Subject: Health

Central idea: The National Health Account Estimates 2019-20 report shows an increase in government spending and a decline in out-of-pocket expenditure on healthcare.

About National Health Account (NHA) estimates

• The NHA estimates for India 2019-20 is the seventh consecutive report prepared by the National Health Systems Resource Centre (NHSRC).
• NHSRC was designated as National Health Accounts Technical Secretariat (NHATS) in 2014 by the Union Health Ministry.
• The NHA estimates use an accounting framework based on the internationally accepted standard of System of Health Accounts, 2011 developed by the WHO.
• India now has a continuous series of NHA estimates from 2013-14 to 2019-20, making the estimates comparable internationally.
• The estimates enable policymakers to monitor progress in different health financing indicators of the country.

Key highlights

	Description
Government spending as % of GDP	Increased from 1.13% (FY 2015) to 1.35% (FY 2020) Per capita health spending of the government has also increased from Rs 1,108 in FY 2015 to Rs 2,014 in FY 2020. Govt share in total healthcare spending has increased from 29% in 2015 to 41.4% in 2020
Declining out-of-pocket expenditure	Proportion of total healthcare spending that comes from people’s pockets has decreased from 62.6% in 2015 to 47.1% in 2020 Govt aims to further reduce out-of-pocket expenditure by investing in public health and insurance To reduce the financial burden of healthcare on individuals and increase the utilization of healthcare services
Government spending on primary healthcare	Increased from 51.3% in 2015 to 55.9% in 2020. Govt. invested in creating 1.5 lakh health and wellness centres that can screen people for cancers, diabetes, and eye disease.
Increase in social security expenditure	Increased from 5.7% of total healthcare spending in 2015 to 9.3% in 2020. Suggests that the government is investing more in social welfare programs.
Increase in spending on insurance	Privately purchased health insurance increased from 3.9% of total health expenditure in 2015 to 7.72% in 2020 Govt. financed health insurance spending also went up from 3.8% in 2015 to 6.37% in 2020
Health spending by states	Only two big states and three smaller ones have crossed the target of 8% of their budget going towards healthcare as set by the National Health Policy 2017.

 

Key issues

• Marginal increase: Activists are concerned about the marginal increase in government spending.
• Global laggard: This increase in government health expenditure as a percentage of GDP also takes into account capital spending, which puts India in 164th place out of 184 countries in terms of government health spending.
• No proportional increase: Total spending on health as a proportion of GDP has been going down, from 3.9% in 2015 to 3.3% in 2020, indicating a decline in consumption of healthcare services.

Conclusion

• Overall, the report shows that government spending on healthcare has been increasing, while out-of-pocket expenditure has been declining.
• There is a need to invest in public health and insurance and increase the contribution of states towards healthcare.

 

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Malaria is all set to become a notifiable disease across India, which will require cases to be reported to government authorities by law.

About Malaria

	Description
Definition	A potentially life-threatening disease caused by parasites that are transmitted through the bite of infected female Anopheles mosquitoes
Causes	Four species of plasmodium parasites, namely plasmodium vivax, plasmodium falciparum, plasmodium malariae, and plasmodium ovale
Spread	Bite of infected female Anopheles mosquitoes
Symptoms	Fever, chills, headache, muscle pain, fatigue, nausea, vomiting
Diagnosis	Blood test
Treatment	Antimalarial drugs
Prevention	Insecticide-treated bed nets, indoor residual spraying, wearing protective clothing, using mosquito repellent, avoiding mosquito bites
Vaccine	RTS,S/AS01 (Mosquirix)

 

Why in news?

• The move is part of India’s vision to become malaria-free by 2027 and to eliminate the disease by 2030.

Menace of malaria in India

• In India, 80% of malaria cases occur among 20% of its population living in the 200 high-risk districts of Andhra Pradesh, Chhattisgarh, Gujarat, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Odisha, West Bengal and the seven north-eastern states.
• With only fewer than half of those infected reaching a clinic or hospital, the cases and deaths are much higher than recorded.

