- Email: [email protected]
The National Health Assurance Mission for India
Correspondence
We declare no competing interests.
Jean-Christophe Lagier, Florence Fenollar, *Didier Raoult [email protected] Aix Marseille Université, INSERM 1095, Marseille 13005, France 1
2
3
4
5
Walters S, Valliani T, Przemioslo R, Rooney N. Whipple’s disease: an unexpected finding in a peripheral lymph node biopsy. Lancet 2014; 383: 2268. Fenollar F, Lagier JC, Raoult D. Tropheryma whipplei and Whipple’s disease. J Infect 2014; 69: 103–12. Lagier JC, Lepidi H, Raoult D, et al. Systemic Tropheryma whipplei: clinical presentation of 142 patients with infections diagnosed or confirmed in a reference center. Medicine (Baltimore) 2010; 89: 337–45. Feurle GE, Junga NS, Marth T. Efficacy of ceftriaxone or meropenem as initial therapies in Whipple’s disease. Gastroenterology 2010; 138: 478–86. Fenollar F, Perreal C, Raoult D. Tropheryma whipplei natural resistance to trimethoprim and sulphonamides in vitro. Int J Antimicrob Agents 2014; 43: 388–90.
www.thelancet.com Vol 384 September 27, 2014
The National Health Assurance Mission for India According to the WHO constitution, the highest attainable standard of health is a fundamental right of every human being. Despite being one of the world’s fastest growing economies during the past decades, India’s health-care indicators are among the worst among developing countries. India’s various health-care challenges need to be tackled efficiently and urgently to sustain economic growth and decrease inequalities. With continuous demand from public health activists and positive interventions of medical journals, such as The Lancet, health care has started climbing up the nation’s list of political priorities.1,2 In this context, it is heartening to note that the government has prioritised health care in its manifesto. The manifesto has promised radical reforms in health care with the National Health Assurance Mission (NHAM). 1,2 The vision to provide accessible and affordable health care to every citizen through the NHAM is a welcome step. However, the government has not specified how health-care reforms will be achieved or how measures will be undertaken to achieve the NHAM. India spends only 1·04% of its gross domestic product (GDP) on publicly funded health, which is one of the lowest in the world.3 Higher amounts of public health finance are pivotal to provide a wide range of essential health services and to create an improved infrastructure, expansion of the health-care workforce, and provision of drugs and equipment to fully and appropriately use the funds allocated. The new government should increase public spending on health to 3% of GDP by 2020, and 4% by 2025.3 The highest priority must be accorded to resource allocation for public health, and implementation
must be monitored by India’s prime minister. In India’s health-care system, nearly 70% of overall health spending is incurred by private out-of-pocket expenditure, and 70% of this is spent on medicines. Private out-of-pocket expenditure on health pushed 60 million Indians below the poverty line in 2010. 4 The government should constitute a National Medical Service Corporation with mandate to procure and provide generic medicine, surgical, and suture goods to all public health institutions across the country.5 Furthermore, the government should institutionalise the National Health Regulatory and Development Authority (NHRDA) for setting normative standards to be followed, including standard treatment guidelines, prescription audits, and quality assurance methods.3 Improved integration of the health and social development sectors is urgently needed. The government should address the causal factors responsible for ill health and start campaigning for a healthy India and a health in all policies approach, with increasing access to basic services, such as water and toilets, nutrition, public health at the community level, and promotive health.6 Barriers to health care are not only technical, but also political. Coordinated political action at both the state and central levels is needed to accomplish the NHAM on a sustainable basis. Hence, a complete overhaul of the health system is warranted to achieve the NHAM. The prime minister and the finance minister should accord a high priority to health as an integral component of the development agenda for improvement of the nation’s health substantially. With political action, backed by vision and vigour of the health minister’s leadership, India’s health can be transformed over the next 5 years.
