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

  • National Health Accounts Estimates: 2017-18

    Out-of-pocket expenditure (OOPE) as a share of total health expenditure and foreign aid for health has both come down as per the findings of the National Health Accounts (NHA) estimates for India for 2017-18.

    What is National Health Accounts (NHA)?

    • The NHA estimates are prepared by using an accounting framework based on internationally accepted System of Health Accounts 2011, provided by the World Health Organization (WHO).
    • It is released by Ministry of Health & Family Welfare.
    • It describes health expenditures and flow of funds in the country’s health system over a financial year of India.
    • It answers important policy questions such as what are the sources of healthcare expenditures, who manages these, who provides health care services, and which services are utilized.
    • It is a practice to describe the health expenditure estimates according to a global standard framework, System of Health Accounts 2011 (SHA 2011), to facilitate comparison of estimates across countries.

    Objective of the NHA

    • To describe the Current Health Expenditures (CHE).

    The details of CHE are presented according to

    • Revenues of healthcare financing schemes: – entities that provide resources to spend for health goods and services in the health system;
    • Healthcare financing schemes: entities receiving and managing funds from financing sources to pay for or to purchase health goods and services;
    • Healthcare providers: entities receiving finances to produce/ provide health goods and services;
    • Healthcare functions: It describes the use of funds across various health care services.

    About NHA (2017-2018)

    • The 2017-18 NHA estimates shows government expenditure on health exhibiting an increasing trend and growing trust in public health care system.
    • With the present estimate of NHA 2017-18, India has a continuous Time Series on NHA estimates for both government and private sources for five years since 2013-14.
    • These estimates are not only comparable internationally, but also enable the policy makers to monitor progress towards universal health coverage as envisaged in the National Health Policy, 2017.

    Key Highlights

    Increase in GDP share: The NHA estimates for 2017-18 clearly show that there has been an increase in the share of government health expenditure in the total GDP from 1.15% in 2013-14 to 1.35% in 2017-18.

    Increase in govt share in expenditures: In 2017-18, the share of government expenditure was 40.8%, which is much higher than 28.6% in 2013-14.

    Per-Capita increase in expenditure: In per capita terms, the government health expenditure has increased from Rs 1042 to Rs.1753 between 2013-14 to 2017-18.

    Focus on total healthcare: The primary and secondary care accounts for more than 80% of the current Government health expenditure.

    Social security expenditure: The share of social security expenditure on health, which includes the social health insurance program, Government financed health insurance schemes, and medical reimbursements made to Government employees, has increased.

    Decline in foreign aid: The findings also depict that the foreign aid for health has come down to 0.5%, showcasing India’s economic self-reliance.

    Decline in OOPE: The government’s efforts to improve public health care are evident with out-of-pocket expenditure (OOPE) as a share of total health expenditure coming down to 48.8% in 2017-18 from 64.2% in 2013-14.

    Way forward

    • After 18 months of Covid-19, financial year 2017-18 appears to be from another era.
    • However, learnings from that year’s NHA help us to plan for health system strengthening in the post-Covid years.
    • The special financing packages for Covid emergency response, announced by the central government in 2020 and 2021, represent an extraordinary situation.
    • The resolve to increase public financing for health must remain strong even after Covid.

     

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  • Key Demographic Transitions captured by 5th round of NFHS

    The Union health ministry released the summary findings of the fifth round of the National Family and Health Survey (NFHS-5), conducted in two phases between 2019 and 2021.

    About NFHS

    • The NFHS is a large-scale, multi-round survey conducted in a representative sample of households throughout India.
    • The previous four rounds of the NFHS were conducted in 1992-93, 1998-99, 2005-06 and 2015-16.
    • The survey provides state and national information for India on:

    Fertility, infant and child mortality, the practice of family planning, maternal and child health, reproductive health, nutrition, anaemia, utilization and quality of health and family planning services etc.

    Objectives of the survey

    Each successive round of the NFHS has had two specific goals:

    • To provide essential data on health and family welfare needed by the Ministry of Health and Family Welfare and other agencies for policy and programme purposes
    • To provide information on important emerging health and family welfare issues.

    Key highlights of the NFHS-5

    [1] Women outnumbering men

    • NFHS-5 data shows that there were 1,020 women for 1000 men in the country in 2019-2021.
    • This is the highest sex ratio for any NFHS survey as well as since the first modern synchronous census conducted in 1881.
    • To be sure, in the 2005-06 NFHS, the sex ratio was 1,000 or women and men were equal in number.

