2009 (SRS) – 51 MATERNAL MORTALITY रेट (NFHS III)तीन में  160  है |(2007-2009 SRS)---153यह है   शायनिइंग हरयाणा की सफरिंग तस्वीर के कुछ पहलू | हरया भरया हरयाणा जित दूध दही का खाना -फेर क्यूं खून की कमी का शिकार याणा |बहुत सी बुनियादी असमानताओं जैसे आर्थिक असमानता , वर्ग व् जाति की असमानता तथा असमान लिंग सम्बन्धों का असर जहाँ विशेषतया महिलाओं के स्वास्थ्य , शिक्षा, उत्पादक रोजगार तथा पर्याप्त वेतन तकपहुँच पर पड़ता है वहीँ आम नागरीक का स्वास्थ्य भी इससे प्रभावित होता है |इन घृणित असमानताओं को छिपाने के लिए जनसँख्या को हथियार  के रूप में इस्तेमाल किया जाता है | जबकि दुनिया में यह सर्व मान्यसत्य है कि जनसँख्या का संतुलन विकास के साथ अभिन्न रूप से जुड़ा हुआ है |महिलाओं व् पुरुषों में बढ़ती लिंग असमानता हमारे स्वास्थ्य कि दिशा का एक प्रतिबिम्ब है | हमने स्वास्थ्य के क्षेत्र में बहुत कुछ विस्तार किया है मगर दलित व् गरीब तबकों के सामाजिक न्याय व् स्वास्थ्य सम्बन्धीआंकड़ों का विश्लेषण किया जाये तो पता लगेगा कि वास्तविक हालत कहीं अधिक ख़राब है |आरोग्य कोष , राष्ट्रिय स्वास्थ्य बीमा योजना ,निधि कैंसर योजना , जननी सुरक्षा योजना , जननी सुविधा योजना , लाडली , डेलिवरी हट्स , हरयाणा रुरल हैल्थ मिशन की  कार्यकर्त्ता आशा , राज्य स्तर पर एक पंचायतको पाँच  लाख रूपये कि प्रोह्त्सान  राशि लिंग अनुपात को ठीक करने में सबसे बेहतर काम  के लिए , एक लाख की  प्रोत्साहन राशि प्रत्येक जिले के एक एक गाँव के लिए आदि  योजनाओं के माध्यम से और सिविलअस्पतालों , सी एच सी  , पी एच सी, सब सेंटरों के माध्यम से स्वास्थ्य सुविधाएँ उपलब्ध करवाने के सतत प्रयास जारी हैं  | यह भी एक सच्चाई है कि प्रति व्यक्ति स्वास्थ्य पर खर्च 66-67 के 1.62 रूपये से बढाकर 490.28 रूपये कर दिया गया है |(2011-2012) मगर  मलेरिया ,टी बी ,एड्स के प्रति जागरूकता अभियानों  के बावजूद इन " Communicable diseases" ने हरयाणा में रिविजिट क्यों किया? यक्ष प्रश्न यही है की इतना सब करते हुए भी  नैशनल फॅमिली हैल्थ  सर्वे  तीन के हिस्साब से हरयाणा के ज्यादातर बच्चे और औरतें स्वास्थ्य नहीं हैं | खून की कमी का शिकार हैं | यह पैराडॉक्स  क्या है ? और क्यों है? इसे समझाना हम सब के लिए बहुत जरूरी है | विकास के मोडल की पूरीतरह से समीक्षा की जरूरत है | मूलभूत कारकों के सम्बन्ध में हम कहाँ तक लोगों को ये सब दे पाए उसकी समीक्षा जरूरी है |हरित क्रांति ने कितनी संकटमय चुनौतियाँ पैदा की हैं उन्हें सामने  सामने की जरूरत है |इसके साथ ही हरयाणा में मौजूदा स्वास्थ्य सेवाओं के ढांचे का निष्पक्ष अवलोकन करना भी जरूरी हो गया है | दावा किया जाता है की बड़ा ढांचा खड़ा कर दिया गया है| जबकि हकीकत कुछ और ही बयाँ करती है | भारतसरकार के माप दण्डों के हिस्साब से 5000 की आबादी पर एक सब सेंटर होना चाहिए , 30,000 की जनसँख्या पर एक (पी एच सी )प्राथमिक स्वास्थ्य केंद्र होना चाहिए तथा एक लाख की आबादी पर एक (सी  एच सी) सामुदायीक स्वास्थ्य केंद्र होना चाहिए | 2011 की जनगणना के अनुसार हरयाणा की कुल जनसँख्या 25353081 है जिसमें 13505130 पुरुष  और 11847011 महिलाएं हैं | 1,6731494 ग्रामीण क्षेत्र की जनसँख्या है |इसके हिसाब से हमारे पास 165 सामुदायीक स्वास्थ्य केंद्र , 551 प्राथमिक स्वास्थ्य केंद्र तथा 3306 सब सेंटर होने चाहियें | इसी प्रकार एक सामुदायीक केंद्र में एक फिजिसियन , एक  शिशु रोग विशेषज्ञ .