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Subject: Governance

Important aspects of Society

  • Making the private sector care for public health

    Context

    As India enters the second week of a national lockdown imposed in response to COVID-19, it is still unclear how well prepared the healthcare system is in dealing with the pandemic.

    Need for roping in the private healthcare

    • No indication of an increase in expenditure on health: A preparedness plan has to address all levels of care in terms of infrastructure, equipment, testing facilities and human resources in both the public and private sectors.
    • However, so far, the Central and State governments have given little indication of bringing an increase in public expenditure on health.
    • So, an already overburdened public health system will be unable to meet the increase in moderate and severe cases of COVID-19 that would require hospitalisation.
    • Need for the comprehensive national policy: While some individual private sector companies have come forward with offers of creating capacity and making it available to COVID-19 patients, there is a need for a comprehensive national policy to ensure that private healthcare capacity is made available to the public.
    • Some states like Chhattisgarh, Rajasthan, Madhya Pradesh and Andhra Pradesh have already roped in the private sector to provide free treatment.

    What the government should do?       

    • Provide universal health service: The governments at the Centre and in States have to take responsibility for providing universal health services free of charge and accessible to all.
    • Tap into private sector capacity: This will require governments to not just expand the capacity within the public sector, but also to tap into the available capacity in the private sector.
    • Faced with a serious health emergency, the silence of the government on the expected role of the private sector is intriguing.
    • Include COVID-19 testing in PM-JAY: The National Health Authority has recommended that the testing and treatment of COVID-19 be included in the PM-Jan Arogya Yojana (PM-JAY) but this proposal is still awaiting clearance.
    • Form the central command: The governance of the health service system is clearly fragmented and has created anxiety among the public.
    • There is a lack of a visible central command, which should be created under the supervision of the Union Health Minister, aided by a team of experts.
    • They should be tasked to make policies as and when required and communicate them to State governments, taking into account an evolving situation.
    • Ensure that there is no cost to the patient: There have been some tentative measures taken by States to allow individuals seeking testing for COVID-19 to access private laboratories at subsidised rates.
    • At present, the government has put a cap on the cost at â‚č4,500 per test, which is a burden for even a middle-class patient.
    • The poor will clearly have no access to this and the government itself does not have adequate facilities to meet the increasing demand. It is here that the government needs to ensure that there is no cost to the patient.
    • Create adequate testing facilities: At this point, and certainly, before the lockdown is lifted, it is absolutely essential that adequate testing and quarantine facilities are created.
    • The Central government has already taken over some private hotels to accommodate persons quarantined for COVID-19.
    • One way of expanding such facilities would be for the government to ‘take over’ private corporate laboratories and hospitals for a limited period.
    • Standard treatment protocol: The political directive for such a move needs to come from the Central government while ensuring that the Ministry of Health provides standard treatment protocols for health personnel.

    Learning lessons from Spanish and British experience

    • The Spanish government issued an order bringing hospitals in the large private corporate sector under public control for a limited period.
    • This tough decision was taken with the understanding that existing public healthcare facilities would not be able to cope with the sudden, if short-term, rise in COVID-19 cases.
    • British trade unions have demanded that the government make the 8,000 beds in 570 private hospitals in the country available.
    • They have argued that while beds in private hospitals are lying empty, there is a severe shortage of beds in public hospitals.
    • The unions have also been critical of the U.K. government decision to rent these beds at an exorbitant cost to the exchequer.

    Way forward

    • Rope in the private healthcare sector: In India, private corporate hospitals have, in the past, received government subsidies in various forms and it is now time to seek repayment from them.
    • They are also well poised to provide specialised care and have the expertise and infrastructure to do so.
    • Bring in the universal public healthcare: Universal public healthcare is essential not only to curb outbreaks but also to ensure crisis preparedness and the realisation of the promise of the right to health.

  • BCG vaccine

    According to a  US-based research, a combination of reduced morbidity and mortality could make the Bacillus Calmette-Guerin (BCG) vaccination a “game-changer” in the fight against novel coronavirus.

    What is BCG Vaccine?