S Nagendra/Science Photo Library
We were surprised that the authors had not used more recent references than one from 2007. 19% of all papers published on Whipple’s disease were published in the past 7 years, and of the reports referenced in ISI Web Of Knowledge about Whipple’s disease or T whipplei, nearly 50% have been published since 2007. Walters and colleagues1 also did not mention that immunohistochemistry on duodenal biopsy samples or other tissues was the most sensitive and specific technique for diagnosis of Whipple’s disease.2 Since the publication of the 2010 randomised controlled trial of ceftriaxone or meropenem followed by co-trimoxazole, 4 we showed that co-trimoxazole was not a recommended treatment for Whipple’s disease, whether based on in-vitro results (16 of 27 strains tested were resistant to sulfonamides5) or on clinical outcome.2 Instead, a 1-year regimen of doxycycline and hydroxychloroquine should be given, followed by lifetime treatment with doxycycline because of the lifelong susceptibility to T whipplei in patients who have had Whipple’s disease.2 A comprehensive analysis of the published work is needed.
I declare no competing interests.
1185
Correspondence
Mahaveer Golechha [email protected] Health Economics and Financing Unit, Public Health Foundation of India, Vasant Kunj, New Delhi, DL 110070, India 1
2
3
4
For New Drugs For Bad Bugs see http://www.imi.europa.eu/ content/nd4bb
5
6
Sachan D. New government gears up for India’s health challenges. Lancet 2014; 383: 2112. Sachan D. Health gets greater attention in the 2014 Indian elections. Lancet 2014; 383: 1281–82. Planning Commission for India. High level expert group report on universal health coverage for India. 2011. http:// planningcommission.nic.in/reports/genrep/ rep_uhc0812.pdf (accessed May 30, 2014). Marten R, McIntyre D, Travassos C, et al. An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS). Lancet 2014; published online April 30. http://dx.doi. org/10.1016/S0140-6736(14)60075-1. Golechha M. Priorities for the next Indian government’s reform of healthcare. BMJ 2014; 348: g2733. Narayan R. Universal health care in India: missing core determinants. Lancet 2011; 377: 883–85.
Funding for antimicrobial resistance research in Europe The growing problem of antimicrobial resistance needs urgent action with a conc erted and global approach. The 2014 World Health Assembly passed a resolution requiring the WHO Secretariat to develop and submit a draft action plan on global antimicrobial resistance to the 2015 Assembly.1 In Europe, the European Commission has prioritised research to combat antimicrobial resistance since 1999 and this strong commitment continues in Horizon 2020. Nearly €800 million has been awarded to transnational collaborative projects for antimicrobial resistance, in areas that affect not only human health but also animal health, food, and the environment. Seven projects launched in 2013 specifically harness the innovative potential of small and medium enterprises to develop novel antibiotics, vaccines, or alternative treatments for drug-resistant 1186
microbial infections. Another eight projects identify better methods to use available antibiotics, study antimicrobial resistance in the food chain, or use nanotechnology to deliver antimicrobial drugs.2 A further funding instrument to rejuvenate the antimicrobial pipeline is the Innovative Medicines Initiative, a public–private partnership set up by the European Federation of Pharmaceutical Industries and Associations and the European Union (EU). In 2012, the Innovative Medicines Initiative launched a large programme called New Drugs For Bad Bugs. New Drugs For Bad Bugs provides a framework for collaboration between experts from small and large biopharmaceutical companies, academia, and regulators, enabling project partners to share data, pool resources, and exchange expertise. 3 So far, the initiative has invested about €380 million into this programme, of which the pharmaceutical industry contributed €165 million; more projects are in development. As an addition to its arsenal of funding instruments, in 2015 the EU will launch an inducement prize for the development of a rapid point-of-care test to identify patients with upper respiratory tract infections who can be safely treated without antibiotics.4 Together with EU member states and international partners, the European Commission is committed to drive the global research agenda and to help to implement innovative partnerships and financing to address antimicrobial resistance. I declare no competing interests.
Máire Geoghegan-Quinn cab-geoghegan-quinn-contact@ ec.europa.eu European Commission, Berlaymont Building, Brussels 1049, Belgium 1
WHO. Draft Global action plan on antimicrobial resistance, 2014. http://www. who.int/drugresistance/amr_global_action_ plan/en/ (accessed Aug 8, 2014).
