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Subject: Social Justice

  • Missed opportunity to opportunity of employment-centred and inclusive growth

    Context

    India continues to rank poorly in various global indices that reflect the quality of life, human capital or human development in the country. In this context, it was expected that the current Budget would see an expansion in government spending on the social sector.

    Need for greater spending on social sector

    • In Human Development Index, India ranks 131 out of 189 countries and on the Global Hunger Index, it ranks 101 out of 116 countries.
    • The pandemic over the last two years has had a severe impact on the health, education and food security of the poor and informal sector workers.
    • The country has been experiencing increasing inequality over the last couple of decades.

    Marginal increase in allocation for school education

    • In the budget, the government announced that it will expand its ‘one class, oneTVchannel’ scheme instead of announcing enhanced allocations for schools  the government announced that it will expand its ‘one class, oneTVchannel’ scheme instead of announcing enhanced allocations for schools so that they can reopen with vigour.
    •  The budget for school education at ₹63,449 crore is a slight improvement over last year’s ₹54,873 crore (2021-22 budget estimates, BE) and a mere increase of 6% in nominal terms compared to 2020-21 BE of ₹59,845 crore.
    • After rechristening the school mid-day meal scheme as Pradhan Mantri Poshan Shakti Nirman, simply called PM Poshan, the allocation for the scheme has reduced from ₹11,500 crore last year to ₹10,233 crore this year.

    Low allocation for health

    • Despite repeated statements about strengthening the public health system, the overall budget for the Department of Health and Family Welfare at ₹83,000 crore has gone up by only 16% over the BE for 2021-22 and by less than ₹1,000 crore compared to the RE for 2021-22, which is ₹82,921 crore.
    • However, by including water and sanitation in the budget for health, there is an increase being shown in health spending as a proportion of GDP.
    • Also, even though the budget for the Jal Jeevan Mission has increased from ₹50,000 crore to ₹60,000 crore, only 44% of the allocated funds to the Department of Water and Sanitation for 2021-22 has been spent as on end December 2021.

    No indication of plan to extend the PMGKAY

    • 60% of the population are covered by ration cards currently under the National Food Security Act.
    • Those who were eligible benefited from the additional free foodgrains that they have been given under the Pradhan Mantri Garib Kalyan Anna Yojana (PMGKAY).
    • However, the food subsidy (BE) for 2022-23 at ₹2.06 lakh crore is only enough to cover the regular NFSA entitlements.
    • The indication is that there is no plan to extend the PMGKAY.
    • The food subsidy RE for 2021-22 is ₹2.86 lakh crore.

    Other schemes

    • Budgets for important schemes such as Saksham Anganwadi, maternity entitlements and social security pensions are around the same as the allocations for last year.
    • The allocation for MGNREGA at ₹73,000 crore also does not reflect the increased demand for work or thethe pending wages of ₹21,000 crore.

    Continued negligence

    • The resources allocated for crucial government schemes in the fields of health, education, nutrition, and social protection have remained stagnant or show negligent increase.
    • In fact, the budgets for these schemes have been declining in real terms since 2015.
    • The World Social Protection Report 2020-22, brought out by the International Labour Organization, shows that the spending on social protection (excluding health) in India is 1.4% of the GDP, while the average for low-middle income countries is 2.5%.

    Conclusion

    This continued negligence does not bode well for inclusive development in India.

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  • How the Budget can push India’s health system transformation

    Context

    After decades of low government expenditure on health, the Covid pandemic created a societal consensus on the need to strengthen our health system.