What is Notifiable Disease?

• A notifiable disease is a disease that is required by law to be reported to government authorities.
• In India, the Ministry of Health and Family Welfare maintains a list of notifiable diseases under the National Health Mission.
• This is done to track the spread of the disease and to take necessary measures to control and prevent its spread.
• Reporting notifiable diseases is important for public health surveillance and response to outbreaks.

Malaria as a Notifiable Disease

• Malaria is currently a notifiable disease in 33 states and Union Territories in India.
• Bihar, Andaman and Nicobar Islands, and Meghalaya are in the process of putting malaria in the notifiable disease category.

Other measures to curb malaria

• Malaria Elimination Programme: The government has launched the National Framework for Malaria Elimination in India 2016-2030 to eliminate malaria from the country by 2030.
• Joint Action Plan: The Health Ministry has initiated a joint action plan with the Ministry of Tribal Affairs for malaria elimination in tribal areas. This plan aims to bring down malaria cases to zero in tribal areas, which are among the most vulnerable to the disease.
• HIP-Malaria Portal: The Ministry has ensured the availability of near-real-time data monitoring through an integrated health information platform and periodic regional review meetings to keep a check on malaria growth across India.

Vaccines developed so far

• The WHO has approved the rollout of two first-generation malaria vaccines, RTS,S and R21, in high-transmission African countries.
• Bharat Biotech, an Indian company, has been licensed to manufacture the RTS,S vaccine, with adjuvant provided by GSK.
• The R21 vaccine, developed by scientists at Oxford University, has shown promising results in phase 2 clinical studies and has been approved by regulatory authorities in Ghana and Nigeria.
• Scientists at the International Centre for Genetic Engineering and Biotechnology (ICGEB) in New Delhi have developed and produced two experimental blood-stage malaria vaccines, with Phase I clinical trials completed for one of them.

 

 

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Central idea: The Centre has exempted all drugs and food for special medical purposes, imported for personal use, for the treatment of rare diseases listed under the National Policy for Rare Diseases 2021 from basic customs duty.

What are Rare Diseases?

• Rare diseases are those medical conditions that affect a small percentage of the population.
• In India, a disease is considered rare if it affects less than 1 in 2,000 people.
• These diseases are often genetic and are chronic, degenerative, and life-threatening.
• There are over 7,000 known rare diseases, and it is estimated that about 70 million people in India are affected by them.
• Many of these diseases do not have a cure, and the treatment can be expensive and difficult to access.

Need for duty exemption

• This decision has been taken to help reduce the burden of the cost of treatment for patients and families.
• The drugs and food required for the treatment of these rare diseases are often expensive and need to be imported.
• This exemption will result in substantial cost savings and provide much-needed relief to patients with rare diseases.

Key medicines under this exemption

• The central government has fully exempted Pembrolizumab (Keytruda), a drug used in the treatment of various types of cancer, from basic customs duty.
• Previously, the GST rate for Keytruda was cut to 5 per cent from 12 per cent in a meeting held in September 2021 by the GST Council.
• Life-saving drugs Zolgensma and Viltepso used in the treatment of spinal muscular atrophy were exempted from GST when imported for personal use.

How the new duty exemption works?

• The exemption has been granted by the Central Board of Indirect Taxes and Customs (CBIC) by substituting “Drugs, Medicines or Food for Special Medical Purposes (FSMP)” instead of “drugs or medicines”.
• To avail of this exemption, the individual importer has to produce a certificate from the central or state director health services or district medical officer/civil surgeon of the district.

How are life-saving medicines taxed?

• Drugs/medicines generally attract basic customs duty of 10 per cent, while some categories of lifesaving drugs/vaccines attract a concessional rate of 5 per cent or nil.
• In its meeting in September 2021, the GST Council had reduced tax rates for several life-saving drugs.