2
3
4
European Commission. EU launches new research projects to combat anti-microbial resistance. Nov 15, 2013. http://europa.eu/ rapid/press-release_MEMO-13-996_en. htm?locale=en (accessed Aug 8, 2014). Rex JH. ND4BB: addressing the antimicrobial resistance crisis. In comment. Nat Rev Microbiol 2014; 12: 231–32. European Commission. First Horizon 2020 Work Programme update—launch of FTI and innovation prizes. July 22, 2014. http://europa. eu/rapid/press-release_MEMO-14-492_en. htm (accessed Aug 8, 2014).
Department of Error Liu P, Guo Y, Qian X, et al. China’s distinctive engagement in global health. Lancet 2014; 384: 793–804—In figure 5 of this Review (Aug 30), the last line of the figure legend should read “Traditional Chinese Medicine with scholarships.” The last sentence of page 794 should end with “…Latin America receiving around 13%, before the end of 2009”. Additionally, on page 795, line 34, “42 of the teams” should read “42 of the countries”, and on page 800, reference 61 at the end of “isolation and identification” should be reference 34. These corrections have been made to the online version as of Sept 26, 2014. PD MED Collaborative Group. Long-term effectiveness of dopamine agonists and monoamine oxidase B inhibitors compared with levodopa as initial treatment for Parkinson’s disease (PD MED): a large, open-label, pragmatic randomised trial. Lancet 2014; 384: 1196–205— On page 6 of the Article (June 11), the first line of the Discussion should read ‘‘Generally, levodopa is accepted to provide better short-term control of the motor symptoms of newly diagnosed Parkinson’s disease and fewer side-effects than do dopamine agonists or MAOBIs, but motor complications are increased (panel)”. Members of the UK PED MED Collaborative Group have also been updated. These corrections have been made to the online version as of Sept 26, 2014, and the printed Article is correct. Newby LK, Marber MS, Melloni C, et al, on behalf of the SOLSTICE Investigators. Losmapimod, a novel p38 mitogen-activated protein kinase inhibitor, in non-ST-segment elevation myocardial infarction: a randomised phase 2 trial. Lancet 2014; 384: 1187–95—In this Article, a footnote has been added to the author line to show senior authorship. These corrections have been made to the online version as of Sept 26, 2014, and the printed Article is correct.
www.thelancet.com Vol 384 September 27, 2014
We declare no competing interests.
Jean-Christophe Lagier, Florence Fenollar, *Didier Raoult [email protected] Aix Marseille Université, INSERM 1095, Marseille 13005, France 1
2
3
4
5
Walters S, Valliani T, Przemioslo R, Rooney N. Whipple’s disease: an unexpected finding in a peripheral lymph node biopsy. Lancet 2014; 383: 2268. Fenollar F, Lagier JC, Raoult D. Tropheryma whipplei and Whipple’s disease. J Infect 2014; 69: 103–12. Lagier JC, Lepidi H, Raoult D, et al. Systemic Tropheryma whipplei: clinical presentation of 142 patients with infections diagnosed or confirmed in a reference center. Medicine (Baltimore) 2010; 89: 337–45. Feurle GE, Junga NS, Marth T. Efficacy of ceftriaxone or meropenem as initial therapies in Whipple’s disease. Gastroenterology 2010; 138: 478–86. Fenollar F, Perreal C, Raoult D. Tropheryma whipplei natural resistance to trimethoprim and sulphonamides in vitro. Int J Antimicrob Agents 2014; 43: 388–90.
