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Subject: Health

  • Put out the data, boost the dose of transparency

    Context

    The Government must make COVID-19 data including that for vaccine regulatory approvals and policy available.

    Kay decisions

    • On December 25, the Prime Minister of India announced two key decisions.
    • Vaccination of children: All children in the 15-17 age bracket will be eligible to receive COVID-19 vaccines from January 3, 2022.
    • Third shot: All health-care workers, frontline workers and the people aged 60 years and above (with co-morbidities and on the advice of a medical doctor) can get a third shot, or ‘precaution dose’.
    •  The eligibility for the precaution dose will be on the completion of nine months or 39 weeks after the second dose.
    • Teenage children whose birth year is 2007 or before will be eligible for COVID-19 vaccines.
    • Children will receive Covaxin, the reason being (according to the note) it is the only emergency use listed (EUL) World Health Organization vaccine available for use in this age group in India.

    Issues with the decision

    • Lack of scientific evidence: The decision is said to be based on ‘advice of the scientific community’.
    • A few members of the National Technical Advisory Group on Immunisation (NTAGI) in India,  have written or spoken publicly about not having enough scientific evidence to administer booster doses and vaccinate children in India.
    • Successive national and State-level sero-surveys have reported that a majority of children in India had got natural infection, while staying at home and thus developed antibodies.
    • The studies have shown that children rarely develop moderate to severe COVID-19 disease.
    • Targeted vaccination approach not adopted: Most public health and vaccine experts favour a ‘targeted vaccination approach’ by prioritising high-risk children for COVID-19 vaccination.
    • However, such an approach is likely to face an operational challenge in the identification of the eligible children.
    • Consultation cost:  A majority of the elderly have one or other comorbidities. Of the 14 crore elderly population in India, an estimated 7 to 10 crore people could have co-morbidities.
    •  If they have to seek advice from a physician, in order to get vaccinated, this essentially means that there would be up to 10 crore of medical consultations, which would come at a cost —  all of which is avoidable.

    Suggestions

    • Do away with prescription: The conditionality of comorbidities and the need for advice/prescription by a doctor for ‘the precaution shot’ in the elderly should be done away with.
    • Third dose to all immunocompromised adults: There is scientific evidence and consensus on administering the third dose for immunocompromised adults.
    • The Indian government should urgently consider administering a third dose for all immunocompromised adults, irrespective of age.
    • Third dose on a different vaccine platform: Studies have found that a heterologous prime-boost approach — third shot on a different vaccine platform — is a better approach.
    • Identify policy questions: Various pending policy questions on COVID-19 vaccine need to be identified urgently.
    • The technical expert should be given complete access to COVID-19 data for analysis and to find answers to those scientific and policy questions.
    • Vaccine supply and stock management: Vaccination for teenage children, exclusively with Covaxin (which means 15 crore doses for this sub-group) has other implications.
    • Covaxin will also be needed for people coming for their first shot, returning for their second shot, and then for their ‘precaution dose’ if a third shot of the same vaccine is allowed.
    • Focus on primary vaccination: The precaution dose and vaccination for children should not divert attention from the task of primary vaccination, which continues to be an unfinished task in India; 46 crore doses are still needed for the first and second shots.
    • Make data public: It is time the Union and State governments in India make COVID-19 data — this includes clinical outcomes, testing, genomic sequencing as well as vaccination — available in the public domain.
    • This would help in formulating and updating COVID-19 policy and strategies and also assess the impact of ‘precaution dose’ as well as vaccination of children.

    Conclusion

    The Indian government urgently needs to make COVID-19 data available, including the one used for regulatory approvals of vaccines and for vaccine policy decisions. This will bring transparency in decision making and increase the trust of the citizen in the process.

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  • NITI Aayog releases fourth edition of State Health Index

    NITI Aayog has released the fourth edition of the State Health Index for 2019–20.

    State Health Index

    • The State Health Index is an annual tool to assess the performance of states and UTs. It is being compiled and published since 2017.
    • The index is part of a report commissioned by the NITI Aayog, the World Bank, and the Union Health and Family Welfare Ministry.
    • The reports aim to nudge states/UTs towards building robust health systems and improving service delivery.