    • Bacillus Calmette–GuĂ©rin (BCG) vaccine is a vaccine primarily used against tuberculosis (TB).
    • In countries where TB or leprosy is common, one dose is recommended in healthy babies as close to the time of birth as possible.
    • In areas where tuberculosis is not common, only children at high risk are typically immunized, while suspected cases of tuberculosis are individually tested for and treated.

    How can TB vaccine help fight COVID-19?

    • The BCG vaccine contains a live but weakened strain of tuberculosis bacteria that provokes the body to develop antibodies to attack TB bacteria.
    • This is called an adaptive immune response, because the body develops a defense against a specific disease-causing microorganism, or pathogen, after encountering it.
    • Most vaccines create an adaptive immune response to a single pathogen.
    • Unlike other vaccines, the BCG vaccine may also boost the innate immune system, first-line defenses that keep a variety of pathogens from entering the body or from establishing an infection.

  • Telemedicine/Telehealth as a tool to fight COVID-19

     

    The Medical Council of India and the NITI Aayog have developed new guidelines released on March 25, 2020 for registered medical practitioners to deliver consultations to patients via telemedicine.

    Telemedicine

    • Telemedicine involves the use of telecom and virtual technology to deliver health care outside of traditional health-care facilities.
    • It is the essential delivery of health care services where distance is a critical factor — comes in.
    • At least one doctor is needed for a population of 1,000, according to WHO guidelines.
    • Telemedicine, thus, holds significance for countries like India that have low doctor-to-patient ratios.

    About the guidelines

    • The guidelines aim to empower registered doctors to reach out to patients safely using technologies for the exchange of valid information.
    • This information can be used for diagnosis, treatment and prevention of disease and injuries, research and evaluation and for continuing the education of healthcare providers.
    • The guidelines have empowered medical practitioners. They have, however, also imposed many restrictions.
    • Registered medical practitioners, for instance, have to take the patient’s consent.
    • If the patient denies her consent, however, the practitioner cannot insist that the patient to go in for telemedicine.

    How telemedicine can help against COVID-19?

    • Telemedicine can help bridging the gap between people, physicians and health systems, enabling everyone, especially symptomatic patients, to stay at home and communicate with physicians through virtual channels.
    • It thus helps reducing the spread of the virus to mass populations and the medical staff on the frontlines.
    • It can help provide routine care for patients with chronic diseases who are at high risk if exposed to the virus.

    Limitations

    • The out-of-hospital management is has not been yet established in India. Perhaps a ‘crisis-based’ evolution of telemedicine can help find local testing centers and also manage the flow of patients seeking a test.
    • However, for a smaller subset of higher risk patients, the clinical course may not be consistent with conventional telemedicine.
    • These patients often present with a more serious condition require rapid hospitalization.
    • Telemedicine hasn’t traditionally been used in response to public health crises. Many health practitioners are not equipped to deliver care in this way.
    • Another issue is access to broadband – some hospitals struggle with running a quality connection within their facilities and now we are faced with taking this to potential new areas of care, such as an outside tent.

  • Price Monitoring and Resource Unit (PMRU)

    The National Pharmaceutical Pricing Authority (NPPA) has set up price monitoring and resource unit (PMRU) in the UT of Jammu and Kashmir. With this J&K has become the 12th State/UT where the PMRU has been set up.

    Price Monitoring and Research Unit (PMRU)

    • It is a registered society set up for drug price monitoring.
    • PMRUs have already been set up by the drug price regulator NPPA in 11 states such as Kerala, Odisha, Gujarat, Rajasthan, Punjab, Haryana, Nagaland, Tripura, Uttar Pradesh, Andhra Pradesh and Mizoram.

    Its composition

    • The State Health Secretary would be the Chairman of the society and the Drugs Controller would be its member secretary.
    • Its members include a State government representative, representatives of private pharmaceutical companies, and those from consumer rights protection fora.
    • The society would also have an executive committee headed by the Drugs Controller.