    [2] Fertility has decreased

    • The Total Fertility Rate (TFR) has also come down below the threshold at which the population is expected to replace itself from one generation to next.
    • TFR was 2 in 2019-2021, just below the replacement fertility rate of 2.1. To be sure, in rural areas, the TFR is still 2.1.
    • In urban areas, TFR had gone below the replacement fertility rate in the 2015-16 NFHS itself.

    [3] Population is ageing

    • A decline in TFR, which implies that lower number of children are being born, also entails that India’s population would become older.
    • Sure enough, the survey shows that the share of under-15 population in the country has therefore further declined from 28.6% in 2015-16 to 26.5% in 2019-21.

    [4] Children’s nutrition has improved

    • The share of stunted (low height for age), wasted (low weight for height), and underweight (low weight for age) children have all come down since the last NFHS conducted in 2015-16.
    • However, the share of severely wasted children has not, nor has the share of overweight (high weight for height) or anaemic children.
    • The share of overweight children has increased from 2.1% to 3.4%.

    [5] Nutrition problem for adults

    • For children and their mothers, there are at least government schemes such as Integrated Child Development Services (ICDS) that seek to address the nutritional needs at the time of childbirth and infancy.
    • However, there is a need to address the nutritional needs of adults too.
    • The survey has shown that though India might have achieved food security, 60% of Indians cannot afford nutritious diets.
    • While the share of women and men with below-normal Body Mass Index (BMI) has decreased, the share of overweight and obese (those with above-normal BMI) and the share of anaemic has increased.

    [6] Basic sanitation challenges

    • Availability of basic amenities such as improved sanitation facilities clean fuel for cooking, or menstrual hygiene products can improve health outcomes.
    • There has been an improvement on indicators for all three since the last NFHS. However, the degree of improvement might be less than claimed by the government.
    • For example, only 70% population had access to an improved sanitation facility.
    • While not exactly an indicator of open defecation, it means that the remaining 30% of the population has a flush or pour-flush toilet not connected to a sewer, septic tank or pit latrine.

    [7] Use of clean fuel

    • The share of households that use clean cooking fuel is also just 59%.

    [8] Financial inclusion

    • The share of women having a bank account that they themselves use has increased from 53% to 79%.
    • Households’ coverage by health insurance or financing scheme also has increased 1.4 times to 41%, a clear indication of the impact of the government’s health insurance scheme.

     

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  • HomoSEP: Robot for cleaning Septic Tanks

    IIT Madras has developed a robot that can, if deployed extensively, put an end to this practice of sending people into septic tanks.

    HomoSEP

    • HomoSEP stands for “homogenizer of septic tanks”.
    • It has a shaft attached to blades that can open like an inverted umbrella when introduced into a septic tank.
    • This is helpful as the openings of the septic tanks are small and the tank interiors are bigger.
    • The sludge inside a septic tank contains faecal matter that has thickened like hard clay and settled at the bottom.
    • This needs to be shredded and homogenized so that it can be sucked out and the septic tank cleaned. The whirring blades of the robot achieve precisely this.

    Manual scavenging deaths in India

    • A statement by the Social Justice and Empowerment Ministry conveyed that in the five years till December 31, 2020, there have been 340 deaths due to manual scavenging.
    • Uttar Pradesh (52), Tamil Nadu (43) and Delhi (36) leads in the list. Maharashtra had 34 and Gujarat and Haryana had 31 each.
    • This is despite bans and prohibitory orders.

    Various policy initiatives

    • Prohibition of Employment as Manual Scavengers and their Rehabilitation (Amendment) Bill, 2020: It proposes to completely mechanise sewer cleaning, introduce ways for ‘on-site’ protection and provide compensation to manual scavengers in case of sewer deaths.
    • Prohibition of Employment as Manual Scavengers and their Rehabilitation Act, 2013: Superseding the 1993 Act, the 2013 Act goes beyond prohibitions on dry latrines, and outlaws all manual excrement cleaning of insanitary latrines, open drains, or pits.
    • Rashtriya Garima Abhiyan: It started national wide march “Maila Mukti Yatra” for total eradication of manual scavenging from 30th November 2012 from Bhopal.
    • Prevention of Atrocities Act: In 1989, the Prevention of Atrocities Act became an integrated guard for sanitation workers since majority of the manual scavengers belonged to the Scheduled Caste.
    • Judicial intervention: In 2014, a Supreme Court order made it mandatory for the government to identify all those who died in sewage work since 1993 and provide Rs. 10 lakh each as compensation to their families.

