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GS Paper: GS2-13.Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources.

  • Settling India’s COVID-19 mortality data

    Context

    Over the last year, the World Health Organization (WHO) has been busy, in an unprecedented effort, to calculate the global death toll from COVID-19.

    Revision of Covid-19 death toll by WHO

    • Globally from an estimated six million reported deaths, WHO now estimates these deaths to be closer to almost triple the number.
    • The new estimates also take into account formerly uncounted deaths, but also deaths resulting from the impact of COVID-19.
    • For example, millions who could not access care, i.e., diagnosis or treatment due to COVID-19 restrictions or from COVID-19 cases overwhelming health services.
    • India’s stand: India is in serious disagreement with the WHO-prepared COVID-19 mortality estimates.
    • The argument being made by India’s health establishment through a public clarification is that this is an overestimation, and the methodology employed is incorrect.

    India’s Covid response

    • India’s COVID-19 response has been replete with delays and denials.
    • For instance, for the longest time that India’s COVID-19 number rose, the health establishment continued to insist that community transmission was not under way.
    • It took months and several lakh cases before they agreed that COVID-19 was finally in community transmission.
    • The devastation of the second wave showed how unprepared we were to combat the deadly Delta variant.
    •  By the time the wave subsided, India’s population was devastated, and helpless, seeing dignity neither in disease nor in death.

    Conclusion

    The figures ratchet up not only issues of administrative but also moral accountability for governments that they have been previously side stepped.

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  • Nutrition status and TB risk

    Context

    Historical importance of good nutrition was ignored by the modern therapist who tried to control TB initially with streptomycin injection, isoniazid and para-aminosalisylic acid. In the ecstasy of finding antibiotics killing the germs, the social determinants of disease were ignored.

    Lack of patient-centric TB treatment

    • With more drug arsenals such as rifampicin, ethambutol, pyrazinamide, the fight against TB bacteria continued, which became multidrug resistant.
    • The regimes and the mode of delivery of drugs were changed to plug the loopholes of non-compliance of patients.
    • Blister packs of a multi-drug regime were provided at the doorstep, and the directly observed treatment/therapy (DOT) mechanism set up.
    • Many of the poor discontinued blister-packaged free drugs thinking that these were “hot and strong” drugs not suited for the hunger pains they experienced every night.

    Role of nutrition in dealing with TB

    • India has around 2.8 million active cases. It is a disease of the poor.
    • And the poor are three times less likely to go for treatment and four times less likely to complete their treatment for TB, according to WHO, in 2002.
    • The fact is that 90% of Indians exposed to TB remain dormant if their nutritional status and thereby the immune system, is good. 
    • When the infected person is immunocompromised, TB as a disease manifests itself in 10% of the infected.
    • The 2019 Global TB report identified malnutrition as the single-most associated risk factor for the development of TB, accounting for more cases than four other risks, i.e., smoking, the harmful use of alcohol, diabetes and HIV.
    • The work and the findings of a team at the Jan Swasthya Sahayog hospital at Ganiyari, Bilaspur in Chhattisgarh established the association of poor nutritional status with a higher risk of TB.

    Way forward

    • Chhattisgarh initiated the supply of groundnut, moong dhal and soya oil, and from April 2018, under the Nikshay Poshan Yojana of the National Health Mission.
    • All States began extending cash support of â‚č500 per month to TB patients to buy food. This amount needs to be raised.
    • Nutrition education and counselling support: Without simultaneous nutrition education and counselling support, this cash transfer will not have the desired outcome.

    Conclusion

    Food is a guaranteed right for life under the Constitution for all citizens, more so for TB patients. Thus, the goals of reducing the incidence of TB in India and of reducing TB mortality cannot be reached without addressing undernutrition.

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  • Common University Entrance Test

    Context

    UGC introduced the Common University Entrance Test (CUET) for admissions in undergraduate courses in 45 central universities in the country.

