Maternity Entitlements in India

Women in informal sector suffer.

The Jaccha-Baccha Survey (JABS) was conducted with student volunteers in 6 States of North India -
Chhattisgarh, Himachal Pradesh, Jharkhand, Madhya Pradesh, Odisha and Uttar Pradesh.
 For lack of knowledge or power, most of the sample households were unable to take care of the special
needs of pregnancy (food, rest or health care).
 Among women who delivered a baby in the preceding 6 months, only 30% had eaten more nutritious
food than usual during their pregnancy.
 Their average weight gain during pregnancy was just 7 kg on average, compared with a norm of 13-18
kg for women with low body-mass index.

Under the National Food Security Act (NFSA), 2013, all pregnant women (except those already receiving
similar benefits under other laws) are entitled to maternity benefits of ₹6,000 per child.
PMMVY violates the NFSA, because in PMMVY the benefits are restricted to the first living child, and to
₹5,000 per woman. A provision of ₹2,700 crore was made for PMMVY in the 2017-18 budget, against the
₹15,000 crore required as per NFSA norms. This allocation was reduced to ₹1,200 crore in Budget 2018-19.

In 2018-19 only around 22% of all pregnant women received PMMVY money.

What factors suggests that PMMVY is ruined?

1) Reduced coverage and benefits compared with NFSA norms
2) Tedious application process
3) Frequent technical glitches in the online application and payment process.
4) Grievance redressal facilities are virtually non-existent.
5) Aadhaar-related problems need a special mention.
Some of them are replays of problems observed earlier with pensions, scholarships and the National Rural
Employment Guarantee Act.
Tamil Nadu - Under the Dr. Muthulakshmi Reddy Maternity Benefit Scheme, pregnant women receive
financial assistance of ₹18,000 per child for the first 2 births, including a nutrition kit.

Materialising Maternity Benefits

There are concerns that the Maternity Benefit (Amendment) Act 2017 would have a negative impact in the
labour market.
 The Act extends women’s paid maternity leave from 12 to 26 weeks. Of these, up to 8 weeks
can be taken pre-delivery.
 Enterprises with ≥50 employees must also provide crèches.
 They should allow the mother 4 crèche visits, daily.
 Women with ≥2 children get reduced entitlements.
 The costs of these benefits are to be borne solely by employers.

Concerns -
1. Employers don’t want to give maternity benefits, hence do not hire women.
2. Childcare - Childcare is treated solely as women’s responsibility.
3. Unspecified parental leave ends up being taken mainly by women.
4. In India, central government employees get only 15 days of paternity leave.
5. Informal sector - Around 93% Indian women workers are in the informal sector. The 2017 Maternity
Benefit Act does not apply to them.
6. It is also unclear about women working on family farms, doing home-based work, urban self-
employed, casual workers on contract.
7. Even the current entitlements under the National Food Security Act 2013 are not fully implemented.
 8. Facilities - Even in the formal sector, the child will need care after 6 months of maternity leave. But
India largely lacks facilities where women can leave their children for care.
9. Integrated Child Development Services to provide nutrition and childcare up to 6 yrs of age, lack in
quality and coverage.

How to address this?

1. 2018 ILO report emphasises the need for govt to share at least 2/3rd of maternity benefits costs.
2. Matching paternity and maternity leave would create a level playing field by reducing employer
discrimination. E.g. Iceland grants 9 months of parental leave with 3 reserved for the mother, 3 for the
father, and 3 to be shared b/w them.
3. Work time - Offering flexible work time for both sexes can help with work-life balance.
4. Large companies in IT and e-commerce support the extended maternity leave in India.
5. Facilities - Providing good crèches and childcare centres, not just for care but also for early childhood
development, is crucial.
6. SMEs located in close proximity could pool resources for creating crèches. This would benefit women
across all sectors, formal and informal.
7. Awareness - Media campaigns

Water Quality in Indian Cities

Going by the matrix of tests carried out by BIS for the Mo Consumer Affairs, major metropolitans such as
Delhi, Chennai and Kolkata had unacceptable low water qualities. Mumbai is the only city with acceptable
results.
Most of the municipal water supply systems do not to comply with the BIS requirements. This is due to
1. lack of accountability
2. absence of robust data in the public domain on quality testing
3. expanding footprint of packaged drinking water
4. high dependence on groundwater in fast-growing urban clusters where State provision of piped water
systems does not exist.
21 major Indian cities could run out of groundwater as early as 2020, as per a NITI Aayog report.
Central Ground Water Board estimates that nearly 1/5th of the ULBs are already facing a water crisis. This is
triggered by excessive extraction, failed monsoons, and unplanned development.

Way forward –
 Instead of the same agency (that provides water) performing the tests for water quality check, the task
should be entrusted on a separate agency in each State.
 Learn water quality management from Norway, Switzerland, New Zealand.

Zero Hunger With Langar

 Langar refers to a system of developing a community kitchen, where people irrespective of their caste,
religion and social status sit together on the floor and have food.
 The institution of langar finds its roots in two teachings of Sikhism -
1. ‘Naam japo, kirat karo, vand chako’ (pray, work and share with others whatever you earn) and
2. ‘Sangat aur pangat’ (eat sitting together in rows on the floor).
 Several Sikh organisations are now branching out to other countries where langar is used to provide
nutritious meals to the undernourished. One such organisation is ‘Zero Hunger With Langar’ which is
specifically working in 2 African countries - Malawi and Kenya. ‘Zero Hunger With Langar’ was found in
2016 by Jagjit Singh. It is currently serving over 1.50 lakh meals a month to malnourished children in
Malawi. This has led to increased attendance in primary schools and nurseries.

Vaccine Hesitancy
  In 2019, there is a spread of misinformation from an UN-based platform about vaccination recently
 This unchallenged spread could affect the global vaccination programme
 WHO listed vaccine hesitancy as among the top 10 threats to global health in 2019
 Vaccine Hesitancy is defined as a reluctance or refusal to vaccinate despite the availability of vaccines
 Vaccine hesitancy – Europe > Africa > South Asia
 45% of children missed different vaccinations in 121 Indian districts that have higher rates of
unimmunised children. A 2018 study found low awareness and fear of adverse effects were the main
reasons for this.
 It is already proven that vaccination offers the best defence against flu and its potentially serious
consequences, reduces flu illnesses, hospitalisations and even deaths.
 Despite H1N1 (swine flu) becoming a seasonal flu virus strain in India, the uptake of flu vaccine in India
is poor - the reason why thousands of cases and deaths get reported each year.

Ten Threats to Global Health in 2019 - WHO

1) Air pollution, climate change - This is the gravest risk, with 9 out of 10 people breathing polluted air
across the world. With 18% of the world’s population, India sees a disproportionately high 26% of the
global premature deaths and disease burden due to air pollution.
2) Non-communicable diseases - NCDs such as diabetes, cancer, and heart disease are responsible for 70%
of deaths worldwide yearly. India, notably, remains the “diabetes capital of the world”.
3) Global influenza pandemic - Global defences are only as effective as the weakest link in any country’s
health emergency preparedness and response system.
4) Fragile, vulnerable settings - >22% of the global population live in places where prolonged crises and
weak health services leave them without access to basic care. The crisis situation includes a combination
of challenges such as drought, famine, conflict, and population displacement.
 In India, the massive distress in farm sector has engendered waves of internal migration for work.
This migrant population often live in unhygienic conditions with very little access to basic care.
 The Rohingya migration crisis unfolding in Bangladesh could send ripples into India.
 Natural calamities - E.g. Kerala floods were followed by a leptospirosis outbreak
5) Antimicrobial resistance - India now has an AMR policy but implementation is poor.
6) Primary healthcare – Poor functioning and high vacancy in [primary health care centres in India
7) Vaccine hesitancy - The Delhi High Court's recent ruling on parental consent in vaccination has the threat
of adversely impacting vaccination drives.
8) Dengue - Dengue is endemic to India, and its season in countries like Bangladesh and India is lengthening
significantly. WHO estimates 40% of the world is at risk of dengue.
9) HIV - HIV/AIDS Act, 2018 makes access to anti-retroviral therapy (ART) an actionable legal right for
Indians living with HIV/AIDS (about 21 lakh). Also, India is a stakeholder in the WHO’s 90-90-90 target for
HIV elimination - By 2020, diagnose 90% of all HIV-positive persons, provide ART for 90% of those
diagnosed, and achieve viral suppression for 90% of those treated
10) Ebola, other pathogens - While India has been spared Ebola so far, the WHO prioritises R&D for several
haemorrhagic fevers, Zika, Nipah, and SARS.

Vaccine Hesitancy - Yellow Fever Controversy

Yellow fever spreads through mosquitoes. It is often associated with jaundice, and hence the name yellow.
It leads to death in a significant proportion of patients. So the vaccine is often compulsory before travelling
to any of the yellow fever-endemic countries in parts of Africa, and Central and South America.
Known as 17D, the yellow fever vaccine is a live, weakened yellow fever virus.
The yellow fever vaccine is considered by the World Health Organization as extremely effective, safe and
affordable. There are, however, reports about multisystem organ failure, deaths or yellow fever after
vaccination.
 Parental Consent for Vaccination - Delhi High Court Order

 Delhi High Court recently put on hold the Delhi government’s plan for a measles rubella (MR) vaccination
campaign in schools.
 The court said the decision did not have the consent of parents, introducing the question of consent in
vaccination.
 India has initiated the world’s largest Measles-Rubella (MR) Campaign targeting vaccination of 410
million children and adolescents aged b/w 9 months and 15 years. Under the programme, two doses of
measles and rubella vaccines are to be given at ages 9-12 months and 16-24 months.
 MR Vaccine has to be administered to all children b/w ages 9 months and 15 years. The vaccine being
given in the MR campaign is produced in India and is WHO prequalified. MR vaccine is safe and effective,
and in use for over 40 years across 150 countries.
 Measles is a serious and highly contagious disease that can cause debilitating or fatal complications.
These include encephalitis, diarrhoea, pneumonia, ear infections and permanent vision loss et
 Spread - Measles is transmitted via droplets from the nose, mouth or throat of infected persons. It
spreads by coughing or sneezing, and someone can spread the virus for 4 days before the rashes appear.
 Rubella, more commonly known as German measles, can have severe consequences during pregnancy.
 An infection just before conception and in early pregnancy may result in miscarriage, foetal death or
congenital defects known as congenital rubella syndrome (CRS).

Concern -
1) Schools were consciously chosen rather than health centres or hospitals as nowhere else can such large
numbers of children in the relevant age group be targeted.
2) In most US states, it is compulsory to provide vaccination records before seeking admission into school,
so that the child is not a danger to others.
3) People argue that for something which is already a part of the universal immunisation programme, written
consent should not be essential.
4) Under the Global Vaccine Action Plan, measles and rubella are targeted for elimination in five WHO
Regions by 2020.

Hepatitis B Control

Bangladesh, Bhutan, Nepal and Thailand became the first 4 countries in the WHO’s South-east Asia region to
have successfully controlled hepatitis B.
Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic disease.
The virus is most commonly transmitted from mother to child during birth and delivery, as well as through
contact with blood or other body fluids.
Hepatitis B can be prevented by vaccines that are safe, available and effective.
India introduced hepatitis B vaccine in the Universal Immunisation Programme in 2002 and scaled-up
nationwide in 2011.
Prevalence - Despite the above, about 1 million people in India become chronically infected with the virus
every year.
Despite the high vaccination coverage, disease prevalence in children aged less than 5 years has not dropped
below 1%. One of the reasons for this is the sub-optimal coverage of the crucial birth dose in all infants
within 24 hours of birth.
Reason for low coverage -
 One of the reasons for the low coverage is the fear of wastage of vaccine when a 10-dose vial is used.
 Unfortunately, health-care workers are very often unaware of the WHO recommendation that allows
hepatitis B open-vial policy.
 Opened vials of hepatitis B vaccine can be kept for a max. duration of 28 days for use in other children
if the vaccine meets certain conditions.
 RTS,S or Mosquirix - World's First Malaria Vaccine

Malaria is a potentially life-threatening parasitic disease. It is caused by the parasites -

1) Plasmodium viviax (P.vivax)
2) Plasmodium falciparum (P.falciparum)
3) Plasmodium malariae (P.malariae)
4) Plasmodium ovale (P.ovale)
The parasite gets transmitted by the female Anopheles mosquito.
In the human liver, it can mature, multiply, re-enter the bloodstream, and infect red blood cells, which can
lead to disease symptoms.
Acc. to the WHO, malaria remains one of the world’s leading killers, claiming the life of a child every 2 minutes.
Moreover, with global warming, there are predictions of vectors such as mosquitos seeing an explosive rise.
India ranks very high in the list of countries with a serious malaria burden. Odisha, Chhattisgarh, Jharkhand
bear the brunt of malaria in India.
The RTS,S vaccine is the first, and to date, the only, vaccine that has demonstrated that it could significantly
reduce malaria in children. RTS,S is designed to prevent the parasite from infecting the liver.

H1N1 Influenza Outbreak

 Influenza (H1N1 or swine flu) virus is the subtype of influenza A virus that was the most common cause
of human influenza (flu).
 Influenza viruses infect the cells in the nose, throat and lungs.
 The virus enter one’s body when he inhale contaminated droplets or transfer live virus from a
contaminated surface to your eyes, nose or mouth.
 The H1N1 infection was originally transmitted through contact with pigs, but now it can be spread from
person to person.
 Its symptoms, which include fever, coughing, a sore throat, and body ache, are similar to the regular flu.
 But if not treated, the H1N1 infection can lead to more serious conditions, including pneumonia and
lung infections.
 The risks are especially high for children under the age of five and the elderly.
 Influenza complications include -
1) Worsening of chronic conditions, such as heart disease and asthma
2) Pneumonia
3) Neurological signs and symptoms, ranging from confusion to seizures
4) Respiratory failure
 The H1N1 virus, which caused a pandemic in 2009, has since become a seasonal flu strain globally,
including in India, and causes fewer deaths.
 But recently it has been found that in a short span of 55 days (till February 24) this year, the number of
influenza A (H1N1) cases and deaths reported from India reached an alarming 14,803 and 448,
respectively, majorly in Rajasthan and Gujarat

What is the issue with govt’s action?

 The quadrivalent vaccine (two influenza A subtypes and two influenza B subtypes — H1N1 and H3N2,
and Victoria and Yamagata respectively) for active immunisation of adults of age 18 to 64 years was
approved in May 2018 by the Drug Controller General of India (DCGI).
 However, most public health programmes are not prepared for a mass adoption of this vaccine.
 There are also reports of non-availability of sufficient doses of quadrivalent vaccine.
 Union Health Ministry has issued a guidance “recommending” vaccines for health-care workers, and
deeming them “desirable” for those above 65 yrs of age and children b/w 6 months and 8 yrs.
 Surprisingly, people with pre-existing chronic diseases, who are most susceptible to H1N1
complications according to the WHO, have been ignored.
Measures needed -
 With H1N1 becoming a seasonal flu virus strain in India even during summer, it is advisable that health-
care workers and others at risk get themselves vaccinated.
 Despite the sharp increase in cases and deaths, the vaccine uptake has been low.
 greater awareness for precautionary measures such as frequent handwashing, and cough etiquette.
 Some state governments have launched screening camps and is going door-to-door to raise awareness
about the disease. However, a lack of testing facilities in the state means that those who have contracted
the disease are likely to infect many others before they are diagnosed.
 Through an umbrella scheme such as Ayushman Bharat, the quadrivalent vaccine should be made
available to the affected people using public and private institutions.
 When it comes to treatment, the availability of anti-viral drugs such as Oseltamivir in the public health
system should be ensured.

Concerns in polio eradication

Though the world is inching towards eradicating polio, vaccination in itself has become the main source of
polio paralysis in the world.

Vaccine-derived polio virus

 Inactivated polio vaccine (IPV) consists of killed poliovirus strains of all 3 poliovirus types and it
produces antibodies in the blood to all 3 types of poliovirus.
 On the other hand, Oral polio vaccine (OPV) contains a weakened vaccine-virus, activating an
immune response in the body.
 When a child is immunized with OPV, the weakened vaccine-virus replicates in the intestine for a
limited period, thereby developing immunity by building up antibodies.
 During this time, the vaccine-virus is also excreted.
 In areas of inadequate sanitation, this excreted vaccine-virus can spread in the immediate community,
before eventually dying out.
 On rare occasions, if a population is seriously under-immunized, an excreted vaccine-virus can
continue to circulate for an extended period of time.
 The longer it is allowed to survive, the more genetic changes it undergoes.
 In very rare instances, the vaccine-virus can genetically change into a form that can paralyse, which is
known as a circulating vaccine-derived poliovirus (cVDPV).

What is the case with India?

 While circulating VDPV strains are tracked, and outbreaks and cases are recorded and shared, little is
known about vaccine-associated paralytic poliomyelitis (VAPP) cases in India.
 VAPP occurs when the virus turns virulent within the body of a recently vaccinated child and causes
polio.
 The frequency of VAPP cases varies across countries.
 With high-income countries switching to the inactivated polio vaccine (IPV) that uses dead virus to
immunise children, the VAPP burden is concentrated in low-income countries like India which
continue to use the OPV.
 In spite of the WHO asking all countries using the OPV to include a continuous and effective system
of surveillance to monitor the frequency of VAPP in 1982, India did not comply.
Concerns with IPV -
 IPV produces humoral immunity (involving antibodies in body fluids) so the immunised child does not
get paralysis, but it can’t stop the circulation of wild polio viruses.
 India licensed the IPV only in 2006 but did not introduce it in routine immunisation.
 The reason for not switching over to the IPV is because global production was too low to meet India’s
demand.
 It is easier and cheaper to administer the OPV than the IPV.
 What should be done?
 IPV is essential for post wild-type polio virus eradication, to get rid of VDPV and VAPP.
 The globally synchronised switch from trivalent to bivalent OPV in mid-2016 was accompanied by
administering a single dose of the IPV prior to administering the OPV.
 A single dose of the IPV primes the immune system and the antibodies against the polio virus.
 Thus India needs to monitor if the use of a single dose of IPV followed by immunisation using bivalent
OPV has led to a reduction in the no. of VAPP cases in the future.

Milk Safety and Quality Survey

A milk safety and quality survey was conducted by an independent agency at the behest of the Food Safety
and Standards Authority of India (FSSAI). This survey has demolished the perception of large-scale milk
adulteration in India. The survey found 93% of the samples were absolutely safe.
Aflatoxin M1 was more widely present in processed milk samples than in raw milk.
Aflatoxin M1 in milk is from feed and fodder, which is not regulated. Improper storage of food harvest in
warm and humid conditions leads to aflatoxin contamination that is much higher than what is seen in the
field.
Aflatoxin M1 has been classified as “possibly carcinogenic to humans”.
Aflatoxin M1 in milk and milk products is a public health concern especially in infants and young children as
milk constitutes one of the major sources of nutrients.

