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  • Regulating the Private Health Sector to Eliminate COVID-19

    Context

    The current COVID-19 crisis that India is battling has brought into sharp focus the public health system’s inadequacy to cope with it.

    Contradictory scenario between public and private healthcare delivery

    • The contrast between public and private: Hospitals with state-of-the-art equipment rivalling five-star hotels in their facilities are mushrooming mostly in cities even as the overburdened public hospitals are valiantly fighting to cope. 
    • Dismal picture in rural areas: As far as the rural areas are concerned, the community health centres and primary health centres and sub-centres present an even more dismal picture in terms of availability of medicine stock, trained para-medical staff, and doctors and nurses.
    • However, it is not as if urban hospitals offer patients excellent care. A common and widely held general misperception is that the private healthcare system is better than the public one.
    • Why private is not always better? Complaints of non-transparent billing, demanding exorbitant sums in advance even in a medical emergency, and cutting corners in services are all too familiar, as are cases of the denial of services.
    • In semi-rural areas and towns, the private sector is not necessarily similar to hospitals in cities.
    • The private hospitals in these areas are small and have basic infrastructure and limited medical and non-medical staff. Unlike the cities, the power and water supply in these areas also constitute a problem to the functioning of these hospitals.

    Problems in the public healthcare system

    • Within the public sector health system, there are a number of trends again that add to the dismal picture.
    • A high number of patients: Doctors in the public hospitals deal with an overwhelming number of patients majorly from the poor and marginalised sections.
    • Issue of contractual staff: Health activists have also pointed out that the growing trend of contractual hiring of paramedical and allied staff leads to an insecurity among them, and thus affects overall caregiving to patients.
    • Consequently, the poor patients’ families, frustrated by the lack of infrastructure and services, turn their anger upon the doctors and nurses.
    • What are the implications? The constant vilification of the public hospital staff coupled with starving these hospitals of resources has led to the view that the private hospitals are “much better” despite their exorbitant rates.

    State-wise variation in healthcare

    • States subject: Health is a state subject, and it is well known that the health delivery systems are not uniform across states.
    • Kerala a role model: Kerala is often held up as a role model generally, and even now in the manner in which it has dealt with the COVID-19 crisis.
    • The dismal system in North India: As it is, certain states in North India have abysmal healthcare systems, and a couple does not have any testing facilities, the media has reported.

    Getting the private sector involved in COVID-19 testing

    • Undoubtedly, at present, the private sector must be involved in screening, tests and treatment for COVID-19.
    • The highly trained professionals in this sector can contribute enormously by helping scale up the testing efforts.
    • Importance of large-scale testing: In South Korea too, it was large-scale testing that was instrumental in reducing mortality rates.
    • The pricing issue: Services across sectors must not be priced differently at a time like this. The media has reported that there is a difference of opinion between the government and private sector on the price of COVID-19 tests flowing from the prices of test kits.
    • Need for the protocol: A clear and non-negotiable protocol for the private sector must be established regarding the present crisis and how the government is going to help financially and otherwise in dealing with it.

    Way forward

    • Regulate the testing, screening and treatment facilities: The experience with the government offering subsidies to hospitals, especially in urban areas in terms of land and other concessions, has not borne out desired objectives such as better care for the poor.
    • Taking a cue from this, the testing, screening, and treatment facilities must be regulated in terms of pricing and quality.
    • Focus on strengthening the public health system: The Supreme Court has held healthcare to be a fundamental right under Article 21. The biggest lesson of the current crisis is that political will must focus on strengthening the public health system.

    Conclusion

    The finance minister has announced a package of `1.7 lakh crore to deal with this catastrophic situation. This is welcome, but long-term resource allocation to invigorate the public health system must be a continual and parallel process.

  • Why has Kerala sought a relaxation of FRBM rules?

    Kerala CM has urged the Centre to provide Kerala with flexibility under the Fiscal Responsibility and Budget Management (FRBM) Act so as to ensure that the State’s finances are not adversely impacted.

    FRBM Act

    • The FRBM is an act of the parliament that set targets for the Government of India to establish financial discipline, improve the management of public funds, strengthen fiscal prudence and reduce its fiscal deficits.
    • It was first introduced in the parliament of India in the year 2000 by Vajpayee Government for providing legal backing to the fiscal discipline to be institutionalized in the country.
    • Subsequently, the FRBM Act was passed in the year 2003.

