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Delhi's irony: Urban Poverty-Srinand Jha

Each time 25 year old Salma takes her one year old son Zubair to the Batla Clinic (a private clinic in Delhi) for a shot of the DPT, the cost of transportation and the vaccine adds up to approximately Rs.500.
 
When it is time for Zubair to take the next immunization dose, Salma may find that the expenses have entirely spiraled out of her reach.

New vaccines and expensive brands of baby foods and tonics are flooding the market. Three shots of the Pneumococcle cost Rs.12, 000; a dose of the Diarrohea Rota Virus comes for Rs.2000; the polio injectible (IPV) comes for approximately Rs.2000.
 
“We end up spending approximately Rs.20,000 on vaccinating one child alone. These expenses are not covered under any insurance scheme. My husband earns a decent sum, but we find it difficult to meet the rising medical expenses.” Said Shweta Jha, mother of two, who owns a three bedroom house in an up-market locality in Delhi’s outskirts in Noida.
 
For Salma, spending Rs.500 (for a shot of the DPT) is hugely prohibitive. She shells out a monthly Rs.1000 rent for a damp and un-ventilated one room house crammed in between the narrow and foul smelling streets of Madanpur Khadar wher– in the absence of civic or sewerage facilities – mosquitoes breed in cesspools and mountains of garbage are stacked up everywhere. A foamy yellow liquid spurts out of the municipality taps – which is used up in the toilets and for washing clothes.
 
Like many of her neighbours, Salma spends Rs.12 to buy a 20 liter can of water filled from the nearby tube-wells for cooking and drinking purposes. “We spend approximately Rs.3,000 each month on medical expenses. My husband Zakir Hussain works as a clerk in a private bank (the family’s only bread earner) and brings home a monthly salary of just Rs.7,000 in all”, said Salma.
 
Rich versus poor divide

Like several resettlement colonies of the poor, Madanpur Khadar – sandwiched between the blue-glass fronted corporate offices and spanking new malls of Sarita Vihar, adjoining the imposing Apollo Hospital – does not have a primary health centre. “People go to quacks or to the private doctors for treatment”, said Madan Lal of the “Mobile Creches” – a voluntary organization working for welfare of children of migrant labor. 
 
Diarrohea, typhoid and respiratory diseases are common among children living at Madanpur Khadar. The 2010 study by the Delhi Forces Neev – a network of organizations working on child-related issues - found 20% children at Madanpur Khadar as being severely malnourished.
 
Delhi- metamorphosing into a capital of the new world and a city that boasts of the country’s second largest per capita income – has an ugly face tucked away in its innards.
 
The Delhi government does not have an estimate of the number of poor living in the metropolis. “We have now started the process of identifying the poor”, women and child development minister Dr. Kiran Walia said.
 
The 'mobile creches' estimates are that more than half of Delhi (64% of the population) is poor – family earnings less than a monthly Rs/4,000.
 
Home to 1.9 million young children; 50% of Delhi’s children live in its slum and squatter settlements. The capital has one of the worst track records on sex ratio (865 girls per 1000 boys) and 50% of the poor women in the reproductive age group are anemic, according to the NFHS-III data.
 
Just one in every four children among the poor is fully immunized. One in every three children is underweight and stunted. Fifteen percent are acutely malnourished and two thirds suffer from nutritional anemia (NFHS-III).
 
The vaccine story

Before 2009, when then Health Minister Anbumani Ramadoss ordered closure of the three vaccine producing public sector undertakings (Central Research Institute, Kasauli; Pasteur Institute of India, Coonoor and the BCG Vaccine laboratory at Chennai), the union government was delivering all three doses of the DPT vaccine at a nominal cost of Rs.15. The three units have now been re-opened, but are not producing vaccines.
 
If and when the new vaccine policy gets adopted – incorporating the suggestion of replacing the DPT with the Pentavalent vaccine – the immunization bill will increase twenty fold: From Rs.15 to Rs.380.
 
The Pentavlent vaccine costs Rs.380 (after a rebate of Rs.165 on each dose by the Global Alliance for Vaccines and Immunization (GAVI) – an organization of vaccine manufacturers, the Bill and Melinda Gates Foundation and the World Health Organization, among others).
 
The draft new vaccine policy – a copy of which is available with the Hindustan Times – seeks to make it mandatory for the government to buy the vaccines from private pharmaceutical companies by making “advance market commitments”. It also suggests the setting up of a vaccine fund through “innovative financing mechanisms”.
 