Common goods for health (CGH)

CGH is a project launched by WHO

There is a need for external funders and governments to prioritize investments in core health system functions
that are fundamental to protecting and promoting health and well-being. As a call for action, WHO, in close
collaboration with external partners, has developed a knowledge program on financing common goods for
health.
Common Goods for Health (CGH) are population-based functions or interventions that require collective
financing, either from the govt or donors based on the following conditions:
 Contribute to health and economic progress
 There is a clear economic rationale for interventions based on market failures, with a focus on (i) Public
Goods (Non-Rival, Non-Exclusionary) or (ii) large social externalities.
CGH avoids the near-universal confusion associated with the terms ‘public health’, ‘public good’, and public
health expenditure.

Need/Importance for CGH

CGH covers market failure in the form of

Fiscal Impetus population-scale interventions
‘public goods’ and ‘externalities

Population-scale interventions reduce new threats such as pandemics, environmental degradation and
air quality, and also the unfinished agenda of traditional public health in India.

Relation b/w CGH and public finance -

1) Reduced health care expenditures - Improvements in public health will reduce the extent to which people get
sick, thus giving reduced health care expenditures.
2) Reducing the fiscal burden on govt.
3) Increased feasibility of Universal Health Coverage (UHC)

Status of India -
 1. CGH Agenda - The CGH agenda cuts across many ministries and agencies of govt. E.g. problems like
air quality or road safety have a major impact upon health care expenses in India, and these problems
lie outside the Mo Health
2. Coordination
3. Difficulties in health care
4. Increasing out of pocket expenditures

Significance of Sexual and Reproductive Health

NFHS 4 shows that the use of modern contraceptive methods (mCPR) continues to be around 48% since
2006. Female sterilisation in India continues to be around 37% since 2006, despite health complications and
deaths, highlighting the gender inequality in contraceptive use.
National Health Policy 2017 which aims uptake of male sterilisation to 30%.

National Data Quality Forum (NDQF)

 It is a multi-institutional initiative hosted by Indian Council of Medical Research (ICMR).
 NDQF aims at improving data quality for better and efficient research.

Prohibition of E-Cigarettes Ordinance, 2019

 It makes production, manufacture, import, export, transport, sale, distribution, storage and
advertisement of e-cigarettes and other Electronic Nicotine Delivery Systems (ENDS) a punishable
offence.
 ENDS includes vapes, e-hookahs and e-cigars.
 While the US plans to ban all e-cigarette flavours (except for tobacco), UK has made sales of ENDS
products legal.

ENDS may be manufactured to look like traditional cigarettes and are marketed as tobacco-free nicotine
delivery devices. It produces aerosol by heating a solution containing nicotine and different other flavours in
the form of liquid primarily composed of solvents such as glycerol/propylene glycol.

Effects -
1) The adverse health effects of e-cigarettes are not yet known, but increased risk of heart attack etc
have been warned about.
2) The solvents include potential carcinogens such as formaldehyde and acetone.
3) Flavours such as diacetyl are linked to serious lung disease.
4) It also contains volatile organic compounds, heavy metals, such as nickel, tin and lead.
5) Exposure to nicotine during adolescence can cause addiction and can harm the developing
adolescent brain.

Are e-cigarettes addictive?

 One of the concerns most often raised is that it attracts young people who have never even smoked
cigarettes, encouraged by aggressive marketing and the variety of alcopops type flavours available.
 The protection of young people is one of the reasons cited by India for its ban on e-cigarettes.
 Flavours in e-cigarettes have been cited as one of the top three reasons for children to use them.

Does it help to stop smoking?

 There is a limited evidence to support the claim that e-cigarettes help people to stop smoking.
 The variable delivery of nicotine in each puff and its different sizes makes it difficult to assess its effects.
 The Truth Initiative has found that 60% of those who used e-cigarettes also smoked cigarettes, called
as dual users.
 The US FDA has not approved e- cigarettes as an alternative to reduce smoking.
  WHO has remained more cautious, saying that vaping is probably less toxic than smoking but that there
was insufficient info. to quantify the risk.

Study on Cardiovascular Diseases and Cancer

Study by the Prospective Urban and Rural Epidemiologic (PURE)

Major reasons for cardiovascular diseases (CVDs) in low income countries -
1) Hypertension
2) high non-HDL cholesterol
3) Household air pollution
4) low education level
CVD remains the leading cause of mortality among middle-aged adults globally. However, this is no longer
the case in high-income countries, where cancer is now responsible for twice as many deaths as CVD.

 In low-income countries, including India, CVD is still the top killer.

 Deaths due to CVD here are three times more frequent than that due to cancer.
 An earlier report from a PURE study showed that Indians had the lowest lung function among the 21
countries studied.
Use of biomass fuel in rural areas, mosquito coils, dhoop sticks and agarbattis in uran areas contribute
to high household air pollution.
 Access to affordable, quality health care is still not ensured in many regions in India.
 Acc. to Health Ministry data for 2014-15, nearly 62% of India’s total health expenditure is out-of-pocket
expenditure.

Way forward
 Targeting risk factors is key to reducing deaths due to cardiovascular diseases.
 Ayushman Bharat Yojana will have to take much of the burden of hospitalisation for complications of
non-communicable diseases.
 National and State schemes running on mission mode will have to step up efforts to target people at
risk with life-saving interventions.

India’s disease burden and mission

In2019, India started a large-scale plan to screen all children for leprosy and tuberculosis under Rashtriya Bal
Swasthya Karyakram (RBSK) infra. will be used for the screening.

Why is the screening necessary?

 Leprosy is a chronic infectious disease caused by Mycobacterium leprae.
 It usually affects the skin and peripheral nerves but has a wide range of clinical manifestations.
 It is a leading cause of permanent physical disability.
 Timely diagnosis and treatment of cases, before nerve damage has occurred, is the most effective way
of preventing disability due to leprosy.
 Tuberculosis infection, caused by Mycobacterium tuberculosis, is one of the most common
communicable diseases in India.
 Its transmission is fuelled by unhygienic, crowded living conditions.
 It is said that most Indians carry the bacterium and the infection flares up when their immunity
levels are low.
 India’s tuberculosis burden is the highest in the world.
 Children tend to be more prone to catching infectious diseases from their peers because of long hours
in confined spaces and more bodily contact than in adults.
 For TB, India’s malnutrition burden is an additional risk factor which should be addressed soon.
What is the burden in India?
 India eliminated leprosy in 2005 — WHO defines elimination as an incidence rate of less than one
case per 10,000 population.
All states except Chhattisgarh and Dadra and Nagar Haveli have eliminated leprosy.
However, 1.2 lakh new leprosy cases are still detected every year, Health Ministry officials said.
 TB kills an estimated average of over 1,300 Indians every day.
Most remain either undiagnosed or unaccountably and inadequately diagnosed and treated in the
private sector.
The problem is that many of these patients do not complete the full course of the antibiotic.
This exposes the bacterium to the medicine without fully killing it, which is more than enough for the
bacterium to evolve resistance to that particular drug.
 Target - End TB to 2025.

What is the mission focus?

 Launched in 2013 under the National Health Mission, RBSK is focused on preventing disease and
disability in children.
 “Child Health Screening and Early Intervention Services” refer to early detection and management of
a set of 30 health conditions prevalent in children less than 18 years of age.
 These conditions are together described as 4Ds and they are defects at birth, diseases in children,
deficiency conditions and developmental delays including disabilities.
 Until now, neither leprosy nor TB was a part of the programme.

Hygiene Products on Price Control

The National List of Essential Medicines (NLEM) already contains 384 categories. Reportedly, NITI Aayog is
planning to create a new list of hygiene products to put under price control.
The new list is expected to have two groups. The primary category is expected to have a price control, and
the secondary one may operate with trade margin limits. The items include commonly used hygiene products
like soaps, adult diapers, sanitary napkins, hospital hand gloves, floor disinfectant, operation theater
gumboots, etc.

Concerns - Price controls may force companies to sell lower quality products etc.

What could have been done - If there is a serious concern over hygiene, the govt can always dispense
sanitary pads free via its Asha and Anganwadi centres. E.g., GoI recently announced that it would sell
them for Rs 1 at such centres

National List of Essential Medicines (NLEM)

 Medicines and devices listed in NLEM must be sold at the price fixed by the govt.
 On the other hand, those in the non-scheduled list are allowed a max. annual price hike of 10%.
 The NLEM list is reviewed every 3 years to include or exclude drugs.

National Pharmaceutical Pricing Authority

 NPPA was constituted through a GoI Resolution in 1997.
 It is an attached office of the Do Pharmaceuticals (DoP), Mo Chemicals & Fertilizers.
 It works as an independent regulator for pricing of drugs, and ensures availability and accessibility of
medicines at affordable prices.
 It implements and enforces the provisions of the Drugs (Prices Control) Order.

The Surrogacy (Regulation) Bill, 2019

 The Surrogacy (Regulation) Bill, 2019 prohibits commercial surrogacy but allows altruistic surrogacy.
 It stipulates that a surrogate mother has to be a ‘close relative’ of the intending couple.
 Altruistic surrogacy - No monetary compensation to the surrogate mother other than the medical
expenses and insurance coverage during the pregnancy.
 Commercial surrogacy - Monetary benefit or reward exceeding the basic medical expenses and
insurance coverage will be given to the surrogate mother.
 Surrogacy clinics must apply for registration within a period of 60 days from the date of appointment of
the appropriate authority.

When is surrogacy permitted?

 When the intending couples suffer from proven infertility.
 When Altruistic and not commercial.
 When Children are not produced for sale, prostitution or other forms of exploitation.
 For any condition or disease specified through regulations.

Eligibility criteria for the intending couple - They should have ‘certificate of essentiality’ and a ‘certificate
of eligibility’ issued by the appropriate authority, with conditions such as
1. A certificate of proven infertility of one or both of the couple from a District Medical Board
2. Insurance coverage for the surrogate.
3. The couple must be Indian citizens and married for at least 5 years;
4. Wife - 23 to 50 years old and Husband - 26 to 55 years old;
5. They do not have any surviving child (biological, adopted or surrogate).

Eligibility criteria for surrogate mother - She should get a certificate of eligibility from the appropriate
authority, the surrogate mother has to be:
1. A 25 to 35 years old married woman with a child of her own, who is a close relative of the
intending couple.
2. Can surrogate only once in her lifetime.
3. Should possess a certificate of medical and psychological fitness for surrogacy.
4. She cannot provide her own gametes for surrogacy.

Central govt shall constitute the National Surrogacy Board (NSB) and by state govts the State Surrogacy
Boards (SSB). Functions of the NSB include advising the Centre on policy matters, laying down the code of
conduct of surrogacy clinics and supervising the SSBs.

What are the other procedures?

 A child born out of a surrogacy procedure will be deemed to be the biological child of the intending
couple.
 An abortion requires the written consent of the surrogate mother and the authorisation of the
appropriate authority, compliant with the Medical Termination of Pregnancy Act, 1971.
 The surrogate mother will have an option to withdraw from surrogacy before the embryo is implanted
in her womb.

The offences under the Bill include:

1. Undertaking or advertising commercial surrogacy
2. Exploiting the surrogate mother
3. Abandoning, exploiting or disowning a surrogate child
4. Selling or importing human embryo or gametes for surrogacy

Concerns about the bill -

1) It did not talk about NRIs who are abroad, who may want to come back home to have a baby.
2) It leaves out unmarried couples who want to have a baby through surrogacy, and gay couples,
single men and single women who want to have a baby through IVF.
3) Altruistic surrogacy has failed in many other countries.
 4) For surrogacy to happen, embryos should be cultured in In-Vitro Fertilisation (IVF) labs. So, before
discussing the surrogacy bill, there is a need to discuss the Assisted Reproductive Tech. (ART) Bill first
5) The govt aimed to widespread commercialisation of the practice. But, it has left a lot of women from
underprivileged backgrounds who lend their wombs worse off.
6) There should be a contract signed b/w the surrogates and the commissioning parents. It should
include details of the payment, insurance coverage, and give an assurance that the mothers will be
treated properly.
7) A woman has the right to privacy when she makes her choice about reproduction. So, this has to be
incorporated into the bill.

What needs to be done further?

 There should be some solution given to people who have already hired surrogates.
 The government had banned surrogacy for foreigners, but some had already put their embryos in
deep freeze here. They asked for the embryos to be returned but the government said there can be no
export and import of embryos any more.

Occupational Safety, Health and Working Conditions Code, 2019

What is the Code for?

 The Code repeals and replaces 13 labour laws relating to safety, health and working conditions. These
include the Factories Act, 1948, the Mines Act, 1952, and the Contract Labour (Regulation and Abolition)
Act, 1970.
 The Code extends the ambit of provisions to all establishments having ≥10 employees. It does not apply
to apprentices.
 Further, it makes special provisions for certain types of establishments and classes of employees, such
as factories, mines, and building and construction workers.

Key provisions -
 All establishments covered by the Code must be registered with registering officers.
 Central and state govts will set up Occupational Safety and Health Advisory Boards at the national and
state level, respectively.
 Duties of employers - The Code specifies several duties of employers which include -
i. providing a workplace that is free from hazards that may cause injury or diseases
ii. providing free annual health examinations to employees, as prescribed
 Rights and duties of employees - Duties of employees under the Code include -
i. taking care of their own health and safety
ii. complying with the specified safety and health standards
iii. reporting unsafe situations to the inspector
 For overtime work, the worker must be paid twice the rate of daily wages.
 Female workers, with their consent, may work past 7pm and before 6am, if approved by the central or
state govt.
 No employee may work for more than 6 days a week.
 Workers must receive paid annual leave for at least one in 20 days of the period spent on duty.
 The employer is required to provide a hygienic work environment.
 Population Growth

Economic Survey 2018-19 notes that India is set to witness a sharp slowdown in population growth in the
next two decades.
By 2030s, some States will start transitioning to an ageing society.

What are the demands on state control?

i. to all political parties to enact population control laws
ii. to annul the voting rights of those having >2 children
iii. for the govt to enact a law where the 3rd child should not be allowed to vote and enjoy facilities
provided by the govt
The demand for state controls on the number of children a couple can have is not a new one. It takes lead
from the perception that a large population is at the root of a nation’s problems, as more and more people
chase fewer and fewer resources.
 Family health, child survival and the number of children a woman has are closely related to the
health and education levels of the parents, especially the woman.
 So, the poorer the couple, the more the children they tend to have. This is because, when it comes
to the poor, -
i. child survival is low
ii. son preference remains high
iii. children lend a helping hand, and support the economic and emotional needs of the family
 The National Family Health Survey-4 (2015-16) notes that the no. of children per woman declines
with a woman’s level of schooling.

What are the alternative measures?

 National Population Policy (NPP) 2000 showcased the govt’s commitment to citizens’ voluntary
and informed choice and consent in reproductive health care services, with a target free approach.
 Lifecycle framework - A similar “lifecycle framework” was proposed by the earlier Health Minister,
J.P. Nadda. This argument is not about denying services but about offering choices and a range of
services to mother and child. It comes with a clear understanding that the demographic dividend can
support growth and drive opportunity for all only when the population is healthy.

Way forward -
 Today, as many as 23 States and UTs, including all the States in the south region, already have fertility
below the replacement level of 2.1 children per woman.
 So, ‘support’ rather than population ‘control’ works better at this juncture.

National Medical Commission (NMC) Bill

The National Medical Commission (NMC) Bill was recently introduced in the Lok Sabha.
What is the Bill about?
 Once the NMC Bill is enacted, the Indian Medical Council Act, 1956, will stand repealed.
 The existing Act provides for the Medical Council of India (MCI), which is the medical education
regulator in India.
 An earlier version of this Bill was introduced in the last Lok Sabha. Click here to know more.
 It had passed the scrutiny of the Parliamentary Standing Committee on Health and Family Welfare.
 However, that Bill lapsed at the end of the term of the last Lok Sabha.
 The present Bill has made some changes to the earlier version.
What are the shortfalls with MCI?
 The MCI is primarily intended to producing competent doctors, ensure adherence to medical
education quality standards, etc.
  The Parliamentary Standing Committee on Health and Family Welfare examined the functioning of
the MCI in its 92nd report (in 2016).
 It noted that the MCI has repeatedly been found short of fulfilling its mandated responsibilities.
 Resultantly, the quality of medical education in India is at its lowest ebb.
 The current medical education model is not producing the right type of health professionals that meet
the basic health needs.
 This is because medical education and curricula are not integrated with the needs of the country’s
health system.
 Those coming out of medical colleges are ill-prepared to serve in poor resource settings like Primary
Health Centre and even at the district level.
 Medical graduates lack competence in performing basic health care tasks like conducting normal
deliveries.
 Consequently, instances of unethical practice continue to grow and the respect for the profession has
diminished.
 Besides these, inefficient individuals have been able to make it to the MCI.
 But, the Ministry is not empowered to remove or sanction a Member of the Council even if s/he has
been proved corrupt.
What are the key provisions of the Bill?
 NMC - The Bill provides for the constitution of a 25-member NMC to replace the MCI.
 The members will be selected by a search committee headed by the Cabinet Secretary.
 Advisory Council - A medical advisory council will advise and make recommendations to the NMC.
 It will include -
1. one member representing each state and Union Territory (vice-chancellors in both cases)
2. chairman of the University Grants Commission
3. director of the National Accreditation and Assessment Council
 Autonomous boards - According to the proposed legislation, NMC will have four autonomous
boards to regulate the sector.
 These are:
1.
1. Undergraduate Medical Education Board
2. Postgraduate Medical Education Board
3. Medical Assessment and Rating Board
4. Ethical and Medical Registration Board
 The structure is in accordance with the recommendations of the Group of Experts headed by Ranjit
Roy Chaudhury.
 It was set up by the Union Health Ministry to study the norms for the establishment of medical
colleges.
 Test - The Bill provides for just one medical entrance test across the country, the National Exit Test
(NEXT).
 The NEXT would serve as -
1. the final MBBS exam, which will work as a licentiate examination
2. the screening test for foreign medical graduates
3. the screening test for admission to PG medical courses
 [NEXT is different from the NEET which is to be taken before joining UG course.]
 Fees - The Bill proposes to regulate the fees and other charges of 50% of the total seats in private
medical colleges and deemed universities.
 Regulation - The Bill marks a radical change in regulatory philosophy.
 Under the NMC regime, medical colleges will need permission only once - for establishment and
recognition.
 There will be no need for annual renewal.
 Also, colleges would be free to increase the number of seats on their own, subject to the present cap
of 250.
  They would also be able to start postgraduate courses on their own.
 Fines for violations, however, are steep at 1.5 times to 10 times the total annual fee charged.
What are the key changes in the 2019 Bill?
 There are two key changes, following the recommendations of the Parliamentary Standing Committee
on Health and Family Welfare.
 One, the Bill has dropped a separate exit examination.
 Two, it has dropped the provision on a bridge course.
 [It allowed for AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy) practitioners
to prescribe allopathy medicines after a bridge course.]
 Besides, the Bill has also removed the exemption hitherto given to Central institutions, the AIIMS and
JIPMER, from NEET for admission to MBBS and allied courses.
 Notably, there was resentment and a charge of elitism at the exclusion of some institutions from an
exam that aimed at standardizing testing.
What lies ahead?
 It is crucial now for the Centre to work amicably with States, and the Indian Medical Association, which
is opposed to the Bill.
 At any cost, it must avoid the creation of rigid roadblocks as happened with NEET in some States.