    Features of the FRBM Act

    • It was mandated by the act that the following must be placed along with the Budget documents annually in the Parliament:
    1. Macroeconomic Framework Statement
    2. Medium Term Fiscal Policy Statement and
    3. Fiscal Policy Strategy Statement

    Fiscal Indicators

    It was proposed that the four fiscal indicators be projected in the medium-term fiscal policy statement viz.

    1. Revenue deficit as a percentage of GDP,
    2. Fiscal deficit as a percentage of GDP,
    3. Tax revenue as a percentage of GDP and
    4. Total outstanding liabilities as a percentage of GDP

    Why is Kerala seeking flexibility under the FRBM?

    • Kerala was one of the earliest States to announce an economic package of ₹20,000 crore to mitigate the impact on livelihoods and overall economic activity.
    • Kerala’s current fiscal position means that it can borrow about ₹25,000 crore during the financial year 2020-21.
    • However the State government is understandably concerned that the stringent borrowing cap under the fiscal responsibility laws should not constrain its borrowing and spending ability over the remaining 11 months.
    • This is a crucial period when the state would have to meet other expenditure for routine affairs related to the running of the State’s socio-economic programmes as well as the post pandemic recovery.

    How does a relaxation of the FRBM work?

    • The law does contain what is commonly referred to as an ‘escape clause’.
    • Under Section 4(2) of the Act, the Centre can exceed the annual fiscal deficit target citing grounds that include national security, war, national calamity, collapse of agriculture, structural reforms and decline in real output growth of a quarter by at least three percentage points below the average of the previous four quarters.
    • The ongoing pandemic could be considered as a national calamity.
    • This would allow both the Union government and States including Kerala to undertake the much-needed increases in expenditure to meet the extraordinary circumstances.

    When have the FRBM norms been relaxed in the past?

    • There have been several instances of the FRBM goals being reset.
    • But the most significant FRBM deviation happened in 2008-09, in the wake of the global financial crisis, when the Centre resorted to a focused fiscal stimulus: tax relief to boost demand and increased expenditure on public projects.
    • This was aimed to create employment and public assets, to counter the fallout of the global slowdown.
    • This led to the fiscal deficit climbing to 6.2%, from a budgeted goal of 2.7%.
    • Simultaneously, the deficit goals for the States too were relaxed to 3.5% of GSDP for 2008-09 and 4% of GSDP for fiscal 2009-10.

  • Convalescent Plasma Therapy

    With no specific treatment available for novel coronavirus disease and a vaccine at least a year away, the US Food and Drug Administration (FDA) has approved use of blood plasma from recovered patients to treat severely critical COVID-19 patients.

    Convalescent Plasma Therapy

    • The therapy seeks to make use of the antibodies developed in the recovered patient against the coronavirus.
    • The whole blood or plasma from such people is taken, and the plasma is then injected in critically ill patients so that the antibodies are transferred and boost their fight against the virus.
    • A COVID-19 patient usually develops primary immunity against the virus in 10-14 days.
    • Therefore, if the plasma is injected at an early stage, it can possibly help fight the virus and prevent severe illness.

    How often has it been used in the past?

    • This therapy is no new wonder. It has been used several times.
    • The US used plasma of recovered patients to treat patients of Spanish flu (1918-1920).
    • In 2014, the WHO released guidelines to treat Ebola patients with convalescent whole blood and plasma.
    • In 2015, plasma was used for treating MERS patients.

    How is it done?

    • The process to infuse plasma in a patient can be completed quickly.
    • It only requires standard blood collection practices, and extraction of plasma.
    • If whole blood is donated (350-450 ml), a blood fractionation process is used to separate the plasma.
    • Otherwise, a special machine called aphaeresis machine can be used to extract the plasma directly from the donor.
    • While blood is indeed extracted from the donor, the aphaeresis machine separates and extracts the plasma using a plasma kit, and the remaining blood components are returned into the donor’s body.

