Tobacco control in India: A case for the Health-in-All Policy approach.

Nearly one in two men and one in five women in India consume tobacco in one form or another.1 Directly or indirectly, tobacco kills one million adult Indians every year.2–4 At the family level, expenditure on tobacco crowds out spending on education and essential items such as food.5 At the societal level, we are yet to come to terms with the ecological impact, through deforestation and environmental degradation, of large-scale tobacco farming and manufacturing processes. In the past decade, the Government of India started making attempts to intervene to reduce the consumption of tobacco.6 In 2003, the Cigarettes and Other Tobacco Products (prohibition of advertisement and regulation of trade and commerce, production, supply and distribution) Act (COTPA) was passed by Parliament. India ratified the World Health Organization’s Framework Convention on Tobacco Control (FCTC) in 2004. The Union Ministry of Health and Family Welfare (MoHFW), the nodal agency for these legal commitments, launched the National Programme for Tobacco Control in 2007. In late 2013, the then Prime Minister of India stated that a combination of multisectoral policies and public awareness was required for the achievement of tobacco control.7 On World No Tobacco Day 2014, the then Health Minister mentioned the need for a strong social movement against tobacco, and the need to engage all sections of people.8 In this commentary, we expand and extend the notion of multisectoral action for tobacco control. The policies are already rooted in various government sectors, but they are still suboptimal and at times, conflicting. We argue that the Indian health sector can and should assume a stronger stewardship role to improve the health of the population and achieve health equity. For this, it is necessary to systematically scrutinize the impact of tobacco policies on health across different sectors and seek synergies which result in the most favourable impacts. This would be a welcome application of what is known as the Health-in-All Policy (HiAP) approach.9 Far from being new, HiAP is based on the long-standing accumulation of evidence for the social, political and economic root causes of ill health and inequity.10,11 It takes the recommendations of the Commission on Social Determinants of Health12 to the policy level. Based on the notion of multisectoral action for health and equity, it relies on mobilization through a proactive health sector.10,13,14 The advocates of HiAP argue that tobacco control is a natural candidate for this approach. Unlike most health issues, the tobacco epidemic already permeates the agenda of a range of government and non-government sectors, and tobacco control has proved to be most successful when based on national coordination involving the widespread participation of stakeholders.15 We briefly discuss four components of tobacco control in India today, describing the achievements and limitations, and outline three challenges that the

Health systems research and the Gadchiroli debate: a plea for universal and equitable ethics.

We were pleased to read, in the January-March 2010 issue of this journal, Abhay Bang’s response to criticism of the Gadchiroli trial on ethical grounds.While it is not within the ambit of this article to comment on the Gadchiroli trial principal investigator’s clarifications, we would like to extend the debate on standards of care that he discusses to standards of ethics, with particular reference to health systems research.

International aid policy: public disease control and private curative care?

Integrating disease control with health care delivery increases the prospects for successful disease control. This paper examines whether current international aid policy tends to allocate disease control and curative care to different sectors, preventing such integration. Typically, disease control has been conceptualized in vertical programs. This changed with the Alma Ata vision of comprehensive care, but was soon encouraged again by the Selective Primary Health Care concept. Documents are analyzed from the most influential actors in the field, e.g. World Health Organization, World Bank, and European Union. These agencies do indeed have a doctrine on international aid policy: to allocate disease control to the public sector and curative health care to the private sector, wherever possible. We examine whether there is evidence to support such a doctrine. Arguments justifying integration are discussed, as well as those that critically analyze the consequences of non-integration. Answers are sought to the crucial question of why important stakeholders continue to insist on separating disease control from curative care. We finally make a recommendation for all international actors to address health care and disease control together, from a systems perspective.

El control de enfermedades es más factible cuando se encuentra integrado con los servicios curativos de salud. Este artículo examina si la actual política de cooperación tiende a atribuir el control de enfermedades y servicios curativos a distintos sectores, impidiendo así su integración. Tradicionalmente, el control de enfermedades fue conceptualizado en programas verticales. Eso cambió mediante la visión comprensiva de Alma Ata, para luego ser reinstaurado por el enfoque de la Salud Primaria Selectiva. Analizamos documentos de los actores más influyentes, tales como la Organización Mundial de la Salud (OMS), el Banco Mundial y la Unión Europea. Estas agencias sí tienen una doctrina en cooperación: la de colocar control de enfermedades dentro del sector público y servicios curativos dentro del sector privado, donde sea posible. Examinamos si hay un respaldo científico detrás de esta doctrina. Ponderamos los argumentos en pro de integración con las consecuencias descritas de no-integración. Determinamos cuáles son los motivos de los actores claves para seguir separando el control de enfermedades de los servicios curativos. Recomendamos, finalmente, a los actores que apoyen simultáneamente el control de enfermedades, los servicios y los sistemas de salud.