    Benefits of Common University Entrance Test (CUET)

    • Deals with the issue of uneven quality of different boards: In a country like ours, because of the uneven quality of different school boards, there is a huge trust deficit and suspicion about the academic quality of even the “toppers”.
    • Eliminate the need for multiple exams: Furthermore, this centralised test would free the tension-ridden youngsters from the pressure of writing multiple entrance tests in different colleges/universities.
    • Eliminate the inflated cut-off: Likewise, the supremacy of the CUET score/ranking in the selection process would invariably eliminate inflated cut-offs for admissions in “branded” colleges.
    • It would avoid subjective biases, cherish objectivity, and quantify and measure one’s mental aptitude and domain knowledge in a specific discipline.

    Issues with the CUET

    • 1] Impact on true learning: the dominant structure of education prevalent in the country is essentially book-centric and exam-oriented.
    • Either rote learning or strategic learning (a gift of coaching centres) is its essence; and far from learning and unlearning with joy, wonder and creativity, young students become strategists or exam-warriors.
    • In the coming years, schools are going to lose their relevance as students and parents are likely to rely primarily on gigantic coaching centres and fancy Ed Tech companies.
    • 2] No scope for subjective interpretation:  The MCQ-centric “objective” tests diminishes what every genuine learner needs — creative exploration, interpretative understanding and self-reflexivity.
    • In the name of “objective” tests, our students are deprived of the hermeneutic art of interpretation and skill of argumentation and compelled to reduce everything into an “objective” fact, we would do great damage to their creativity.

    Conclusion

    For real transformation, we have to see beyond the CUET, work on the quality of schools and creatively nuanced life-affirming pedagogy; and we must think of honest and fair recruitment of spirited teachers, and relative autonomy of academic institutions.

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  • Fighting TB with lessons learnt during Covid pandemic

    Context

    On World TB day, we need to ask how best we can leverage the lessons learnt from Covid-19 to help gain a new momentum in TB control.

    Comparing the impact of Covid-19 and TB

    • In the first year of the Covid-19 pandemic, 1.8 million people were reported to have succumbed to the virus.
    • In the decade between 2010-20, 1.5-2 million individuals died every year because of tuberculosis.
    • The difference in responses to the two pandemics can only be explained by the differences in the profiles of those who get infected.
    • TB disproportionately affects people in low-income nations, the poor and the vulnerable.
    • The increased burden on healthcare to manage Covid has led to a serious setback in TB control.

    Using lessons from Covid-19 for TB control

    • To leverage the lessons learnt from Covid-19 to control TB, we need to focus on the epidemiological triad: Agent, host and the environment.
    • Test, treat and track has been a strategy successfully employed for Covid.
    • Scaling up testing: We need to aggressively scale up testing with innovative strategies such as active surveillance, bidirectional screening for respiratory tract infections using the most sensitive molecular diagnostics, and contact tracing.
    • Vaccine: The biggest victory against Covid has been the speed with which vaccines were developed, scaled up and deployed.
    • We need to replicate the same for tuberculosis, lobbying for funding from governments and industry to develop a successful vaccine for TB.
    • Social security programs for the prevention of risk: Malnutrition, poverty and immuno-compromising conditions such as diabetes are some of the factors strongly associated with TB.
    • Social security programmes that work towards prevention of modifiable risk factors would possibly pay richer dividends than an exclusive focus on “medicalising” the disease.
    • Environmental factors: Environmental factors which have been neglected include ventilation of indoor spaces, educating individuals to avoid crowds when possible, and to encourage voluntary masking, especially in ill-ventilated and closed spaces.
    • Investment and actions: Covid has been a stellar example of how investments and actions can be swift, and public education can transform behaviour.
    • Similar aspirations for TB can help turn this crisis into an opportunity to re-imagine our overburdened and underfunded systems.
    • Involvement of private sector: We need to actively engage the private sector, build bridges and partnerships as we did in the case of Covid.

    Way forward

    • The country needs to invest in state-of-the-art technologies, build capacity, expand its health workforce and strengthen its primary care facilities.
    • It also needs to consider telemedicine and remote support as important aspects of health services.
    • We need to build an open and collaborative forum where all stakeholders, especially affected communities and independent experts, take a lead role.