www.thelancet.com Vol 384 September 27, 2014
The National Health Assurance Mission for India According to the WHO constitution, the highest attainable standard of health is a fundamental right of every human being. Despite being one of the world’s fastest growing economies during the past decades, India’s health-care indicators are among the worst among developing countries. India’s various health-care challenges need to be tackled efficiently and urgently to sustain economic growth and decrease inequalities. With continuous demand from public health activists and positive interventions of medical journals, such as The Lancet, health care has started climbing up the nation’s list of political priorities.1,2 In this context, it is heartening to note that the government has prioritised health care in its manifesto. The manifesto has promised radical reforms in health care with the National Health Assurance Mission (NHAM). 1,2 The vision to provide accessible and affordable health care to every citizen through the NHAM is a welcome step. However, the government has not specified how health-care reforms will be achieved or how measures will be undertaken to achieve the NHAM. India spends only 1·04% of its gross domestic product (GDP) on publicly funded health, which is one of the lowest in the world.3 Higher amounts of public health finance are pivotal to provide a wide range of essential health services and to create an improved infrastructure, expansion of the health-care workforce, and provision of drugs and equipment to fully and appropriately use the funds allocated. The new government should increase public spending on health to 3% of GDP by 2020, and 4% by 2025.3 The highest priority must be accorded to resource allocation for public health, and implementation
must be monitored by India’s prime minister. In India’s health-care system, nearly 70% of overall health spending is incurred by private out-of-pocket expenditure, and 70% of this is spent on medicines. Private out-of-pocket expenditure on health pushed 60 million Indians below the poverty line in 2010. 4 The government should constitute a National Medical Service Corporation with mandate to procure and provide generic medicine, surgical, and suture goods to all public health institutions across the country.5 Furthermore, the government should institutionalise the National Health Regulatory and Development Authority (NHRDA) for setting normative standards to be followed, including standard treatment guidelines, prescription audits, and quality assurance methods.3 Improved integration of the health and social development sectors is urgently needed. The government should address the causal factors responsible for ill health and start campaigning for a healthy India and a health in all policies approach, with increasing access to basic services, such as water and toilets, nutrition, public health at the community level, and promotive health.6 Barriers to health care are not only technical, but also political. Coordinated political action at both the state and central levels is needed to accomplish the NHAM on a sustainable basis. Hence, a complete overhaul of the health system is warranted to achieve the NHAM. The prime minister and the finance minister should accord a high priority to health as an integral component of the development agenda for improvement of the nation’s health substantially. With political action, backed by vision and vigour of the health minister’s leadership, India’s health can be transformed over the next 5 years.
S Nagendra/Science Photo Library
We were surprised that the authors had not used more recent references than one from 2007. 19% of all papers published on Whipple’s disease were published in the past 7 years, and of the reports referenced in ISI Web Of Knowledge about Whipple’s disease or T whipplei, nearly 50% have been published since 2007. Walters and colleagues1 also did not mention that immunohistochemistry on duodenal biopsy samples or other tissues was the most sensitive and specific technique for diagnosis of Whipple’s disease.2 Since the publication of the 2010 randomised controlled trial of ceftriaxone or meropenem followed by co-trimoxazole, 4 we showed that co-trimoxazole was not a recommended treatment for Whipple’s disease, whether based on in-vitro results (16 of 27 strains tested were resistant to sulfonamides5) or on clinical outcome.2 Instead, a 1-year regimen of doxycycline and hydroxychloroquine should be given, followed by lifetime treatment with doxycycline because of the lifelong susceptibility to T whipplei in patients who have had Whipple’s disease.2 A comprehensive analysis of the published work is needed.
I declare no competing interests.
1185
Correspondence
Mahaveer Golechha [email protected] Health Economics and Financing Unit, Public Health Foundation of India, Vasant Kunj, New Delhi, DL 110070, India 1
2
3
4
For New Drugs For Bad Bugs see http://www.imi.europa.eu/ content/nd4bb
5
6
Sachan D. New government gears up for India’s health challenges. Lancet 2014; 383: 2112. Sachan D. Health gets greater attention in the 2014 Indian elections. Lancet 2014; 383: 1281–82. Planning Commission for India. High level expert group report on universal health coverage for India. 2011. http:// planningcommission.nic.in/reports/genrep/ rep_uhc0812.pdf (accessed May 30, 2014). Marten R, McIntyre D, Travassos C, et al. An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS). Lancet 2014; published online April 30. http://dx.doi. org/10.1016/S0140-6736(14)60075-1. Golechha M. Priorities for the next Indian government’s reform of healthcare. BMJ 2014; 348: g2733. Narayan R. Universal health care in India: missing core determinants. Lancet 2011; 377: 883–85.