    WHO’s guidelines

    • WHO guidelines in 2014 mandate a donor’s permission before extracting plasma.
    • Plasma from only recovered patients must be taken, and donation must be done from people not infected with HIV, hepatitis, syphilis, or any infectious disease.
    • If whole blood is collected, the plasma is separated by sedimentation or centrifugation, then injected in the patient.
    • If plasma needs to be collected again from the same person, it must be done after 12 weeks of the first donation for males and 16 weeks for females, the WHO guidelines state.

    How optimistic is the latest move?

    • COVID-19 does not have a specific treatment, only supportive care— including antiviral drugs, oxygen supply in mild cases and extracorporeal membrane oxygenation.
    • Plasma can be infused into two kinds of COVID-19 patients— those with a severe illness, or individuals at a higher risk of getting the virus.
    • However, that while plasma transfers immunity from one person to another, it is not known if it can save lives in COVID-19 infection.
    • The treatment could be effective for patients in the age group 40-60, but may be less effective for people aged beyond 60 years.

    Can it be done in India?

    • India has facilities for removing 500 ml of plasma from a donor using aphaeresis.
    • For this experimental therapy to be tried out, the Drug Controller General of India will first have to grant blood banks approval for removal of plasma from recovered COVID-19 patients.
    • The procedure is simple and can be done in India, but it is important to control the risk of infection during transfusion, and the patient’s acceptance is required.
    • It’s like a vaccine. It will engulf the virus and kill it. But it is easier said than done. We may need a series of approvals which India has never done before.

  • Sections 269 & 270 IPC invoked against those accused of spreading COVID-19

    Sections 269 & 270 IPC invoked are being invoked against persons who malignantly do any act which is likely to spread the infection of any disease dangerous to life.

    Sections 269 and 270 of the IPC

    • Sections 269 (negligent act likely to spread infection of disease dangerous to life) and 270 (malignant act likely to spread infection of disease dangerous to life) come under Chapter XIV of the IPC.
    • The chapter is named ‘Of Offences Affecting The Public Health, Safety, Convenience, Decency and Morals’.
    • While Section 269 provides for a jail term of six months and/or fine, Section 270 provides for a jail term of two years and/or fine.
    • In Section 270, the word ‘malignantly’ indicates a deliberate intention on the part of the accused.
    • During the coronavirus outbreak, penal provisions, such as Sections 188, 269 and 270 of the IPC, are being invoked to enforce the lockdown orders in various states.

    Earlier instances of invocation

    • Both Sections have been used for over a century to punish those disobeying orders issued for containing epidemics.
    • The Sections were similarly enforced by colonial authorities during outbreaks of diseases such as smallpox and bubonic plague.

  • [pib] National Teleconsultation Centre (CoNTeC)

    The Union Ministry of Health & Family Welfare has launched the National Teleconsultation Centre (CoNTeC).

     About CoNTeC

    • The CoNTeC is a Telemedicine Hub established by AIIMS, New Delhi, wherein expert doctors from various clinical domains will be available 24×7 to answer the multifaceted questions from specialists from all over the country.
    • It is a multi-modal telecommunications hub through which 2 way audio-video and text communications can be undertaken from any part of the country as well as the world at large.
    • The modes of communication will include simple mobile telephony as well as two way video communications, using WhatsApp, Skype and Google Duo.
    • The CoNTeC is also fully integrated with the National Medical College Network (NMCN) to conduct a full fledged Video Conference (VC) between the 50 Medical Colleges.

    How to Contact the CoNTeC?

    • A single mobile number (+91 9115444155) can be dialled from anywhere in the coutnry/world by COVID-19 treating doctors to reach the CoNTeC which has six lines that can be used simultaneously at present.
    • This number of lines can be increased in future if needed.
    • The incoming calls will be picked up by the CoNTeC Managers, who will then handover the call to the appropriate expert doctors from the clinical domains as desired by the calling specialists managing the COVID-19 cases anywhere in the country.
    • The Managers will guide the callers in establishing a two way video call using the WhatsApp, Skype or Google Duo as preferred by the caller.
    • The callers from the NMCN network can connect anytime using the Telemedicine infrastructure at their end.

  • Schedule H1 drugs

    Hydroxychloroquine is now a schedule H1 drug and can be sold on prescription only.

    What are Schedule H1 drugs?