    Components of the index

    • It is a weighted composite index based on 24 indicators grouped under the domains of ‘Health Outcomes’, ‘Governance and Information’, and ‘Key Inputs/Processes’.
    1. Health outcomes: It includes parameters such as neonatal mortality rate, under-5 mortality rate, and sex ratio at birth.
    2. Governance: This includes institutional deliveries, average occupancy of senior officers in key posts earmarked for health.
    3. Key inputs: It consists of the proportion of shortfall in healthcare providers to what is recommended, functional medical facilities, birth, and death registration, and tuberculosis treatment success rate.

    Performance of the states

    • For the fourth year in a row, Kerala has topped a ranking of States on health indicators. Uttar Pradesh has come in at the bottom.
    • Kerala is followed by Tamil Nadu and Telangana, which improved its ranking.

     

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  • Issues with Health Surveys in India

    This article discusses the feasibility of conducting a single comprehensive survey for collecting health-related data in India.

    Context

    • In a country perennially thirsty for reliable health data, the National Family Health Survey (NFHS) is like an oasis.
    • It has a large volume of data that is openly accessible.
    • The report of the fifth round of the NFHS was recently released. Since then, we had many articles covering different aspects (malnutrition, fertility, and domestic violence to name a few).

    What is NFHS?

    • The NFHS is a large-scale, multi-round survey conducted in a representative sample of households throughout India.
    • Three rounds of the survey have been conducted since the first survey in 1992-93.
    • Currently, the survey provides district-level information on fertility, child mortality, contraceptive practices, reproductive and child health (RCH), nutrition, and utilization and quality of selected health services.
    • The Ministry of Health has designated the International Institute for Population Sciences (IIPS) Mumbai, as the nodal agency, responsible for providing coordination and technical guidance for the survey.

    Issues with health surveys in India

    • Multiple surveys: The NFHS is not the only survey. In the last five years, there has been the National NCD Monitoring Survey (NNMS), the National Mental Health Survey (NMHS) etc.
    • Huge cost: Each survey funding for different rounds of NFHS costs upto ₹250 crore.
    • Huge chunk of data: The size of the survey has obvious implications for data quality.
    • Different estimates: Multiple surveys also raise the problem of differing estimates, as is likely, due to sampling differences in the surveys.
    • Limited respondents: The respondents are largely women in the reproductive age group (15-49 years) with husbands included.
    • Global obligations: Some of these surveys are done to meet the global commitments on targets (NCDs, tobacco, etc.).
    • Undefined purpose The health surveys have confusing research with programme monitoring and surveillance needs. Ex. Questions on domestic violence in NFHS.

    Need of the hour

    • Alignment of purpose: There have been previous attempts to align these surveys but they have failed as different advocates have different “demands” and push for inclusion of their set of questions.
    • Regularity of surveys: NFHS is the only major survey that India has a record of doing regularly. One does not know if and when the other surveys will be repeated.

    One-stop solution

    • National health data architecture: With diverse aspects of health, there is a need to plan the public health data infrastructure for the country.
    • Budgetary outlay: We also need to ensure that these data are collected in an orderly and regular manner with appropriate budgetary allocation.
    • Purpose definition: This requires clarity of purpose and a hard-nosed approach to the issue that randomized activities.
    • National-level indicators: We have to identify a set of national-level indicators and surveys that will be done using national government funds at regular intervals.

    How should surveys be done?

    • There should be three national surveys done every three to five years in a staggered manner:
    1. NFHS focuses on Reproductive and Child Health (RCH) issues
    2. Behavioral Surveillance Survey (focusing on HIV, NCD, water sanitation and hygiene (WASH)-related and other behaviors) and
    3. Nutrition-Biological Survey (entails collection of data on blood pressure, anthropometry, blood sugar, serology, etc.)

    We need to look at alternate models and choose what suits us best.

    Way forward

    • Important public health questions can be answered by specific studies conducted by academic institutions on a research mode based on availability of funding.
    • States have to become active partners including providing financial contributions to these surveys.
    • It is also very important to ensure that the data arising from these surveys are in the public domain.

    Conclusion

    • We are ready to establish public health data architecture for our complexity of needs.
    • We have the technical capacity to do so.
    • All it requires now is the political will.

     

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  • Extending outpatient health care coverage

    Context

    Over the past two decades, initiatives announced to extend health care coverage to the indigent sections have come under criticism due to their near-exclusive focus on hospitalisation (inpatient, IP) care.

