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Subject: Social Justice

  • The fault line of poor health infrastructure

    The poor public health infrastructure in India hits the poor hard. The article examines the factors responsible for poor public health infrastructure and suggests the measures to deal with it.

    Poor state of health infrastructure

    • World Bank data reveal the poor state of India’s health infrastructure.
    • It reveals that India had 85.7 physicians per 1,00,000 people in 2017.
    • In contrast, it is 98 in Pakistan, 58 in Bangladesh, 100 in Sri Lanka and 241 in Japan.
    • India had 53 beds per 1,00,000 people.
    • It is 63 in Pakistan, 79.5 in Bangladesh, 415 in Sri Lanka and 1,298 in Japan.
    • India had172.7 nurses and midwives per 1,00,000 people in contrast to 220 in Sri Lanka, 40 in Bangladesh, 70 in Pakistan, and 1,220 in Japan.

    What are the factors responsible for poor health infrastructure?

    • Stagnant expenditure: Analysis by the Centre for Economic Data and Analysis (CEDA), Ashoka University, shows that health expenditure has been stagnant for years.
    • Lack of expertise with states: Despite health being a state subject, the main bodies with technical expertise are under central control.
    • The States lack corresponding expert bodies such as the National Centre for Disease Control or the Indian Council of Medical Research.
    • Inter-State variation: States also differ a great deal in terms of the fiscal space to deal with the novel coronavirus pandemic because of the wide variation in per capita health expenditure.
    • Kerala and Delhi have been close to top in years from 2011 to 2019-20.
    • Bihar, Jharkhand and Uttar Pradesh, States that have been consistently towards the bottom of the ranking in the same years.

    Out-of-pocket expenditure and its impact on the poor

    • Due to low levels of public health provision, the World Health Organization estimates that 62% of the total health expenditure in India is OOP, among the highest in the world.
    • Some of the poorest States, Uttar Pradesh, Bihar, Madhya Pradesh, Jharkhand and Odisha, have a high ratio of OOP expenditures in total health expenditure.
    • Impact on the poor: High ratio of OOP means that the poor in the poorest States, the most vulnerable sections, are the worst victims of a health emergency.

    Way forward

    1) Coordinated national plan

    • The inter-State variation in health expenditure highlights the need for a coordinated national plan at the central level to fight the pandemic.
    • The Centre already tightly controls major decisions, including additional resources raised specifically for pandemic relief, e.g. the PM CARES Fund.
    • The need for a coordinated strategy on essential supplies of oxygen and vaccines is acute.
    • The Centre can bargain for a good price from vaccine manufacturers in its capacity as a single large buyer like the European Union did for its member states.
    • Centre will also benefit from the economies of scale in transportation of vaccines into the country.
    • Once the vaccines arrive in India, these could be distributed across States equitably in a needs-based and transparent manner.
    • Another benefit of central coordination is that distribution of constrained resources like medical supplies, financial resources can internalise the existing disparities in health infrastructure across States.

    2) Form Pandemic Preparedness Unit

    • There is a need for the creation of a “Pandemic Preparedness Unit” (PPU) by the central government.
    • PPU would streamline disease surveillance and reporting systems; coordinate public health management and policy responses across all levels of government.
    • It will also formulate policies to mitigate economic and social costs, and communicate effectively about the health crisis.

    Consider the question “India has among the highest out-of-pocket expenditure in the world, which is the result of poor public health infrastructure. Examine the factors responsible for poor public health infrastructure and suggest the ways to deal with it.”

    Conclusion

    As and when we emerge on the other side of the pandemic, bolstering public health-care systems has to be the topmost priority for all governments: the Centre as well as States.

  • Brain drain of India’s health worker

    The article highlights the issue of shortage of healthcare workers in India even as it exports its healthcare workers to other countries.

    India as an exporter of healthcare workers

    • For several decades, India has been a major exporter of healthcare workers to developed nations particularly to the Gulf Cooperation Council countries, Europe and other English-speaking countries.
    • As per OECD data, around 69,000 Indian trained doctors worked in the UK, US, Canada and Australia in 2017.
    • In these four countries, 56,000 Indian-trained nurses were working in the same year.
    • There is also large-scale migration of health workers to the GCC countries but there is a lack of credible data on the stock of such workers in these nations.
    • There is no real-time data on high-skilled migration from India as in the case of low-skilled and semi-skilled migration.