    • The sale of the Hydroxychloroquine drug from now on should be in accordance with the conditions for sale of drugs specified in Schedule H1 to the Drugs and Cosmetics Rules, 1945.
    • In exercise of the powers conferred by Section 26B of the Drugs and Cosmetics Act, 1940 (23 of 1940), the Central Government can direct that sale by retail of any drug.

    Why such move?

    • The Central Government is satisfied that the drug ‘Hydroxychloroquine’ is essential to meet the requirements of emergency arising due to pandemic COVID-19.
    • And in the public interest, it is necessary to regulate and restrict the sale and distribution of the drug ‘Hydroxychloroquine’ and preparation based thereon for preventing their misuse.

    Hydroxychloroquine

    • Hydroxychloroquine is used to prevent or treat malaria infections caused by mosquito bites.
    • It does not work against certain types of malaria (chloroquine-resistant).

    Pls take a note-

    • Hydroxychloroquine and a related drug, chloroquine, are currently under study as possible treatments for COVID-19.
    • These drugs have not yet been approved for this use.
    • Do not use these medications to treat COVID-19 unless your doctor recommends that you do so.

  • Serological test for COVID-19

    The ICMR invited bids for an estimated 10 lakh antibody kits (for serological tests) for the diagnosis of COVID-19.

    What are serological tests?

    • Viral infections are mainly identified by two kinds of tests– genetic and serological.
    • Genetic tests can identify infections that are active but cannot be used to detect past infections.
    • To trace how infections like the novel coronavirus have spread so far, it is important to detect people who contracted the disease in the past and have recovered.
    • This is what serological tests seek to determine.

    How are the two different?

    • The genetic test is conducted on a swab collected from the back of the throat, a liquid sample from the lower respiratory tract, or a simple saliva sample.
    • For SARS-COV-2, the virus’s RNA is first converted into DNA.
    • By a process called polymerase chain reaction (PCR), DNA fragments in the sample are copied exponentially — one is copied into two, the two are copied into four, and so on.
    • Unlike genetic tests, which look for RNA in swab samples, serological tests work on antibodies in blood samples. Hence, they are also called ‘antibody tests’.

    How serological tests work?

    • Antibodies, or protective proteins produced by the immune system to neutralize pathogens such as bacteria and viruses, are present in one’s bloodstream for a considerable period of time after the infection has gone.
    • To disable a pathogen, the antibody latches to a unique protein molecule on pathogen’s surface, called an antigen.
    • Serological tests use antigen molecules to detect the presence of antibodies relevant to the infection.
    • Generally, a blood sample is placed in a test tube that is lined with antigens on the inside. If the relevant antibodies are present, they latch on to the antigens.
    • Such tests are relatively inexpensive, and can display results within a few minutes.

  • [pib] Virtual Summit of G20 Leaders

    A Virtual G20 Leaders’ Summit was recently convened yesterday to discuss the challenges posed by the outbreak of the COVID-19 pandemic and to forge a globally coordinated response.

    About G20

    • Formed in 1999, the G20 is an international forum of the governments and central bank governors from 20 major economies.
    • Collectively, the G20 economies account for around 85 percent of the Gross World Product (GWP), 80 percent of world trade.
    • To tackle the problems or the address issues that plague the world, the heads of governments of the G20 nations periodically participate in summits.
    • In addition to it, the group also hosts separate meetings of the finance ministers and foreign ministers.
    • The G20 has no permanent staff of its own and its chairmanship rotates annually between nations divided into regional groupings. 

    Aims and objectives

    • The Group was formed with the aim of studying, reviewing, and promoting high-level discussion of policy issues pertaining to the promotion of international financial stability.
    • The forum aims to pre-empt the balance of payments problems and turmoil on financial markets by improved coordination of monetary, fiscal, and financial policies.
    • It seeks to address issues that go beyond the responsibilities of any one organisation.

    Member Countries

    The members of the G20 consist of 19 individual countries plus the European Union (EU).

    • The 19 member countries of the forum are Argentina, Australia, Brazil, Canada, China, France, Germany, India, Indonesia, Italy, Japan, Mexico, Russia, Saudi Arabia, South Africa, South Korea, Turkey, United Kingdom and the United States.
    • The European Union is represented by the European Commission and by the European Central Bank.

     Who are the G20 Sherpas?