    Terms of reference

    PMRU offers technical help to the State Drug Controllers and the NPPA to:

    • Monitor notified prices of medicines
    • Detect violation of the provisions of the DPCO
    • Look at price compliance
    • Collect test samples of medicines, and
    • Collect and compile market-based data of scheduled as well as non-scheduled formulations.

    Why need PMRU?

    • Pharma companies have been accused of overcharging prices of drugs in the scheduled category fixed by the DPCO and those outside its ambit too.
    • The suggestion to set up PMRUs was made against the backdrop of the lack of a field-level link between the NPPA and the State Drugs Controllers and State Drug Inspectors to monitor drug prices.

    Expected outcomes

    • The NPPA had fixed the prices of around 1,000 drugs and the unit would track if buyers were being overcharged.
    • It would also check if pharma companies were hiking the prices of non-scheduled drugs by more than 10% a year.
    • It will check if there is any shortage of essential medicines.

  • [pib] ArogyaSetu App

     

    The Government of India has launched a mobile app ArogyaSetu developed in a public-private partnership to bring the people of India together in a resolute fight against COVID-19.

    AarogyaSetu App

    • The App enables people to assess themselves the risk of their catching the Corona Virus infection.
    • It will calculate this based on their interaction with others, using cutting edge Bluetooth technology, algorithms and artificial intelligence.
    • Once installed in a smartphone through an easy and user-friendly process, the app detects other devices with AarogyaSetu installed that come in the proximity of that phone.
    • The app can then calculate the risk of infection based on sophisticated parameters if any of these contacts has tested positive.
    • The personal data collected by the App is encrypted using state-of-the-art technology and stays secure on the phone till it is needed for facilitating medical intervention.

  • A pandemic in an unequal India

    Context

    The official strategies to deal with the virus place the responsibility on citizens, a majority without privilege, to fight the virus.

    The poor disproportionately affected

    • If the COVID-19 pandemic lashes India with severity, it will not be just the middle class who will be affected.
    • India’s impoverished millions are likely to overwhelmingly bear the brunt of the suffering which will ensue.
    • Inequality and impact of a pandemic: The privileged Indian has been comfortable for too long with some of the most unconscionable inequalities in the planet.
    • But with the pandemic, each of these fractures can decimate the survival probabilities and fragile livelihoods of the poor.

    Inadequate capacity of the health system  

    • Low investment in public health: India’s investments in public health are among the lowest in the world, and most cities lack any kind of public primary health services.
    • A Jan Swasthya Abhiyan estimate is that a district hospital serving a population of two million may have to serve 20,000 patients, but they are bereft of the beds, personnel and resources to do this. Few have a single ventilator.
    • The poor left with meagre services: India’s rich and middle-classes have opted out of public health completely, leaving the poor with unconscionably meagre services.
    • The irony is that a pandemic has been brought into India by people who can afford plane tickets, but while they will buy private health services, the virus will devastate the poor who they infect and who have little access to health care.

    No planning and preparation by the state

    • Official strategies placing responsibility on citizens: Most of the official strategies place the responsibility on the citizen, rather than the state, to fight the pandemic.
    • No preparation by the states: The state did too little in the months it got before the pandemic reached India for expanding greatly its health infrastructure for testing and treatment.
    • This includes planning operations for food and work; security for the poor; for safe transportation of the poor to their homes; and for special protection for the aged, the disabled, children without care and the destitute.

    What must be done?

    • 25 day’s minimum wage: For two months, every household in the informal economy, rural and urban, should be given the equivalent of 25 days’ minimum wages a month until the lockdown continues, and for two months beyond this.
    • Pensions must be doubled and home-delivered in cash.
    • There should be free water tankers supplying water in slum shanties throughout the working days.
    • Double the PDS entitlement: Governments must double PDS entitlements, which includes protein-rich pulses, and distribute these free at doorsteps.
    • Provide cooked and packed food: In addition, for homeless children and adults, and single migrants, it is urgent to supply cooked food to all who seek it, and to deliver packed food to the aged and the disabled in their homes using the services of community youth volunteers.
    • Ensure prisons are safe: To ensure jails are safer, all prison undertrial prisoners, except those charged with the gravest crimes, should be released.
    • Likewise, all those convicted for petty crimes. All residents of beggars’ homes, women’s rescue centres and detention centres should be freed forthwith.