    Shortage of nurses and doctors

    • The migration of healthcare workers is part of the reason for the shortage in nurses and doctors.
    • If we look at the figures for countries where we export our healthcare workers, we see just how big the difference is between the sending and the receiving countries.
    • As per government reports, India has 1.7 nurses per 1,000 population and a doctor to patient ratio of 1:1,404.
    • This is well below the WHO norm of 3 nurses per 1,000 population and a doctor to patient ratio of 1:1,100.
    • But, this does not convey the entire problem.
    • The distribution of doctors and nurses is heavily skewed against some regions.
    • Moreover, there is high concentration in some urban pockets.

    Factors driving migration

    • There are strong pull factors associated with the migration of healthcare workers, in terms of higher pay and better opportunities in the destination countries.
    • However, there are strong push factors that often drive these workers to migrate abroad.
    • The low wages in private sector outfits along with reduced opportunities in the public sector plays a big role in them seeking employment opportunities outside the country.
    • The lack of government investment in healthcare and delayed appointments to public health institutions act as a catalyst for such migration.

    Measures to check brain drain and issues with it

    • Over the years, the government has taken measures to check the brain drain of healthcare workers with little or no success.
    • In 2014, it stopped issuing No Objection to Return to India (NORI) certificates to doctors migrating to the US.
    • The NORI certificate is a US government requirement for doctors who migrate to America on a J1 visa and seek to extend their stay beyond three years.
    • The non-issuance of the NORI would ensure that the doctors will have to return to India at the end of the three-year period.
    • The government has included nurses in the Emigration Check Required (ECR) category.
    • This move was taken to bring about transparency in nursing recruitment and reduce the exploitation of nurses in the destination countries.
    • The government’s policies to check brain drain are restrictive in nature and do not give us a real long-term solution to the problem.

    Way forward

    • We require systematic changes that could range from increased investment in health infrastructure, ensuring decent pay to workers and building an overall environment to motivate them to stay in the country.
    • The government should focus on framing policies that promote circular migration and return migration — policies that incentivise healthcare workers to return home after the completion of their training or studies.
    •  It could also work towards framing bilateral agreements that could help shape a policy of “brain-share” between the sending and receiving countries.
    • The 2020 Human Development Report shows that India has five hospital beds per 10,000 people — one of the lowest in the world.
    • Increased investment in healthcare, especially in the public sector, is thus the need of the hour.
    • This would, in turn, increase employment opportunities for health workers.

    Consider the question “What are the factors driving the migration of healthcare workers from India? Suggest the measure to stem their migration.”

    Conclusion

    India needs systematic changes that could range from increased investment in health infrastructure, ensuring decent pay to health workers and building an overall environment that could prove to be beneficial for them and motivate them to stay in the country.

  • ICMR drops Plasma Therapy for COVID-19

    The use of convalescent plasma has been dropped from the recommended treatment guidelines for COVID-19, according to an advisory from the Indian Council of Medical Research (ICMR).

    Q.What is convalescent plasma therapy and what are the issues involved in its adoption?

    Convalescent Plasma Therapy

    • The therapy seeks to make use of the antibodies developed in the recovered patient against the coronavirus.
    • The whole blood or plasma from such people is taken, and the plasma is then injected into critically ill patients so that the antibodies are transferred and boost their fight against the virus.
    • A COVID-19 patient usually develops primary immunity against the virus in 10-14 days.
    • Therefore, if the plasma is injected at an early stage, it can possibly help fight the virus and prevent severe illness.

    How often has it been used in the past?

    • This therapy is no new wonder. It has been used several times.
    • The US used plasma of recovered patients to treat patients of Spanish flu (1918-1920).
    • In 2014, the WHO released guidelines to treat Ebola patients with convalescent whole blood and plasma.
    • In 2015, plasma was used for treating MERS patients.

    How is it done?