Sample Registration System Survey

 The Sample Registration System (SRS) survey data compiled by the Registrar General of India (RGI) for
2017 was released recently.
 While the total fertility ratio (TFR) of India, in both rural and urban areas, is declining, which is good
news, the sex ratio is worsening.
What is SRS?
 The Government of India, in the late 1960s, initiated the Sample Registration System (SRS).
 SRS aims to provide reliable estimates of birth and death rates for the States and also at All India level.
 At present, the Sample Registration System (SRS) provides reliable annual data on fertility and mortality
at the state and national levels for rural and urban areas separately.
 In this survey, the sample units, villages in rural areas and urban blocks in urban areas are replaced once
in ten years
What are the highlights?
 Birth rate - The birth rate is the total number of live births per 1,000 in a population in a year or a
particular period.
 The Crude Birth Rate (CBR) at the national level during 2017 stands at 20.2, registering a decline of 0.2
points over 2016 (20.4).
 [The crude birth rate is called "crude" because it does not take into account the age or sex differences
among the population.]
 The maximum CBR has been reported in Bihar (26.4) while Kerala in the south recorded the lowest (14.2).
 In both rural and urban India, the birth rate has gone down by 1.3 points and 0.6 points, respectively.
 Death rate - The Crude Death Rate (CDR) at the national level stood at 6.3 in 2017.
 Chhattisgarh (7.5) recorded maximum CDR and Delhi (3.7), minimum CDR.
 The female death rate has declined by 0.5 points and male, by 1.0 points.
 Due to better health care, the all India level death rate has declined from 14.9 to 12.5 during 1971 to
1981.
 Thereafter, it has declined from 9.8 to 6.3 during 1991 to 2017.
 It has registered a decline of 0.7 points in the last 5 years.
 Sex ratio - Sex ratio indicates the number of females per 1000 males.
 The already skewed sex ratio in India further plunged from 898 in 2014-2016 to an all-time low of 896
in 2015-17.
 In the Population Census of 2011, it was 940 females per 1000 males.
 During the 2017 SRS survey, Chhattisgarh reported the highest sex ratio at birth (SRB) of 961.
 Haryana recorded the lowest sex ratio at birth of 833.
  Fertility rate - The total fertility ratio (TFR) is the number of children expected to be born per woman
during her entire span of reproductive period.
 India’s total fertility rate (TFR) has fallen to 2.2 in 2017 which is just above the WHO recommended
replacement level of 2.1.
 The total fertility ratio (TFR) of India, in both rural and urban areas, is declining, which is a positive
development.
 Factors such as improvement in education levels, especially among women, and access to healthcare
and contraception for women has contributed to this.

 IMR - The Infant Mortality Rate (IMR) registered a marginal decline of 1 point from 34 in 2016 to 33 in
2017.
 Madhya Pradesh (47) has recorded maximum IMR, and Kerala (10) recorded the minimum.
 IMR for the country has come down to 33 per 1000 live births in 2017 from 42 in 2012.
 In 2017, about 47% of the deaths were institutional and 53% received medical attention other than in
institutions.
 There is a decline in rural IMR, indicating better chances of survival among rural young ones as compared
to urban.
 In rural India, the decline has been to the tune of 9 points from 46 in 2012 to 37 in 2017.
 In, urban India, the decline is from 28 in 2012 to 23 in 2017.
 Both the gender have shown decline in the 2012-17 period.
 However, one out of 30 infants at the National level, one in every 27 infants in rural areas and one in
every 43 in urban areas, still die within one year of life.
What is the key concern?
 As per an analysis, the declining sex ratio means 117 lakh girls are missing in the country.
 This is unfortunate, as the SRB (sex ratio at birth) had been improving over the past few years.
 It was 909 females for every 1,000 men in the 3 years ending 2013.
 More worrying, the SRB is lower in urban areas at 890 which is much lower than the 898 in rural areas.
 The SRB has risen in states like Uttar Pradesh, Bihar, Maharashtra and Gujarat that were traditionally seen
as less progressive states.
 However, a state like Kerala that traditionally had a high SRB has seen a big dip from 974 to 948.
 While the fall in fertility rate is welcome, combined with the decline in the SRB, this means there will be
a continued fall in fertility rates in India.
 Therefore, over the next couple of decades, India may have to be dealing with a big dependency
problem.
What lies ahead?
 The sex ratio skew hints at increasing illegal sex determination and related termination of pregnancy,
despite the laws to stop this.
 A crackdown in Punjab (a state with one of the worst SRBs in the country) resulted in 60 sex-
determination centres being caught so far this year.
  So, the government must realise that the Beti Bachao, Beti Padhao programme needed to be re-targeted.
 It is now focused primarily on the poor and in rural areas; the problem is equally large in urban areas
and among the not-so-poor as well.

Acknowledging the WASH Amenities

Water, Sanitation and Hygiene (WASH) amenities are critical to the safe functioning of health care systems.
What is the global estimates on WASH amenities?
 Whatever the healthcare systems may be the adequate Water, Sanitation and Hygiene (WASH)
amenities, including waste management and environmental cleaning services, are critical to their safe
functioning.
 According to a joint report of World Health Organization and the UN Children’s Fund (UNICEF)
outlines, WASH services in many facilities across the world are missing or substandard.
 According to data from 2016, an estimated 896 million people globally had no water service at their
healthcare facility.
 More than 1.5 billion had no sanitation service.
 One in every six healthcare facilities was estimated to have no hygiene service (meaning it lacked hand
hygiene facilities at points of care, as well as soap and water at toilets), while data on waste
management and environmental cleaning was inadequate across the board.
What are the issues with lack of WASH?
 When a healthcare facility lacks adequate WASH services, infection prevention and control are severely
compromised.
 This has the potential to make patients and health workers sick from avoidable infections.
 As a result (and in addition), efforts to improve maternal, neonatal and child health are undermined.
 Lack of WASH facilities also results in unnecessary use of antibiotics, thereby spreading antimicrobial
resistance.

What measures are needed for the better reach of WASH?

 Recommendations of WHO - According to a World Health Assembly Resolution it is important to
ensure at least 60% of all healthcare facilities have basic WASH services by 2022, at least 80% have the
same by 2025, and 100% of all facilities provide basic WASH services by 2030.
 For this, member states should implement each of the WHO and UNICE recommended practical steps.
 Health authorities should conduct in-depth assessments and establish national standards and
accountability mechanisms.
  Across the region, and the world, a lack of quality baseline data limits authorities’ understanding of the
problem.
 As this is done, and national road-maps to improve WASH services are developed, health authorities
should create clear and measurable benchmarks that can be used to improve and maintain
infrastructure and ensure that facilities are ‘fit to serve’.
 Engagement of Healthcare professionals - Health authorities should increase engagement and work
to instill a culture of cleanliness and safety in all healthcare facilities.
 Alongside information campaigns that target facility administrators, all workers in the health system
from doctors and nurses to midwives and cleaners should be made aware of, and made to practice,
current WASH and infection prevention and control procedures (IPC).
 To help do this, modules on WASH services and IPC should be included in pre-service training and as
part of ongoing professional development.
 In addition, authorities should work more closely with communities, especially in rural areas, to
promote demand for WASH services.
 Personalizing Health advice - Authorities should ensure that collection of data on key WASH
indicators becomes routine.
 Doing so will help accelerate progress by promoting continued action and accountability.
 It will also help spur innovation by documenting the links b/w policies and outcomes.
 In this regard WHO is working with member states as well as key partners to develop a data
dashboard that brings together and tracks indicators on health facilities, including WASH services, with
a focus on the primary care level.
What lies ahead for India?
 India certainly has a serious problem with health literacy and it is the responsibility of public health
professionals to close this gap.
 As a member state, India need to achieve the ‘flagship priorities’ and work towards the SDG targets.
 Indeed, whatever the healthcare facility, whoever the provider, and wherever it is located, securing safe
health services is an objective India must boldly pursue.
 Thus Improving WASH services are deemed essential to enhancing the quality of primary healthcare
services, increasing equity and bridging the rural-urban divide.

Issues with USA’s Policy on Drug Vigilance

US recently highlighted the fraud concerning generic drugs manufactured oversees, especially in India.
What are the issues with drug manufacturers?
 Allegations of widespread fraud concerning generic drugs manufactured overseas, were recently
highlighted in the U.S.
 Much focus was on the contamination found in one drug made by Ranbaxy.
 For instance, the Ranbaxy saga unfolded 14 years ago, since then, several pharmaceutical companies,
both foreign and local, generic and innovative, have been implicated in similar or worse behaviour.
 Notable examples include those of Martin Shkreli’s Turing Pharmaceuticals, which hiked the price of a
drug to 5,000%, and Purdue Pharmaceuticals, a company currently implicated for causing the opioid
crisis.
What are the concerns with USA’s action in this regard?
 USA’s Food Safety Modernization Act (FSMA) has a provision to conduct global inspections.
 One objective in thus empowering the Food and Drug Administration (FDA) was to work with regulators
of foreign countries and create a universal Current Good Manufacturing Practice (CGMP) system for
drugs.
 Instead, the FDA has positioned itself as a ‘global regulator’.
 For example, in a recent statement, it mentioned that it inspects all brand-name and generic
manufacturing facilities around the world based on information from whistleblowers or out of concern
for drug safety.
 Arguably, this amounts to regulatory overreach as there is no international instrument standardizing
American CGMP practices as the global standard.
  In 2018, out of the 4,676 human pharmaceutical sites inspections that the FDA conducted worldwide,
61% were of foreign-based facilities.
 Similarly, out of 1,365 human drug CGMP surveillance inspections conducted, 55% were conducted at
facilities outside the U.S.
 The FDA’s publicizing of its ‘global vigilante experience’ paints a picture of foreign-manufactured drugs
as ‘defective’ or ‘contaminated’ while not fully acknowledging some of the regulatory failures within
America.
 US doesn’t have a proper scale to measure defectiveness of a drug, this provides a loophole, enabling
the regulator to cherry-pick and treat all instances of non-compliance as egregious violations.
What lies ahead for India?
 USA’s strategy of raising fears of ‘contaminated’ foreign generics has successfully prejudiced Americans
against valid generic drugs, even though they have remained a viable option.
 For India, the discussion in the U.S. is notable not only because it houses generic manufacturing facilities
but also because India is a nation on the verge of breaking into the innovation market.
 Thus, it is time India took a more robust role to ensure public availability of facts on both the importance
of generics and their limitations.
 The country needs to create strong voices and partnerships that can highlight the benefits and pitfalls
alike to create a robust space for innovation that can coexist with access to medication.

Strengthening Primary Healthcare System - Bihar Case

 Nearly 150 children in Bihar recently died due to acute encephalitis syndrome (AES).
 This brings to light the worrisome capacity of the State’s healthcare apparatus to handle such disease
outbreaks and calls for concerted actions.
What are the healthcare concerns in Bihar?
 PHC personnel - In Bihar, one PHC (primary health centre) caters to about 1 lakh people rather than
the norm of 1 PHC per 30,000 people.
 Furthermore, it is critical for such a PHC, catering to more than 3 times the standard population size,
to have at least 2 doctors.
 However, three-fourths of the nearly 1,900 PHCs in Bihar have just one doctor each.
 Muzaffarpur district has 103 PHCs (about 70 short of the ideal number) with 98 of them falling short
of the basic requirements mandated.
 There is a one-fifth shortage of ASHA personnel, and nearly one-third of the sub-health centres have
no health workers at all.
 PHC functioning - Even those PHCs with adequate supplies remain under-utilised.
 Selective healthcare services by PHCs, like family planning and immunisation, have resulted in the
perception that PHCs are incompetent as centres of general healthcare.
 This leads patients either to apex government hospitals situated far away or to unqualified private
providers.
 This results in patients losing time in transit and landing up in a hospital in a critical and often
irreversible stage of illness.
 Malnutrition - Bihar reels under the highest load of malnutrition in India.
 But, around 71% and 38% of funds meant for hot, cooked meals and take-home ration, respectively,
do not reach the beneficiaries.
 Meals were served for just more than half the number of prescribed days, and only about half the
number of beneficiaries on average actually received them.
How should AES outbreak be dealt with?
 AES is largely preventable both before and just after the onset of the disease.
 It is largely treatable with high chances of success on availability of medical intervention within 2-4
hours of symptoms.
 Therefore, the first signs of an outbreak must prompt strong prevention measures.
 Robust health education drive and replenishing primary health centres (PHCs) are essential.
  Besides these, extensive deployment of peripheral health workers (ASHA workers) and providing
ambulance services should be ensured.
 These are essential to facilitate rapid identification and management of suspected cases.
 Vacant doctor positions in PHCs must be urgently filled through deputation.
 Furthermore, short-term scaling-up of the Poshan Abhiyaan and the supplementary nutrition
programme are imperative.
 Nearly every one of these elements lies undermined in Bihar.
What should the long-term priorities be?
 Merely strengthening the tertiary care sector will be inefficient and ineffective.
 A narrow focus on the hospital sector will wastefully increase costs, ignore the majority of cases,
increase the number of cases that are in advanced stages, and continue to strain public hospitals.
 Instead, revamping primary health infrastructure should be the key priority for a susuatinable and
effective health response.
 The upcoming measures and efforts should involve -
i. building more functional PHCs and sub-health centers
ii. scaling-up the cadres of ASHA workers
iii. strict monitoring of nutrition programmes
iv. addressing the mal-distribution of doctors and medical colleges
 Decades of hospital-centric growth of health services have eroded faith in community-based
healthcare.
 In these circumstances, even easily manageable illnesses increase demand for hospital services rather
than PHCs.
 There is thus the need to work on inculcating confidence in community-based care.
 Besides these, enhancing the technical capacity to better investigate the causes of outbreaks as the
recent one and operationalising a concrete long-term strategy are crucial.

Self-Care Health Interventions - WHO Guidelines

The World Health Organisation (WHO) has recently launched its first guidelines on self-care interventions for
health.
What is self-care?
 Self-care would mean the ability of individuals, families and communities to access health care with or
without the support of a health-care provider.
 This may include promoting health, preventing disease, maintaining health, and coping with illness and
disability.
 The practice of self-care has been there for long.
 But now, increasingly, there are new diagnostics, devices and drugs that are transforming the way
common people access care.
 Self-care interventions are thus gaining more importance now than before.
What are the recent WHO guidelines on?
 In its first volume, the WHO guidelines focus on sexual and reproductive health and rights.
 Some of the interventions include -
1.
i. self-sampling for human papillomavirus (HPV) and sexually transmitted infections
ii. self-injectable contraceptives
iii. home-based ovulation predictor kits
iv. human immunodeficiency virus (HIV) self-testing
v. self-management of medical abortion
 Self-care neither replaces high-quality health services nor are they a shortcut to achieving universal
health coverage.
 Instead, the guidelines look at the scientific evidence for health benefits of certain interventions that can
be done outside the conventional sector.
What is the need for self-care?
  Millions of people, including in India, face the twin problems of acute shortage of healthcare workers
and lack of access to essential health services.
 WHO reports that over 400 million across the world already lack access to essential health services.
 Also, around 1 in 5 of the world’s population could be living in settings that are experiencing
humanitarian crises.
 Reportedly, there will be a shortage of about 13 million health-care workers by 2035.
 So, self-care offers the possibility to meet the health care needs with or without reliance on health-care
workers.
What is the WHO’s observation?
 Self-help would mean different things for people living in very diverse conditions.
 For people of the upper strata who have easy access to healthcare facilities, self-help would mean
convenience, privacy and ease.
 In contrast, for those living in conditions of vulnerability and lack access to health care, self-help
becomes the primary, timely and reliable form of care.
 These include people who are negatively affected by gender, political, cultural and power dynamics and
those who are forcibly displaced.
 Given this, the WHO recognises self-care interventions as a means to expand access to health services.
 So soon, the WHO would expand the self-help guidelines to include other self-care interventions.
 These could include prevention and treatment of non-communicable diseases.
 WHO is also establishing a community of practice for self-care, and will be promoting research and
dialogue in this area.
Where does India stand in this regard?
 India has some distance to go before making self-care interventions for sexual and reproductive health
freely available to women.
 Home-based pregnancy testing is the most commonly used self-help diagnostics in this area in India.
 Interventions also include self-managed abortions using approved drugs that can be had without the
supervision of a healthcare provider.
 E.g. morning-after pills taken soon after unprotected sex, mifepristone and misoprostol taken a few
weeks into pregnancy
 While the morning-after pills are available over the counter, the other two are scheduled drugs that
need prescription from a medical practitioner, thus defeating the very purpose of the drugs.
 The next commonly consumed drug to prevent illness and disease is the pre-exposure prophylaxis (PrEP)
for HIV prevention.
 India is yet to come up with guidelines for PrEP use and to include it in the national HIV prevention
programme.
 The WHO has approved the HIV self-test to improve access to HIV diagnosis in 2016.
 But despite this, the Pune-based National AIDS Research Institute in India is still in the process of
validating it for HIV screening.
 One of the reasons why people shy away from getting tested for HIV is the stigma and discrimination
associated with it.
 In this context, the home-based testing provides the much-needed privacy.
 India has in principle agreed that rapid HIV testing helps to get more people diagnosed and opt for
treatment, thus reducing transmission rates.

Health Index 2019 - NITI Aayog

The second edition of NITI Aayog’s Health Index was recently released in its report titled ‘Healthy States,
Progressive India: Report on Rank of States and UTs’.
What is the index on?
 The Index ranks the States and Union Territories based on 23 health-related indicators which include
–
i. neonatal mortality rate
ii. under-five mortality rate
 iii. proportion of low birth weight among new-borns
iv. progress in treating tuberculosis and HIV
v. full immunisation coverage
vi. improvements to administrative capability and public health infrastructure
vii. proportion of districts with functional Cardiac Care Units
viii. proportion of specialist positions vacant at district hospitals
 The report has ranking in three categories - larger States, smaller States and Union Territories, to
ensure comparison among similar entities.
 The Health Index does not capture other related dimensions, such as non-communicable diseases,
infectious diseases and mental health.
 It also does not get uniformly reliable data, especially from the growing private sector.
What are the report highlights?
 Kerala continued to top the list for the best performing State in the health sector among the 21 large
States.
 Kerala was followed by Andhra Pradesh, Maharashtra, Gujarat and Punjab, Himachal Pradesh, Jammu
and Kashmir, Karnataka and Tamil Nadu.
 Andhra Pradesh and Maharashtra have had the additional distinction of making incremental progress
from the base year.
 Uttar Pradesh retains the worst performer tag in the index.
 Uttar Pradesh continued to be at the bottom of the list with its score falling to 28.61; Kerala got a
score of 74.01.
 Other States at the bottom of the list are Bihar (32.11), Odisha (35.97) and Madhya Pradesh (38.39).
 Among the UTs, Chandigarh jumped one spot to top the list with a score of (63.62).
 It is followed by Dadra and Nagar Haveli, Lakshadweep, Puducherry, Delhi, Andaman and Nicobar and
Daman and Diu (41.66).
 Overall, only about half the States and UTs showed an improvement in the overall score b/w 2015-16
(base year) and 2017-18 (reference year).
 Among the 8 Empowered Action Group States, only 3 States (Rajasthan, Jharkhand and Chhattisgarh)
showed improvement in the overall performance.