    Conclusion

    We have ignored TB for too long. It’s time we acknowledge the magnitude of the disease, and work harder at offering individuals equitable healthcare access and resources that the disease warrants.

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  • Mid day Meal Scheme

    A parliamentarian has recently asked the government to re-start the mid-day meals in reopening schools and to ensure that the meals provided are cooked and nutritious.

    What is the Mid-Day Meal Scheme?

    • The Midday Meal Scheme is a school meal program designed to better the nutritional standing of school-age children nationwide.
    • It was launched in the year 1995.
    • It supplies free lunches on working days for children in primary and upper primary classes in:
    1. Government, government aided, local body schools
    2. Education Guarantee Scheme, and alternate innovative education centres,
    3. Madarsa and Maqtabs supported under Sarva Shiksha Abhiyan, and
    4. National Child Labour Project schools run by the ministry of labour
    • The Scheme has a legal backing under the National Food Security Act, 2013.

    Objective: To enhance the enrolment, retention and attendance and simultaneously improve nutritional levels among school going children studying in Classes I to VIII

    History of the scheme

    • In 1925, a Mid Day Meal Programme was introduced for disadvantaged children in Madras Municipal Corporation.
    • By the mid-1980s three States viz. Gujarat, Kerala and Tamil Nadu and the UT of Pondicherry had universalized a same scheme with their own resources for children studying at the primary stage.
    • In 2001, the Supreme Court asked all state governments to begin this programme in their schools within 6 months.

    Features: Calorie approach

    • Primary (1-5) and upper primary (6-8) schoolchildren are currently entitled to 100 grams and 150 grams of food grains per working day each.
    • It also include adequate quantities of micronutrients like iron, folic acid, Vitamin-A, etc.
    • The calorific value of a mid-day meal at various stages has been fixed at a minimum:
    Calories Intake Primary Upper Primary
    Energy 450 calories 700 calories
    Protein 12 grams 20 grams

     

    Why in news?

    • The flagship report of The State of Food Security and Nutrition in the World 2020 estimated that as of April 2020 369 million children globally were losing out on school meals, a bulk of whom were in India.
    • As many as 116 million children — actually, 116 million hungry children — is the number of children impacted due to indefinite school closure during the pandemic.

    Why discuss it now?

    • The recent Global Hunger Index (GHI) report for 2020 ranks India at 94 out of 107 countries and in the category ‘serious’, behind our neighbours Pakistan, Bangladesh and Nepal.
    • The index is a combination of indicators of undernutrition in the population and wasting (low weight for height), stunting (low height for age), and mortality in children below five years of age.

    What measures were resorted to counter this?

    • In March and April 2020 the GoI had announced that the usual hot-cooked mid-day meal or an equivalent food security allowance/dry ration would be provided to all eligible school-going children even during vacation.
    • Nearly three months into this decision, States were still struggling to implement this.

    What lies ahead?

    • Across the country and the world, innovative learning methods are being adopted to ensure children’s education outcomes.
    • The GHI report calls for effective delivery of social protection programmes.
    • With continuing uncertainty regarding the reopening of schools, innovation is similarly required to ensure that not just food, but nutrition is delivered regularly to millions of children.
    • For many of them, that one hot-cooked meal was probably the best meal of the day.

     

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  • TB’s steep socio-economic cost to women

    Context

    As India steadily steers its way through the pandemic to safer shores, we must foreground a disease which has been impacting our country for years, and disproportionately affecting women –  tuberculosis.

    Toll of TB

    • In India, the TB case fatality ratio increased from 17 per cent in 2019 to 20 per cent in 2020.
    • According to a joint report (2010-13) of the Registrar General of India and the Centre for Global Health Research, TB was the fifth-leading cause of death among women in the country, accounting for nearly 5 per cent of fatalities in women aged 30–69.

    How TB affects women more than men

    • Much steeper socio-economic price: While both men and women suffer the consequences of this debilitating disease, women patients pay a much steeper socio-economic price.
    • Beyond clinical metrics: From social ostracisation and lack of family support to the negative impact on marital prospects, women absorb the repercussions of TB beyond the clinical metrics.
    • Stigma also acts as a strong deterrent when it comes to health-seeking behaviour.
    • Fewer women, therefore, get included in the available cascade of care for TB.