    • The process to infuse plasma in a patient can be completed quickly.
    • It only requires standard blood collection practices and extraction of plasma.
    • If whole blood is donated (350-450 ml), a blood fractionation process is used to separate the plasma.
    • Otherwise, a special machine called aphaeresis machine can be used to extract the plasma directly from the donor.
    • While blood is indeed extracted from the donor, the aphaeresis machine separates and extracts the plasma using a plasma kit, and the remaining blood components are returned into the donor’s body.

  • NITI Aayog’s proposal of allowing private entities to take over district hospitals

    The article highlights the issue of shortage of doctors in India and issues with the involvement of private sector in it.

    Government approach

    • Market-oriented approach towards medical education: NITI Aayog’s proposal of allowing private entities to take over district hospitals for converting them into teaching hospitals with at least 150 MBBS seats.

  • India resists Community Transmission tag despite soaring cases

    How other countries are classifying themselves

    • Inspite of adding the highest number of cases in the world every day, India continues to label itself as a country with no community transmission (CT) according to the latest weekly report by the World Health Organisation (WHO) on May 11.
    • India opts for the lower, less serious classification called ‘cluster of cases’.
    • Countries such as the United States, Brazil, United Kingdom, France have all labelled themselves as being in ‘community transmission.
    • Among the 10 countries with the most number of confirmed cases, only Italy and Russia do not label themselves as being in community transmission.
    • Both countries have been on a declining trajectory for at least a month and together contribute less than 20,000 cases a day — about 5% of India’s daily numbers.
    • India, since the beginning of the pandemic has never marked itself as being in community transition.

    Understanding the classification

    • Broadly, CT is when new cases in the last 14 days can’t be traced to those who have an international travel history, when cases can’t be linked to specific cluster.
    • Instead, the classification, ‘cluster of cases’ says “Cases detected in the past 14 days are predominantly limited to well-defined clusters that are not directly linked to imported cases”.
    • The WHO guidelines further suggest four subcategories within the broader definition of CT.
    • CT-1 implying “Low incidence of locally acquired, widely dispersed cases…and low risk of infection for the general population.
    • The highest, a CT-4 suggests very high incidence of locally acquired, widely dispersed cases in the past 14 days.
    • Very high risk of infection for the general population.

    Why right classification matters

    • If cases were still a cluster, it would mean that the government ought to be prioritising testing, contact tracing and isolating to prevent further infection spread.
    • CT, on the other hand meant prioritising treatment and observing advisories to stay protected.
    • CT — far from being stigmatic or an indicator of failure — has a bearing on how authorities addressed a pandemic.

  • Black marketing during the pandemic

    The article highlights the issue of black-marketing of drugs during the pandemic and the factors responsible for it.

    Problem of fake and sub-standard drugs

    • There have been reports of fake remdesivir amid the Covid pandemic.
    • It is difficult to quantify the morbidity and mortality effects of fake or sub-standard drugs, but they are substantial.
    • Legally, the Drugs and Cosmetics Act (DCA) has different categories of misbranded, adulterated and spurious drugs.
    • In 2003 Mashelkar Committee noted that although the Drugs and Cosmetics Act has been in force for the past 56 years, but the level of enforcement in many States has been far from satisfactory.
    • The committee also noted that the problems in the regulatory system in the country were primarily due to inadequate or weak drug control infrastructure at the State and Central level.

    Steps taken to deal with the issue

    • Assistance has also been provided under the World Bank assisted Capacity Building Project to upgrade testing facilities and to establish new drug testing laboratories.
    • The Drugs & Cosmetics Act, 1940 has recently been amended in 2008 for providing more stringent penalties to those involved in the trade of spurious drugs.
    • There are specially designated courts and regulatory infrastructure has been strengthened.
    •  There is also a whistle-blower scheme.

    Distinction between hoarding and black-marketing

    • A hoarder is anyone who stocks up items.
    • The crime isn’t hoarding per se but of selling a drug without a licence.
    • Data on prosecutions, and convictions when prosecuted, of crimes under Drugs and Cosmetics Act, are not encouraging.
    • Incidentally, courts have ruled police officers can’t register FIRs, arrest and prosecute (for cognisable crimes) under this law.
    • That’s the job of drugs inspectors.
    • The notion of a black market is different, though the two can be related.
    • In this context, it means charging a premium when there is a shortage.
    • A black market occurs when the price at which a product is sold is higher than an administratively determined price.