 

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The Indian Council of Medical Research (ICMR) has recently released the first-ever set of ethical guidelines for the application of artificial intelligence (AI) in biomedical research and healthcare.

Ethical Guidelines for AI usage in Healthcare

• The guidelines aim to create “an ethics framework which can assist in the development, deployment, and adoption of AI-based solutions” in specific fields.
• Through this initiative, the ICMR aims to make “AI-assisted platforms available for the benefit of the largest section of common people with safety and highest precision possible”.
• It seeks to address emerging ethical challenges when it comes to AI in biomedical research and healthcare delivery.

Key features

• Effective and safe development, deployment, and adoption of AI-based technologies: The guidelines provide an ethical framework that can assist in the development, deployment, and adoption of AI-based solutions in healthcare and biomedical research.
• Accountability in case of errors: As AI technologies are further developed and applied in clinical decision making, the guidelines call for processes that discuss accountability in case of errors for safeguarding and protection.
• Patient-centric ethical principles: The guidelines outline 10 key patient-centric ethical principles for AI application in the health sector, including accountability and liability, autonomy, data privacy, collaboration, risk minimisation and safety, accessibility and equity, optimisation of data quality, non-discrimination and fairness, validity and trustworthiness.
• Human oversight: The autonomy principle ensures human oversight of the functioning and performance of the AI system.
• Consent and informed decision making: The guidelines call for the attainment of consent of the patient who must also be informed of the physical, psychological and social risks involved before initiating any process.
• Safety and risk minimisation: The safety and risk minimisation principle is aimed at preventing “unintended or deliberate misuse”, anonymised data delinked from global technology to avoid cyber attacks, and a favourable benefit-risk assessment by an ethical committee among a host of other areas.
• Accessibility, equity and inclusiveness: The guidelines acknowledge that the deployment of AI technology assumes widespread availability of appropriate infrastructure and thus aims to bridge the digital divide.
• Relevant stakeholder involvement: The guidelines outline a brief for relevant stakeholders including researchers, clinicians/hospitals/public health system, patients, ethics committee, government regulators, and the industry.
• Standard practices: The guidelines call for each step of the development process to follow standard practices to make the AI-based solutions technically sound, ethically justified, and applicable to a large number of individuals with equity and fairness.
• Ethical review process: The ethical review process for AI in health comes under the domain of the ethics committee which assesses several factors including data source, quality, safety, anonymization, and/or data piracy, data selection biases, participant protection, payment of compensation, possibility of stigmatisation among others.

Policy moves for streamlining AI in Healthcare

• India already offers streamlining of AI technologies in various sectors, including healthcare, through the National Health Policy (2017), National Digital Health Blueprint (NDHB 2019), and Digital Information Security in Healthcare Act (2018) proposed by the Health Ministry.
• These initiatives pave the way for the establishment of the National Data Health Authority and other health information exchanges.

Potential applications of AI in healthcare

Artificial Intelligence (AI) has revolutionized the healthcare industry by enabling various applications. These applications include:

• Diagnosis and screening: AI can be used to identify diseases from medical images like X-rays, CT scans, and MRIs.
• Therapeutics: AI can assist in the development of personalised medicines by analyzing a patient’s genetic makeup.
• Preventive treatments: AI can predict the risk of developing a disease, helping healthcare professionals to take preventive measures.
• Clinical decision-making: AI can analyze large amounts of data to assist healthcare professionals in making treatment decisions.
• Public health surveillance: AI can be used to monitor disease outbreaks and inform public health policies.
• Complex data analysis: AI can analyze large amounts of data from multiple sources to identify patterns and inform healthcare decision-making.
• Predicting disease outcomes: AI can predict disease outcomes based on patient data, enabling early
• Behavioural and mental healthcare: AI can help diagnose and treat mental health conditions.
• Health management systems: AI can assist in managing patient records, appointment scheduling and reminders, and medication management.