What does the trend imply?

 Some States and Union Territories are doing better on health and well-being even with a lower
economic output.
 In contrast, others are not improving upon high standards, and some are actually slipping in their
performance.
 In the assessment during 2017-18, a few large States showed less encouraging progress.
  This reflects the low priority their governments have accorded to health and human development
since the first edition of the ranking for 2015-16.
 The disparities are very evident in the rankings, with the populous and politically important Uttar
Pradesh being in the bottom of the list.
What is the way forward?
 For the Health Index concept to encourage States into action, public health must become part of the
mainstream politics.
 The Centre has paid attention to tertiary care and reduction of out-of-pocket expenses through
financial risk protection initiatives such as Ayushman Bharat.
 But several States lag behind when it comes to creating a primary health care system with well-
equipped PHCs (Primary Health Centres) as the unit.
 Neglect of such a reliable primary care approach affects States such as Bihar where infant and neonatal
mortality and low birth weight are high.
 Special attention is needed to raise the standards of primary care in low performing states such as
Odisha, Madhya Pradesh, Uttarakhand, Rajasthan, Assam and Jharkhand.
 State governments now have greater resources at their command under the new scheme of financial
devolution.
 So States, in partnership with the Centre, must use the funds to upgrade and transform the primary
health care.

Enforcing Basic Rights

 The outbreak of acute encephalitis syndrome (AES) in Bihar led to close to 350 cases and around 100
deaths. Click here to know more.
 The incident highlights the systemic failure of health care in the country and more importantly, calls
for a discourse on the basic rights of citizens.
What are basic needs?
 Needs are different from wants; while the former is an unavoidable necessity, the latter is a wish.
 The determination of needs is done by a more objective criterion unlike wants which are driven by
subjective criteria.
 Baisc needs are that without which people would be denied of a minimally decent life.
 Non-fulfillment of basic needs can cause great harm, even kill people. E.g. lack of adequate supply of
water, food and air
What are basic rights?
 A right is something that is owed to people; it is not a favour offered.
 Basic rights flow from basic needs such as physical security or subsistence.
 In simple terms, basic rights are claims on the state to provide citizens with goods and services that
satisfy their basic needs.
 Significantly, basic rights are a shield for the defenceless against the most damaging threats to their
life.
 The basic rights that could possibly be prioritised as among the firsts are:
1. right to physical security - socially guaranteed when the state provides a professional police
force
2. right to minimum economic security and subsistence - includes clean air, uncontaminated
water, nutritious food, clothing and shelter
3. right to primary health care
4. right to free public expression of helplessness and frustration, if deprived of basic rights
What role does the State have?
 When something is identified as a basic right, it puts the state under a duty to enable its exercise i.e.
the State becomes its guarantor.
 Elementary justice requires that before anything else, the state does everything at its disposal to satisfy
all basic needs of its citizens.
 This particularly applies to those who cannot fend for themselves.
  Credible threats to the basic rights should be reduced by the government by establishing institutions
and practices to assist the vulnerable.
 This, in turn, requires proper budgetary allocation.
 These demands, therefore, incorporate the rights -
i. to make one’s vulnerability public
ii. to be informed about the acts of commission and omission of the government regarding
anything that adversely affects the satisfaction of basic needs
iii. to critically examine and hold state officials publicly accountable
What is the way forward?
 The basic rights must be viewed primarily as positive.
 In other words, basic rights should be rights not against interference from the State (negative rights)
but to the provision of something by the State.
 Just as individuals are punished for legal violations, the government must be held legally accountable
for the violation of these basic rights.
 The systematic violation of basic rights must be treated on a par with the breakdown of constitutional
machinery.
 To sum up, like the constitutional principle of a basic structure, it is time to articulate an equally robust
doctrine of basic rights.

Acute Encephalitis Syndrome in Bihar - Litchi Connect, Malnutrition

 The outbreak of acute encephalitis syndrome (AES) in Bihar has led to close to 350 cases and around
100 deaths.
 While the causes of AES are still researched, the association with hypoglycaemia and litchi fruit has drawn
attention.
What is AES?
 Acute Encephalitis Syndrome (AES) is a broad term involving several infections, and it affects young
children.
 AES is not a disease;it is a syndrome.
 Under its umbrella comes the hypoglycaemia, Japanese Encephalitis, Herpes meningitis, Race syndrome,
cerebral malaria, scrub typhus, etc.
 All of them are grouped under AES as they have a classical triad of sudden onset of fever, convulsions
and loss of consciousness.
How prevalent is AES?
 The first AES case was recorded in 1995 in Muzaffarpur, Bihar.
 Eastern Uttar Pradesh too sees frequent outbreaks.
 There is no fixed pattern, but a year with high temperature and scanty rain usually witnesses high cases.
 Last year, there had been very few cases (in Muzaffarpur) because the general pattern of a few days of
high temperature followed by rain showers was there.
 There were 143 deaths in 2013 and 355 in 2014, which dropped to 11 in 2017 and 7 in 2018.
 But this year, the heat has been prolonged with no spells of rain.
What causes AES?
 The syndrome can be caused by viruses, bacteria or fungi.
 In India, the most common cause is the virus that causes Japanese encephalitis (JE).
 Health Ministry estimates attribute 5-35% of AES cases to the JE virus.
 In Bihar, the Directorate of Health Services claimed that the JE virus had caused only two of the total 342
AES cases this year.
 The syndrome is also caused by infections such as scrub typhus, dengue, mumps, measles, and even
Nipah or Zika virus.
 In the latest outbreak in Muzaffarpur, the cause is yet to be clinically identified in most of the children.
How is hypoglycaemia linked to AES?
 Hypoglycaemia (low blood sugar) is a commonly seen sign among AES patients, and the link has been
the subject of research for long.
 The combination of AES with hypoglycaemia is unique to Muzaffarpur, Vietnam and Bangladesh.
 A 2014 study in Muzaffarpur suggested that hypoglycaemia was the trigger that led to diagnosis of
encephalitis.
 So, Hypoglycaemia is not a symptom but a sign of AES.
 With 98% of AES patients in Bihar also suffering hypoglycaemia, doctors are attributing deaths to the
latter.
 In Bihar, convulsions in children (which is AES) are found in combination with hypoglycaemia.
What is the litchi connect?
 Early researcheshave drawn parallel b/w cases in Bihar’s Muzaffarpur and in Vietnam’s Bac Giang
province.
 In both places, there were litchi orchards in the neighbourhood.
 Methylene cyclopropyl glycine (MCPG), also known as hypoglycin A, is known to be a content of litchi
fruit.
 Undernourished children who ate litchi during the day and went to bed on an empty stomach presented
with serious illness early the next morning.
 When litchi harvesting starts in May, several workers spend time in the fields.
  There, it is common for children to feed on fallen litchis and sleep without food.
 The toxin in litchi (MPCG) lowers blood sugar level during night, and these children are found
unconscious in the morning.
 Blood glucose falls sharply causing severe brain malfunction (encephalopathy), leading to seizures and
coma, and death in many cases.
 However, this remains a subject of debate, and the possible association needs to be documented.
What role does malnutrition play?
 If toxins from litchi were causing hypoglycaemia, then these cases should have remained consistent each
year.
 Also, it should have affected children of all socio-economic strata.
 But in contrast, this year, all deaths have been recorded in the lower income groups.
 While well-nourished children eating litchi remain unaffected even if they go to bed on an empty
stomach, the under-nourished ones were at grave risk.
 This is because under-nourished children lack sufficient glucose reserve in the form of glycogen.
 Also, the production of glucose from non-carbohydrate source is unsafe as it is unsustainable and thus
stopped midway.
 This leads to low blood sugar level, giving way for further health complications.
 In all, even if litchi is a triggering factor, the real cause for adverse effects is said to be malnutrition.
 So, while the cause of AES is still being researched, hypoglycaemic AES may be caused by malnutrition,
heat, lack of rain, and entero-virus.
What makes Bihar and UP so vulnerable?
 Malnutrition is high in both states, and malnourished children are prone to infection.
 As per Health Ministry data, UP and Bihar together account for over 35% of child deaths in the country.
 National Family Health Survey-4 data show that in 2015-16, 48% children aged less than 5 in Bihar were
stunted, which is the highest in India.
 Also, heat, humidity, unhygienic conditions and malnutrition which are unique to these areas, together
contribute to the rise in AES.
 Incidence is higher in litchi fields around which malnourished children live.
What are the measures taken?
 In 2014, 74% of sick children were saved through a simple intervention by infusing 10% dextrose within
4 hours of the onset of illness.
 [Infusing dextrose is necessary to completely stop the attempt by the body to produce glucose from
non-carbohydrate source.]
 Also, the prevention strategy of ensuring that no child goes to bed without eating a meal was adopted
from 2015.
 This ensured a sharp drop in the number of children falling sick.
 The Bihar government introduced free vaccines at all primary health centres.The current coverage is
70%.
 The central and state governments have also conducted awareness campaign asking people not to
expose their children to sun.
 Also, ensuring a proper diet and increased fluid intake were insisted.
 Besides these, early hospital referral and standard treatment for convulsions, high fever and vomiting
can save lives.

Source: Indian Express, The Hindu

Quick Fact
Litchi
 Lychee, (Litchi chinensis), also spelled litchi or lichi, is an evergreen tree of the soapberry family
(Sapindaceae).
 Lychee is native to Southeast Asia.
 Lychee is of local importance throughout much of Southeast Asia and is grown commercially in China
and India.
  They require very little pruning and no unusual attention, though they should have abundant moisture
around the roots most of the time.
 The trees come into production at 3 to 5 years of age.

Dextrose
 Dextrose is the name of a simple sugar that is made from corn and is chemically identical to glucose, or
blood sugar.
 Dextrose is often used in baking products as a sweetener, and can be commonly found in items such as
processed foods and corn syrup.
 For medical purposes, it is dissolved in solutions that are given intravenously, which can be combined
with other drugs, or used to increase a person’s blood sugar.
 As dextrose is a “simple” sugar, the body can quickly use it for energy.
 Simple sugars can raise blood sugar levels very quickly, and they often lack nutritional value.

Doctors Strike - Kolkata Case

 Junior doctors in a medical college in Kolkata were recently attacked causing serious injuries, over the
death of a patient.
 This has led to widespread protests by doctors, across the country.
What is the growing mob culture in this regard?
 The mob mentality has come to dominate India’s social consciousness, causing impact across various
sections of the society.
 Such violence is unique to the Indian Subcontinent.
 Notably, there is increasing institutionalisation of violence through politics, caste, religion, economics
and gender discrimination.
 Institutionalised violence has, in turn, created a hierarchical social order.
 Doctors are amongst those at the top of this hierarchy.
 Doctors - In India, doctors in both public and private sectors are at the receiving end of violence.
 Violence at the workplace, in general, can have negative and disastrous effects on employee satisfaction
and work performance.
 It is essential here to understand why reactions are different when it comes to doctors.
What is exclusive to the health sector?
 Insensitivity - Violence as a means of effecting “justice” is common in Indian society.
 But a large part of the intellectual class, including doctors, remains insensitive to this problem, till they
are affected.
 This is largely because doctors have an insulated existence, unaware of the institutionalised violence
faced by common people.
 Dalits, minorities, women and other underprivileged sections of Indian society suffer violence on a
regular basis.
 But doctors being unaware of this is the most important reason for violence coming back to haunt them.
 As, insensitivity to such violence makes one vulnerable to it.
 The doctor-patient relationship in India is more than merely “professional” as doctors in India are
considered next to god.
 The acceptance of this god-like status by Indian physicians is problematic, as at times, it works against
them.
  The illiterate and deprived people unleash violence on their god-like doctors when they make money
illegally, commit flaws, and fall short of such standards of divinity.
 Corporatisation - The rampant corporatisation of medical practice and erosion of medical ethics in
private and public set-ups is another reason.
 Corporatisation is known to have changed the behavioural patterns of healthcare personnel.
 Misbehaviour, over-treatment, under-treatment and blatantly over-priced treatment have become a part
of the medical culture, giving rise to dissatisfaction.
 Limitations - The country’s medical fraternity, especially young doctors, should realise that they work
with limitations of infrastructure.
 The poor conditions of government hospitals, especially in rural India, is well known.
 This leads to improper care and thus creates conditions rife for violence.
 With just one doctor for every 2,000 people, the situation is only worsened.
 State governments’ reluctance to fill vacancies in public hospitals, and the increasingly high cost of
medical education in the private sector add to the above.
What are the other concerns?
 The working hours for residents, who form the backbone of public-funded healthcare, is dreadfully
irrational.
 But no one, not even the medical fraternity, wants to raise the issue with the administrative authorities
concerned.
 Without raising such issues, it would be wrong for doctors, including those involved in the current
agitation, to turn against patients.
 Strikes by doctors is also debatable from an ethical standpoint.
 Striking work complicates the issue in other ways too by loss of public sympathy and influence of the
administrators, eroding the moral standing of the doctors.
What lies ahead?
 In the Kolkata case, it should be ascertained whether there was a delay in treatment due to manpower
shortage, as the patient’s kin claim.
 West Bengal CM must reach out to the medical community and restore normality.
 The Indian Medical Association (IMA) should help arrive at a solution that can address the concerns of
both doctors and patients.
 Besides, doctors should, in fact, send out the message that they are not against patients.
 A simple way to assert this point would be to run the out-patient clinics outside their hospitals on days
when they are on strike.
 Doctors’ demands for a safe working environment and measures to ensure that unsuccessful
treatments do not become a trigger for revenges have to be looked upon.
 But given the varied reasons for the issue, it is fair now that the doctors’ attention is directed to systemic
failures in the healthcare system.
 At government hospitals, efforts to scale up infrastructure and the capabilities have to be taken up.
 Solutions like fault-finding in security within hospital premises can only provide temporary relief.
 Sensitising young doctors towards the problems of the poor and underprivileged is a more workable
and sustainable solution.
 Teaching behavioural sciences at undergraduate and post-graduate levels can be helpful at bringing the
compassion that is needed.
 Acquainting the young doctors to the prevailing social prejudices could also be a way to inculcate
compassion.

Source: The Hindu, Indian Express

Quick Fact
Indian Medical Association (IMA)
 IMA is the only representative, national voluntary organisation of Doctors of Modern Scientific System
of Medicine in India.
 It looks after the interest of doctors as well as the well being of the community at large.
  It was established in 1928 as the All India Medical Association, and renamed as Indian Medical
Association in 1930.
 IMA, in 1946, helped in organisation of the World body, namely, World Medical Association, and thus
became its founder member.
Nipah Virus Case in Kerala
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Why in news?
A youth from Ernakulam district in Kerala has tested positive for the Nipah virus infection (a year after a similar
outbreak in Kerala had claimed 17 lives).
What is the Nipah virus infection?
 Cause - The natural host of the Nipah virus are fruit bats of the Pteropodidae family and Pteropous
genus, widely found in South and South East Asia.
 However, the actual source of the current infection is not yet known.
 Scientists are currently working on finding the epidemiological link of the outbreak.
 Transmission - The infection is generally transmitted from animals to human beings, mainly from bats
and pigs.
 Human-to-human transmission is also possible, and so is transmission from contaminated food.
 Effect - Nipah virus causes a so far incurable infection in human beings, which can sometimes be fatal.
 Patients either show no symptoms of the infection (asymptomatic infections), thereby making it difficult
to detect.
 Otherwise, patients develop acute respiratory problems, or encephalitis that often becomes fatal.
 The World Health Organization (WHO) says the infection has been found to be fatal in 40% to 75% of
the infected patients.
 There is no treatment available as of now, either for humans or animals, nor any vaccine.

What are the previous incidents of infection?

 Nipah virus infections were first identified in 1999 in Malaysia.
 From then on infections have been detected quite frequently in Bangladesh.
 Kerala - There have been a few incidents of infection in India earlier, apart from the 2018 outbreak in
Kerala.
 The 2018 outbreak was confined to two districts of Kerala, Kozhikode and Malappuram.
 Studies have revealed that a particular kind of fruit bat, Pteropus spp, was most likely the source of
human infection in 2018.
 Research suggested that this particular strain might have been circulating in the local bat population.
 The newly detected case in Kerala is believed to have actually been a result of intensified preventive and
containment efforts after last year’s outbreak.
 The increased awareness and vigilance in the community has helped in early detection this time.
 Elsewhere in India - The first outbreak was in 2001 in Siliguri, West Bengal.
 More than 30 people were hospitalised with suspected infection then.
 Another outbreak happened in 2007 in Nadia of West Bengal, with over 30 cases of fever with acute
respiratory distress and/or neurological symptoms.
 Notably, five of them turned out to be fatal.
Who are potentially at risk?
 Transmission to 18 contacts last year and the two health-care workers this year has been only through
the human-to-human route.
 As of now, the current outbreak is likely localised, like last year’s.
 More people showing symptoms are being screened and so are people in physical contact with them.
  Those with exposure to body fluids (saliva, urine, sputum) of infected patients had higher risk for
asymptomatic infections, than those who only had physical contact with the infected patients.
What are the measures taken?
 The National Institute of Virology (NIV) advised extreme care for healthcare workers and caregivers.
 These include providing double gloves, fluid-resistant gown, goggles, face shields, closed shoes and
similar other protective gear.
 Currently, steps are being taken to prevent the spread of the disease by tracing the contacts, setting up
isolation wards and public engagement.
What is the way forward?
 Containing the spread of the Nipah virus is important as the mortality rate was 89% last year.
 The recurrence of the infection possibly suggests that the virus is in circulation in fruit bats.
 Analysing the evolutionary relationships, a study found 99.7-100% similarity b/w the virus in humans
and bats.
 The confirmation of the source and the recurrence mean that Kerala must be alert to the possibility of
frequent outbreaks.
 It is high time that the state takes continuous monitoring and surveillance for the virus in fruit bats.
 One reason for the failure in not doing so till now could be the absence of a public health protection
agency.
 The government has been in the process of formulating it for over 5 years now, to track such infective
agents before they strike.
 The state should also equip the Institute of Advanced Virology in Thiruvananthapuram to undertake
testing of dangerous pathogens.