     

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  • Health Care Equity in Urban India

    The report on ‘Health Care Equity in Urban India’ exploring health vulnerabilities and inequalities in cities in India was recently released.

    About the report

    • The report is released recently by Azim Premji University in collaboration with 17 regional NGOs across India.
    • It notes that a third of India’s people now live in urban areas, with this segment seeing rapid growth from about 18% (1960) to 28.53% (2001) to 34% (in 2019).
    • The study draws insights from data collected through detailed interactions with civil society organizations in major cities and towns.
    • This also included an analysis of the National Family and Health Surveys (NHFS), the Census of India, and inputs from State-level health officials on the provision of health care.
    • It also looks at the availability, accessibility, and cost of healthcare facilities, and possibilities in future-proofing services in the next decade.

    Key highlights of the report

    • Urban poverty on rise: Close to 30% of people living in urban areas are poor.
    • Declining life expectancy: Life expectancy among the poorest is lower by 9.1 years and 6.2 years among men and women, respectively, compared to the richest in urban areas.
    • Chaotic health governance: The report, besides finding disproportionate disease burden on the poor, also pointed to a chaotic urban health governance.
    • Multiplicity and non-coordination: The multiplicity of healthcare providers both within and outside the government without coordination challenges to urban health governance.
    • Lack of political attention: Urban healthcare has received relatively less research and policy attention.

    Major recommendations

    The report calls for:

    • Strengthening community participation and governance
    • Building a comprehensive and dynamic database on the health and nutrition status, including co-morbidities of the diverse, vulnerable populations
    • Strengthening healthcare provisioning through the National Urban Health Mission, especially for primary healthcare services
    • Putting in place policy measures to reduce the financial burden of the poor
    • A better mechanism for coordinated public healthcare services and better governed private healthcare institutions

    Conclusion

    • As urbanization is happening rapidly, the number of the urban poor is only expected to increase.
    • A well-functioning, better coordinated, and governed health care system is crucial at this point.
    • The pandemic has brought to attention the need for a robust and resourced healthcare system.
    • Addressing this will benefit the most vulnerable and offer critical services to city dwellers across income groups.

     

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  • Assessing the digital gap and learning losses

    A recent survey released seeks to analyze the COVID-impact on digital connectivity in the context of healthcare, education, and work.

    About the Survey

    • LIRNEasia, an Asia Pacific think tank focussed on digital policy, tied up with the Indian Council for Research on International Economic Relations (ICRIER).
    • They took part in a global study funded by the Canada’s International Development Centre to assess the socio-economic impacts of COVID-19 .
    • They sought to analyse access to services, with a focus on digital technologies in healthcare, education and work.

    Highlights of the Survey:

    [A] Internet Access and Use

    (1) Internet users

    • The survey found that 47% of the population are Internet users, a significant jump from the 19% who were identified as Internet users in late 2017.
    • At least 5 crores have already become new Internet users in 2021.

    (2) Gender and internet

    • Men still use the Internet more than women.
    • There is a 37% gender gap among users, although this is half of the 57% gap present four years ago.

    (3) Rural-urban Gap

    • The rural-urban gap has dropped from 48% in 2017 to just 20% now as more rural residents come online.

    (4) Education

    • Among those with college education, 89% are Internet users, compared to 60% of those who completed secondary school.
    • Only 23% of those who dropped out of school after Class 8, and 9% of those without any education, are able to use the Internet.

    Major inferences drawn

    • Among non-users, lack of awareness is still the biggest hurdle.
    • The percentage of non-users who said they do not know what the Internet is dropped from 82% to 49% over the last four years.
    • Increasingly, lack of access to devices and lack of skills are the reason why people do not go online.

    Loopholes in Remote Education

    • 80% of school-age children in the country had no access to remote education at all during the 18 months of lockdown.
    • This happened even though 64% of households actually had Internet
    • Situation was worse for those homes without Internet connections, where only 8% of children received any sort of remote education.