    Steps to strengthen our health system

    • The Fifteenth Finance Commission recommended greater investment in rural and urban primary care, a nationwide disease surveillance system extending from the block-level to national institutes, a larger health workforce and the augmentation of critical care capacity of hospitals.
    • The Union budget of 2021 reflected these priorities in a proposed Pradhan Mantri Aatmanirbhar Swasth Bharat Yojana (PMASBY) to be made operational over six years, with a budget of Rs 64,180 crore.
    • Broader vision of health: The Finance Minister also projected a broader vision of health beyond healthcare by merging allocations to water, sanitation, nutrition and air pollution control with the health budget.
    • Under the Ayushman Bharat umbrella the Digital Health Mission was launched in September 2021.
    • The Health Infrastructure Mission, launched in October 2021, was a renamed and augmented version of the PMASBY.
    • These missions join the two other components of Ayushman Bharat launched in 2018.
    • The Comprehensive Primary Health Care (CPHC) component is nested in the National Health Mission (NHM) while the Pradhan Mantri Jan Arogya Yojana (PMJAY) is steered by the National Health Authority (NHA).

    Way forward

    • While much of the following needs to be done by the states, the Centre should incentivise and support such efforts by the states.
    • Link synergically: Primary healthcare services under the CPHC and linkage with water, sanitation, nutrition and pollution control programmes will strengthen the capacity of the health system for health promotion and disease prevention.
    • The budget of 2022 must not only fund these missions adequately but indicate how they will link synergically while functioning under different administrative agencies.
    • Allocate more funds: The NHM received only a 9.6 per cent increase in the 2021 budget.
    • PMJAY did not see an increase in allocation last year, because its utilisation for non-Covid care declined sharply in the previous year.
    •  More importantly, limiting cost coverage to hospitalised care reduces the PMJAY’s capacity to significantly lower out-of-pocket expenditure (OOPE) on health, which is driven mostly by outpatient care and expenditure on medicines.
    • Focus on Digital Heath Mission: The Digital Health Mission can enhance efficiency of the health systems in a variety of ways.
    • These include better data collection and analysis, improved medical and health records, efficient supply chain management, tele-health services, support for health workforce training, implementation of health insurance programmes, real time monitoring and sharper evaluation of health programme performance along with effective multi-sectoral coordination.
    • Improve the skill and number of healthcare workers:  We need to increase the numbers and improve the skills of all categories of healthcare providers.
    • While training specialist doctors could take time, the training of frontline workers like Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs) can be done in a shorter time.
    • Upgrade district hospitals: District hospitals need to be upgraded, with greater investment in infrastructure, equipment and staffing.
    • In underserved regions, such district hospitals should be upgraded to become training centres for students of medical, nursing and allied health professional courses.

    Conclusion

    The expanded ambit of health, as defined in last year’s budget, must continue for aligning other sectors to public health objectives. The Union budget of 2022 can add further momentum to our health system transformation.

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  • Extinguishing the tobacco industry’s main narrative

    Context

    There is no doubt that tobacco use is highly detrimental to public health. We have to find the ways and the means to reduce the demand for tobacco among existing as well as aspiring users.

    Impact of tobacco

    • Tobacco is a product that kills more than 13 lakh Indians every year.
    • Annual burden: The annual economic burden from tobacco use is estimated to be ₹177,340 crore which is more than 1% of India’s GDP.
    • About 27 crore people above the age of 15 years and 8.5% of school-going children in the age group 13-15 years use tobacco in some form in India.

    Are price and tax measures effective against tobacco use?

    • When tobacco products become more expensive, people either quit using them or use them less, and it incentivises many to not initiate the habit.
    • Because it hurts both revenue and profits, the tobacco industry, globally, is always devising tactics and narratives that will pre-empt any kind of tax increases on tobacco products.
    • The narrative of “increasing illicit trade” is something the tobacco industry has historically used to pre-empt potential tax increases on tobacco products in most countries around the world.
    • The story is no different in India.
    • In a recent report by the Tobacco Institute of India, it was said that the illicit cigarette volume in India has grown by 44% from 2011 to 2019 while adding that high and increasing tax rates provide a profitable opportunity for tax evasion and encourage growth in illegal trade.
    • A study published in 2018 which used a survey of empty cigarette packs collected from retail outlets across different cities in India estimated that illicit cigarettes constitute 2.7% of the market.
    • The second study published in 2020 used tax-gap analysis to estimate that the percentage of illicit cigarettes was 5.1% in 2009-10 and 6.6% in 2016-17.