    Significance of outpatient health care

    • What is outpatient health care: Outpatient (OP) health care, mainly comprising doctor consultations, drugs, and tests, can be called ‘the elephant in the room’ of Indian public health care policy.
    • OP expenses have the majority share in total out-of-pocket (OOP) expenditure on health.

    Why do we need to extend OP care coverage?

    • How IP care differs from OP care? IP care comprises high-impact and unavoidable episodes that are less prone to misuse than OP care, for which demand is considerably more sensitive to price and is thus more prone to overuse under health insurance.
    • IP insurance prioritised: This logic, among other reasons, has led to IP insurance schemes being prioritised.
    • [1] OP care and preventive care is neglected: While a price-sensitive demand for OP care entails that it could be misused under insurance, it also means that OP care is the first to come under the knife when there is no insurance.
    • In India, where there are many public IP insurance schemes but no OP coverage, this incentive is further amplified.
    • The mantra of ‘prevention is better than cure’ thus goes for a toss.
    • [2] Against economic sense: It defies economic sense to prioritise IP care over OP care for public funds.
    • Preventive and primary care services which often come with externalities, elicit little felt need and demand, and must therefore be the primary recipients of public investment.
    • Not conducive to epidemiological profile: Greater investments in IP care today translate to even greater IP care investments in future, further reduction in primary care spending, and ultimately lesser ‘health’ for the money invested.
    • None of these are conducive to the epidemiological profile that characterises this country.

    Issues with using private commercial insurance to extend OP care coverage nationwide

    • Some recent policy pronouncements by the Centre have conveyed an inclination to expand healthcare coverage with little fiscal implications for the government.
    • Challenges:
    • [1] The OP practices are under-regulated and there is a lack of standards.
    • [2] The difficulty to monitor OP clinical and prescribing behaviours and the concomitant higher likelihood of malpractices.
    • [3] Low public awareness of insurance products and a low ability to discern entitlements and exclusions.
    • [4] Add to it the inexperience that a still under-developed private OP insurance sector brings.
    • All these entail tremendous and largely wasteful costs and administrative complexity, and it would be of little help even if the government was to step in with considerable subsidies.

    Suggestion

    • Need for fiscal and time commitment: Significant improvements in healthcare are implausible without significant fiscal and time commitments.
    • No perfect model: There is no ‘perfect’ model of expanding healthcare — the emphasis must be on finding the best fit.
    • Implementing even such a best fit could involve adopting certain modalities with known drawbacks.
    • Expand public spending: The focus must be on expanding public OP care facilities and services financed mainly by tax revenues.
    • For India, wisdom immediately points to successful countries that are (or were, at one point) much closer to its socioeconomic fabric, such as Thailand, than countries like the U.S. which we currently look to emulate.
    • Now, the sparse number and distribution of public facilities offers various modes of rationing care, and their expansion is likely to result in a considerable spike in demand.
    • Contracting with private players: Contracting with private players based on objective and transparent criteria would also be called for, with just enough centralised supervision to deter corruption while preserving local autonomy.
    • To deter supply-side malpractices, low-powered modes of provider payment, such as capitation, may be considered for private providers wherever possible.

    Conclusion

    There are several compelling reasons for extending outpatient health care coverage even though there are several challenges to overcome to achieve this.

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  • Risks of mandatory Iron Fortification

    Many things have been said about the necessity for mandatory iron fortification of foods in India.

    Iron fortification

    • Iron fortification of food is a methodology utilized worldwide to address iron deficiency.
    • A critical problem in some food fortification programs is the lack of bioavailability of iron compounds.

    Why need iron fortification?

    Ans. Prevalence of Anaemia

    • Iron deficiency anaemia is due to insufficient iron.
    • National Family Health Survey (NFHS)-5 provides insights into anaemia prevalence in the country, indicating that 57.2% of women ages 15 to 49 are anaemic, up from 49.7% in NFHS-4.
    • Without enough iron, the body can’t produce enough of a substance in red blood cells that enables them to carry oxygen (hemoglobin).
    • Severe anemia during pregnancy increases your risk of premature birth, having a low birth weight baby and postpartum depression.
    • Some studies also show an increased risk of infant death immediately before or after birth.

    Concerns over iron fortification

    Ans. Fear of diabetes and heart ailments

    • Iron increases the risk for many non-communicable diseases like diabetes, hypertension and even high blood cholesterol.
    • A US based survey shows that high ferritin level had a four-fold higher risk of having diabetes.
    • The Comprehensive National Nutrition Survey of Indian adolescents to resulted in such scary outcomes.
    • There was a clear and significant risk for each of these conditions as serum ferritin increased.