Various challenges for imbibing

• Data privacy and security: With the use of AI in healthcare, there is a significant amount of personal and sensitive data is collected. This data needs to be kept secure and protected from potential cyber-attacks.
• Regulatory and ethical issues: AI technology is still in its early stages of development and there are no clear guidelines or regulations in place for its use in healthcare. There are also ethical considerations, such as accountability, transparency, and bias that need to be addressed.
• High cost involved: The implementation of AI in healthcare requires significant investment in terms of infrastructure, software, and training. This cost can be a major challenge for healthcare organizations, especially in developing countries.
• Integration with existing systems: AI systems need to be integrated with existing healthcare systems and processes. This can be challenging, especially in cases where the existing systems are outdated or incompatible with AI technology.
• Lack of trust and acceptance: AI technology is still relatively new in healthcare and there is a lack of trust and acceptance among healthcare professionals and patients. This can be a major hurdle in the widespread adoption of AI in healthcare.

Threats posed by AI to healthcare

• Data privacy and security: The use of AI in healthcare requires the collection and analysis of vast amounts of personal health data, which could be at risk of being stolen or misused.
• Bias and discrimination: There is a risk that AI algorithms could perpetuate existing biases and inequalities in healthcare, such as racial or gender bias.
• Lack of transparency: Some AI models are complex and difficult to understand, which can make it difficult to explain the reasoning behind a particular decision.
• Medical errors: AI systems can make errors if they are trained on biased or incomplete data, or if they are used inappropriately.
• Ethical concerns: There are several ethical concerns associated with the use of AI in healthcare, including the potential for AI to replace human doctors, the impact on patient autonomy, and the implications for informed consent.

Way forward

• Develop a national AI strategy for healthcare: This strategy should include policies for data sharing, privacy, and security, as well as guidelines for the ethical and responsible use of AI.
• Invest in AI research and development: The government should invest in research and development of AI technologies that can help address the challenges in healthcare.
• Promote collaboration between stakeholders: Collaboration between stakeholders such as healthcare providers, researchers, government agencies, and industry can help accelerate the development and adoption of AI technologies in healthcare.
• Train healthcare professionals in AI: The government can work with academic institutions and the industry to create training programs and certifications for healthcare professionals.
• Address regulatory challenges: The government should work to address regulatory challenges related to the use of AI in healthcare.
• Focus on affordability and accessibility: This can be achieved by promoting innovation, encouraging competition, and ensuring that AI technologies are integrated into existing healthcare infrastructure.

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The Rajasthan Assembly passed the Right to Health (RTH), even as doctors continued their protest against the Bill, demanding its complete withdrawal.

Right to Health (RTH): A conceptual insight

• RTH is a fundamental human right that guarantees everyone the right to enjoy the highest attainable standard of physical and mental health.
• It is recognized as a crucial element of the right to an adequate standard of living and is enshrined in international human rights law.

Scope of RTH

• RTH covers various health-related issues, including-

1. Access to healthcare services, clean water and sanitation, adequate nutrition, healthy living and working conditions, health education, and disease prevention.
2. Accessible, affordable, and quality healthcare services,
3. Eliminating barriers to healthcare access
4. Informed consent to medical treatment and accessing information about their health.

What is the Rajasthan Right to Health Bill?

• Free treatment: RTH gives every resident of the state the right to avail free Out Patient Department (OPD) services and In Patient Department (IPD) services at all public health facilities and select private facilities.
• Wider scope of healthcare: Free healthcare services will include consultation, drugs, diagnostics, emergency transport, procedures, and emergency care. However, there are conditions specified in the rules that will be formulated.
• Free emergency treatment: Residents are entitled to emergency treatment and care without prepayment of fees or charges.
• No delay in treatment: Hospitals cannot delay treatment on grounds of police clearance in medico-legal cases.
• State reimbursement of charges: After emergency care and stabilisation, if patients do not pay requisite charges, healthcare providers can receive proper reimbursement from the state government.