    [B] Internet connectivity

    • Apart from not having any devices, poor 3G/4G signal and high data cost were listed as the biggest hurdles.
    • Even among the 20% who received education, only half had access to live online classes which required a good Internet connection and exclusive use of a device.
    • Most depended on recorded lessons and WhatsApp messages which could be sent to a parent’s phone and downloaded at leisure.
    • Others were able to have more direct contact with teachers via phone calls or physical visits.

    Worst consequences: Dropouts

    • Nationwide, 38% of households said at least one child had dropped out of school completely due to COVID-19.
    • The situation was significantly worse among those from lower socio-economic classes, or where the head of the household had lower education levels.

    [C] Internet access and healthcare

    • About 15% required healthcare access for non-COVID related purposes during the most severe national and State lockdown.
    • Of the 14% who required ongoing treatment for chronic conditions, over a third missed at least one appointment due to the lockdown.
    • Telemedicine and online doctor consultations surged during these times, but only 38% said they were able to access such services.
    • With regard to COVID-19, about 40% of respondents depended on television channels for advice as their most trusted source.

     

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  • First National Achievement Survey (NAS) held

    The first National Achievement Survey (NAS) in four years was conducted, in a bid to assess the competencies of children in Class 3, 5 and 8.

    National Achievement Survey (NAS)

    • NAS is a nationally representative large-scale survey of students’ learning undertaken by the Ministry of Education.
    • It is implemented on a sample size aiming to assess students of 3rd, 5th, 8th and 10th
    • It gives a system level reflection on effectiveness of school education.
    • The NCERT has developed the Assessment Framework for gauging the competencies attained by the student’s vis-a-vis learning outcomes.

    Features of the Survey

    • The Survey goes beyond the scorecard and includes the background variables to correlate student’s performance in different learning outcomes vis-a-vis contextual variables.
    • The Survey was conducted in a monitored environment in the sampled schools.
    • Selection of sampled schools was based on UDISE+ (Unified District Information System for Education) 2019-20 data.

    Significance of NAS

    • NAS findings would help diagnose learning gaps of students and determine interventions required in education policies, teaching practices and learning.
    • Through its diagnostic report cards, NAS findings help in capacity building for teachers, officials involved in the delivery of education.
    • This will help to assess the learning interruptions and new learnings during the COVID pandemic and help to take remedial measures.

     

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  • Project Sampoorna: A successful measure against malnutrition

    Project Sampoorna’s success in reducing child malnutrition is a model that can be easily implemented anywhere.

    What is Project Sampoorna?

    • Project Sampoorna has been implemented in the Bongaigaon district of Assam.
    • It aims to target Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM).
    • It was launched to target the mothers of SAM/ MAM children with the tagline being ‘Empowered Mothers, Healthy Children’.
    • It was based on the success of the community-based COVID-19 management model (Project Mili Juli).

    Key features of the project

    • Under this project, the mother of a healthy child of an Anganwadi Centre was paired with the target mother and they would be Buddy Mothers.
    • They were usually neighbours and shared similar socioeconomic backgrounds.
    • They were given diet charts to indicate the daily food intake of their children and would have discussions on all Tuesdays at the Anganwadi centres.
    • 100 millilitres of milk and an egg on alternate days for the children for the first 3 months were provided so that their mothers could stabilise themselves in the newly found jobs.
    • Children who had not improved were checked and treated by doctors under the Rashtriya Bal Swasthya Karyakram (RBSK).

    Success of the project

    • This project has prevented at least 1,200 children from becoming malnourished over the last year.
    • National Nutrition Mission and the State government recognised this project in the ‘Innovation Category’.
    • The mothers were enrolled in Self Help Groups (SHGs) under the National Rural Livelihoods Mission (NRLM) and were thus working.

     

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  • Global Drug Policy Index inaugurated

    The first-ever Global Drug Policy Index was recently inaugurated.

    Global Drug Policy Index

    • It is released by the Harm Reduction Consortium, ranks Norway, New Zealand, Portugal, the UK and Australia as the five leading countries on humane and health-driven drug policies.
    • It is a data-driven global analysis of drug policies and their implementation.
    • It is composed of 75 indicators running across five broad dimensions of drug policy:
    1. Criminal justice
    2. Extreme responses
    3. Health and harm reduction
    4. Access to internationally controlled medicines and
    5. Development

    Highlights of the 2021 ranking

    • The five lowest-ranking countries are Brazil, Uganda, Indonesia, Kenya, and Mexico.
    • Norway, despite topping the Index, only managed a score of 74/100.
    • And the median score across all 30 countries and dimensions is just 48/100.

