Costing of a State-Wide Population Based Cancer Awareness and Early Detection Campaign in a 2.67 Million Population of Punjab State in Northern India.

BACKGROUND: Punjab state is particularly reporting a rising burden of cancer. A 'door to door cancer awareness and early detection campaign' was therefore launched in the Punjab covering about 2.67 million population, wherein after initial training accredited social health activists (ASHAs) and other health staff conducted a survey for early detection of cancer cases based on a twelve point clinical algorithm. OBJECTIVE: To ascertain unit cost for undertaking a population-based cancer awareness and early detection campaign. MATERIALS AND METHODS: Data were collected using bottom-up costing methods. Full economic costs of implementing the campaign from the health system perspective were calculated. Options to meet the likely demand for project activities were further evaluated to examine their worth from the point of view of long-term sustainability. RESULTS: The campaign covered 97% of the state population. A total of 24,659 cases were suspected to have cancer and were referred to health facilities. At the state level, incidence and prevalence of cancer were found to be 90 and 216 per 100,000, respectively. Full economic cost of implementing the campaign in pilot district was USD 117,524. However, the financial cost was approximately USD 6,301. Start-up phase of campaign was more resource intensive (63% of total) than the implementation phase. The economic cost per person contacted and suspected by clinical algorithm was found to be USD 0.20 and USD 40 respectively. Cost per confirmed case under the campaign was 7,043 USD. CONCLUSIONS: The campaign was able to screen a reasonably large population. High to high economic cost points towards the fact that the opportunity cost of campaign put a significant burden on health system and other programs. However, generating awareness and early detection strategy adopted in this campaign seems promising in light of fact that organized screening is not in place in India and in many developing countries.

Unintentional injury mortality in India, 2005: nationally representative mortality survey of 1.1 million homes.

BACKGROUND: Unintentional injuries are an important cause of death in India. However, no reliable nationally representative estimates of unintentional injury deaths are available. Thus, we examined unintentional injury deaths in a nationally representative mortality survey. METHODS: Trained field staff interviewed a living relative of those who had died during 2001-03. The verbal autopsy reports were sent to two of the 130 trained physicians, who independently assigned an ICD-10 code to each death. Discrepancies were resolved through reconciliation and adjudication. Proportionate cause specific mortality was used to produce national unintentional injury mortality estimates based on United Nations population and death estimates. RESULTS: In 2005, unintentional injury caused 648,000 deaths (7% of all deaths; 58/100,000 population). Unintentional injury mortality rates were higher among males than females, and in rural versus urban areas. Road traffic injuries (185,000 deaths; 29% of all unintentional injury deaths), falls (160,000 deaths, 25%) and drowning (73,000 deaths, 11%) were the three leading causes of unintentional injury mortality, with fire-related injury causing 5% of these deaths. The highest unintentional mortality rates were in those aged 70 years or older (410/100,000). CONCLUSIONS: These direct estimates of unintentional injury deaths in India (0.6 million) are lower than WHO indirect estimates (0.8 million), but double the estimates which rely on police reports (0.3 million). Importantly, they revise upward the mortality due to falls, particularly in the elderly, and revise downward mortality due to fires. Ongoing monitoring of injury mortality will enable development of evidence based injury prevention programs.

Bilateral parotid tuberculosis.

Tuberculosis of parotid is a rare clinical entity, and cases of bilateral tubercular parotitis are even rarer. We present a case of bilateral primary parotid tuberculosis in a 49-year-old female. The patient received anti-tuberculosis treatment for six months, resulting in complete resolution of the disease. We also review the theories related to the pathogenesis of tubercular parotitis, and propose a novel hypothesis about greater involvement of parotid gland as compared to other salivary glands in primary tuberculosis.

Social and Economic Implications of Noncommunicable diseases in India.