    Conclusion

    Action not taken in the best of times now strikes back at us in the worst of times.

  • EdTech needs an ethics policy

    The article highlights the privacy concerns associated with EdTech apps in the absence of a regulatory framework.

    Privacy risks associated with EdTechs

    • Since the onset of the pandemic, online education has replaced conventional classroom instruction.
    • This has given rise to several EdTech apps which have become popular.
    • To perform the process of learning customisation, the apps collect large quantities of data from the learners through the gadgets that the students use.
    • These data are analysed in minute detail to customise learning and design future versions of the app.
    • The latest mobile phones and hand-held devices have a range of sensors like GPS, gyroscope, accelerometer, magnetometer and biometric sensors apart from the camera and microphones.
    • These provide data about the learner’s surroundings along with intimate data like the emotions and attitudes experienced and expressed via facial expressions and body temperature changes.
    • In short, the app and device have access to the private spaces of the learner that one would not normally have access to.

    Informed consent in research

    • Researchers dealing with human subjects need to comply with ethics rules along with global standards.
    • One of the cardinal rules that should never be broken is informed consent.
    • Before any research on human subjects is undertaken, researchers have to submit detailed proposals to their respective ethics committees and obtain their permissions.
    • Further, a researcher working with children, for example, would also have to convince schoolteachers, parents, and school managements about the nature of the research to be undertaken, type of data to be collected, method of storage, the potential harmful effects of such data, etc.

    Minimal safeguards in EdTech

    • The safeguards that traditional researchers are subject to are either missing or minimal in research that the EdTech industry promotes.
    • The concept of informed consent is not meaningful since there are no proper primers to explain to stakeholders the intricacies in layperson terms.
    • Since India does not have protection equivalent to the GDPR, private data collected by an EdTech company can be misused or sold to other companies with no oversight or protection.

    Way forward

    • Given these realities, it is necessary to formulate an ethics policy for EdTech companies.
    • Such a policy draft should be circulated both online and offline for discussions and criticism.
    • Issues of fairness, safety, confidentiality and anonymity of the user would have to be dealt with.
    • EdTech companies would have to be encouraged to comply in the interest of a healthier learning ecosystem.

    Consider the question “What are the challenges associated with the adoption of online education mode? Suggest the ways to deal with these challenges.”

    Conclusion

    The lack of a regulatory framework in India along the lines of the General Data Protection Regulation (GDPR) in Europe could impinge on the privacy of students. What we need is ethics policy in online education space.

  • Digital Technologies and Inequalities

    Impact of pandemic

    • The novel coronavirus pandemic has accelerated the use of digital technologies in India, even for essential services such as health and education, where access to them might be poor.
    • Economic inequality has increased: people whose jobs and salaries are protected, face no economic fallout.
    • Well-recognised channels of economic and social mobility — education and health — are getting rejigged in ways that make access more inequitable in an already unequal society.

    Growing inequality in access to education

    • According to National Sample Survey data from 2017, only 6% rural households and 25% urban households have a computer.
    • Access to Internet facilities is not universal either: 17% in rural areas and 42% in urban areas.
    • Surveys by the National Council of Educational Research and Training (NCERT), the Azim Premji Foundation, ASER and Oxfam suggest that between 27% and 60% could not access online classes for a range of reasons: lack of devices, shared devices, inability to buy “data packs”, etc.
    • Further, lack of stable connectivity jeopardises their evaluations.
    • Besides this, many lack a learning environment at home.
    • Peer learning has also suffered.