    Measures by government

    • In 2019, the Health Ministry-Central TB Division developed a national framework for a gender-responsive approach to TB in India.
    • The document takes cognisance of the challenges faced by women in accessing treatment and offers actionable solutions.
    • Gender-responsive policy interventions: In December 2021, a parliamentary conference on ‘Women Winning Against TB’ was organised by the Ministry of Women and Child Development where gender-responsive policy interventions were discussed.
    • The Vice-President of India urged states to take proactive steps such as ensuring nutritional support to women and children and the doorstep delivery of TB services, especially for women from socio-economically weaker backgrounds.

    Suggestions

    1] Highlight the issue at the relevant forum

    • One, as elected representatives, we need to come together more to highlight the issue at all relevant forums and spaces.
    • These meetings see increased participation of women leaders from all walks of life in the community going forward.

    2] Strengthen counselling network

    • We need to strengthen counselling networks for women patients and their families.
    • Irrespective of where the patient seeks care – public or private sector – build the capacity of healthcare workers to educate the patient’s family about the importance of providing her a supportive environment during the course of her treatment.

    3] Nutritional needs

    • We need to ensure that the nutritional needs of women are being met.
    • Undernutrition is a serious risk factor for TB and research indicates such risks are higher for women.
    • It is commendable that the government, through Nikshay Poshan Yojana, has effectively provided a monthly benefit of Rs 500 to enable a nutritious diet for TB patients in the last few years.
    • For the 2020 cohort, the total amount paid under NPY via DBT has been over  Rs 200 crore.
    • Additionally, we can look to further strengthen inter-departmental coordination, wherein the Public Distribution System can explore appropriate linkages with relevant departments of the MoHFW and even include a protein-rich diet for TB patients.

    4] Amplify accurate TB messaging

    • At a community level, we must amplify accurate TB messaging and showcase how gender plays a role in determining the course of action on the ground.

    Conclusion

    These are universal problems that must transcend gender binaries. Only when equitable solutions are offered to vulnerable sections of society will we be able to realise the dream of TB-Mukt Bharat.

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  • Maternal Mortality in India

    Kerala has yet again emerged on top when it comes to maternal and child health, with the State recording the lowest Maternal Mortality Ratio (MMR) of 30 (per one lakh live births) in the country.

    What is Maternal Mortality?

    • Maternal mortality refers to deaths due to complications from pregnancy or childbirth.
    • The maternal mortality ratio (MMR) is defined as the number of maternal deaths during a given time period per 100,000 live births during the same time period.
    • It depicts the risk of maternal death relative to the number of live births and essentially captures the risk of death in a single pregnancy or a single live birth.

    Trends in India

    • India’s maternal mortality ratio (MMR) has improved to 103 in 2017-19, from 113 in 2016-18.
    • Seven Indian states have very high maternal mortality. These are Rajasthan, Uttar Pradesh, Madhya Pradesh, Chhattisgarh, Bihar, Odisha and Assam.
    • The MMR is ‘high’ in Punjab, Uttarakhand and West Bengal. This means 100-130 maternal deaths per 100,000 live births.
    • It is ‘low’ in Haryana and Karnataka.
    • The states of Uttar Pradesh, Rajasthan and Bihar have seen the most drop in MMR.
    • West Bengal, Haryana, Uttarakhand and Chhattisgarh have recorded an increase in MMR over the last survey.

    Various determinants of maternal health in India

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  • Tobacco and related issues in India

    Context

    Tobacco is a silent killer in our midst that kills an estimated 1.35 million Indians every year.

    The harm caused by tobacco

    • It is the use of tobacco as a result of which more than 3,500 Indians die every single day, as estimated by scientific studies.
    • It also comes at a heavy cost: an annual economic burden of â‚č1,77,340 crore to the country or more than 1% of India’s Gross Domestic Product (GDP).

