Subject: Governance

Context

• In her 2023-24 Union Budget speech, the finance minister announced that the total central government budget for health (not including research) will be roughly Rs 86,175 crore ($10 billion) that is, roughly Rs 615 for every citizen. This is a 2.7 per cent increase from the previous fiscal year and lower than the rate of inflation.

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Government’s current Health spending

• Current health spending lower than middle income countries: India currently spends about Rs 8 lakh crore ($100 billion) or about 3.2 per cent of its GDP on health. This is much lower than the average health spending share of the GDP at around 5.2 per cent of the Lower- and Middle-Income Countries (LMIC)
• Health expenditure in India compared to other countries: Of this, the government (Centre and states put together) spends about Rs 2.8 lakh crore (about $35 billion) roughly 1.1 per cent of the GDP. Contrast this with the government health expenditure in countries like China (3 per cent), Thailand (2.7 per cent), Vietnam (2.7 per cent) and Sri Lanka (1.4 per cent).

How health expenditure affects people especially poor?

• Hospitalisation cost for a day: A Day of hospitalisation at a public hospital is estimated at Rs 2,800. At a private hospital, it is Rs 6,800.
• Disproportionate financial impact on poor households: A greater proportion of disposable incomes is taken away from a poor household as compared to a non-poor one, further broadening the gap between the two.
• Impact of Health expenditure on employment and income: If sickness hits a working member of the household, she/he must often withdraw from active employment and their main source of income dries up at the time when they urgently need more money for treatment.
• Sell or mortgage of assets to cover treatment costs: Households have to often sell or mortgage their productive assets, such as land and cattle, to cover the treatment costs.
• Burden of health expenditures on vulnerable populations: The poor, elderly and sick are already at a disadvantage and the burden of health expenditure makes this even worse.
• Falling into poverty due to health expenditures: This further reduces their capacity to bounce back. According to the WHO, 55 million people fall into poverty or deeper poverty every year due to catastrophic expenditures on health.

Areas where greater spending by the government could help in the immediate term

• Focus should be balanced for both communicable and noncommunicable: The National Health Mission allocates less than 3 per cent (Rs 717 crore) to non-communicable diseases (NCDs) compared to communicable diseases and reproductive and child health services, despite NCDs causing more than half of the total burden of disease and this proportion further increases in both rural as well as urban areas.
• Public health and primary health care focus on rural areas: Urban areas have poorly developed infrastructure for primary care even if secondary and tertiary health care services are better. For example, immunisation coverage is now lower in urban India than in rural India. A third of the country now lives in urban areas and greater resources are needed to improve health here.
• Health research has been neglected for too long: The allocation for the Department of Health Research in this year’s budget is Rs 2,980 crore, flat from last year. Spending Rs 20 per Indian is inconsistent with the need for innovations and technologies in the sector. The bulk of the resources provided to the Indian Council of Medical Research goes towards maintaining a large payroll of scientists and the output is poor.

Way forward

• Maximizing India’s potential: India stands on the brink of a massive opportunity. Quality education and health for the 26 million children born each year and the 65 per cent of the population under the age of 35 could help provide a workforce that would propel India forward.
• Harnessing the Demographic Dividend: India has a growing working-age population, but needs urgent action to harness the demographic dividend and potentially become a developed country within a generation.
• Adopting Competitive funding System for health research: India should adopt a competitive grant system for government-funded health research like other successful countries, to encourage top-notch research. The Wellcome Trust/DBT-India Alliance is a successful example of this system.

Conclusion

• The health (and education) of Indians is the most important determinant of what the country can achieve during the next 25 years of Amrit Kaal. We must find ways to both find more money for health, and also more health for the money to ensure that all Indians achieve their true potential.

Mains question

Q. Highlight the present status of Government’s healthcare spending. How out of pocket health expenditure affects people especially poor? Suggest what government must do and areas where it must focus in the immediate term?

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Context

• Menstrual leave is a workplace policy that allows female employees to take time off from work during their menstrual cycle due to physical discomfort or pain. This policy has been a topic of debate, with some arguing that it is necessary to accommodate the needs of women during their period, while others argue that it creates discrimination and reinforces gender stereotypes.