    • A Sherpa is the personal representative of a head of state or government who prepares an international summit, particularly the annual G7 and G20 summits.
    • Between the summits, there are multiple Sherpa conferences where possible agreements are laid out.
    • This reduces the amount of time and resources required at the negotiations of the heads of state at the final summit.
    • The Sherpa is generally quite influential, although they do not have the authority to make a final decision about any given agreement.
    • The name is derived from the Sherpa people, a Nepalese ethnic group, who serve as guides and porters in the Himalayas, a reference to the fact that the Sherpa clears the way for a head of state at a major summit.

  • Let’s use follower’s advantage

    Context

    How this coronavirus pandemic threat will pan out no one knows but what we do know is that the intensity of the challenge and its impact on our well-being will depend greatly on how we reach out to ordinary people, and the policies we implement.

    Historical perspective and comparison

    • Compared to the fatality numbers of some earlier pandemics, such as the Asian flu, 1957-58 (1.1 million dead) and Hong Kong Flu, 1968 (2 million dead), the fatality numbers of the current coronavirus pandemic are, as yet, nowhere near.
    • One of the most comprehensive studies on the pandemic, by the Imperial College of London, shows that the “case fatality rate”, or fatality among those who get coronavirus is 0.9 per cent — this means a 99.1 per cent survival rate among the people who get it.
    • What makes this pandemic special is that it is happening in the age of digital connectivity and greater scientific knowledge than we have ever had.
    • We can inform people quickly and take big steps to contain it.
    • But this also has a danger we have never faced.
    • Policy actions can have a mega backlash on the economy.
    • We are in uncharted territory — never before have we taken the kind of collective action against a pandemic as we are doing now.

    Time to collectively confront our common humanitarian challenge

    • Using the experience of South Korea: There is some evidence from history, and from the country that has been the most successful in dealing with this pandemic —South Korea.
    • The country’s success has saved lives, protected the economy from undue damage, boosted the popularity of the Korean President Moon Jae-In across political divides and raised the global standing of South Korea.
    • France’s President Emmanuel Macron and Sweden’s Prime Minister Stefan Lofven have consulted Moon Jae-In for advice.
    • We have some evidence and estimates about the kind of damage this pandemic can do.
    • China’s industrial production in January-February 2020 declined by 5 per cent compared to a year ago.
    • Goldman Sachs has estimated that the US’s GDP growth could decline 24 per cent for the second quarter this year.
    • Data are coming in on recent US unemployment claims climbing by 30 per cent.
    • This is clearly time to put political differences aside, and collectively confront our common humanitarian challenge.

    Designing policy to deal with the pandemic

    • Economic implications: In designing policy, it is important to realise that all interventions to contain the pandemic have economic implications.
    • Some people react to this by saying that our first priority is to save lives, not the economy. This is a mistake. The two are not separate matters.
    • A poorly-executed policy can damage the economy and this can end up taking more lives than the original problem.
    • Examples of policy doing damage to lives: We have examples of the damage policies can do from history. In 1958, Mao Zedong initiated the Great Leap Forward to boost China’s production. This unleashed the biggest famine in modern times, which resulted in 20 to 40 million deaths.
    • The Bengal Famine of 1943 occurred with no decline in food production but there were disruptions in supply chains from the farms to those who needed food.
    • The death toll was two to three million. Such evidence from the past warns us that policies not designed well can cause more deaths than the pandemic itself.

    Three lessons from South Korea

    • We already have three lessons from Korea, which are being widely discussed in newspapers and the media around the world.
    • First, you need strong leadership.
    • Second, it is critically important to have trust between society and government. There is only that much you can do if people do not cooperate.
    • Third, the need is for nuanced policies, with the government having the courage to make course correction as it goes along.

    Way forward

    • First, trust can be a casualty with the lockdown. There are reports of the police wielding the baton too quickly on ordinary vendors, small grocers and sellers. They need to explain to people so that they begin to actually cooperate, instead of complying only when under observation. That is the key difference between a trusting society and a trustless one.
    • The government cannot be a substitute for the private firms: To believe that small traders and private firms can be substituted by the government is the mistake Communist China made in the 1960s and 1970s, before the arrival of Deng Xiaoping.
    • An example of the importance of specialised knowledge — this applies to the US as well — pertains to the role of cash grants to the poor. Such grants work well in normal times but may need to be supplemented with the direct support of food and medical services.