Source: Indian Express, The Hindu

Quick Fact
National Institute of Virology
 The National Institute of Virology is one of the major Institutes of the Indian Council of Medical Research
(ICMR).
 It was established at Pune, Maharashtra in 1952 as Virus Research Centre (VRC) under the auspices of
the ICMR and the Rockefeller Foundation (RF), USA.
 It was an outcome of the global programme of the RF for investigating the Arthropod Borne viruses.
 The RF withdrew its support in 1967 and since then the Institute is entirely funded by the ICMR, taking
up intensive training and research in virology.
Human Health Impacts of Air Pollution
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Why in news?
 The World Environment Day is being celebrated on June 5 every year.
 In this backdrop, the United Nations has warned that 9 out of 10 people on the planet are now breathing
polluted air and nobody is safe from air pollution.
What causes air pollution?
 The five main sources of air pollution are -
1. indoor burning of fossil fuels, woods and other biomass to cook, heat and light homes
2. industry, including power generation such as coal-fired plants and diesel generators
3. transport, especially vehicles with diesel engines
4. agriculture, including livestock, which produces methane and ammonia, rice paddies, which
produce methane, and the burning of agricultural waste
5. open waste burning and organic waste in landfills
 Burning fossil fuels for power, transport and industry is a major contributor to air pollution.
  Some of the same pollutants contribute to both climate change and local air pollution, including black
carbon or soot and methane.
How serious is air pollution?
 Air pollution has led to a growing global health crisis, which already causes about 7 million deaths per
year according to WHO.
 It is as well the main source of planet-warming carbon emissions.
 In the 15 countries that emit the most planet-warming gases, the cost of air pollution for public health
is estimated at more than 4% of GDP.
 In comparison, keeping heat to the Paris Agreement temperature limits would require investing about
1% of global GDP.
What are the evident human impacts of air pollution?
 Air pollution kills 800 people every hour or 13 every minute.
 This accounts for more than 3 times the amount of people who die from malaria, tuberculosis and AIDS
combined each year.
 Air pollution is responsible for 26% of deaths from ischemic heart disease, 24% of deaths from strokes,
43% from chronic obstructive pulmonary disease and 29% from lung cancer.
 Household air pollution causes about 3.8 million premature deaths each year.
 The vast majority of them are in the developing world, and about 60% of these deaths are among women
and children.
 93% of children worldwide live in areas where air pollution exceeds WHO guidelines.
 600,000 children below the age of 15 died from respiratory tract infections in 2016.
 In children, it is associated with low birth weight, asthma, childhood cancers, obesity, poor lung
development and autism, among others.
 As many as 97% of cities in low- and middle-income countries with more than 100,000 inhabitants do
not meet the WHO minimum air quality levels.
 In high-income countries, 29% of cities fall short of guidelines.
 Among urban ambient air pollution factors from fine particulate matter, -
i. about 25% is contributed by traffic
ii. 20% is contributed by domestic fuel burning
iii. 15% is contributed by industrial activities including electricity generation
 Keeping global warming well below 2°C could save about one million lives a year by 2050 through
reducing air pollution alone.
Under-Five Mortality and Low Birth Weight - Lancet Global Health
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May 16, 2019
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Why in news?
The Lancet Global Health journal recently published the results of studies on under-five mortality and low
birth weight.
How is under-five mortality rate?
 The deaths among children under five years in India was higher than in any other country in 2015.
 India has reduced annual mortality among children under five.
 It is down from 2.5 million in 2000 (90.5 per 1,000 live births) to 1.2 million in 2015 (47.8 per 1,000 live
births).
 However, it was still the highest in the world.
 Among the states, the highest mortality rate, in Assam at 73.1 per 1,000, was more than 7 times that in
Goa’s 9.7.
 Among the regions, the mortality rate ranged from a low of 29.7 per 1,000 (South) to 63.8 (Northeast).
 Globally, there are large disparities in the child mortality rate b/w richer and poorer states.
What is the low birth weight scenario?
 India - Every newborn must be weighed; yet worldwide, there are no records for the birth weight of
nearly one-third of all newborns.
 India is among 47 countries which had insufficient data.
 These include 40 low- and middle-income countries that account for almost a quarter of all births
worldwide.
 The researchers said they were unable to arrive at national estimates for India as only partial data were
available.
 The national estimate and time trend for India was not reported.
 The National Family Health Survey (2005-06) was included in the analysis.
 But for the latest NFHS (2015-16), only data for a single year met the inclusion criteria and these partial
data were used.
 Nevertheless, the estimated prevalence of low birth weight in South Asia has decreased from 32.3% in
2000 to 26.4% in 2015.
 There is optimism that India, in view of its large population, will have made an important contribution
to this decline.
 Notably, India has made progress in improving newborn care by building 834 newborn care units in the
last decade.
 Moreover, in 2011, The Indian Statistical Institute had reported that nearly 20% of newborns have low
birth weight in India.
 Besides, the Union Ministry of Health and Family Welfare reports that the prevalence of low birth weight
was b/w 15% and 20%.
 Globally, one in every 7 babies [20.5 million babies (14.6%)] was born with low birth weight i.e. less than
2.5 kg, in 2015.
 The prevalence in 2015 was lower than the 17.5% (22.9 million babies with low birth weight) in 2000.
 However, over 90% of the low-weight babies in 2015 were born in low- and middle-income countries.
 In high-income countries in Europe, North America, and Australia and New Zealand, there has been no
progress in reducing low birth weight rates since 2000.
 However, prevalence is low in most of these countries.
 One of the lowest rates of low birth weight in 2015 was estimated in Sweden (2.4%).
 It is around 7% in some high-income countries including the USA (8%), the UK (7%), Australia (6.5%),
and New Zealand (5.7%).
 The regions making the fastest progress are those with the highest numbers of low birth weight babies.
 E.g. Southern Asia and Sub-Saharan Africa recorded a yearly decline in prevalence of 1.4% and 1.1%,
respectively, b/w 2000 and 2015.
What does it call for?
 Under-five mortality - The UN Millennium Development Goals (MDG) set in 2000 was to reduce the
under-five mortality rate in 2015 to one-third of the 1990 figure.
 For India, that would have meant reducing the under-five mortality rate to 39 deaths per 1,000 live births.
 In India, most under-five deaths were due to preterm complications.
 But preventable infectious diseases too featured prominently as causes of death in higher-mortality
states.
 India can accelerate reduction of under-five mortality rates by scaling up vaccine coverage and
improving childbirth and neonatal care.
 Low birth weight - The study highlights that national governments are doing too little to reduce low
birth weight.
 There is little change over 15 years, even in high-income settings.
 Here, low birth weight is often due to prematurity as a result of high maternal age, smoking, etc.
 Caesarean sections not medically indicated and fertility treatments that increase the risk of multiple
births are also the causes.
 The study thus noted that annual decline will need to more than double to meet the global target of a
30% reduction b/w 2012 and 2025.
 The study calls for immediate action to tackle the underlying causes of low birth weight.

Report on Economic Impacts of Antimicrobial Resistance

iasparliament
May 02, 2019
7 months
1181
0
Why in news?
The Interagency Coordination Group on Antimicrobial Resistance (IACG) has brought out a report on
economic impacts of antimicrobial resistance.
What is the report for?
 Antimicrobial resistance (AMR) refers to a condition of antibiotics becoming inefficient against a wide
range of pathogenic bacteria.
 It is emerging as a global public health concern and is acknowledged by policymakers as a major
health crisis.
 But the economic impacts of AMR are not taken into account by many.
 The IACG report titled “No Time to Wait: Securing The Future From Drug Resistant Infections” brings
attention to the financial implications of AMR.
What are the highlights?
 In about 3 decades from now, uncontrolled AMR will cause global economic shocks on the scale of
the 2008-09 financial crisis.
 Nearly 10 million people are estimated to die annually from resistant infections by 2050.
 The health-care costs and the cost of food production will spike as a result of this.
 On the other hand, the income inequality will widen too.
 In the worst-case scenario, the world will lose 3.8% of its annual GDP by 2050 on this account.
 Alongside, 24 million people will be pushed into extreme poverty by 2030.
 For high- and mid-income nations, the price of prevention, at $2 per head a year, is extremely
affordable.
 For poorer countries, the price is higher but still modest compared to the costs of an antibiotic
disaster.
 The ICAG thus calls for the nations to acknowledge this eventuality, and act to fight against it.
Where does India stand?
 India first published almost 9 years ago the broad outlines of a plan to fight antimicrobial resistance.
 But the difficulty has been in implementing it, given the twin challenges of antibiotic overuse and
underuse.
 On the one hand, many Indians still die of diseases like sepsis and pneumonia because they do not
get the right drug at the right time.
 On the other hand, a poorly regulated pharmaceutical industry means that antibiotics are freely
available to the affordable ones.
Click here to read more on causes for AMR and the measures in place.
What is to be done?
 Some immediate steps could include measures such as phasing out critical human-use antibiotics in
the animal husbandry sector, such as quinolones.
 The only way to postpone resistance is through improved hygiene and vaccinations, and it demands
a multi-stakeholder approach.
 It is a challenging task as India still struggles with low immunisation rates and drinking water
contamination.
 So besides regulators, it needs the involvement of the private industry, philanthropic groups and
citizen activists.
 Private pharmaceutical industries must take it upon themselves to distribute drugs in a responsible
manner.
 Philanthropic charities must fund the development of new antibiotics, while citizen activists must drive
awareness.
 The emerging challenge is a serious one, as once crucial antibiotics are lost to humankind, they may
be lost for decades.

Source: The Hindu

Quick Fact
Interagency Coordination Group on Antimicrobial Resistance
 In 2016, the United Nations General Assembly adopted the Political Declaration of the High-level
Meeting on Antimicrobial Resistance.
 It called for the establishment of the Interagency Coordination Group on Antimicrobial Resistance
(IACG).
 The IACG’s mandate is to provide practical guidance for approaches needed to ensure sustained,
effective global action to address AMR.
 It is also tasked to report back to the UN Secretary-General in 2019.
 The IACG Secretariat is hosted by WHO, with contributions from FAO (Food and Agriculture
Organization) and the World Organisation for Animal Health (OIE).
Life Expectancy - World Health Statistics Overview 2019
iasparliament
April 08, 2019
8 months
1416
0
Why in news?
The World Health Organization (WHO) recently released the World Health Statistics Overview 2019.
What are the highlights?
 For men and women combined, average life-expectancy has increased by 5½ years since the turn of the
century.
 It has increased from 66.5 years in 2000 to 72 years in 2016.
 On the other hand, “healthy” life expectancy (number of years lived in full health) increased from 58.5
years in 2000 to 63.3 years in 2016.
 In 2019, more than 141 million children will be born - 73 million boys and 68 million girls.
 Based on recent mortality risks the boys will live, on average, 69.8 years and the girls 74.2 years, which
is a difference of 4.4 years.
 Likewise, life expectancy at age 60 years is also greater for women (21.9 years) than men (19.0 years).
 Overall, women outlive men everywhere.
 Whether it’s homicide, road accidents, suicide, cardiovascular disease, men are doing worse than women.
 Global suicide mortality rates were 75% higher in men than in women in 2016.
 Death rates from road injury are more than twice as high in men as in women from age 15.
 Mortality rates due to homicide are 4 times higher in men than in women.
  Country-wise discrepancy - There is 18.1-year gap in life expectancy b/w poorest and richest countries.
 The report also indicates that the life expectancy gap is narrowest where women lack access to health
services.
 Maternal deaths contribute “more than any other cause” to reducing female life expectancy.
 Here too, the risk of maternal death is hugely different b/w high-income and low-income countries.
 Notably, one in 41 women dies from a maternal cause in a low-income country.
 In contrast, only one in 3,300 women die from a maternal cause in a high-income setting.
 In more than 90% of low-income countries, there are fewer than 4 nursing and midwifery personnel per
1000 people.
What are the possible reasons?
 The report attributes the discrepancy b/w men and women to differing attitudes to healthcare b/w them.
 E.g. in countries with generalised HIV epidemics, men are less likely than women to take an HIV test
 Hence men are less likely to access antiretroviral therapy and more likely to die of AIDS-related illnesses
than women.
 The same principle applies for tuberculosis sufferers, with male patients less likely to seek care than
women.
 So men are much more likely to die from preventable and treatable non-communicable diseases.

Addressing Undernutrition in India

iasparliament
March 25, 2019
8 months
831
0
What is the issue?
 There is decline in infant and under-five mortality rates in India along with a simultaneous increase in
undernutrition.
 This calls for adopting a holistic approach in child healthcare and addressing the root causes for
undernutrition.
What is the undernutrition scenario?
 Through the interaction of the indices of height, weight and age, undernutrition takes the form of -
i. stunting (low height-for-age)
ii. wasting (low weight-for-height)
iii. underweight (low weight-for-age)
 As opposed to macroeconomic indicators, social development indicators change gradually over a longer
period of time.
 Accordingly, the results of these interventions are reflected with a lag.
 Despite an understanding on this fact, the incidence of undernutrition in children in India is high.
 The proportion of children under 5 years of age in the stunted and underweight category has witnessed
only a marginal decline in the previous decade.
 On the other hand, wasting and severe wasting have increased significantly.
What is the infant mortality scenario?
 Historically, childbirth has been dangerous for both women and infants, despite largely preventable
causal factors.
 But, the government interventions in recent years in healthcare in terms of budget allocation, healthcare
schemes and health outcomes have helped significantly.
 Sustained efforts at addressing the causal factors of high infant mortality rate (IMR) have resulted in its
consistent decline from 55.7 (2005) to 32 (2017).
 The percentage of institutional deliveries has nearly doubled from around 38% (2005-06) to 78% (2015-
16) through initiatives such as Janani Suraksha Yojana.
 Interventions in neonatal (first 28 days of birth) and post-neonatal healthcare (first 28 days of birth to 1
year) have played a pivotal role in bringing down child mortality.
 Furthermore, schemes such as the National Rural Health Mission and the Reproductive, Maternal,
Newborn, Child and Adolescent Health (RMNCH+A) strategy have helped much.
 India is thus moving closer to the Sustainable Development Goals (SDGs) target of ending preventable
deaths of infants and mothers by 2030.
 Meanwhile, the commensurate decline in under-five mortality rate (U5MR) has taken place at a visibly
faster pace than IMR.
 U5MR for India is now almost at par with the global average of 39.
 This is a result of measures and efforts in immunisation coverage and other factors.
What do these imply?
 Clearly, on one hand, IMR and U5MR are declining, and on the other, the burden of undernutrition in
children in absolute numbers is on the rise.
 Undernutrition certainly indicates the much-to-be-desired nutritional status of the country.
 The nascent stages of policy intervention towards addressing moratlity rates have prioritised the survival
of children.
 It reflects the principle of "first ‘survive’ and then ‘thrive’", as advocated by the World Health Organisation
(WHO).
What is the policy shortfall?
 The government policy has focused on significant causal factors of IMR and U5MR, like postnatal
healthcare.
 However, other important factors like nutritional status of adolescent girls (future mothers) and prenatal
nutrition have received scant attention.
 But notably, nutritional status runs in a viscous intergenerational cycle.
 The adolescent girls with poor nutritional status later become undernourished pregnant women.
 They, in turn, are likely to give birth to children who are stunted, wasted or underweight.
What lies ahead?
 A lower IMR and U5MR means that the total population of surviving children has increased in absolute
numbers.
 As a consequence, the total proportion of undernourished children has also increased in absolute
numbers.
 The next logical step would thus involve shifting focus of government policy towards tackling the
incidence of undernutrition.
 Any attempt to reduce undernutrition in India should address the root causes.
 Policy intervention should now focus on bringing down the incidence of undernutrition in adolescent
girls, pregnant women and young children.

Trade Margin Cap on Anti-Cancer Drugs

iasparliament
March 13, 2019
9 months
1787
0
Why in news?
The National Pharmaceutical Pricing Authority (NPPA) has imposed a trade margin cap on 42 non-scheduled
anti-cancer drugs.
What are scheduled and non-scheduled drugs?
 “Scheduled drugs” or “Scheduled formulations” are those medicines which are listed out in the Schedule
I of Drug Price Control Order (DPCO) and on which price controls are applicable.
 Since 2013, scheduled drugs consist of the “Essential Medicines” declared so by the Government through
its National List of Essential Medicines (NLEM).
 Any formulation based on combination of any one of the drugs appearing under NLEM can be subject
to price fixation.
 In other words, NLEM forms the basis of deciding on the “Scheduled drugs”.
 On the other hand, non-scheduled formulations are medicines that are not under price control of NPPA.
  In this case, the Drug Prices Control Order, 2013 allows manufacturers to increase the MRP by 10%
annually.
 So while essential medicines are subject to absolute price controls in the form of ceiling prices, the non-
essential/non-scheduled medicines are subject to a managed price increase.
What is NPPA's present order?
 Currently, 57 anti-cancer drugs are under price control as scheduled formulations.
 Now, 42 non-scheduled anti-cancer medicines have been selected for price regulation, with MRP
reduction up to 87%.
 These would cover more than 7o formulations and around 390 brands.
 Trade margins are capped at 30% of the MRP, or conversely a 43% mark-up on the price to the stockist
(price at which manufacturers supply to retailers).
 The manufacturers of these 42 drugs have been directed not to reduce production volumes of brands
under regulation.
Why is it significant?
 Being non-scheduled, these 42 life-saving drugs do not fall under the ambit of price control.
 The NPPA has thus invoked its extraordinary powers in public interest, under Para 19 of the Drugs (Prices
Control) Order, 2013, for this move.
 As per this, the Government may fix the ceiling price or retail price of any drug, whether scheduled or
non-scheduled or a new drug, for such period as it may deem fit.
 NPPA'S move is thus a new paradigm of regulation by the pharma industry.
How will it benefit?
 According to the NPPA, the rationalisation of trade margins will lead to an MRP reduction of 50-75% in
the case of 124 brands.
 In the case of another 121 brands, the reduction will be 25-50% and up to 87% in some cases.
 The price rationalisation move is expected to benefit 22 lakh cancer patients in the country.
 This is likely to result in annual savings of approximately Rs. 800 crores to the consumers.
 Notably, the average out of pocket expenditure for cancer patients is 2.5 times that for other diseases.
 Out of pocket expenses in India account for nearly 70% of total healthcare expenses.
 Significantly, cancer care forces even middle-class households into debt and economic distress.