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Background

• Recently, Kerala government announced that the state government will grant menstrual leave for female students in all state universities under the Department of Higher Education.
• The declaration occurred shortly after the Cochin University of Science and Technology (CUSAT) announced the decision, in response to a request by the students’ union, to grant menstruation leave to all of its female students.

Menstrual leave and the debate

• Widespread conversation in recent years: The adoption of voluntary menstrual leave policies by some companies in recent years has led to a widespread conversation on periods in India.
• Termed as Special leave for women: When the Bihar government implemented a period leave policy in 1992, it was termed special leave for women due to the stigma attached to the word menstruation.
• Normalising conversation: The recent initiative by employers to provide period leave has been discussed and debated in the public sphere, thereby normalising the conversation around menstruation to an extent.

Who are menstruators?

• Menstruators is an inclusive term refers to individuals who have female reproductive anatomy and experience menstrual periods.
• It includes, women, trans men, and non-binary persons as well.
• This biological process also decouples menstruation from womanhood.

Arguments in favour

• Biological process comes with physical pain: Though menstruation is a biological process, it is accompanied by cramps, nausea, back and muscle pains, headaches, etc.
• Polycystic ovary syndrome (PCOS): Additionally, these can take a debilitating form amongst menstruating people who suffer from polycystic ovary syndrome (PCOS) and endometriosis.
• For instance: In India, 20 per cent of menstruators have PCOS and approximately 25 million suffer from endometriosis. The intensity of pain can vary for individuals for a variety of reasons.
• Acknowledges the reality: For many menstruators, it is a biological process intertwined with medical symptoms. Mandatory period leave is an affirmative action policy that acknowledges this reality.
• Kerala governments announcement is a welcome step: The Kerala government’s announcement to grant menstrual leave to all female students of state universities is a welcome move that takes the discourse a step further into educational institutions.
• It should be replicated across universities and schools in India: This will also help reduce the drop-out rates of female students from government schools in rural India caused by the lack of clean toilets, running water, sanitary pads, etc.

Arguments against

• Fear of bias in hiring: The major opposition to a menstrual leave policy is the fear of bias in hiring due to the financial costs to employers. Discriminatory hiring has been a cause of concern in many countries.
• Probable decline in women labour force participation: It is often equated to the decline in the labour force participation of women following the introduction of mandatory paid maternity leave.
• Medicalising normal biological process: Period leave is often seen as medicalising a normal biological process.

Did you know?

“Female sugarcane cutters surgically remove their uteri to secure work”

• A widely accepted menstrual health framework can also ameliorate the conditions of female workers in the unorganised sector.
• In Maharashtra’s Beed district, contractors in the sugarcane industry do not hire anyone who menstruates.
• More than 10,000 female sugarcane cutters have had to surgically remove their uteri to secure work.
• Most of them are in their twenties and thirties, and now experience various post-surgery health complications. Such exploitation is a human rights violation.

Way ahead

• Need to bridge the gaps: The path to equality does not lie in inaction due to fear of further discrimination. What is needed is a holistic outlook aimed at bridging existing gaps.
• Comprehensive and inclusive approach is must: The implementation of menstrual leave should be based on a comprehensive and inclusive approach that takes into account the needs and rights of all employees, regardless of gender.
• Mandatory self-care leaves as an alternative: Employers should be made to introduce a mandatory self-care leave as an alternative to period leaves for those who cannot avail of the latter. Employees should be able to utilise their self-care leave as they deem fit. This will reduce burnout and increase productivity.
• Self-care leave will also destigmatise menstruation: The names menstrual leave and self-care leave will also destigmatise menstruation and self-care respectively. Further, employers should be made to implement a stringent diversity, equity, and inclusion (DEI) framework.
• Safeguards menstruators in unorganized sector: A formal menstrual leave policy in the organized sector can act as a catalyst in safeguarding menstruators in the unorganized sector too.

Conclusion

• Menstrual health is a public health issue. Considering the sizable population of menstruators in India who face stigma, period leave cannot be dismissed anymore as a foreign concept. It is a pivotal step in ensuring proper reproductive health equity in India.