    India’s vulnerability

    Ans. India is world capital of diabetes and hypertension

    • No less than 50% of Indian children, aged 5-19 years, already had a biomarker of either high blood sugar or high blood lipids, even when thin or stunted.
    • Thus, the risk of chronic disease is already very high in our children.
    • Thus mandatory cereal fortification has severe hazards for India.

    Why mandatory fortification is not a feasible option?

    • Occurrence of deficiencies: We do not even know if anaemia is as rampant to warrant such mandatory measures.
    • Manipulating food choices: When mandatory fortification is enforced in parts of the population that do not need this, it removes their choice of foods, or autonomy.
    • Morbidities due to excess: It could even be unethical if the risk of other morbidities is increased.
    • No successful example: Rice fortification has not been shown to work in a combined analysis.

    Conclusion

    • Food fortification is not a magic bullet.
    • It should be viewed as a complementary strategy for the prevention and control of micronutrient deficiencies.
    • As dietary patterns and deficiency states change, monitoring and periodic evaluation will be essential in helping to make necessary changes.

     

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  • How lack of public data on pandemic could harm us

    Context

    Questions are being asked about India’s preparedness as the cases with the Omicron variant of the Coronavirus has been on the rise in the country.

    Where does India stand?

    [1] The Positives

    • Addressing oxygen shortage: The extreme shortages of oxygen that we saw barely six months ago will hopefully not be a feature of a third wave.
    • Vaccinated population: We have now vaccinated more than 50% of the adult population with both doses of vaccine, and approximately 85% have received one or two doses.
    • Ramping up testing to deal with a spike should not require an increase in capacity.
    • More vaccine doses: We have more vaccine doses than in May 2021 and the potential for oral antiviral therapy in the near future.

    [2] The negatives

    • Lack of data: An urgent and important one is the lack of publicly available data on the pandemic from Government sources, particularly in regard to testing, but also in terms of being able to correlate disease severity with age, prior medical conditions, locations and other variables.
    • Data from the Indian Council of Medical Research (ICMR), India’s premier medical research agency, remains inaccessible.
    • The National Centre for Disease Control (NCDC) has not responded.
    • The CoWIN data contains valuable information but it is of little value for future planning and prediction unless it can be tied to testing data and clinical information at the level of individuals.
    • ICMR data not correlated to CoWIN platform data: The Indian Council of Medical Research holds data on every COVID-19 test conducted in India.
    • However, these data are not correlated to the vaccine data in the CoWIN platform.
    • Data with States is inaccessible: Data on hospitalisations, etc. are apparently available at the State level, but seem inaccessible.

    What we can know from the data about pandemic

    • Infer the probability of reinfection: If we knew that a person had tested positive on successive tests separated by, say four months or more, with a negative test in-between, that would suggest a reinfection.
    • We could then infer the probability of such a reinfection.
    • Probability of vaccine breakthrough infection: With information about testing and vaccination status, we could compute the probability of a vaccine breakthrough event.
    • To know the efficacy of single vaccine dose: By checking to see whether the positive test happened after the first but before the second dose of vaccine, or after the second dose, the relative efficacy of such single vaccine doses at preventing disease could be derived.
    • Effect of the vaccine on disease severity: By examining symptoms reported after a vaccine breakthrough event, we could understand the extent to which vaccines reduce disease severity.
    • Impact of new variant: Add to this a layer of sequence information, and we could study the impact of new variants.

    Role of the volunteer organisation

    • The most trustworthy and granular data on cases in India have resulted from the remarkable and public-spirited work of a volunteer organisation, Covid19India.org.
    • Their work has now been taken over by several other voluntary groups, all operating on the same broad principles of data accessibility: covid19bharat.org, incovid19.org and covid19tracker.in.

    Way forward

    • Commitment towards data accessibility: We need to stress on data availability because this is the one area where a swift realignment is possible.
    • The more widely data are shared, the greater the likelihood of integration of the rapidly shifting scientific frontier with clinical practice.
    • Learning from the experience of South Africa: With the advantages of a relatively high-quality surveillance system among low- and middle-income countries (LMIC) countries, bolstered by a commitment towards transparency and data accessibility, South Africa’s rapid sharing allowed the world to prepare swiftly for the appearance of the highly mutated Omicron variant.
    • It is clear that pre-emptive decisions on vaccination and other measures could be made faster and better if more integrated data were available.