    Way forward

    • Commit 3% of GDP on health: India must immediately commit 3% of its GDP for public spending on health services, with the focus on free and universal primary and secondary health care.
    • Nationalise private healthcare: Since the need is immediate, authorities should follow the example of Spain and New Zealand and nationalise private health care.
    • An ordinance should be passed immediately that no patient should be turned away or charged in any private hospital for diagnosis or treatment of symptoms which could be of COVID-19.

    Conclusion

    While one part of the population enjoys work and nutritional security, health insurance and housing of globally acceptable standards, others survive at the edge of unprotected and uncertain work, abysmal housing without clean water and sanitation, and no assured public health care. Can we resolve to correct this in post-COVID India? Can we at least now make the country more kind, just and equal?

  • Lock, don’t shut

    Context

    Economy is a living machine — cannot be simply turned off and on. Even in lockdown, it needs to be kept alive.

    Movement of goods exempted

    • Essential and non-essential distinction removed: It is, welcome that the Centre has now exempted transportation of all goods from the lockdown’s provisions, without distinction of “essential” and “non-essential”.
    • When goods aren’t the culprit — it didn’t make sense, in any case, to allow bureaucrats and local authorities to decide what is essential and hold up trucks carrying material deemed non-essential.
    • One cannot expect officials or state border police to have intimate knowledge of production processes and inputs that go into every good, essential or otherwise.
    • The purpose of a lockdown is to minimise physical human interaction and maintain social distancing even if people have to meet.
    • Blocking movement of goods, far from achieving that objective, only results in overcrowding and snarls at check posts.

    How allowing Industrial establishment to operate matters?

    • Allowing industrial establishment to operate: There’s no reason why even industrial establishments cannot be permitted to run during the lockdown.
    • Again, it shouldn’t matter whether these units are producing essential or non-essential goods. What matters is only social distancing.
    • Right step by the Punjab government: The Punjab government has taken the right step of permitting all factories in the state to resume operations, subject to their being able to provide in-house lodging, food and medical facilities to workers and ensure no overcrowding at the plant.
    • Mass exodus could have been avoided: Most factories today, whether in Punjab, Haryana and Delhi or Maharashtra, Gujarat and Tamil Nadu, are manned by migrant labourers from Bihar, Uttar Pradesh and other eastern states.
    • Had measures to retain this workforce within or close to the premises of factories been in place — instead of a blanket order to shut down — the current situation of a mass exodus of labourers and the attendant risk of COVID-19 transmission may have been avoided.
    • Difficulty in getting the labour back: It isn’t going to be easy for the closed units to get this labour back even when the lockdown ends.

    Conclusion

    • The economy needs to be kept alive: An economy is ultimately a living machine — one that cannot simply be turned off and on. Even in lockdown, it needs to be kept alive and whirring.
    • Difficulty in resumption: The danger from mechanically ordered closure of activities is that resumption becomes difficult. Rebuilding broken supply chains is easier when things are allowed to run even if at low key so that the system can respond when demand returns.
    • Lockdown is not an end in itself: Combating COVID-19 should obviously be the government’s top priority now. Lockdown is a necessary part of that strategy, but cannot be an end in itself. It is necessary primarily for social distancing, which can also be achieved without bringing the wheels of commerce to a complete halt.

  • 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.

  • 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.

  • PM-CARES Fund

    Our PM has called for donations to the newly instituted PM-CARES Fund which has been formed on popular demand to help fight the novel coronavirus.

    PM-CARES Fund

    • The fund will be a public charitable trust under the name of ‘Prime Minister’s Citizen Assistance and Relief in Emergency Situations Fund’.
    • The PM is Chairman of this trust and members include the Defence Minister, Home Minister and Finance Minister.
    • Contributions to the fund will qualify as corporate social responsibility (CSR) spending that companies are mandated to make.
    • The Fund accepts micro-donations as well.