Funding for antimicrobial resistance research in Europe The growing problem of antimicrobial resistance needs urgent action with a conc erted and global approach. The 2014 World Health Assembly passed a resolution requiring the WHO Secretariat to develop and submit a draft action plan on global antimicrobial resistance to the 2015 Assembly.1 In Europe, the European Commission has prioritised research to combat antimicrobial resistance since 1999 and this strong commitment continues in Horizon 2020. Nearly €800 million has been awarded to transnational collaborative projects for antimicrobial resistance, in areas that affect not only human health but also animal health, food, and the environment. Seven projects launched in 2013 specifically harness the innovative potential of small and medium enterprises to develop novel antibiotics, vaccines, or alternative treatments for drug-resistant 1186
microbial infections. Another eight projects identify better methods to use available antibiotics, study antimicrobial resistance in the food chain, or use nanotechnology to deliver antimicrobial drugs.2 A further funding instrument to rejuvenate the antimicrobial pipeline is the Innovative Medicines Initiative, a public–private partnership set up by the European Federation of Pharmaceutical Industries and Associations and the European Union (EU). In 2012, the Innovative Medicines Initiative launched a large programme called New Drugs For Bad Bugs. New Drugs For Bad Bugs provides a framework for collaboration between experts from small and large biopharmaceutical companies, academia, and regulators, enabling project partners to share data, pool resources, and exchange expertise. 3 So far, the initiative has invested about €380 million into this programme, of which the pharmaceutical industry contributed €165 million; more projects are in development. As an addition to its arsenal of funding instruments, in 2015 the EU will launch an inducement prize for the development of a rapid point-of-care test to identify patients with upper respiratory tract infections who can be safely treated without antibiotics.4 Together with EU member states and international partners, the European Commission is committed to drive the global research agenda and to help to implement innovative partnerships and financing to address antimicrobial resistance. I declare no competing interests.
Máire Geoghegan-Quinn cab-geoghegan-quinn-contact@ ec.europa.eu European Commission, Berlaymont Building, Brussels 1049, Belgium 1
WHO. Draft Global action plan on antimicrobial resistance, 2014. http://www. who.int/drugresistance/amr_global_action_ plan/en/ (accessed Aug 8, 2014).
2
3
4
European Commission. EU launches new research projects to combat anti-microbial resistance. Nov 15, 2013. http://europa.eu/ rapid/press-release_MEMO-13-996_en. htm?locale=en (accessed Aug 8, 2014). Rex JH. ND4BB: addressing the antimicrobial resistance crisis. In comment. Nat Rev Microbiol 2014; 12: 231–32. European Commission. First Horizon 2020 Work Programme update—launch of FTI and innovation prizes. July 22, 2014. http://europa. eu/rapid/press-release_MEMO-14-492_en. htm (accessed Aug 8, 2014).
Department of Error Liu P, Guo Y, Qian X, et al. China’s distinctive engagement in global health. Lancet 2014; 384: 793–804—In figure 5 of this Review (Aug 30), the last line of the figure legend should read “Traditional Chinese Medicine with scholarships.” The last sentence of page 794 should end with “…Latin America receiving around 13%, before the end of 2009”. Additionally, on page 795, line 34, “42 of the teams” should read “42 of the countries”, and on page 800, reference 61 at the end of “isolation and identification” should be reference 34. These corrections have been made to the online version as of Sept 26, 2014. PD MED Collaborative Group. Long-term effectiveness of dopamine agonists and monoamine oxidase B inhibitors compared with levodopa as initial treatment for Parkinson’s disease (PD MED): a large, open-label, pragmatic randomised trial. Lancet 2014; 384: 1196–205— On page 6 of the Article (June 11), the first line of the Discussion should read ‘‘Generally, levodopa is accepted to provide better short-term control of the motor symptoms of newly diagnosed Parkinson’s disease and fewer side-effects than do dopamine agonists or MAOBIs, but motor complications are increased (panel)”. Members of the UK PED MED Collaborative Group have also been updated. These corrections have been made to the online version as of Sept 26, 2014, and the printed Article is correct. Newby LK, Marber MS, Melloni C, et al, on behalf of the SOLSTICE Investigators. Losmapimod, a novel p38 mitogen-activated protein kinase inhibitor, in non-ST-segment elevation myocardial infarction: a randomised phase 2 trial. Lancet 2014; 384: 1187–95—In this Article, a footnote has been added to the author line to show senior authorship. These corrections have been made to the online version as of Sept 26, 2014, and the printed Article is correct.
www.thelancet.com Vol 384 September 27, 2014