    Consider the question “Why availability and accessibility of data is important in dealing with the Covid-19 pandemic? What are the challenges facing health data accessibility in India?”

    Conclusion

    Now, more than ever before is the time for us to urgently reassess our attitude towards data for public health purposes and the role of national health agencies in sharing data, generated with public funds, with scientists in India and across the world.

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  • Amendment to the NDPS Act

    The Narcotic Drugs and Psychotropic Substances (Amendment) Bill, 2021 was passed by Lok Sabha.

    Must read:

    [Burning Issue] Substance Abuse in India

    About NDPS Act

    • The Narcotic Drugs and Psychotropic Substances Act, commonly referred to as the NDPS Act was promulgated in 1985.
    • It prohibits a person from the production/manufacturing/cultivation, possession, sale, purchasing, transport, storage, and/or consumption of any narcotic drug or psychotropic substance

    What is the 2021 amendment?

    • The 2021 Bill amends the Narcotic Drugs and Psychotropic Substances Act, 1985 and seeks to rectify a drafting “anomaly” created by a 2014 amendment to the parent legislation.
    • It contains a legislative declaration about what one section refers to.
    • It says Section 2 clause viii(a) corresponds to clause viii(b) in Section 27, since 2014 when the provision was first brought in.
    • Section 27A of the NDPS Act, 1985, prescribes the punishment for financing illicit traffic and harbouring offenders.

    Earlier amendment in 2014

    • In 2014, a substantial amendment was made to the NDPS Act to allow for better medical access to narcotic drugs.
    • It defined “essential drugs”; under Section 9 and allowed the manufacture, possession, transport, import inter-State, export inter-State, sale, purchase, consumption and use of essential narcotic drugs.
    • But before the 2014 amendment, a Section 2(viii)a already existed and contained a catalogue of offences for which the punishment is prescribed in Section 27A.

    What is Section 21A?

    • Section 27A reads: Whoever indulges in financing, directly or indirectly or harbours any person engaged in any of the aforementioned activities, shall be punishable with rigorous imprisonment.
    • The term shall not be less than ten years and may extend to twenty years.
    • The accused shall also be liable to fine which shall not be less than one lakh rupees but which may extend to two lakh rupees.

    What was the drafting “anomaly”?

    • While defining “essential drugs” in 2014, the legislation re-numbered Section 2.
    • The catalogue of offences, originally listed under Section 2(viii)a, was now under Section 2(viii)b.
    • In the amendment, Section 2(viii)a defined essential narcotic drugs.
    • However, the drafters missed amending the enabling provision in Section 27A to change Section 2(viii)a to Section 2(viii)b.

    What was the result of the drafting error?

    • Section 27A punished offences mentioned under Section 2(viiia) sub-clauses i-v.
    • However, Section 2 (viiia) sub-clauses i-v, which were supposed to be the catalogue of offences, does not exist after the 2014 amendment. It is now Section 2(viiib).
    • This error in the text meant since 2014, Section 27A was inoperable.

    When was the error noticed?

    • In June this year, the Tripura High Court, while hearing a reference made by the district court, flagged the drafting error, urging the Centre to bring in an amendment and rectify it.
    • In 2016, an accused had sought bail before a special judge in West Tripura in Agartala, citing this omission in drafting.

    Why can’t it be applied retrospectively?

    • Article 20(1) of the Constitution says that no person shall be convicted of any offence except for violation of the law in force at the time of the commission.
    • The person shall not be subjected to a penalty greater than that which might have been inflicted under the law in force at the time of the commission of the offence.
    • This protection means that a person cannot be prosecuted for an offence that was not a “crime” under the law when it was committed.

    Does the latest amendment make it retrospective?

    • In September, the government brought in an ordinance to rectify the drafting error, which Lok Sabha. “It shall be deemed to have come into force on the 1st day of May 2014,” the Bill reads.
    • Retrospective application is permitted in clarificatory amendments.
    • This 2021 amendment is not a substantive one, that is why the retrospective is allowed.

     

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  • Tobacco Consumption in India

    Tobacco use is known to be a major risk factor for several non-communicable diseases in India.