    Inequality in access to health care

    •  India’s public spending on health is barely 1% of GDP.
    • Partly as a result, the share of ‘out of pocket’ (OOP) health expenditure (of total health spending) in India was over 60% in 2018.
    • Even in a highly privatised health system such as the United States, OOP was merely 10%.
    • Moreover, the private health sector in India is poorly regulated in practice.
    • Both put the poor at a disadvantage in accessing good health care.
    • Right now, the focus is on the shortage of essentials: drugs, hospital beds, oxygen, vaccines.
    • In several instances, developing an app is being seen as a solution for allocation of various health services. 
    • Digital “solutions” create additional bureaucracy for all sick persons in search of these services without disciplining the culprits.
    • Platform- and app-based solutions can exclude the poor entirely, or squeeze their access to scarce health services further.
    • In other spheres (e.g., vaccination) too, digital technologies are creating extra hurdles.
    • The use of CoWIN to book a slot makes it that much harder for those without phones, computers and the Internet. 

    Issues with the creation of centralised database

    • The digital health ID project is being pushed during the pandemic when its merits cannot be adequately debated.
    • Electronic and interoperable health records are the purported benefits.
    • For patients, interoperability i.e., you do not have to lug your x-rays, past medication and investigations can be achieved by decentralising digital storage say, on smart cards as France and Taiwan have done.
    • Given that we lack a data privacy law in India, it is very likely that our health records will end up with private entities without our consent, even weaponised against us.
    • For example, a private insurance companies may use health record to deny poor people an insurance policy or charge a higher premium.
    • There are worries that the government is using the vaccination drive to populate the digital health ID database.

    Way forward

    • Unless health expenditure on basic health services (ward staff, nurses, doctors, laboratory technicians, medicines, beds, oxygen, ventilators) is increased, apps such as Aarogya Setu, Aadhaar and digital health IDs can improve little.
    • Unless laws against medical malpractices are enforced strictly, digital solutions will obfuscate and distract us from the real problem.
    • We need political, not technocratic, solutions.

    Conclusion

    Today, there is greater understanding that the harms from Aadhaar and its cousins fall disproportionately on the vulnerable. Hopefully, the pandemic will teach us to be more discerning about which digital technologies we embrace.

  • What patent waiver in the COVID fight mean for global health equity

    The article highlights the implications of patent waiver for Covid-19 for global health equity.

    Where the opposition to waiver proposal came from

    • Recently, the US agreed to support the India-South Africa proposal, seeking a waiver of patent protection for technologies needed to combat and contain COVID-19.
    • Response to the proposal was divided during earlier debates at the WTO.
    • While many low and middle income countries supported it, resistance came from the U.S., the United Kingdom, the European Union, Switzerland, Australia and Japan.
    • Since the WTO operates on consensus rather than by voting, the proposal did not advance despite drawing support of over 60 countries.
    • Predictably, the pharmaceutical industry fiercely opposed it and vigorously lobbied many governments.
    • Right-wing political groups in the high income countries sided with the industry.

    Issues with the reasons given for opposition to the waiver proposal

    1) Quality and safety of vaccine production in low and middle-income countries

    • It was argued that the capacity for producing vaccines of assured quality and safety was limited to some laboratories.
    • So, it is argued that it would be hazardous to permit manufacturers in low and middle-income countries.
    • However, pharmaceutical manufacturers have no reservations about contracting industries in those countries to manufacture their patent-protected vaccines for the global market.

    2) Licenced manufacturing

    • The counter to patent waiver is an offer to license manufacturers in developing countries while retaining patent rights.
    • This restricts the opportunity for production to a chosen few.
    • The terms of those agreements are opaque and offer no assurance of equity in access to the products at affordable prices, either to the country of manufacture or to other developing countries.

    3) Supplying vaccines through COVAX facility

    • It was also stated that developing countries could be supplied vaccines through the COVAX facility, set up by several international agencies and donors.
    • While well-intended, it has fallen far short of promised delivery.
    • Some U.S. states have received more vaccines than entire Africa has from COVAX.

    4) No availability of extra capacity for vaccine production

    • Critics of a patent waiver say there is no evidence that extra capacity exists for producing vaccines outside of firms undertaking them now.
    • Even before the change in the U.S.’s position, manufacturers from many countries expressed their readiness and avidly sought opportunities to produce the approved vaccines.
    • They included industries in Canada and South Korea, suggesting that capable manufacturers in high income countries too are ready to avail of patent waivers but are not being allowed to enter a restricted circle.
    • The World Health Organization’s mRNA vaccine technology transfer hub has already drawn interest from over 50 firms.
    • Instead of arguing that capacity is limited, high-income countries and other donors should be supporting the growth of more capacity to meet the current and likely future pandemic.
    • They should learn from the manner in which India built up capacity and gained a reputation as a respected global pharmacy by moving from product patenting to process patenting between 1970 and 2005.