एक सर्जन ,और एक महिला रोग  विशेषज्ञ कुल मिलाकार चार  विशेषज्ञ जरूर होने चाहियें | मतलब हमें 660 विशेषज्ञों की जरूरत है | वास्तव में हरयाणा स्वास्थ्य विभाग के आंकड़े क्या कहते हैं :सामुदायीक स्वास्थ्य केंद्र =111प्राथमिक स्वास्थ्य केंद्र =330सब सेंटर                     =2630सर्जन                         =??महिला रोग विशेषज्ञ   =??शिशु रोग विशेषज्ञ       =??फिजिसियन               =??हमारे स्वास्थ्य सेवाओं के अन्दर मौजूद कमियों और कमजोरियों के चलते हरयाणा भर में प्राईवेट नर्सिंग होमज की बाढ़  सी आई हुई है जिनपर कोई सामाजिक नियंत्रण लागू नहीं है | प्राथमिक स्वास्थ्य केन्द्रों में किसीतरह के वहां की सुविधा नहीं है | ज्यादातर प्राथमिक स्वास्थ्य केंद्र बिना महिला डाक्टर के काम  कर रहे हैं | कई प्राथमिक स्वास्थ्य केन्द्रों के पास अपनी खुद की बिल्डिंग नहीं है , कईयों के भवनों की खस्ता हालत है |कई केन्द्रों की स्थापना गाँव से दूर असुरक्षित स्थानों पर की गयी है जहाँ डाक्टरों  और बाकि स्टाफ का रहना मुस्किल है | दवाओं व् उपकरणों की कमी अखरने  वाली है जबकि कई जगह कीमती उपकरण पड़े हैं औरइस्तेमाल नहीं किये जा रहे हैं | Halothane जैसी दवा सी एच सी पे भेज दी जाती हैं जो इस्तेमाल नहीं होती क्योंकि बेहोशी का डाक्टर वहां नहीं होता | गाँव में बिजली की निरंतर सप्लाई न होना टीकाकरण के काम  मेंबड़ी बाधा है तथा आपरेसन का काम  बाधित होता है | इन सब हालातों ने डाक्टरों और स्टाफ का हेड क्वाटर पर टिका रहना बहुत मुस्किल बना दिया है तथा इस क्षेत्र में गलत तरीके से हाजरी दिखाने  की शिकायतें भीसुनने को मिलती  रहती हैं | दो बातें साफ उभरती हैं की जितना ग्रामीण स्वास्थ्य सेवाओं का ढांचा हमें अपनी जनसँख्या के हिसाब से चाहिए वह हम विकसित नहीं कर पाए | और दूसरी बात यह है कि जो ढांचा हमनेविकसित कर भी लिया उसका भी सही सही और समुचित इस्तेमाल हम नहीं कर पा रहे हैं |हरयाणा में 5 मैडीकल कालेज , 9 डेंटल कालेज , 21 नर्सिंग कालेज , 11 फिजियोथेरपी कालेज ,6 आयुर्वेदिक कालेज , 28  फार्मेसी कालेज कुल मिलाकार 81 कालेज हैल्थ  युनिवर्सिटी में हैं | इन सबमें कितनीगुणवत्ता वाली शिक्षा कहाँ कहाँ दी जा रही है यह बहस का मुद्दा है | फैकल्टी  की कमी, इन्फ्रास्ट्रकचर की कमी आम बातें  हैं  | मरीजों की कमी बड़ी समस्या है जिस कारण प्रैक्टिकल ट्रेनिंग बहुत कमजोर रहती है | टरसरी स्तर पर मौजूद पी जी आई एम् एस  संसथान की भी दयनीय स्थिति है | बाकि प्राइमरी व् सैकंडरी स्तरीय सेवाओं में ढील के कारण तथा प्राइवेट सैक्टर में इलाज और महंगा हो जाने के कारण , पी जी आई एम् एस मेंमरीजों का दबाव हर साल बढ़ता जा रहा है | 2000  में ओपीडी के कुल मरीज थे 819411 और दाखिले वाले मरीज थे 