    How price and taxation of tobacco matters

    •  Research from many countries around the world including India shows that a price increase induces people to quit or reduce tobacco use as well as discourages non-users from getting into the habit of tobacco use.
    • There is overwhelming consensus within the research community that taxation is one of the most cost-effective measures to reduce demand for tobacco products.
    • There has been no significant tax increase on any tobacco product for four years in a row.
    • This is quite unlike the pre-GST years where the Union government and many State governments used to effect regular tax increases on tobacco products.
    • As peer-reviewed studies show, the lack of tax increase over these years has made all tobacco products increasingly more affordable.
    •  The absence of a tax increase on tobacco has the potential to reverse the reduction in tobacco use prevalence that India saw during the last decade and now push more people into harm’s way.
    •  It would also mean foregone tax revenues for the Government.

    Way forward

    • The Union Budget exercise is not the only opportunity to initiate a tax increase on tobacco products.
    • The Goods and Services Tax (GST) Council could well raise either the GST rate or the compensation cess levied on tobacco products especially when the Government is looking to rationalise GST rates and increase them for certain items.
    • For example, there is absolutely no public health rationale why a very harmful product such as the bidi does not have a cess levied on it under the GST while all other tobacco products attract a cess.
    • GST Council meetings must strive to keep public health ahead of the interests of the tobacco industry and significantly increase either the GST rates or the GST compensation cess rates applied on all tobacco products.

    Conclusion

    The aim should be to arrest the increasing affordability of tobacco products in India and also rationalise tobacco taxation under the GST.

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  • Why do Indians go abroad for medical studies?

    • According to estimates from Ukraine, reported in the media, around 18,000 Indian students are in Ukraine (before Operation Ganga).
    • Most of them are pursuing medicine.
    • This war has turned the spotlight on something that has been the trend for about three decades now.

    Preferred countries for medical degree

    • For about three decades now, Indian students have been heading out to Russia, China, Ukraine, Kyrgyzstan, Kazakhstan, and Philippines to pursue a medical degree.

    Hype of becoming a Doctor

    • Prestige: The desire to study medicine still holds a lot of value in the Indian community (the other is becoming an IAS officer).
    • Shortages of Doctor: In many rural areas, people still look at doctors as god’s incarnate.
    • Rarity of opportunity: The lack of equal opportunities exacerbated by the caste factor in the Indian context, has a great deal of impact on the prestige still associated with being a doctor.
    • Social upliftment ladder: For years, certain communities were denied the opportunities, and finally they do have a chance at achieving significant educational status.

    Why go abroad?

    • No language barrier: The medium of education for these students is English, a language they are comfortable with.
    • Affordability: The amount spent on living and the medical degree are far more affordable than paying for an MBBS seat in private medical colleges in India.
    • Aesthetics and foreign culture: People are willing to leave their home to study far away in much colder places and with completely alien cultures and food habits.
    • Practice and OPD exposure: It broadens students’ mind and thinking, expose them to a whole range of experiences, and their approach to issues and crises is likely to be far better.

    Doesn’t India have enough colleges?

    (a) More aspirants than seats

    • There are certainly far more MBBS aspirants than there are MBBS seats in India.
    • In NEET 2021, as per a National Testing Agency press release, 16.1 lakh students registered for the exam, 15.4 lakh students appeared for the test, and 8.7 lakh students qualified.
    • As per data from the National Medical Commission (NMC), in 2021-22, there were 596 medical colleges in the country with a total of 88,120 MBBS seats.
    • While the skew is in favour of Government colleges, it is not greatly so, with the number of private medical institutions nearly neck-to-neck with the state-run ones.

    (b) Fees structure

    • That means over 50% of the total seats are available at affordable fees in Government colleges.
    • Add the 50% seats in the private sector that the NMC has mandated must charge only the government college fees.
    • In fully private colleges, the full course fees range from several lakhs to crores.

    (c) Uneven distribution of colleges

    • These colleges are also not distributed evenly across the country, with States such as Maharashtra, Karnataka, Tamil Nadu and Kerala having many more colleges.

    What about costs?