    Are taxes and prices key determinants of illicit trade?

    • It is to be noted that taxes and prices are not the key determinants of illicit trade.
    • There is sufficient evidence in the literature on illicit trade in cigarettes that shows tax increases only have a minimal impact, if at all, on illicit trade.
    • There are several countries where tobacco taxes are quite high and yet have low levels of illicit trade, while there are also countries with high levels of illicit trade despite having relatively low tax rates.
    • Several factors such as the quality of tax administration, the strength of the regulatory framework, government commitment to control illicit trade, the strength of governance, social acceptance, and the presence of informal distribution networks are known to play a larger role in determining the scale and the extent of an illicit market.

    Way forward

    • WHO protocol: Eliminating all forms of illicit trade in tobacco products through a package of measures is one of the major objectives of the Protocol to Eliminate Illicit Trade in Tobacco Products under the World Health Organization’s Framework Convention on Tobacco Control.
    • The Protocol provides the tools and the measures to eliminate or minimise illicit trade which includes strong governance, establishing an international track and trace system, and securing supply chains.
    • India has already ratified the World Health Organization Protocol and it should now show leadership in implementing these measures to effectively address even the relatively lower levels of illicit trade.

    Conclusion

    There is no scientific or public health rationale not to increase tax on tobacco products for unfounded fear of increasing illicit trade.

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  • Worrying trends in nutrition indicators in NFHS-5 data

    Context

    The NFHS-5 factsheets for India and all states and Union territories are now out. At first glance, it appears to be a mixed bag — much to cheer about, but concern areas remain.

    Positives from the NFHS-5 survey

    • Change in demographic trends: For the first time since the NFHS 1992-93 survey, the sex ratio is slightly higher among the adult population.
    • Improvement in sex ratio at birth: For the first time in 15 years that the sex ratio at birth has reached 929 (it was 919 for 1,000 males in 2015-16).
    • The total fertility rate has also dropped from 2.2 per cent to a replacement rate of 2 per cent, albeit with not much change in the huge fertility divide between the high and low fertility states.
    • Improvement in literacy level of women: There has been an appreciable improvement in general literacy levels and in the percentage of women and men who have completed 10 years or more of schooling, which has reached 41 per cent and 50.2 per cent respectively.
    • Improvements in health indicators: The health sector deserves credit for achieving a significant improvement in the percentage of institutional births, antenatal care, and children’s immunisation rates.
    • There has also been a consistent drop in neonatal, infant and child mortality rates — a decrease of around 1 per cent per year for neonatal and infant mortality and a 1.6 per cent decrease per year for under five mortality rate.

    Nutrition: Area of concern

    • Increase in anaemic people: India has become a country with more anaemic people since NFHS-4 (2015-16), with anaemia rates rising significantly across age groups, ranging from children below six years, adolescent girls and boys, pregnant women, and women between 15 to 49 years.
    • Why anaemia is a concern? Adverse effects of anaemia affect all age groups — lower physical and cognitive growth and alertness among children and adolescents, and lesser capacity to learn and play, directly impacting their future potential as productive citizens.
    •  Further, anaemia among adolescent girls (59.1 per cent) advances to maternal anaemia and is a major cause of maternal and infant mortality and general morbidity and ill health in a community.
    • The detailed report will explain why a dedicated programme like Anaemia Mukt Bharat which focused on IFA consumption failed to gain impetus.
    • Slow pace of improvement in nutritional indicators: Between NFHS 4 and NFHS 5, the percentage of children below five years who are moderately underweight has reduced from 35.8 per cent to 32.1 per cent.
    • Moderately stunted children have fallen from 38.4 per cent to 35.5 per cent, moderately wasted from 21 per cent to 19.3 per cent and severely wasted have increased slightly from 7.5 per cent to 7.7 per cent.
    • Inadequate diet: The root cause for this is that the percentage of children below two years receiving an adequate diet is a mere 11.3 per cent, increasing marginally from 9.6 per cent in NFHS-4.