Existing schemes in Rajasthan

• The flagship Chiranjeevi Health Insurance Scheme provides free treatment up to Rs 10 lakh, which has been increased to Rs 25 lakh in the latest budget.
• The Rajasthan Government Health Scheme covers government employees, ministers, current and former MLAs, etc.
• The Nishulk Nirogi Rajasthan scheme provides free OPD and IPD services in government hospitals and covers about 1,600 medicines, 928 surgicals, and 185 sutures.
• The Free Test scheme provides up to 90 free tests in government hospitals and has benefited 2.93 crore persons between March-December 2022.

Need for the RTH Scheme

• The state prioritizes healthcare and wants Rajasthan to be a great example of good health.
• The Health Minister has received many complaints about private hospitals asking for money from patients who have the Chiranjeevi card.
• So, they are bringing in a new law to stop this.
• The new law will make sure that future governments follow it and provide free healthcare to everyone.

Controversy with the RTH Law: Emergency Care Provisions

• Emergency care was a contentious issue in the RTH.
• The clause states that people have the right to emergency treatment and care for accidental emergency, emergency due to snake bite/animal bite and any other emergency decided by the State Health Authority under prescribed emergency circumstances.
• Emergency treatment and care can be availed without prepayment of requisite fee or charges.
• Public or private health institutions qualified to provide such care or treatment according to their level of health care can offer emergency care.

Issues raised by healthcare professionals

• Existing burden of schemes: Doctors are protesting against the RTH because they question the need for it when there are already schemes like Chiranjeevi that cover most of the population.
• Specialization concerns: They are also objecting to certain clauses, such as defining “emergency” and being compelled to treat patients outside their specialty as part of an emergency.
• Unnecessary obligations: The Bill empowers patients to choose the source of obtaining medicines or tests at all healthcare establishments, which means that hospitals cannot insist on in-house medicines or tests.

Way forward

• Given the contentious nature of the Bill, it is important for all stakeholders to come to the table and engage in constructive dialogue to resolve the issues at hand.
• It should involve liaison between government, doctors, patient advocacy groups, and other relevant stakeholders to discuss the concerns raised by all parties and identify potential solutions.
• This could be followed by a revision of the Bill, incorporating feedback and suggestions from all stakeholders, and a renewed effort to build consensus and support for the legislation.
• Additionally, greater efforts could be made to improve transparency and accountability in the healthcare system, with a focus on educating patients about their rights.

 

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Tamil Nadu has pioneered an initiative across the State to reduce the mortality rate among people with tuberculosis named: TN-KET (Tamil Nadu Kasanoi Erappila Thittam) meaning TB death-free project.

What is TN-KET?

• TN-KET aims to reduce the mortality rate among people with tuberculosis.
• This initiative, which began in April 2022, has already achieved significant reduction in the number of early TB deaths.

Unique features

• Differentiated TB Care: This is at the heart of the initiative, which aims at assessing whether people with TB need ambulatory care or admission in a health facility to manage severe illness at the time of diagnosis.
• Radiological assessment: The guidelines require comprehensive assessment of 16 clinical, laboratory and radiological parameters.
• Triage of assessment: The preliminary assessment of patients based on just three conditions — very severe undernutrition, respiratory insufficiency, and inability to stand without support — was found to be feasible for quick identification at diagnosis.

Outcome: Significant reduction in early TB deaths

• Above features vastly cut down the delay and increasing the chances of saving lives.
• The initiative has achieved the initial target of 80% triaging of patients, 80% referral, comprehensive assessment and confirmation of severe illness, and 80% admission among confirmed.
• The State’s target is to achieve 90%-90%-90% at each district.

Key challenges

• The challenge is to increase the duration of admission, especially for people with very severe undernutrition, which comprises 50% of the admitted patients.

 

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