    5) Time required to utilise patented technology is long

    • Patent waivers are also dismissed as useless on the grounds that the time taken for their utilisation by new firms will be too long to help combat the present pandemic.
    • But many countries have low vaccination rates and variants are gleefully emerging from unprotected populations.
    • This makes it difficult to put the end date for the pandemic to end

    6) China factor

    • An argument put forth by multinational pharmaceutical firms is that a breach in the patent barricade will allow China to steal their technologies, now and in the future.
    • The original genomic sequence was openly shared by China, which gave these firms a head start in developing vaccines.

    Issue of rewarding innovation financially

    • Much of the foundational science that built the path for vaccine production came from public-funded universities and research institutes.
    • Further, what use is it to hold on to patents when global health and the global economy are devastated?
    • It is often argued that for defending patent protection, is that innovation and investment by industry need to be financially rewarded to incentivise them to develop new products.
    • Even if compulsory licences are issued bypassing patent restrictions, royalties are paid to the original innovators and patent holders.

    Way forward

    • Developing countries must take heart from his gesture and start issuing compulsory licences.
    • The Doha declaration on TRIPS flexibilities permits their use in a public health emergency.
    • High-income countries and multilateral agencies should provide financial and technical support to enable expansion of global production capacity.

    Consider the question “Why are the implications of patent waiver for Covid-19 vaccine for the global health equity? What were the reasons for opposition to waiver proposal?” 

    Conclusion

    The U.S.-supported patent waiver in the COVID fight has the potential to bring in much-needed global health equity.

  • [pib] Kerala presents its Annual Action plan under Jal Jeevan Mission

    Annual Action Plan presented

    • Annual Action Plan (AAP) on planning and implementation of Jal Jeevan Mission (JJM) in Kerala was presented.
    • Kerala State officials outlined the roadmap of the financial year 2021-2022 to the national committee via video conferencing.
    • The State plans to achieve the target of ‘Har Ghar Jal’ by 2024.
    • The State also plans to provide potable water in all quality-affected habitations by June 2021 through piped water supply or Community Water Purification Plants (CWPP).
    • The national committee analysed and advised on the plan presented by the State.
    • The committee emphasized the preparation of Village Action Plans and the constitution of Village Water &Sanitation Committee/ Pani Samiti as a sub-committee of Gram Panchayat with a minimum 50% of women members.
    • Also, emphasis is required on Water Quality Monitoring & Surveillance (WQM&S) activities to ensure Field Test Kit testing at Gram Panchayat level, Aanganwadi centres and schools.

    About Jal Jeevan Mission

    • Jal Jeevan Mission is the flagship programme of Government of India, which aims to provide household tap water connection to every rural household by 2024.
    • Since announcement of the mission in August 2019, 4.17 Core new tap connections have been provided in the rural areas of the country during this period.
    • As a result, 7.40 Crore (38.56%) rural households have tap water supply vis-Ă -vis 3.23 Crore (17%) in 2019.
    •  Efforts are made to dovetail all available resources by convergence of different programmes viz. MGNREGS, SBM, 15th Finance Commission Grants to PRIs, CAMPA funds, Local Area Development Funds, etc.

    Allocation for the JJM

    •  In 2021-22, Rs. 50,000 Crore budgetary allocation has been made for Jal Jeevan Mission.
    • In addition to this, there is also Rs. 26,940 Crore assured fund available under the 15th Finance Commission tied grants to RLBs/ PRIs for water & sanitation, matching State share and externally aided projects.
    • Thus, in 2021-22, more than Rs. 1 lakh Crore is planned to be invested in the country on ensuring tap water supply to rural homes.
    • This huge investment will give a boost to manufacturing activities, create employment opportunities in rural areas as well boost the rural economy.