    Way forward

    • India’s nutrition programmes must undergo a periodic review.
    • The Integrated Child Development Services (ICDS), which is perceived as the guardian of the nation’s nutritional well-being must reassess itself and address critical intervention gaps, both conceptually and programmatically, and produce rapid outcomes.

    Conclusion

    The nutritional deficit which ought to be considered an indicator of great concern is generally ignored by policymakers and experts. Unless this is addressed, rapid improvement in nutritional indicators cannot happen.

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  • HC allows woman to terminate 28-week pregnancy

    The Delhi High Court has permitted a 28-week pregnant woman to undergo medical termination of pregnancy on account of substantial foetal abnormality.

    What did the HC rule?

    Ans. Termination of Pregnancy is a matter of Right

    • The High Court said the woman cannot be deprived of the freedom to take a decision to continue or not to continue with the pregnancy, due to foetal abnormalities.
    • HC ruled that reproductive choice is a dimension of personal liberty that is enshrined in Article 21 of the Constitution.
    • It stated that allowing the pregnancy to continue would have a deleterious impact on the petitioner’s mental health.
    • The petitioner cannot be deprived of the freedom to take a decision to continue or not to continue with the pregnancy in view the medical board’s opinion.

    What is the Medical Termination of Pregnancy (MTP) Act?

    • Abortion in India has been legal under various circumstances for the last 50 years with the introduction of MTP Act in 1971.
    • The Act was amended in 2003 to enable women’s accessibility to safe and legal abortion services.

    Termination of pregnancy is permitted for a broad range of conditions up to 20 weeks of gestation as detailed below:

    1. Threat to mother: When the continuation of pregnancy is a risk to the life of a pregnant woman or could cause grave injury to her physical or mental health;
    2. Child abnormalities: When there is substantial risk that the child, if born or dead would be seriously handicapped due to physical or mental abnormalities;
    3. Rape survivors: When pregnancy is caused due to rape (presumed to cause grave injury to the mental health of the woman);
    4. Failure of contraception: When pregnancy is caused due to failure of contraceptives used by a married woman or her husband (presumed to constitute grave injury to mental health of the woman).

    Conditions for abortion

    • The MTP Act specifies – (i) who can terminate a pregnancy; (ii) till when a pregnancy can be terminated; and (iii) where can a pregnancy be terminated.
    • There must be an opinion formed of a doctor, that the pregnancy would cause a risk to the life of the pregnant woman or grave injury to her physical or mental health.
    • When a pregnancy exceeds 20 weeks but not 24 weeks, termination is permissible on the opinion formed of two registered medical practitioners.

    What was the recent case?

    • In the present case, the woman has completed 28 weeks of pregnancy.
    • As the MTP Act does not permit pregnancy termination beyond 24 weeks, she approached the court.
    • Various anomalies were found in the heart of the foetus in the foetal ECG.

    Key issues

    There are differing opinions with regard to allowing abortions.

    • One opinion is that terminating a pregnancy is the choice of the pregnant woman and a part of her reproductive rights.
    • The other is that the state has an obligation to protect life, and hence should provide for the protection of the foetus.
    • Across the world, countries set varying conditions and time limits for allowing abortions, based on foetal health, and risk to the pregnant woman.

    Conclusion

    • Access to abortion facilities is limited not just by legislative barriers but also the fear of judgment from medical practitioners.
    • It is imperative that healthcare providers be sensitized towards being scientific, objective and compassionate in their approach to abortions.

    Also read

     

    Termination of Pregnancy (MTP) Amendment Bill, 2020

     

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  • 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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