Source: Business Line, PIB, The Hindu

Quick Facts
National Pharmaceutical Pricing Authority
 National Pharmaceutical Pricing Authority (NPPA) was constituted through a Government of India
Resolution in 1997.
 It is an attached office of the Department of Pharmaceuticals (DoP), Ministry of Chemicals & Fertilizers.
 It works as an independent regulator for pricing of drugs and also ensures availability and accessibility
of medicines at affordable prices.
 It implements and enforces the provisions of the Drugs (Prices Control) Order in accordance with the
powers delegated to it.
Climate Change and India's Nutritional Security
iasparliament
March 09, 2019
9 months
1413
0
What is the issue?
 Climate change and global warming are increasingly posing risks to India's food and nutritional security.
 This requires urgent prioritisation, strong political will and dedicated resources for sustainable and
public health friendly measures.
What is the looming threat?
  The Intergovernmental Panel on Climate Change shared that human activities have led to a 1°C (0.8°C
to 1.2°C) rise in temperatures above pre-industrial levels.
 This will reach 1.5°C b/w 2030 and 2052, if it continues to increase at the current rate.
 The atmospheric concentrations of carbon dioxide (the primary greenhouse gas) have risen to 410 parts
per million (ppm) from about 280 ppm in pre-industrial times.
 The World Health Organisation estimated that approximately 250,000 deaths annually b/w 2030 and
2050 could be due to climate change.
 Several reports confirm that the poorest people, already suffering from the highest rates of under-
nutrition, will be the most vulnerable to climate change.
How vulnerable is India?
 Agriculture - Indian agriculture, and thereby India’s food production, is highly vulnerable to climate
change.
 This is largely because the sector continues to be highly sensitive to monsoon variability.
 About 65% of India’s cropped area is rain-fed.
 Nutrition - India already is one of the top rankers in multiple forms of malnutrition globally.
 There are multiple reasons contributing to poor nutritional status of India's population.
 They range from food scarcity to food excess (unhealthy), increased consumption of refined cereals,
simple sugars and salt, etc.
 However, adverse variables like climate change, pollution, etc, added to this scenario can further
worsen the public health nutrition (PHN) indices.
 With only about one in 10 children getting adequate nutrition, India at least ought to keep other
potentially influential variables favourable.
How serious is nutrition and climate change link?
 India already depends a lot on imports for fulfilling nutritional needs of the population.
 With the ensuing climate change, the access to safe and nutritious food, and affordability, is bound to
be impacted severely.
 Under-nutrition (increased nutrient demands and reduced nutrient absorption) can be exacerbated by
the effects of climate change.
 Suboptimal diet (micronutrient deficiencies and overall poor nutritional status) during vulnerable stages
(e.g. pregnancy lactation) may have adverse repercussions for several generations.
 The onset of risk factors for non-communicable diseases (hypertension, diabetes, cardiovascular
problems, etc) is faster and earlier in people with nutrient deficiencies.
 The EAT-Lancet Commission’s food advisory recommends consumption of fruits and vegetables rather
than meat for preserving own health and nature.
 But evidently, environmental changes reduce yields of starchy staple crops and alter nutrient
composition of fruits, vegetables and legumes.
 This is a serious issue in a country like India with micronutrient and protein deficiency in more than half
of its population.
 Furthermore, various other factors negatively affect vegetable and legume yields, which are -
i. the absence of adaptation strategies.
ii. the increasing ambient temperature in (sub)tropical areas
iii. tropospheric ozone
iv. water salinity and decreasing water availability
 Also, the increasing level of carbon dioxide is implicated in “dilution effect” resulting in lesser vitamins
and minerals per unit of yield.
What should be done?
 Funding needs to be earmarked for designing, rolling out modern climate change-
resistant infrastructure and technology.
 Early warning systems are needed for farmers to produce sufficient food and traders to adequately store
food in the face of extreme weather events.
 More sustainable, resilient and efficient ways of producing, trading, distributing and
consuming diversified agricultural food products should be adopted.
  Involving food technologists to devise food storage and processing practices to reduce climate-related
food safety concerns can help.
 These strategies can also support reducing food waste.
 Building and strengthening the capacity of public health professionals and allied forces, increasing the
number of healthcare facilities/staff could help.
 Academic and research ccapacity needs to be augmented.
 drawing upon best practices from agriculture, public health, nutrition, transport and environment is
essential to prepare Integrated curriculum qualified interdisciplinary workforce.
 Investment in social protection schemes and livelihood security mechanisms can significantly tackle
malnutrition and build resilience.
 The cross-sectoral nature of nutrition, adverse impact of climate change, and the interaction b/w these
two calls for increased policy coherence.
 India’s recently launched National Nutrition Mission or the POSHAN Abhiyaan is an ideal way to start
advocating for PHN in an environment-friendly manner.

Regulating drug prices

iasparliament
February 28, 2019
9 months
1231
0
What is the issue?
Out-of-pocket expenditure on health is higher in India and hence more needs to be done to make
medicines affordable.
How are prices regulated?
 The largest share of out-of-pocket expenditure on health is due to medicines in India (approximately
70%, according to the NSSO).
 This is a major access barrier to healthcare, especially for the poor.
 Thus, to make medicines affordable, the DPCO (Drug price control order) was made to control the
prices of all essential medicines by fixing ceiling prices, limiting the highest prices companies can
charge.
 The National List of Essential Medicines (NLEM) is drawn up to include essential medicines that satisfy
the priority health needs of the population.
 The list is made with considerations of safety, efficacy, disease prevalence and the comparative cost-
effectiveness of medicines.
 The list is updated periodically by an expert panel set up for this purpose under the aegis of the
Ministry of Health and Family Welfare.
 This list forms the basis of price controls under the DPCO.
What is the mechanism for price capping?
 The NLEM 2015 contains 376 medicines on the basis of which the National Pharmaceutical Pricing
Authority (NPPA) has fixed prices of over 800 formulations using the provisions of the DPCO.
 However, these formulations cover less than 10% of the total pharmaceutical market.
 The DPCO follows a market-based pricing mechanism.
 Accordingly, the ceiling price is worked out on the basis of the simple average price of all brands
having at least 1% market share of the total market turnover of that medicine.
Have any other methods been used?
 Prior to 2013, the DPCO followed a cost-based pricing mechanism that was based on the costs
involved in manufacturing a medicine along with reasonable profit margins.
 Health experts have argued that this policy resulted in comparatively lower prices than the current
market-based policy.
 Since the implementation of the DPCO, 2013, the NPPA has made certain departures from the market-
based pricing mechanism, which was found to be insufficient for ensuring affordability.
  This has been done through the use of special powers to act in public interest under Paragraph 19 of
the DPCO.
 In 2013, the government had delegated these powers to NPPA to set the price cap of scheduled and
non-scheduled drugs.
 These are the same powers NPPA used in 2017 to cap prices of cardiac drugs, stents and knee
implants.
What is the case with cancer drugs?
 The government recently planned to cap the trade margins for highly priced drugs for cancer and rare
diseases to bring down their prices.
 This is because of the recent amendments to the DPCO that exempted patented medicines and rare
disease drugs from price controls.
 Under the amendment, a drugmaker who has brought in an innovative patented drug will be exempt
from the price control regulations for 5 years from the date of marketing.
 Also, drugs for treating rare or “orphan” diseases too will be exempt from price control, with a view to
encouraging their production.
 However, only MNCs are manufacturing orphan drugs at the moment; so lack of price control will have
a detrimental effect on affordability.
 Along with that, cancer drugs are increasingly patented with no generic competition, putting them out
of the reach of poor patients.
 Even the recent plan to cap trade margins will not sufficiently bring down prices.
 Thus, the government should take serious policy measures to ensure true affordability such as through
price controls, implementation of the national rare disease policy and the use of legal flexibilities under
patent law.
Regulating drug prices
iasparliament
February 28, 2019
9 months
1231
0
What is the issue?
Out-of-pocket expenditure on health is higher in India and hence more needs to be done to make
medicines affordable.
How are prices regulated?
 The largest share of out-of-pocket expenditure on health is due to medicines in India (approximately
70%, according to the NSSO).
 This is a major access barrier to healthcare, especially for the poor.
 Thus, to make medicines affordable, the DPCO (Drug price control order) was made to control the
prices of all essential medicines by fixing ceiling prices, limiting the highest prices companies can
charge.
 The National List of Essential Medicines (NLEM) is drawn up to include essential medicines that satisfy
the priority health needs of the population.
 The list is made with considerations of safety, efficacy, disease prevalence and the comparative cost-
effectiveness of medicines.
 The list is updated periodically by an expert panel set up for this purpose under the aegis of the
Ministry of Health and Family Welfare.
 This list forms the basis of price controls under the DPCO.
What is the mechanism for price capping?
 The NLEM 2015 contains 376 medicines on the basis of which the National Pharmaceutical Pricing
Authority (NPPA) has fixed prices of over 800 formulations using the provisions of the DPCO.
 However, these formulations cover less than 10% of the total pharmaceutical market.
 The DPCO follows a market-based pricing mechanism.
  Accordingly, the ceiling price is worked out on the basis of the simple average price of all brands
having at least 1% market share of the total market turnover of that medicine.
Have any other methods been used?
 Prior to 2013, the DPCO followed a cost-based pricing mechanism that was based on the costs
involved in manufacturing a medicine along with reasonable profit margins.
 Health experts have argued that this policy resulted in comparatively lower prices than the current
market-based policy.
 Since the implementation of the DPCO, 2013, the NPPA has made certain departures from the market-
based pricing mechanism, which was found to be insufficient for ensuring affordability.
 This has been done through the use of special powers to act in public interest under Paragraph 19 of
the DPCO.
 In 2013, the government had delegated these powers to NPPA to set the price cap of scheduled and
non-scheduled drugs.
 These are the same powers NPPA used in 2017 to cap prices of cardiac drugs, stents and knee
implants.
What is the case with cancer drugs?
 The government recently planned to cap the trade margins for highly priced drugs for cancer and rare
diseases to bring down their prices.
 This is because of the recent amendments to the DPCO that exempted patented medicines and rare
disease drugs from price controls.
 Under the amendment, a drugmaker who has brought in an innovative patented drug will be exempt
from the price control regulations for 5 years from the date of marketing.
 Also, drugs for treating rare or “orphan” diseases too will be exempt from price control, with a view to
encouraging their production.
 However, only MNCs are manufacturing orphan drugs at the moment; so lack of price control will have
a detrimental effect on affordability.
 Along with that, cancer drugs are increasingly patented with no generic competition, putting them out
of the reach of poor patients.
 Even the recent plan to cap trade margins will not sufficiently bring down prices.
 Thus, the government should take serious policy measures to ensure true affordability such as through
price controls, implementation of the national rare disease policy and the use of legal flexibilities under
patent law.
Understanding Zika
iasparliament
February 28, 2019
9 months
1460
0
What is the issue?
India should have a clear knowledge on Zika epidemiology before its next outbreak.
What is Zika?
 Zika is a viral infection, spread by mosquitoes, the vector is the Aedes aegypti mosquito, which also
spreads dengue and chikungunya.
 Additionally, infected people can transmit Zika sexually.
 Most people infected with the virus do not develop symptoms, the symptoms are similar to those of flu,
including fever body ache, headache etc.
 Additional symptoms can include the occasional rash like in dengue, while some patients also have
conjunctivitis.
 Also, fears around Zika primarily involve microcephaly, especially when pregnant women are infected.
 Microcephaly is a condition in which babies are born with small and underdeveloped brains.
 In India, Madhya Pradesh and Rajasthan saw large outbreaks of Zika in 2018.
How does dengue influence Zika outbreaks?
  Two studies published earlier this year show conflicting evidence for the role of dengue in Zika
outbreaks.
 The first study showed that in mice, the presence of dengue antibodies led to more placental damage
and restricted foetal growth due to Zika.
 Another study showed that people infected by dengue were protected against Zika during an outbreak
in Salvador, Brazil.
 Given this conflicting evidence, scientists are very far from understanding what makes Zika deadly to
foetuses.
 This means that any data on how the pregnancies of Zika-infected women pan out in India can be of
much help to the health authorities.
 Thus, careful studies must be carried out to see if there is increased prevalence of microcephaly in India,
and to understand the risk-factors.
What are the measures needed?
 Screening - The TORCH (Toxoplasmosis, Other, Rubella, Cytomegalovirus, and Herpes) infections are
known to cause foetal abnormalities, including microcephaly, among newborns.
 Thus, wherever women are screened for TORCH, they must also be screened for Zika.
 Monitoring - There is no evidence conclusively linking a particular viral strain or mutation with foetal
anomalies so far.
 The Indian Council of Medical Research (ICMR) said during the outbreak in Rajasthan, the Rajasthan
strain did not have the S139N mutation – which is linked to microcephaly.
 However, conclusion from several research across the globe shows that all Zika strains can cause
microcephaly.
 Thus, the health authorities in the states of Rajasthan and Madhya Pradesh must follow up on every
pregnant woman who was diagnosed Zika positive last year.
 Focus - Health authorities should gather information that concerns population immunity.
 To study immunity, authorities must conduct seroprevalence surveys, in which they screen people in
several States for antibodies to zika and subsequently identify pockets of low immunity in India.
 Health authorities can then focus their efforts on these regions, because they would be most vulnerable
to future outbreaks.
What should be done further?
 Seroprevalence studies are not easy to do, given the cross-reactivity that plagues flaviviruses.
 The Enzyme-linked immunosorbent Assay (ELISA), which is commonly used in seroprevalence studies to
detect antibodies, can throw up false positives for Zika if a person has dengue antibodies.
 This is because dengue antibodies can neutralise Zika and vice versa.
 Hence, the researchers around the globe are working to develop alternative tests that are specific to
Zika alone.
 A multinational team has developed an ELISA test that is able to distinguish Zika from dengue.
 The test was used in a survey at Managua, Nicaragua after a large epidemic hit the city in 2016.
 It found that in 2017, 56% of tested adults had antibodies to Zika, suggesting that the city wouldn’t see
another large epidemic in the near future.
 Thus, India should consider doing such surveys in its own geographical region as soon as possible and
should not wait until the mosquito season begins again.

Promoting E-pharmacies
iasparliament
February 26, 2019
9 months
772
0
What is the issue?
Entry of e-pharmacies will bring down the price of medicine for Indian patients.
What are E-pharmacies?
  Nearly 8.4 lakh pharmacists run the brick and mortar pharmacies in neighbourhoods across India.
 E-pharmacies operate through websites or smartphone apps on the Internet with the convenience of
home delivery of medicines to one’s doorstep.
 They offer medicines for sale at a discount of at least 20% when compared to traditional pharmacists.
 For scheduled drugs, patients can submit photographs of prescriptions while placing orders.
 However, despite operating in India for at least four years now, the legal status of these e-pharmacies is
not clear because the government is yet to notify into law draft rules that it published in 2018.
What are the views against e-pharmacies?
 The fiercest opponents of e-pharmacies are trade associations of existing pharmacists and chemists.
 They argue that their livelihoods are threatened by venture capital backed e-pharmacies and also the
employment that the sector generates.
 They also argue that e-pharmacies will pave the way for drug abuse and also the sale of sub-standard
or counterfeit drugs, thereby threatening public health.
What are the barriers for the entry of e-pharmacies?
 A free market is efficient only if all sellers are competing with each other to offer the lowest price to the
customer.
 Entry of e-pharmacies will promote competition which will have the effect on lowering the price of
medicine for Indian patients.
 However, over the last decade, trade associations of pharmacists are providing platforms
for cartelisation where pharmacists are basically rigging the market.
 Pharmacists prefer to enter into agreements with each other to fix the price at which they will sell
medicines to patients.
 This has resulted in an artificial inflation of medicine prices, making pharmacists to gain higher profits
at the cost of the patient who now has to pay higher prices.
 Also, regional trade associations require pharmaceutical companies to apply for a no-objection-
certificate (NOC) before they appoint new stockists in a region to sell a particular drug.
 This has the effect of artificially restricting competition in certain markets because more stockists mean
more competition.
 By creating such artificial, extra-legal barriers to the free trade of medicines within India, these trade
associations create huge distortions in the Indian market.
What does the competition commission of India say in this regard?
 The CCI in its recent policy note pointed out that unreasonably high trade margins contribute to high
drug prices in India.
 It also noted that self-regulation by trade associations contributes towards high margins for them.
 This is because these trade associations control the entire drug distribution system in a manner
that mutes competition.
 Hence, the CCI proposed that more e-pharmacies should be encouraged.
 Electronic trading of medicines via online platforms, with appropriate regulatory safeguards, can bring
in transparency.
 It can also spur price competition among platforms and among retailers, as has been witnessed in other
product segments.

Report on Magnitude of Substance Use in India

iasparliament
February 22, 2019
9 months
1663
0
Why in news?
The Ministry of Social Justice & Empowerment recently released the 'Magnitude of Substance Use in India'
report.
What is the report on?
  It is based on a survey conducted by the National Drug Dependence Treatment Centre (NDDTC) under
the AIIMS, Delhi.
 The survey was sponsored by the ministry of social justice and empowerment.
 It covered general population (10-75 years) in all the 36 states and union territories.
What are the highlights?
 Alcohol/Liquor - India is home to 6 crore alcohol 'addicts', and there are 16 crore people who consume
alcohol.
 Nearly 1.6% women and 27.3% men in the country use alcohol.
 The consumption level is very high among the male population and many fall in the age bracket of 18-
49 years.
 Also, 1.3% of children (ages 10-17) are alcohol users, as opposed to 17.1% in the 18-plus age group.
 States with high prevalence are Chhattisgarh (35.6%), Tripura (34.7%), Punjab (28.5%), Arunachal Pradesh
(28%) and Goa (28%).
 Among women, states with the largest prevalence of alcohol use are Arunachal Pradesh (15.6%) and
Chhattisgarh (13.7%).
 Among children, a high prevalence was found in Punjab (6%), West Bengal (3.9%) and Maharashtra
(3.8%).
 Country liqour (Desi Sharab) accounts for 30% of the total liquor consumption.
 Indian made foreign liquor (spirits) also account for the same amount.