    Tobacco abuse in India

    • In India, 28.6% of adults above 15 years and 8.5% of students aged 13-15 years use tobacco in some form or the other.
    • This makes the country the second-largest consumer of tobacco in the world.

    Concern: No action against Tobacco

    • India bears an annual economic burden of over ₹1, 77,340 crores on account of tobacco use.
    • There has been no major increase in taxation of tobacco products to discourage the consumption of tobacco in the past four years since the introduction of GST.
    • Only in 2020-21, the Union Budget had the effect of increasing the average price of cigarettes by about 5%.
    • Yet, the excise duty on tobacco in India continues to remain extremely low.

    A worrying trend

    • No increase in tax: The absence of an increase in tax means more profits for the tobacco industry and more tax revenue foregone for the government.
    • Revenue losses: This revenue could have easily been utilized during the COVID-19 pandemic.
    • Losses due to GST: There has been a 3% real decline in GST revenues from tobacco products in each of the past two financial years.

    Present governance of Tobacco

    • GST slab: Tobacco at present is a highly taxed commodity. It is kept in the 28% GST slab (other than for tobacco leaves which is taxed at 5%).
    • Heavy cess: Tobacco and its various forms are also subject to a heavy burden of cess, given that the commodity is seen as a sin good.
    • Statutory warning: The government also uses pictures of cancer patients on the packages of cigarettes to discourage its use.

    Federal issues

    • Excise taxes on many tobacco products used to be regularly raised in the annual Union Budgets before the GST.
    • Similarly, several State governments used to regularly raise value-added tax (VAT) on tobacco products.
    • During the five years before the introduction of the GST, most State governments had moved from having a low VAT regime on tobacco products to having a high VAT regime.

    Implication of such policies

    • Increased consumption: The lack of tax increases in post-GST years might mean that some current smokers smoke more now and some non-smokers have started smoking.
    • Reverse trend in decline: This could potentially lead to a reversal of the declining trend in prevalence.
    • Affordability: Tobacco products are more affordable post-GST as shown in recent literature from India.
    • Missing up national target: This might jeopardise India’s commitment to achieving 30% tobacco use prevalence reduction by 2025 as envisaged in the National Health Policy of 2017.

    Way forward

    • Several countries in the world have high excise taxes along with GST or sales tax and they are continuously being revised.
    • We must adhere to the WHO recommendation for a uniform tax burden of at least 75% for each tobacco product.
    • The Union government should take a considerate view of public health and significantly increase excise taxes — either basic excise duty or NCCD — on all tobacco products.
    • Taxation should achieve a significant reduction in the affordability of tobacco products to reduce tobacco use prevalence and facilitate India’s march towards sustainable development goals.

     

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  • Global Health Security Index, 2021

    Countries across all income levels remain dangerously unprepared to meet future epidemic and pandemic threats, according to the new 2021 Global Health Security (GHS) Index.

    About GHS Index

    • The GHS Index is the first comprehensive assessment and benchmarking of health security and related capabilities across the 195 countries that make up the States Parties to the International Health Regulations.
    • It is a project of the Johns Hopkins Centre for Health Security, the Nuclear Threat Initiative (NTI) and the Economist Intelligence Unit (EIU) and was first launched in October 2019.
    • It assesses countries across 6 categories, 37 indicators, and 171 questions using publicly available information.
    • It benchmarks health security in the context of other factors critical to fighting outbreaks, such as political and security risks, the broader strength of the health system, and country adherence to global norms.

    Parameters assessed

    The report is based on a questionnaire of 140 questions, organized across 6 categories, 34 indicators, and 85 sub-indicators. The six categories are:

    1. Prevention: Prevention of the emergence or release of pathogens
    2. Detection and Reporting: Early detection and reporting for epidemics of potential international concern
    3. Rapid Response: Rapid response to and mitigation of the spread of an epidemic
    4. Health System: Sufficient and robust health system to treat the sick and protect health workers
    5. Compliance with International Norms: Commitments to improving national capacity, financing plans to address gaps, and adhering to global norms
    6. Risk Environment: Overall risk environment and country vulnerability to biological threats

    Global performance

    • In 2021, no country scored in the top tier of rankings and no country scored above 75.9, the report showed.
    • The world’s overall performance on the GHS Index score slipped to 38.9 (out of 100) in 2021, from a score of 40.2 in the GHS Index, 2019.
    • This, even as infectious diseases are expected to have the greatest impact on the global economy in the next decade.
    • Some 101 countries high-, middle- and low-income countries, including India, have slipped in performance since 2019.