    India’s performance

    • India’s rank is 18 out of 30 countries
    • It has an overall score of 46/100.

     

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  • There’s a mismatch between India’s graduate aspirations and job availability

    Context

    There is a huge pool of unemployed university graduates with unfulfilled aspirations. This group of dissatisfied, disgruntled youth can lead to disastrous consequences for our society.

    Enhanced enrollment

    • Reservation: The extension of reservations to OBCs and EWS increased the enrollment of students from these socio-economic backgrounds.
    • Increased education institutions: In addition, the massive increase in the number of higher education institutions has led to an enlargement of the number of available seats — there are more than 45,000 universities and colleges in the country.
    • The Gross Enrollment Ratio for higher education, which is the percentage of the population between the ages of 18-23 who are enrolled, is now 27 per cent.

    Issues of employment opportunities

    • Unfortunately, the spectacular increase in enrollment in recent years has not been matched by a concomitant increase in jobs.
    •  Employment opportunities in the government have not increased proportionately and may, in fact, have decreased with increased contractualisation.
    •  Even in the private sector, though the jobs have increased with economic growth, most of the jobs are contractual.
    • Worse, the highest increase in jobs is at the lowest end, especially in the services sector — delivery boys for e-commerce or fast food for instance.
    • Thus what we see is a huge pool of unemployed university graduates with unfulfilled aspirations.
    • This group of dissatisfied, disgruntled youth can lead to disastrous consequences for our society, some of which we are already witnessing.

    Way forward

    • A reduction in the rate of increase of universities and colleges might not be politically feasible given the huge demand for higher education.
    • Increase vocation institutions: A concurrent increase in the number of high-quality vocational institutions is something that can be done.
    • There are upwards of 15,000 Industrial Training Institutes (ITIs) in the country currently.
    • Upgrading the existing ITIs, opening many more new ones with high-quality infrastructure and updated curriculum is something which should be done urgently.
    • There is a scheme to upgrade some ITIs to model ITIs.
    • However, what is required is not a selective approach but a more broad-based one that uplifts the standards of all of them besides adding many more new ones.
    • Industry might be more than willing to pitch in with funding (via the CSR route) as well as equipment, training for the faculty and internships for students.

    Conclusion

    These steps could help mitigate the mismatch between employment opportunities and the increasing number of educated youth in the country.

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  • Strengthening healthcare through ABHIM

    Context

    The Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (ABHIM), announced recently, seeks to realise greater investment in the health system as proposed in the Budget, implement the Fifteenth Finance Commission recommendations such as strengthening of urban and rural primary care, stronger surveillance systems and laboratory capacity.

    Measures of ABHIM

    • It will support infrastructure development of 17,788 rural health and wellness centres (HWCs) in seven high-focus States and three north-eastern States.
    • In addition, 11,044 urban HWCs will be established in close collaboration with Urban Local Bodies.
    • The various measures of this scheme will extend primary healthcare services across India.
    • Areas like hypertension, diabetes and mental health will be covered, in addition to existing services.
    • Support for 3,382 block public health units (BPHUs) in 11 high-focus States and establishment of integrated district public health laboratories in all 730 districts will strengthen capacity for information technology-enabled disease surveillance.
    • To enhance the capabilities for microbial surveillance, a National Platform for One Health will be established.
    • Four Regional National Institutes of Virology will be established.
    • Laboratory capacity under the National Centre for Disease Control, the Indian Council of Medical Research and national research institutions will be strengthened.
    • Fifteen bio-safety level III labs will augment the capacity for infectious disease control and bio-security.

    Way forward

    • There is a need to train and deploy a larger and better skilled health workforce.
    • We must scale up institutional capacity for training public health professionals.
    • Private sector participation in service delivery may be invited by States, as per need and availability.
    • ABHIM, if financed and implemented efficiently, can strengthen India’s health system by augmenting capacity in several areas and creating a framework for coordinated functioning at district, state and national levels.
    • Many independently functioning programmes will have to work with a common purpose by leaping across boundaries of separate budget lines and reporting structures.
    • That calls for a change of bureaucratic mindsets and a cultural shift in Centre-State relations.

    Conclusion

    The ABHIM can fix the weaknesses in India’s healthcare system.

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