    Conclusion

    Some say that the Korea analogy is of no use to us because it is a relatively small country. It is true that everything will not apply here. But on the other hand, Korea and Hubei province of China are very comparable. Korea’s population is 52 million, Hubei’s is 58 million. The number of people who died of the virus in Korea is 126. The figure for Hubei is 3,160. Korea, of course, had the follower’s advantage since the virus struck there later. But we too have that advantage.

  • Mind your own economic health

    Context

    The fragility of the global economy has been exposed twice within the last two decades. In 2008, the collapse of a financial services firm in the US triggered a global financial meltdown. In 2020, the emergence of a novel virus in a food market in Wuhan has done it again.

    The global economy and system theory

    • Systems theory: It that systems take various forms. Broadly speaking, there are three types of systems-1. Chaotic systems. 2. Engineered Systems, and 3. Complex self-adaptive systems.
    • As the weather in a storm, chaotic systems are unpredictable and uncontrollable.
    • The global economy is behaving like a chaotic system.
    • Engineered systems, on the other hand, can be controlled quite tightly, like machines.
    • However, they are dull. A nuclear power plant is a well-engineered system. We would want it to do just what it is supposed to and not produce any surprises.
    • In contrast to these systems is the design of nature. It is a complex self-adaptive system. It produces myriad innovations. It evolves. Yet, its fundamental stability is very reassuring.
    • The realisation that mankind’s technologies and engineering marvels are disrupting nature’s stability, has raised alarms about the architecture of global economic governance.
    • More about self-adaptive systems: The architecture of complex self-adaptive systems is formed by essential design principles. One is “permeable boundaries”.
    • The many parts of a complex self-adaptive system have permeable boundaries between themselves. Each part has its integrity. The parts exchange information and energy across their boundaries as required.
    • When there are no boundaries within, or they are too weak, an accident at one end will soon sink the whole ship.

    Consequences of boundarylessness within the global financial system

    • The drive for boundarylessness within the global financial system since the 1990s caused the sloshing around of contagion during the global financial crisis in 2008.
    • Whereas global economic growth has undoubtedly been enabled by global supply chains, the vulnerability of economies everywhere to their disruption has become painfully evident with the COVID-19 pandemic.
    • Complex adaptive systems exhibit “fractal-like” shapes. Their parts are complex, combining the same diverse energies that permeate across the whole.
    • Social forces, economic forces, and environmental forces combine within all countries, and in parts within countries too, albeit in different ways.
    • Though the parts are similar to each other, they are not the same. Therefore, the same solutions will not fit all.
    • An insight from systems theory is that global systemic problems such as climate change, persistent economic inequality, among others, will require local systems solutions.

    Six reforms for reshaping Indian economy

    • Stress test: Crises create stress tests for the health of systems. The financial crisis of 2008 exposed the fragility of an inter-connected and under-regulated financial system.
    • The COVID-19 pandemic has exposed the architectural weaknesses in the global economy.
    • Instead of worrying too much about the reversal of globalisation, national leaders should now focus on the well-being of their citizens and the health of their own economies.
    • Six reforms are essential for reshaping the Indian economy.
    • First, focus on the provision of universal social security, rather than on the misdirected demand for even more “flexibility” in labour laws
    • Second, respect the “informal” sector which provides the majority of Indians with opportunities to earn incomes, and give it more strength. It is also a great source for practical innovations and widespread entrepreneurship.
    • Third, change the economic paradigm from “trickle-down” to “build up”. Build the internal engine of growth of India’s economy by increasing incomes of India’s citizens.
    • Fourth, strengthen public health services. Medical tourism may put India’s private hospitals on the global map. However, they are not the solution to India’s huge health problems.
    • Fifth, reform and strengthen the public education system. It will contribute greatly to creating a level playing field for all children.
    • Sixth, strengthen local governance in India’s towns and districts to develop and implement local systems solutions. The well-being of Indian citizens will be improved, and India’s economy will be more resilient too.

    Conclusion

    • All governments are asking their citizens to increase “social distancing” between themselves to prevent the spread of a health contagion. It would be wise for countries to maintain sufficient “economic distancing” amongst themselves too. They should mind the health of their own economies. Thereby, they will improve the health of the global economy too.