The Pentavalent is already licensed in the country and is now being used in the private sector. “The government has decided to introduce the pentavalent vaccine in the two states of Tamil Nadu and Kerala”, the union government’s health ministry spokesman said.
 
Union Minister of State for Health Sudip Bandopadhyaya said, “If at al the costs of the vaccines rise, the poor need not worry on this count. These will be provided to them free. Any enhanced costs (of vaccines) will be borne by the government”.  
 
The Minister’s claims appear flawed.
 
National Family Health Survey (NFHS-III) data shows that the UPA government ensures only 35% immunization coverage of the delivery of basic vaccines (DPT, Oral Polio, BCG and Measles) in the first year to 25 million children annually born in India.
 
“Given the shortage of doctors and para-medical staff, citizens will naturally have to end up paying much much more on medical expenses”, Delhi-based paedtrician Dr. Onkar Mittal said.
 
India’s health establishment continues to grapple with huge infrastructure and manpower shortage. A September 2011 report by the “Save the Children” (a voluntary organization) points out that the country is short of 2.6 million health workers. Rural Health statistics data for 2009 show that only 29 percent posts of doctors at the Primary Health Centers (PHCs) are filled.
 
“Either the doctors/nurses are either unavailable at the primary health centers, or there is no stock of medicines. For vaccinations – or any ailments – we invariably have to go the big government hospitals or to the private doctors”, said Ramesh Kumar at Holambi Kalan – a resettlement colony at Delhi ’s outskirts.
 
Dr Jacob Puliyel - member of the National Technical Advisory Group on Immunization (NTAIG) and of the Working group on Food and Drug Regulation in the 12th five year plan – has pointed out in an article that repeated studies have shown that the Pneumococcal vaccine reduces 4 cases of cough and cold per 1000 vaccinated. Thus it costs Rs 12 lakh for reducing pneumonia in 4 children, while the cost of treating four children with antibiotics is a mere Rs.40.
 
The Rota virus vaccine has also not shown to reduce even one case of diarrohea.
 
“It is nobody’s case that expensive vaccines sold by private manufacturers must not be introduced in the public health system in India. But, when repeated studies have shown that these vaccines do not actually reduce the “disease burden”, why they are being pushed into the Indian market, Puliyel asks.
 
Responding to a HT questionnaire, union health ministry spokesman said that the “issue of advance market commitment was being discussed strictly in the context of Product development for public health emergency”.
 
Delhi’s irony

Infrastructure development of medical facilities in Capital Delhi has been unable to keep pace with the rapid growth of urbanization. “Beyond perfunctory and pious announcements, the state government has not demonstrated a political will to effectively tackle the problem of child malnutrition”, said Enakshi Ganguly of the Haq, Centre for Child Rights –a Delhi-based voluntary organization.

The Haq report of 2011 brings out rather startling facts:

·The Delhi budget for 2011-12 has no specific scheme for routine immunization (Titnus, Diptheria, Hooping Cough, Pertusis and Measles).

·The Special Immunization program under the minor head of prevention and control of diseases has ceased to have any allocation. The last occasion when money was allocated under the scheme was 2007-08, when Rs.27 crore was allocated.

·The Special Immunization program MMR (Measles, Mums and Rubella) has witnessed an under-spending of 40.4% from 2007-08 to 2009-10.

·The budget documents also do not show any allocation specifically for the ambitious Chacha Nehru Sehat Yojna – dedicated to providing free health care to all children in the state up to the age of 14. Chief minister Sheila Dixit had initially announced an initial corpus of Rs.100 crore, with a scope for increase at a later stage.

·The budget documents also do not make it clear that the over 100% raise in the allocation for the school health scheme is to implement the Chacha Nehru scheme.
 
“These are exaggerations and generalizations. Delhi does have an immunization scheme for MMR and Typhoid (Rs.196 lakh allocated) and the Chacha Nehru scheme is part of the school health scheme. It is not true to say that there is a shortage of vaccines. As far as other issues are concerned (under-spending of health budget), matters relate to the past. I have been in the job (as Health Minister) for only four months”, Delhi Health Minister Dr. AK Walia said.

Delhi stats

* One in 25 children in Delhi die within the first year of life. One in 21 die before reaching age five.

* Percentage of fully vaccinated children aged 12-23 months has actually gone down from 70% (NFHS-II) to 63% (NFHS-III).

* 57% children (age group 6 months to five years) are anemic.

* Just 10% of pregnant and lactating mothers have received nutritional support at the ICDS centers.

* One fifth of the children (21%) in Delhi have still not received three doses of the polio vaccine.

Source: NFHS-III data