 Drugs - More than 3.1 crore Indians (2.8%) have reported using cannabis products (Bhang, Ganja,
Charas, Heroin and Opium) in last one year.
 At the national level, Heroin is most commonly used substance followed by pharmaceutical opioids,
followed by opium (Afeem).
 Cannabis consumption is higher than the national average in Uttar Pradesh, Punjab, Sikkim, Chhattisgarh
and Delhi.
 In Punjab and Sikkim, the prevalence of cannabis use disorders is considerably higher (more than thrice)
than the national average.
  Sedatives and inhalants - Less than 1% or nearly 1.18 crore people use sedatives, non medical or non
prescription use.
 Strikingly, its prevalence is high among children and adolescents.
 Addiction of children is more prevalent in U.P, Madhya Pradesh, Maharashtra, Delhi and Haryana.
 At national level, there are 4.6 lakh children that need help against the harmful or dependence over
inhalants.
 Injection of drugs - 8.5 lakh people in the country inject drugs.
 Users of opium-based drugs report high incidence of injecting drug.
 A large number of these drug users report risky injecting practices.
 It is more prevalent in U.P, Punjab, Delhi, Andhra Pradesh, Telangana, Haryana, Karnataka, Maharashtra,
Manipur and Nagaland.
How accessible is the treatment?
 In general, access to treatment services for drug or alcohol addicts are grossly inadequate.
 Nearly one in five alcohol users suffers from dependence, and alcoholism is a condition that requires
medical attention.
 But only less than 3% of the people with drinking problem get any treatment in India.
 Only one person in 38 alcohol addicts is getting any treatment, and one in 180 addicts is getting
inpatient treatment at a hospital.
 72 lakh of 'other drugs' users are addicted to them, but only one in 20 drug addicts seems to be receiving
in patient treatment for drug addiction.
Illegal Usage of Meldonium
iasparliament
February 22, 2019
9 months
1374
0
Why in news?
The Anti-Doping Appeal Panel of the National Anti-Doping Agency (NADA) has recently blacklisted two
persons related to illegal supply of meldonium.
What is meldonium?
 Meldonium is manufactured by the Latvian company Grindeks, and is prescribed for ischemia, a
condition in which there is an insufficient flow of blood to tissues, which are then starved of oxygen and
glucose.
 Meldonium gives those suffering from heart and circulatory conditions more physical capacity and
mental function.
What are the concerns with its usage?
 Though not approved by the US FDA, the drug has been easily available over the counter in Eastern
Europe and Russia.
 Since meldonium aids oxygen uptake and endurance, several athletes have been caught using it.
 The World Anti-Doping Agency (WADA) put it on the list of banned substances in September 2015, and
the ban went into effect on January 1, 2016.
 However, a number of athletes were using it before it was banned.
 Meldonium became famous after tennis superstar Maria Sharapova tested positive for it in 2016.
 In 2015, anti-doping group Partnership for Clean Competition said meldonium was found in 182 of 8,300
urine samples it tested as part of a study.
 WADA confirmed at the time of the Sharapova scandal that since the ban, meldonium had been found
in 55 samples.
 A study published in Drug Testing and Analysis in 2015 concluded that the drug demonstrates –
1. An increase in endurance performance of athletes
2. Improved rehabilitation after exercise
3. Protection against stress
4. Enhanced activations of central nervous system (CNS) functions
  The manufacturing company has said meldonium can provide an improvement of work capacity of
healthy people at physical and mental overloads and during rehabilitation period.
 However, it believed that the substance would not enhance athletes’ performance in competition, and
might even do the opposite.
What is the role of World Anti doping agency here?
 The World Anti-Doping Agency (WADA) was established in 1999 as an international independent agency
composed and funded equally by the sport movement and governments of the world.
 Its mission is to lead a collaborative worldwide movement for doping-free sport.
 Its key activities include scientific research, education, development of anti-doping capacities, and
monitoring of the World Anti-Doping Code (Code).
 The World Anti-Doping Code is the document that brings consistency to anti-doping rules, regulations
and policies worldwide.
 Since 2004, and as mandated by World Anti-Doping Code, WADA has published an annual List of
Prohibited Substances and Methods (List).
 The List, which forms one of the six International Standards, identifies the substances and methods
prohibited in- and out-of-competition, and in particular sports.
 In India, National Anti Doping Agency (NADA) is responsible for promoting, coordinating, and
monitoring the doping control programme in sports in all its forms in the country.
 The primary objectives are to implement anti-doping rules as per WADA code, regulate dope control
programme, to promote education and research and creating awareness about doping and its ill effects.
What is the case with India?
 Jagtar, a decathlete, who appeared to give the urine sample at the Federation Cup in Patiala in 2017, has
been tested positive for Meldonium.
 He was banned for a maximum period of four years for a first-time dope offence.
 Recently, his ban was reduced from four years to two, after he provided substantial evidence that helped
bust a ring of illegal performance-enhancing drug suppliers.
 Jagtar contended that he had consumed the food supplements provided by a regular supplement
supplier at the Jawaharlal Nehru Stadium, who is also the husband of a Commonwealth Games
participant.
 The case lead to the discovery of a very important source of illegal/unlicensed supply of prohibited
substance to athletes at the Jawaharlal Nehru Stadium, New Delhi.
 This is because the stadium also serves as a hub of national and international athletic sporting activity
in India.
 Thus, the Anti-Doping Appeal panel directed NADA to issue appropriate warning to be affixed on notice
boards/websites of NADA regarding prohibited substances and the risk of procuring any supplies by the
athletes from illegal suppliers.

Concerns in Access to Safe and Sufficient Blood

iasparliament
February 14, 2019
10 months
949
0
What is the issue?
In India regulatory framework must be reformed to ensure access to safe and sufficient blood.
What are the shortfalls in the blood collection in India?
 In 2015-16, India was 1.1 million units short of its blood requirements, there were considerable regional
disparities, with 81 districts in the country not having a blood bank at all.
 In April 2017, it was reported that blood banks in India had in the last five years discarded a total of 2.8
million units of expired, unused blood (more than 6 lakh liters).
 Due to practical constraints, tests are only conducted post-collection, and blood donor selection relies
on donors filling in health questionnaires truthfully.
  However, these tests are not foolproof as there is a window period after a person first becomes infected
with a virus during which the infection may not be detectable.
 This makes it crucial to minimize the risk in the first instance of collection.
What are practical difficulties in collection and storing of blood?
 Blood that is donated voluntarily and without remuneration is considered to be the safest.
 Unfortunately, professional donors (who accept remuneration) and replacement donation (which is not
voluntary) are both common in India.
 In the case of professional donors there is a higher chance of there being TTIs in their blood, as these
donors may not provide full disclosure.
 In the case of replacement donation, relatives of patients in need of blood are asked by hospitals to
arrange for the same expeditiously.
 This blood is not used for the patient herself, but is intended as a replacement for the blood that is
actually used.
 In this way, hospitals shift the burden of maintaining their blood bank stock to the patient and her family.
 Here again, there could be a higher chance of TTI’s because replacement donors, being under
pressure, may be less truthful about diseases.
What are the issues in regulatory framework of blood banks?
 The regulatory framework which governs the blood transfusion infrastructure in India is scattered across
different laws, policies, guidelines and authorities.
 Blood is considered to be a ‘drug’ under the Drugs & Cosmetics Act, 1940.
 Therefore, just like any other manufacturer or storer of drugs, blood banks need to be licensed by the
Drug Controller-General of India (DCGI).
 For this, they need to meet a series of requirements with respect to the collection, storage, processing
and distribution of blood, as specified under the Drugs & Cosmetics Rules, 1945.
 Blood banks are inspected by drug inspectors who are expected to check not only the premises and
equipment but also various quality and medical aspects such as processing and testing facilities.
 Their findings lead to the issuance, suspension or cancellation of a license.
 In 1996, the Supreme Court directed the government to establish the National Blood Transfusion Council
(NBTC) and State Blood Transfusion Councils (SBTCs).
 The NBTC functions as the apex policy-formulating and expert body for blood transfusion services and
includes representation from blood banks. However, it lacks statutory backing (unlike the DCGI), and as
such, the standards and requirements recommended by it are only in the form of guidelines.
 The DCGI does not include any experts in the field of blood transfusion, and drug inspectors do not
undergo any special training for inspecting blood banks.
 This gives rise to a peculiar situation, the expert blood transfusion body can only issue non-binding
guidelines, whereas the general pharmaceutical regulator has the power to license blood banks.
 This regulatory dissonance exacerbates the serious issues on the ground and results in poor coordination
and monitoring.
What measures are needed?
 In order to ensure the involvement of technical experts who can complement the DCGI, the rules should
be amended to involve the NBTC and SBTCs in the licensing process.
 Given the wide range of responsibilities the DCGI has to handle, its licensing role with respect to blood
banks can even be delegated to the NBTC under the rules.
 This would go a long way towards ensuring that the regulatory scheme is up to date and accommodates
medical and technological advances.
 Despite a 2017 amendment to the rules which enabled transfer of blood b/w blood banks, the overall
system is still not sufficiently integrated.
 A collaborative regulator can, more effectively, take the lead in facilitating coordination,
planning and management.
 This may reduce the regional disparities in blood supply as well as ensure that the quality of blood does
not vary b/w private, corporate, international, hospital-based, non-governmental organizations and
government blood banks.
  The aim of the National Blood Policy formulated by the government back in 2002 was to
“ensure easily accessible and adequate supply of safe and quality blood”.
 To achieve this goal, India should look to reforming its regulatory approach at the earliest.
Toxic Alcohol - U.P. and Uttarakhand Death Tragedy
iasparliament
February 13, 2019
10 months
1150
0
Why in news?
More than 100 people recently died due to toxic alcohol in Uttar Pradesh and Uttarakhand.
What is the recent finding?
 Preliminary investigation has confirmed the well-entrenched system of illicit liquor outlets in the U.P.,
Uttarakhand region.
 Several factories producing hooch (toxic drink) in U.P. were unearthed within a couple of days of the
recent deaths.
 Majority of the deaths were in Saharanpur district of U.P.
 In U.P., many communities have protested the sale of cheap liquor in pouches that are freely distributed
during social events.
How is it all over India?
 Of the estimated 5 billion litres of alcohol consumed every year in India, about 40% is illegally produced.
 Cheap, locally made liquor is common in parts of rural India.
 Sellers often add methanol, a highly toxic form of alcohol, to their product to increase its strength.
 [Toxicity often comes from drinking methanol, which results in blindness, tissue damage or death.]
 The Malvani hooch tragedy in Mumbai in 2015 that killed 106 people, have been attributed to the lack
of affordable liquor for the poor.
 High taxes and excise on liquor raise prices, and so cheap brews are promoted by criminal organisations.
 However, often, this is done in collusion with law enforcement personnel.
 India thus remains among the countries with a high number of alcohol-related deaths.
 Poor governance, corruption and distorted policies contribute to such periodic tragedies.
What does it call for?
 A multi-pronged plan is needed to prevent the sale and consumption of toxic alcohol.
 Illicit liquor sale should be curbed with zero tolerance, and consumption should be discouraged through
social campaigns.
 Besides, reviewing of levies on less harmful beverages is also crucial to prevent the spread of cheap,
harmful ones.
 At the moment, it is essential to investigate on those who participated in the sale of the lethal brew, and
look into any nexus with the authorities.
 Parallelly, it is vital to upgrade the capacities of the health system to handle victims of toxic alcohol.
 Timely treatment through haemodialysis, infusion of sodium bicarbonate and ethyl alcohol can save
lives.
Concerns in Marijuana Legalization
iasparliament
January 26, 2019
10 months
1280
0
What is the issue?
 India is struggling to control the three addictive substances of tobacco, alcohol and areca nut.
 In this scenario legalization of Marijuana would worsen our overburdened healthcare system.
What is the brief account of Marijuana usage in India?
  In India the earliest known reports regarding the use of cannabis come from the Atharva-Veda, written
around 2000-1400 BCE.
 Cannabis has been consumed in different ways—smoking (ganja), chewing (bhaang), drinking (tea), etc.
 Its plant has been used for manufacturing clothes, shoes, ropes and paper.
 In ancient India, it was used for treating or alleviating symptoms of several diseases.
What are the ill effects of Marijuana usage?
 Marijuana and hemp are members of the cannabis family and contain chemicals with varying degrees
of psychoactive properties.
 While marijuana induces intense psychoactive effects, hemp is low on that.
 Ganja, charas and hashish are known to cause hallucinogen, euphoria, temporary loss of senses and a
funny behavior.
 The International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders
designate cannabis as an addictive substance, with recognized dependence disorders.
 Around 9% of people who try it ultimately become addicts.
 Its withdrawal symptoms are irritability, sleeping difficulties, dysphoria, etc.
 For those who try to quit, relapse rates are a high 71% at six months.
 It noted there is substantial evidence that its use may lead to cancer, cardiovascular illness, lung diseases,
road accidents, impaired adolescent health, serious drug interaction and reproductive health disorders.
 There is an increased incidence of vehicle accidents in those who may be either short-term or long-term
users of marijuana.
What are the efficacy of Marijuana’s medicinal purposes?
 Cannabis is effective in pain management, but it is weaker and less safe than opiates that are approved.
 A study did show beneficial effects of cannabis in a small percentage of extremely rare form of epilepsy
and multiple sclerosis.
 Similarly, there is no data to support its use in oncology practice outside of clinical experiments cannabis
derivatives are known to have immunosuppressive that can promote cancer.
 In summary, its medicinal benefits aren’t as strong as presented by the proponents of legalization safer
and effective alternatives are available in the market.
What is India’s regulation on Marijuana?
 The Narcotic Drugs and Psychotropic Substances Act, 1985, prohibited cultivation or production of
cannabis plant by anybody, while reserving these rights with central and state governments if they wish
to do so, by creating rules later.
 It is alleged that the NDPS was a result of an intense international pressure following the UN’s Single
Convention on Narcotic Drugs, 1961.
 In India there is no restriction for cultivation and procurement of cannabis for therapeutic use or
experimentation.
 The government has been generous in giving licenses for such purposes.
What is status of Marijuana legalization?
 There is a global wave of legalization of cannabis, based on its medicinal properties and commercial
utilities.
 In the US, the use of marijuana (a more addictive derivative) for medicinal purposes is legal in a number
of states, whereas its use for recreational purpose has also been legalized in some states.
 Canada has legalized its use for recreational as well as medicinal purposes.
 Europe recognizes the use of marijuana for recreational purposes as a crime, but its use for medical
purposes is permitted in many countries.
 Buoyed by success in the West, cannabis supporters are pushing for legalization in India.

What are the challenges for India in legalizing Marijuana?

 India has a history of misuse of even prescription drugs that are otherwise beneficial.
 In Indian context, when prescription drugs are grossly misused, It is hard to use ensure disciplined used
of cannabis.
 Already India is struggling to control the three addictive substances of tobacco, alcohol and areca nut.
  As per the Global Adult Tobacco Survey, 270 million Indians use tobacco and it kills around 1.35 million
Indians every year.
 Nearly 30% of India’s adult population is using alcohol, leading to 3.3 million deaths.
 Legalization of cannabis is not only going to worsen these alarming statistics, but also serve as a gateway
for one of these carcinogens.
 Introduction of yet another psychoactive drug will wreak havoc on a population still struggling with
tobacco, alcohol and pan masala.
Bringing Behavioural Change - Swachh Bharat Mission
iasparliament
January 23, 2019
10 months
2697
0
What is the issue?
 The Swachh Bharat Mission (SBM), despite its intent, is less encouraging in terms of the outcome
achieved so far.
 In this context, it is imperative to acknowledge the behavioural component in the implementation of the
programme.
What are the complexities?
 Under the Swachh Bharat Mission (SBM), the two complex challenges are:
i. changing behaviour by getting people to use toilets and stop defecating in the open
ii. sustaining the changed behaviour over time
 These challenges transforms SBM from an infrastructure-focused “toilet construction” programme to a
more complex behaviour change social revolution.
 Moreover, the SBM “market” is more complex, where there is no intrinsic demand for “goods” (toilets).
 It is hampered by the deeply ingrained habit of open defecation and the cultural norm of not having a
toilet near one’s residence.
What are the key challenges?
 Scale - The task at the start of the SBM in October 2014 was changing the behaviour of 550 million
people living in rural India.
 Speed - The programme had to be implemented in 5 years.
 Stigma - The centuries-old taboos needed to be challenged. E.g. it was considered impure to have a
toilet inside or near the home
 Sustainability - There was a huge task of having to make the recently changed behaviour stick, as
sustaining it was more difficult than achieving it.
 Despite these, there was little prior experience of doing all this, which made learning hard and the degree
of difficulty more severe.
 It literally took a village, peer pressure and whole-hearted community participation to make a village
ODF (open defecation free).
What should be done?
 Demand for a toilet had to be stimulated to wean people away from the habit of open defecation.
 From the supply side, the programme needed to provide both toilets as well as a behaviour programme
at scale for changing preferences.
 There is a need for having systems and incentives in place for sustaining the behaviour change achieved.
Integrate AYUSH with Modern Medicine for Holistic Health
iasparliament
January 17, 2019
11 months
973
0
What is the issue?
AYUSH has to be combined with modern medicine for holistic health and to treat non-communicable diseases
effectively.
What is the current scenario of health in India?
 India is facing double burden of under-nutrition and communicable diseases along with the non-
communicable ailments affecting millions of people.
 And the World Health Organisation Report for 2018 highlights that non-communicable diseases account
for 63% of deaths in India.
 This is an alarming statistic and modern medicine alone is unlikely to provide the solutions.
Why integration of medicines is the solution?
 Unlike modern medicine, alternative systems follow a more holistic approach, with the objective of
promoting overall well-being instead of focussing on curing illness alone.
 Such an approach assumes greater significance in the case of non-communicable diseases which are
difficult to treat once they have developed into chronic conditions.
 Internationally, greater scientific evidence is becoming available regarding the health impact of
alternative systems of medicine, especially Yoga.
 Apart from a rich heritage in traditional medicine, India has nearly eight lakh registered Ayurveda, Yoga,
Unani, Siddha and Homoeopathy (AYUSH) practitioners whose services can be better utilised for
delivering healthcare to the population.
What steps are taken by the government to promote AYUSH?
 The government set up a dedicated ministry to promote AYUSH at the Central level in 2014.
  Mainstreaming AYUSH was a clearly stated policy objective under the National Health Policy, 2017.
 Another pioneering initiative is the establishment of a Centre for Integrative Medicine & Research by
AIIMS, Delhi.
 Several union ministries also plan to set up AYUSH units in the hospitals operated by them.
 Further, AYUSH is one of the 12 champion services sectors promoted by the government through soft
loans and interest subsidies to AYUSH establishments as well as 100% FDI.
What is the way forward?
 Co-Location - There is a need for co-location of AYUSH with facilities providing allopathic medicine.
 The ‘Strategy for New India @ 75’ released by NITI Aayog sets out the explicit target of co-locating
AYUSH services in at least 50% of primary health centres, 70% of community health centres and 100%
of district hospitals by 2022-23.
 Co-location must also be achieved in the 1.5 lakh health and wellness centres announced in Union
Budget 2018-19.
 Education & Research - Investments in AYUSH education and research needs to be stepped up.
 Mechanisms should be identified for integrating modern medicine and AYUSH curricula at the
undergraduate and postgraduate levels in educational institutions.
 Developing a credible research base is critical to embed AYUSH within the overall framework of
healthcare by addressing the lingering concerns around its effectiveness.
 Awareness - Range of communication channels should be leveraged to popularise Ayurveda and Yoga
and inform citizens about their preventive and curative properties.
 While Yoga has gained immensely in popularity as a form of exercise, the full range of physical and
mental health benefits it can yield must be propagated.
 Medicines - Essential AYUSH medicines must be included in various national health programmes and
guidelines should be developed for ensuring their quality.
 The rich history of traditional medicine must be tapped to reduce the health burden affecting India and
its growth.
Withdrawal from Ayushman Bharat Scheme
iasparliament
January 14, 2019
11 months
1667
0
Why in news?
West Bengal recently announced its withdrawal from Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana
(PMJAY).
Click here to know more on the scheme.
Why has West Bengal exited?
 Beneficiaries of the Centre's Ayushman Bharat insurance programme have been sent a two-page
customised letter from the prime minister outlining the importance and benefits of the project.
 The government also planned to send similar letters to 10.74 crore beneficiary families across the
country.
 The letter mentions that the beneficiary family can avail the scheme in hospitals in their area and
health facilities empanelled under the scheme across the country.
 Since the letter sent to beneficiaries has photos of Prime Minister, the state contended that as over
branding.
 The West Bengal government feels that given the 60:40 partnership in the scheme, the state
government should get similar space on documents.
 Also there is a problem with name of the scheme itself, wherein the West Bengal government chose
to call the scheme Jan Arogya Yojana rather than Pradhan Mantri Jan Arogya Yojana.
 The MoU of JAY signed b/w Government of West Bengal and Government of India clearly stipulated
that since West Bengal already had a well-established scheme Swasthyasathi, the state government
would like to retain the name Swasthyasathi in the scheme.
  But the entitlement letter/card issued by the central Ministry mentions the name of the scheme as
PMJAY.
 The state contended that as not only a violation of the stipulations of the said MoU but has created
confusion at the grassroots level.
What are the consequences?
 West Bengal’s Swasthyasathi scheme was launched in 2016.
 It provides a basic health cover for secondary and tertiary care up to Rs 5 lakh per annum per family,
the same as PMJAY.
 So far, around 1 crore people have been enrolled under the central scheme in West Bengal while the
state scheme already had 40 lakh beneficiaries.
 For PMJAY, the pullout is a setback because it affects the national portability of the scheme.
 Kolkata serves as the preferred destination for many people from the Northeast and from states such
as Bihar for healthcare.
 Thus, officials fear it could impact more people than just the beneficiaries in West Bengal.
Why have three other states stayed out?
 Along with West Bengal, other states like Delhi, Telangana and Odisha have also stayed out of the
programme.
 Odisha announced the launch of Biju Swasthya Kalyan Yojana (BSKY), about 40 days before the launch
of PMJAY in September 2018.
 BSKY will give an insurance cover up to Rs 5 lakh per eligible family and Rs 7 lakh for treatment of
female members.
 The state also lists other state schemes such as Niramaya (free medicines), Nidan (free diagnostics),
and Sahay (dialysis and chemotherapy in all districts) to every beneficiary family.
 Delhi, like West Bengal, has an issue with the name of the central scheme and has also raised this with
the implementing agency - National Health Agency.
 Delhi wanted the name of the scheme as Mukhya Mantri Aam Aadmi Swasthya Bima Yojana Ayushman
Bharat for implementation in the union territory.
 However, the NHA responded that, since this is a national scheme with national character, it’s critical
that the name of the scheme starts with AYUSHMAN BHARAT.
 It also added that this will also help in operationalising portability and easy identification of
beneficiaries.
 Since either sides failed to lower its taken stand, NHA has started empanelling Delhi hospitals on its
own rather than through the State Health Agency as has been done in all other states.
 Telangana has one of the oldest functioning tertiary care health schemes in the country.
 The Arogyashri scheme provides financial protection to families living below the poverty line up to Rs
2 lakh in a year.
 Altogether 949 treatments are covered, including treatment of serious ailments that requires
hospitalisation and surgery.
 According to a 2017-18 report, there are 77.19 lakh beneficiary cards with 330 empanelled hospitals.
 Thus, the state has so far not enrolled itself into the Ayushman Bharat programme.
What is the stand of the centre in this issue?
 It says that Ayushman Bharat family letter is neither a beneficiary card nor an entitlement card.
 The said letter is only one of the modes of spreading awareness among eligible families.
 The distribution of the letter is an integral part of the beneficiary identification guidelines, given that
Ayushman Bharat is an entitlement based scheme.
 Hence, the centre urges West Bengal to reconsider its position and to co-operate in the
implementation of the scheme.
Approach to Address Leptospirosis – Kerala Model
iasparliament
January 09, 2019
11 months
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What is the issue?
 Post 2018 Flood Kerala faced after effects like infectious diseases caused by animals.
 Collective actions and prolonged efforts of the respective departments mitigated the after-effects of the
events.
What are the lethal zoonosis across the globe?
 The term “zoonosis”, means infectious diseases that can be naturally transmitted b/w animals and
humans.
 Anthrax, plague, leptospirosis, rabies and worm infestations are some of other zoonotic diseases that
occur regularly in India.
 The recent zoonosis which has affected the mankind globally includes diseases like nipah, ebola and
zika.
What are the cause and effect of Leptospirosis?
 Leptospirosiscommonly known as rat fever or Andaman hemorrhagic fever, a bacterial infection caused
by ‘spirochete’, is naturally carried by more than a dozen species of rodents, wildlife and domestic
animals.
 Dogs, cattle and rabbits also transmit the infection, Rodents have an enormous ability to excrete large
number of leptospirae in the urine, which is the main source of contamination incriminating human and
animal leptospirosis.
 Infection can also occur through aborted fetuses, afterbirth or uterine discharges of cattle or the semen
of an infected bull.
 Humans can become infected by all these animals, and especially if mucous membranes and/or skin is
damaged, the bacteria get an opportunity to invade.
 Clinically, patients may suffer from non-specific symptoms like fever, body ache, vomiting, redness of
eyes, cough and chest pain.
 There can be severe kidney and liver impairment in some cases. Leptospirosis during pregnancy has
adverse outcomes especially in first trimester and near-term mothers.
What are the detection and prevention methods of the diseases?
 On emergence of earliest signs, one should immediately report to the nearest health facility and get
tested for the leptospirae infection by methods available depending on the stage of illness.
 Once the diagnosis is established, immediate treatment should be started.
 A medicine named Doxycycline 100 mg should be prescribed twice a day for seven days and
ampicillin/amoxicillin should be prescribed to children and pregnant and lactating women for seven
days.
 Severely ill patients need an aggressive treatment format with parenteral therapy.
 Hygienic practices including avoiding direct and indirect human contact with animal urine are
recommended as preventive measures.
 Doxycycline can also be given as a preventive drug in the dose of 200mg per week maximally for eight
weeks, to those exposed and at great risk, especially in a flood situation.
How Kerala Addressed Leptospirosis?
 After the catastrophic floods in Kerala in 2018, the State grappled with massive loss of life and property.
 Adding to its woes was the threat of infectious diseases like Leptospirosis claimed lives and affected
many in Kerala post-floods, there have been 1,807 confirmed cases and 74 confirmed deaths.
 Kerala has been successful in tackling the menace of leptospirosis post floods when water receded.
 This is due to the timely leadership showcased by the Central and Kerala Governments that initiated
immediate action.
 The State health authorities have provided appropriate health care to the affected, including setting up
of medical camps, deployment of health personnel, provision of drug supplies and emergency
healthcare services.