Noncommunicable diseases (NCDs) have become a major public health problem in India accounting for 62% of the total burden of foregone DALYs and 53% of total deaths. In this paper, we review the social and economic impact of NCDs in India. We outline this impact at household, health system and the macroeconomic level. Cardiovascular diseases (CVDs) figure at the top among the leading ten causes of adult (25-69 years) deaths in India. The effects of NCDs are inequitable with evidence of reversal in social gradient of risk factors and greater financial implications for the poorer households in India. Out-of-pocket expenditure associated with the acute and long-term effects of NCDs is high resulting in catastrophic health expenditure for the households. Study in India showed that about 25% of families with a member with CVD and 50% with cancer experience catastrophic expenditure and 10% and 25%, respectively, are driven to poverty. The odds of incurring catastrophic hospitalization expenditure were nearly 160% higher with cancer than the odds of incurring catastrophic spending when hospitalization was due to a communicable disease. These high numbers also pose significant challenge for the health system for providing treatment, care and support. The proportion of hospitalizations and outpatient consultations as a result of NCDs rose from 32% to 40% and 22% to 35%, respectively, within a decade from 1995 to 2004. In macroeconomic term, most of the estimates suggest that the NCDs in India account for an economic burden in the range of 5-10% of GDP, which is significant and slowing down GDP thus hampering development. While India is simultaneously experiencing several disease burdens due to old and new infections, nutritional deficiencies, chronic diseases, and injuries, individual interventions for clinical care are unlikely to be affordable on a large scale. While it is clear that "treating our way out" of the NCDs may not be the efficient way, it has to be strongly supplemented with population-based services aimed at health promotion and action on social determinants of health along with individual services. Since health sector alone cannot deal with the "chronic emergency" of NCDs, a multi-sectoral action addressing the social determinants and strengthening of health systems for universal coverage to population and individual services is required.

How to Effectively Monitor and Evaluate NCD Programmes in India.

Program monitoring and evaluation (M and E) are important components of any program and are critical to sound strategic planning. The Ministry of Health and Family Welfare, Government of India, launched the National Programme for Prevention and Control of Cancer, Diabetes, Cardio-vascular diseases and Stroke (NPCDCS) with the objectives to prevent and control common noncommunicable diseases (NCDs) through behaviour and lifestyle changes, and to provide early diagnosis and management of common NCDs. M and E of program requires identification of indicators that measure inputs, process, outputs, and outcomes. The frequency of collecting information for these indicators will vary depending on the level of use and type of indicator as well as time interval over which we expect to see a change in that parameter. A group of indicators for different domains in the three major strategies has been proposed. For effective monitoring and evaluation of NPCDCS, the way forward is to finalize the list of indicators; evolve sustainable systems for surveillance; collect baseline assessment of the indicators at district level; fix targets for each indicator for different time frames; periodic review at state and national level for monitoring progress; and establish external review mechanisms. Monitoring and evaluation require complex set of co-ordinated action, responsibility for which has to be taken up by the NCD Cell within the Ministries of Health at state and national level. However, the routine data collection and compilation could be the responsibility of Central Bureau of Health Intelligence. Integrated population-based surveys with existing disease and behaviour surveillance could be undertaken by National Centre for Disease Control. The national NCD cell should compile all these information into a meaningful policy brief so that appropriate programmatic interventions can be identified. The launch of a national program to tackle the burden of NCDs is just the beginning, and the final success of the program will depend on how effectively we monitor and evaluate it.

Role of medical education in preventing and control of noncommunicable diseases in India?

India has approximately 335 medical colleges, which produce around 40,000 medical graduates annually. Even though medical professional have a critical role in prevention and control of noncommunicable diseases (NCDs) including injuries, it has been observed that the present medical and nursing curriculum in India does not adequately cover prevention and control of NCDs. The topics for specific approach to prevent NCDs and various strategies can be incorporated into public health and clinical courses in undergraduate medical education, with brief optional courses in residency and continuing medical education for established practitioners. High-level expert group instituted by Planning Commission of India on Universal Health Coverage recommended that medical education requires greater orientation of providers to the social determinants of health as well as to gender and equity issues. Curricula in medical schools should keep pace with the changing dynamics of public health, health policy, and health demographics. Medical education and training should be reoriented by introducing competency-based, health system connected curricula, and continuous education. There is a need to review of medical curriculum, introducing innovative integrated teaching methods, and capacity building of teachers for meeting the challenge of rising burden of NCDs in India.