    Indian scenario

    • India, with a score of 42.8 (out of 100) too, has slipped by 0.8 points since 2019.
    • Three neighboring countries — Bangladesh, Sri Lanka and Maldives — have improved their score by 1-1.2 points.

    Conclusion

    • Health emergencies demand a robust public health infrastructure with effective governance.
    • The trust in government, which has been a key factor associated with success in countries’ responses to COVID-19, is low and decreasing, the index noted.

     

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  • Need for closer scrutiny of reduced out-of-pocket expenditure on health

    Context

    The National Health Accounts (NHA) report for 2017-18 is being celebrated widely as it shows that total public spending on health as a percentage of GDP has increased to a historic high of 1.35% of GDP.

    India’s total public spending on health

    • One of the lowest in the world: India’s total public spending on health as a percentage of GDP or in per capita terms has been one of the lowest in the world.
    • Majority spent by the States: The Union government traditionally spends around a third of the total government spending whereas the majority is borne by the States.
    • There has been a policy consensus for more than a decade now that public spending has to increase to at least 2.5% of GDP.
    • However, there has not been any significant increase so far.
    • Despite several pronouncements, it has continued to hover around 1%-1.2% of GDP.

    Why NHA report is being celebrated?

    • The National Health Accounts (NHA) report capture spending on health by various sources, and track the schemes through which these funds are channelised to various providers in a given time period for a given geography.
    • The National Health Accounts (NHA) report for 2017-18 is being celebrated widely as it shows that total public spending on health as a percentage of GDP has increased to a historic high of 1.35% of GDP.
    • The increase shown in NHA 2017-18 is largely due to increase in Union government expenditure.
    • Increase in Centre’s share: For 2017-18, the Centre’s share in total public spending on health has jumped to 40.8%.
    • However, if we study the spending pattern of the Ministry of Health and Family Welfare and the Ministry of AYUSH, we see that expenditure increased to 0.32% of GDP from 0.27% in 2016-17 — insufficient to explain the overall jump.

    Issues with NHA report

    • Expenditure of DMS included: Much of this increase has actually happened on account of a tripling of expenditure of the Defence Medical Services (DMS).
    • Compared to an expenditure of ₹10,485 in 2016-17, it increased to ₹32,118 crore.
    • Though the increasing spending for the health of defence personnel is a good thing, such spending does not benefit the general population. 
    •  Within government expenditure, the share of current health expenditure has come down to 71.9% compared to 77.9% a year ago.
    • Capital expenditure included: This essentially means, capital expenditure has increased, and specifically in defence.
    • There is a problem in accounting capital expenditure within the NHA framework.
    • Why capital expenditure needs to be left out: Equipment brought or a hospital that is built serves people for many years, so the expenditure incurred is used for the lifetime of the capital created and use does not get limited to that particular year in which expenditure is incurred.
    • The World Health Organization proposes to leave out capital expenditure from health accounts estimates, instead focus on current health expenditure.
    • Incomparable to other countries: In NHA estimates in India, in order to show higher public investment, capital expenditure is included; thus, Indian estimates become incomparable to other countries.
    • The NHA estimate also shows that out-of-pocket expenditure as a share of GDP has reduced to less than half of the total health expenditure.
    • NSSO 2017-18 data suggest that during this time period, utilisation of hospitalisation care has declined compared to 2014 NSSO estimates for almost all States and for various sections of society.
    • Sign of distress: The decline in out-of-pocket expenditure is essentially due to a decline in utilisation of care rather than greater financial protection.
    • Actually, the NSSO survey happened just after six months of demonetisation and almost at the same time when the Goods and Services Tax was introduced.
    • The disastrous consequences of the dual blow of demonetisation and GST on the purchasing power of people are quite well documented.
    • Another plausible explanation is linked to limitations in NSSO estimates. The NSSO fails to capture the spending pattern of the richest 5% of the population (who incur a large part of the health expenditure).
    • Thus, out-of-pocket expenditure measured from the NSSO could be an under-estimate as it fails to take into account the expenditure of the richest sections.

    Conclusion

    The reduction of out-of-pocket expenditure is a sign of distress and a result of methodological limitations of the NSSO, rather than a sign of increased financial protection.

     

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