Mains question.

Q. The topic of Menstrual leave is in the headlines for some time now. Anaalyse the dabate

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Context

• Suicides rates in India are amongst the highest when compared to other countries at the same socio-economic level. According to WHO, India’s suicide rate in 2019, at 12.9/1,00,000, was higher than the regional average of 10.2 and the global average of 9.0. Suicide has become the leading cause of death among those aged 15–29 in India.

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Background: Mental Health

• While every precious life lost through suicide is one too many, it represents only the tip of the mental health iceberg in the country, particularly among young adults. Women tend to suffer more.
• Across the world, the prevalence of some mental health disorders is consistently higher among women as compared to men.

Prevalence of Mental ill-health

• The pandemic has further exacerbated the problem: Globally, it might have increased the prevalence of depression by 28 per cent and anxiety by 26 per cent in just one year between 2020 and 2021, according to a study published in Lancet.
• Increased among younger age groups: Again, the large increases have been noted among younger age groups, stemming from uncertainty and fear about the virus, financial and job losses, grief, increased childcare burdens, in addition to school closures and social isolation.
• Use of social media exacerbating the stress: Increased use of certain kinds of social media is also exacerbating stress for young people. Social media detracts from face-to-face relationships, which are healthier, and reduces investment in meaningful activities. More importantly, it erodes self-esteem through unfavourable social comparison.

Socio-economic implications of Mental ill-health

• People living in poverty are at greater risks: Mental ill health is a leading cause of disability globally and is closely linked to poverty in a vicious cycle of disadvantage. People living in poverty are at greater risk of experiencing such conditions.
• People experiencing mental health problems likely to fall in poverty: On the other hand, people experiencing severe mental health conditions are more likely to fall into poverty through loss of employment and increased health expenditure.
• Stigma and discrimination: Stigma and discrimination often further undermine their social support structures. This reinforces the vicious cycle of poverty and mental ill-health.
• Higher income inequality has high prevalence of ill mental ill health: Not surprisingly, countries with greater income inequalities and social polarization have been found to have a higher prevalence.

Approach to protect, promote and care for the mental health of people?

• Killing the deep stigma surrounding mental health issues: The first step should be killing the deep stigma which prevents patients from seeking timely treatment and makes them feel shameful, isolated and weak. Stigma festers in the dark and scatters in the light. We need a mission to cut through this darkness and shine a light.
• Making Mental health an integral part of public health programme: There is need to make mental health an integral part of the public health programme to reduce stress, promote a healthy lifestyle, screen and identify high-risk groups and strengthen interventions like counselling services. Special emphasis will need to be given to schools.
• Paying attention to highly vulnerable: In addition, we should pay special attention to groups that are highly vulnerable because of the issues such as victims of domestic or sexual violence, unemployed youth, marginal farmers, armed forces personnel and personnel working under difficult conditions.
• Creating a strong infrastructure for mental health care and treatment: Lack of effective treatment and stigma feed into each other. Currently, only 20-30 per cent of people with such disorders receive adequate treatment.
• Mental health services should be made affordable for all: Improved coverage without corresponding financial protection will lead to inequitable service uptake and outcomes. All government health assurance schemes, including Ayushman Bharat, should cover the widest possible range.

Why is the wide treatment gap?

• One major reason for a wide treatment gap is the problem of inadequate resources.
• Less than two per cent of the government health budget, which itself is the lowest among all G20 countries, is devoted to mental health issues.
• There is a severe shortage of professionals, with the number of psychiatrists in the country being less than those in New York City, according to one estimate.
• Substantial investments will be needed to address the gaps in the health infrastructure and human resources.
• Currently, most private health insurance covers only a restricted number of mental health conditions. Similarly, the list of essential medicines includes only a limited number of WHO-prescribed medications.

Conclusion

• We need an urgent and well-resourced whole of society approach to protecting, promoting and caring for the mental health of our people, like we did for the Covid pandemic. Brock Chisholm, the first Director General of WHO, famously said, “there is no health without mental health”.

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