57456 | 2010 में ओपीडी की संख्या थी 1311043 और दाखिल मरीज थे 93048| इन्फ्रा स्ट्रक्चरविकशित करने पर तो जोर ठीक है मगर इसमें कार्यरत कर्मचारियों , डाक्टरों व् वरिष्ठ फैकल्टी की जरूरतों के हिसाब से संख्या और इन सब की खुद की सेहत की तरफ कम ध्यान होने के कारण माहौल मरीज के पक्ष मेंज्यादा बेहतर नहीं हो पा रहा है | सुपर स्पेसियलिटी का समुचित विकास काफी धीमी गति से हो रहा है | इसके अलावा अग्रोहा बूढ़ेडा  , गोल्ड फिल्ड पलवल फरीदाबाद और मौलाना में प्राइवेट मेडिकल कालेज हैं जिनकाआकलन भी नहीं किया गया है | खानपुर ,मेवात, करनाल में खुलने वाले तीन मडिकल कालेज अभी अपने शैशव काल  में हैं |पी जी आई एम् एस में जन्में बच्चों में लिंग अनुपात ज्यादा सुधार की तरफ इशारा नहीं करता |2001---1000/8172002--- 1000/7812003--- 1000/ 8762004---1000/ 8752005--- 1000/ 829 2006 --- 1000/ 8732007 ---1000/ 831लिंग अनुपात  को  ठीक  करने  में  सुधार के  लिए  बहुत  प्रयास   किये जा रहे हैं मगर सकारात्मक नतीजे अभी दूर हैं जिस पर पुनर्विचार की जरूरत है | 2011 के    Central registration System(CRS)  के  मुताबिक  हरयाणा  का  लिंग अनुपात 826  है | लोगों की निष्क्रियता तथा जागरूकता की कमी की वजह से स्वास्थ्य क्षेत्र की समस्या और अधिक जटिल हो गयी है | इन्ही कारणों की वजह से "सबके लिए स्वास्थ्य 2000 तक" का नारा भुला दिया गया और अब to इस नारे को yad भी नहीं किया जाता | यूजर चार्जर की परिधारणा को केंद्र में रख कर यूरोपयन कमीशन की सहायता से इस क्षेत्र में कुछ काम हुआ है जिसका अवलोकन शायद किसी स्तर पर भी नहीं हो पाया | पब्लिकप्राइवेट पार्टनर शिप का मॉडल भी पूरे देश भर में बहुत कारगर सिद्ध हुआ हो ऐसा जानकारी में नहीं आया | 20 साल के वैश्वी करण तथा निजी करण की नीतियों के चलते हमारे स्वास्थ्य के आंकड़े बता रहे हैं कि इन दोनोंका हमारे स्वास्थ्य पर बुरा असर ज्यादा पड़ा है | स्वास्थ्य सेवाओं का अपेक्षित उचित उपयोग न होना - अपर्याप्त प्रबंधन के साधनों , स्टाफ के गिरे हुए होंसले तथा कमजोर प्रोत्साहन , स्वास्थ्य सुविधाओं की मांग की सीमा , पूरे समाज में व्याप्त भ्रष्टाचार आदि कारणों -के कारण से   माना जाता है | इसके साथ ही हमारे स्वास्थ्य का मुद्दा हमारे व्यवहार व् तौर तरीकों तथा जीवन शैलियों  के माध्यम से सांस्कृतिक धरातल से भी जुड़ा  हुआ है | हमें उन सांस्कृतिक शैलियों को बढ़ावा देने केप्रयास करने होंगे जो हमारे स्वास्थ्य को ठीक रखने में सहायक हैं | हमने भोजन के पुराने ढंग छोड़ दिए जबकि हमारी पुराणी  डाईट  बहुत पौष्टिक  थी | हमारे समाज में पुत्र लालसा बहुत गहरे जड़ें जमायें बैठी है | यदिलिंग असमानता की सामाजिक बुराई से लड़ना है तो पुत्र लालसा के खिलाफ भी लड़ना जरूरी है |कुल मिलाकार कहा जा सकता है की बहुत से प्रयत्नों के सकारात्मक नतीओं के बावजूद स्वस्थ हरयाणा के निर्माण में जन पक्षीय नजर से और ज्यादा विमर्श की आवश्यकता है और फिर ठीक दिशा में कारगर कदमउठाने की राजनैतिक इच्छा शक्ति की आवश्यकता है  और यह सब हो इसके लिए जनता के जन आन्दोलन की आवश्यकता है |