    • The cost factor on both sides of an MBBS degree is significant.
    • The costs of an MBBS degree in a Government college tot up to a few lakhs of rupees for the full course, but in a private medical college, it can go up to â‚č1 crore for the five-year course.
    • In case it is a management seat, capitation fees can inflate the cost by several lakhs again.
    • Whereas, an MBBS course at any foreign medical university in the east and Eastern Europe costs far less (upto â‚č30lakh-â‚č40 lakh).

    Way forward

    • While PM Modi emphasised that more private medical colleges must be set up in the country to aid more people to take up MBBS, medical education experts have called for pause on the aspect.
    • If the aim is to make medicine more accessible to students of the country, the path ahead is not in the private sector, but in the public sector, with the Central and State governments’ involvement.
    • Starting private medical colleges by reducing the strict standards set for establishing institutes may not actually be the solution to this problem, if we think this is a concern.

    Conclusion

    • Creating more medical colleges will be beneficial for the country, if access and availability can be ensured.
    • This will not be possible by resorting to private enterprise only.
    • The State and Central governments can start more medical colleges, as recommended by NITI Aayog, by utilising district headquarters hospitals, and expanding the infrastructure.
    • This way, students from the lower and middle socio-economic rung, who are otherwise not able to access medical seats, will also benefit.

     

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  • What is ‘Front-of-Pack Labelling’ (FoPL)?

    The Food Safety and Standards Authority of India (FSSAI) will soon start labelling the front of packaged food products with Health Star Rating (HSR).

    What is FoPL?

    • In India, packaged food has had back-of-package (BOP) nutrient information in detail but no FoPL.
    • Counter to this, FoPL can nudge people towards healthy consumption of packaged food.
    • It can also influence purchasing habits.
    • The study endorsed the HSR format, which speaks about the proportions of salt, sugar, and fat in food that is most suited for consumers.
    • Countries such as the UK, Mexico, Chile, Peru, Hungary, and Australia have implemented FoPL systems.

    What warranted such rating in India?

    • Visual bluff: A lot of Indian consumers do not read the information available at the back of the packaged food item.
    • Burden of NCDs: Also, India has a huge burden of non-communicable diseases that contributes to around 5.87 million (60%) of all deaths in a year.
    • Healthy dietary choices: HSR will encourage people to make healthy choices and could bring a transformational change in the society.
    • Supreme court order: A PIL seeking direction to the government to frame guidelines on HSR and impact assessment for food items and beverages was filed in the Supreme Court in June 2021.

    Which category of food item will have HSR?

    • All packaged food items or processed food will have the HSR label.
    • These will include chips, biscuits, namkeen, sweets and chocolates, meat nuggets, and cookies.
    • However, milk and its products such as chenna and ghee are EXEMPTED as per the FSSAI draft notified in 2019.

    Will there be pushback from food industry?

    • Negative warning: Some experts opposed the use of the HSR model in India, suggesting that consumers might tend to take this as an affirmation of the health benefits rather than as a negative warning of ill effects.
    • Lack of awareness: This is significant because there is lack of awareness on star ratings related to consumer products in India.
    • Impact on Sale: Certain organisations fear it might affect the sale of certain food products.

    When will the rating come into force?

    • FSSAI’s scientific panel recommends voluntary implementation of HSR format from 2023 and a transition period of four years for making it mandatory.
    • FSSAI noted that the proposed thresholds are in alignment with the models implemented in other countries and ‘WHO population nutrient intake goals recommendations’.
    • FSSAI will analyse the nutritional information in 100 mg of packaged food.
    • The food safety compliance system licensing application portal will have a module for generating certificates wherein a licensee can enter details of a product.

     

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    Back2Basics: Food Safety and Standards Authority of India (FSSAI)

    • The FSSAI is an autonomous body established under the Ministry of Health & Family Welfare, Government of India.
    • It has been established under the Food Safety and Standards Act, 2006 which is a consolidating statute related to food safety and regulation in India.
    • It is responsible for protecting and promoting public health through the regulation and supervision of food safety.
    • It is headed by a non-executive Chairperson, appointed by the Central Government, either holding or has held the position of not below the rank of Secretary to the Government of India.