Drugs (Prices Control) Amendment Order, 2019

iasparliament
January 05, 2019
11 months
2646
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Why in news?
The Ministry of Chemicals and Fertilizers has recently released the Drugs (Prices Control) Amendment Order,
2019.
What is it for?
 Drug price control is all about striking the right balance b/w consumer and producer interests.
 The DPCO (Drugs Prices Control Order) fixes the prices of scheduled drug formulations.
 It also monitors maximum retail prices of all drugs, including the non-scheduled formulations.
What are the key provisions in the recent order?
 A drugmaker who has brought in an innovative patented drug will be exempt from the price control
regulations for 5 years from the date of marketing.
 The Drug Price Control Order (DPCO), 2013, has been amended to this effect.
 The amendments were made on the basis of the NITI Aayog’s recommendations to the Department of
Pharmaceuticals (DoP).
 Drugs for treating rare or “orphan” diseases too will be exempt from price control, with a view to
encouraging their production.
 Under the amended DPCO, the Centre will continue fixing prices in line with market-based data available
on drugs.
 The source of market-based data shall be the data available with the pharmaceutical market data
specialising company as decided by the government.
 If the government deems it necessary, it may validate such data by appropriate survey or evaluation.
 [Alternatively, cost-based pricing model takes into account the actual money that went into developing
the drug, sourcing the raw material and so on].
What are the concerns?
 The changes are aimed at lifting foreign investor sentiment, particularly of US companies.
 But not bringing orphan drugs into price control will significantly impact patients.
 Only MNCs are manufacturing orphan drugs at the moment; so lack of price control will have a
detrimental effect on affordability.
 Also, cancer drugs are increasingly patented with no generic competition, putting them out of the reach
of poor patients.
What should be done?
 Medicines account for over half the costs of inpatient care and 80% in the case of out-patient care.
 So, there must be a way of ensuring that their prices remain accessible without producers feeling
disincentivised in the process.
 The Competition Commission of India’s recent report identifies retailers’ margins as a major cause of
high prices.
 This can best be addressed by investing in wholesale public procurement, as Tamil Nadu and Rajasthan
have shown.
 A combination of State-led insurance, such as Arogyashree in Andhra Pradesh, and public procurement
can help keep health costs down.
 All these essentially require increasing the budget allocation for the health sector.

Primary Health Care - Lessons from Kerala

iasparliament
January 03, 2019
11 months
1286
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What is the issue?
  Proper systems in Universal primary health care are crucial in India for achieving Universal Health
Coverage, one of the SDGs.
 The experience of Kerala in transforming primary care has lessons for the country in achieving the Astana
Declaration goals.
What is the Astana Declaration?
 In October 2018, at Astana, Kazakhstan, world leaders declared their commitment to ‘Primary Care’.
 The Astana Declaration aims to meet all people’s health needs across the life course.
 This would be through comprehensive preventive, promotive, curative, rehabilitative services and
palliative care.
 A representative list of primary care services are provided in this, which includes but not limited to -
i. vaccination
ii. screenings
iii. prevention, control and management of non-communicable and communicable diseases
iv. care and services that promote, maintain and improve maternal, newborn, child and adolescent health
v. mental health
vi. sexual and reproductive health
What is Kerala's experience in this regard?
 The 'Aardram mission' in Kerala aims at creating “People Friendly” Health Delivery System in the state.
 The approach is need-based and aims at treating every patient with ‘dignity’.
 In 2016, Kerala had, as part of the Aardram mission, attempted to re-design its primary care.
 In the revamped primary care, Kerala tried to provide the services enlisted in the Astana declaration and
more, with mixed results.
 These services cannot be provided without adequate human resources.
 It is nearly impossible to provide them with the current Indian norm of one primary care team for a
population of 30,000.
 So Kerala tried to reduce the target population to 10,000, but even this turned out to be too high to be
effective.
 It thus suggests that providing comprehensive primary care would require at least one team for 5,000
populations.
 This would mean a six-fold increase in the cost of manpower alone.
What does this call for?
 Fund - Most successful primary care interventions allocate not more than 2,500 beneficiaries per team.
 But the supply of more human resources would generate demand for services.
 So there would be a corresponding increase in the cost of drugs, consumables, equipment and space.
 So the commitment to provide comprehensive primary care would be meaningful only with a substantial
increase in fund allocation.
 Training - Providing the entire set of services is beyond the capacity of medical and nursing graduates
without specialised training.
 Practitioners in most good primary care systems are specialists, often with postgraduate training.
 The Post Graduate Course in Family Medicine, which is the nearest India has to such a course, is available
in very few institutions.
 Kerala has addressed this challenge through short courses in specific areas.
 E.g. management of diabetes mellitus, hypertension, chronic obstructive pulmonary disease, and
depression
 India has to build its capacity in this regard if it is to offer services as is planned in many States.
 Data - Providers have to assume responsibility for the health of the population assigned to them and
the population should trust them.
 Both are linked to capacity, attitude and support from referral networks and the systemic framework.
 It will not be possible unless the numbers assigned are within manageable proportions.
 So access to longitudinal data on individuals will be helpful in achieving the link.
 Thus, dynamic electronic health records and decision support through analysis of data are essential.
  Private sector - The private sector provides primary care in most countries though it is paid for from
the budget or insurance.
 In India, more than 60% of primary care is provided by the private sector.
 It can provide good quality primary care if there are systems to finance care and if it is prepared to invest
in developing the needed capacities.
 Devising and operating such a system (more fund management than insurance though it can be linked
to insurance) is needed.

Concerns in Ayushman Bharat

iasparliament
December 28, 2018
11 months
1598
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What is the issue?
 The Ayushman Bharat-National Health Protection Mission (AB-NHPM) needs a relook, given the
implementation concerns with it.
 Click here to know more on the scheme.
Why AB-NHPM?
 Rising out-of-pocket expenditure (OOPE) of the citizens is a key concern in the healthcare sector.
 Among different sources of healthcare financing, 67% of the total health expenditure comes from
households’ pockets.
 Health expenses push about 7% of the population below the poverty threshold every year.
 In this backdrop, the government launched the Ayushman Bharat-National Health Protection Mission
(AB-NHPM) to reduce OOPE.
Is it a workable measure?
 The AB-NHPM shares its objectives with the Rashtriya Swasthya Bima Yojana (RSBY) scheme.
 RSBY sanctioned Rs 30,000 health insurance coverage per family per year for secondary and tertiary
hospitalisation.
 In the nearly 9 years of RSBY’s existence, the scheme objectives are yet to be met.
 The quality of healthcare provisioned under the RSBY was compromised because of insufficient
coverage.
 In this respect, the Ayushman Bharat scheme is a positive step up, with an increased coverage limit of
Rs 5 lakh.
 However, some less-desired aspects of the RSBY are reflecting in the AB-NHPM scheme as well.
 The capacity of increased coverage to reduce the actual OOPE is limited in the current form of this
scheme.
What are the continuing concerns?
 Coverage - Despite the increase in coverage amount, the AB-NHPM is limited to only inpatient care.
 The Rs 5 lakh cover is intended for secondary and tertiary care ‘hospitalisation’ only.
 The outpatient expenditure, which forms a major part of OOPE, has been left out of the ambit of the
AB-NHPM.
 Poorer people, functioning on daily income, tend to avoid hospitalisation due to the associated loss
in working income.
 Therefore, outpatient care inclusive of diagnostics and medicines needs to be insured for them.
 Private players - Private sector participation in healthcare services has been increasing at a quick rate
in urban areas, while remaining more or less constant in rural areas.
 In 2014-15, over 68% of hospitalised cases in urban areas, and 42% in rural areas, got recorded in
private hospitals.
 Even in top-performing states with the highest government health expenditure, the spending in
private sector in OOPE form is quite high.
  But the scheme, in its current form, may not be able to account for this rising private players'
participation.
 The increase in compensation under AB-NHPM holds value only when it is able to induce insurance
coverage for healthcare services provided by the private sector.
 The list of hospitals empanelled under the scheme does contain many private hospitals.
 But under the single rate card provision of the scheme, the private sector’s willing participation seems
unlikely.
 This is because the prices proposed under the rate card fall much below the expectations of private
sector healthcare providers.
 Medical packages list - Preparing the entire medical procedure list at the central level is a potentially
suboptimal move.
 This is a challenge given the heterogeneity in healthcare needs and disease prevalence across the
country.
 A study under the India State-Level Disease Burden Initiative highlights the need for state-specific
health interventions.
 There are comprehensive inequalities in disease burden and its causes across states.
 So there is a deep-rooted need for disease-specific interventions, with specialised attention to
associated risk factors.
What is to be done?
 Cooperative federalism can go a long way in addressing the above challenges.
 States’ role needs to be enhanced at planning stages, a shift from their current role as implementers.
 E.g. states could be given the responsibility of preparing the medical package list
 This will encourage cost-effective accounting for inter-state variation.
 Also, if poorer states could set up lucrative prices for healthcare packages, it could augment private
investment in these states.
 So, while the objective of the scheme is welcome, the implementation challenges deserve some
serious thought.
 Increased states’ participation and inflation-adjusted rates for procedures could help India progress
towards its universal healthcare goal.
Restoring Oxytocin Sale - Delhi High Court Order
iasparliament
December 18, 2018
12 months
1086
0
Why in news?
The Delhi High Court has quashed a government ban on the retail sale and private manufacture of oxytocin.
Click here to know more on the ban.
Why was the ban challenged?
 Union Ministry of Health and Family Welfare earlier notified the ban of oxytocin.
 This was after widespread concerns with the misuse of the drug in dairy cattle, fruits and vegetables.
 But the ban was opposed as oxytocin is a life-saving drug used to stop post-partum bleeding among
new mothers.
 Around 45,000 women die from post-partum complications in India each year, and in 38% of the
cases, haemorrhaging is the reason.
 Without the easy availability of inexpensive oxytocin, addressing the maternal mortality epidemic
could have been difficult.
 In fact, oxytocin had been listed by both the World Health Organization and the Health Ministry as an
essential medicine.
 So the All India Drug Action Network (AIDAN), a patient-rights group, challenged the government
ban in the Delhi High Court.
What is the Delhi High Court's rationale?
  The ban came despite the fact that all statutory bodies, including the Drugs Technical Advisory Board,
had advised against a ban.
 There was no scientific basis to the conclusion that oxytocin's existing availability/manner of
distribution posed a risk to human life.
 So in response to AIDAN’s and drug manufacturers’ petitions, the court struck down the ban, calling
it “unreasonable and arbitrary”.
 It thus restored the retail sale and private manufacture of a life-saving drug, oxytocin.
 The government failed to weigh the adverse effect, to the public in general and women in particular,
of possible restricted supply if manufacture is confined to one unit.
 The scarcity or even a restricted availability can cause increase in maternal fatalities, during childbirth.
 Notably, the Karnataka Antibiotics & Pharmaceuticals Limited (the only authorised producer after the
ban) did not have the capability to manufacture it until mid-2017.
 The Centre has put down licensed manufacturers with a proven track record, while roping in this state
firm with no real experience.
 It had also failed to show that the drug was widely misused for veterinary purposes, the actual reason
behind the ban.
 Also, though the Centre claims to have made 25 illegal drug seizures across India in a 3-year period,
12 of them did not actually find oxytocin.
 Among those that did, none involved licensed drugmakers.
What lies ahead?
 The whole oxytocin episode calls for the policy-makers to reflect on the process that led to the ill-
conceived order.
 The basis for the Centre to overrule the advice of multiple statutory bodies should be investigated.
 The reason for the government to accept the reports of the drug’s misuse without any valid proofs
should be looked into.
 The country needs a relook on the mechanism for health policy-making, for it to safeguard the right
to health of Indian citizens.

Depression in workplaces
iasparliament
December 17, 2018
12 months
711
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What is the issue?
Companies in India should recognise the problem of depression among its staff and put in place policies to
help them.
What is the status of mental health issues in workplaces?
 The number of workers, severely depressed or vulnerable to taking their lives, is increasing in India.
 India is on the verge of a mental health epidemic with employees across the corporate sector bearing
the brunt of it.
 Depression among employees is a big cause of lost productivity.
 50% of India’s workforce suffers from some form of stress and of these, as much as 8% are showing a
high tendency to commit suicide.
What are the causes for depression?
 Most of the people across the country are depressed by work, money and family issues.
 Many people suffer from extreme stress as a consequence of pressure related to jobs.
 A recent study by Assocham concluded that more and more professionals were experiencing workplace
fatigue, sleep disorders and a general feeling of ‘poor health’.
 It also says that companies or HR departments rarely make any attempt to gauge employers from their
mental health perspective.
 Seniors in supervisory roles are also ill-equipped to cope with or respond to such scenarios.
  According to a Wall Street Journal report, Indian millennials spend more time at work than their
counterparts in 25 other countries.
 Indian workplace is highly competitive with very little or no sensitivity towards the mentally unfit or those
who have issues with performance.
 However, employees might not be keen to seek treatment, fearing that it would jeopardise their career
and even personal life.
 Thus, corporate India needs to rethink in terms of the work style, work hours and opportunities at
workplace.
What should be done?
 Companies in India have to frame policy that deals with the mental health status of an employee with
an overall guideline from the government.
 According to the WHO guidelines, common signs of depression include -
1. Difficulty in concentrating
2. Difficulty in making decisions
3. A visible change in performance
4. Inconsistent productivity
5. Increasing errors and diminished work quality
6. Overly sensitive reactions
 Within the workplace, if the conversation becomes uncomfortable for the employee, he or she should
be referred to a more clinically trained person.
 Every employer must introspect his/her organisation regarding inadequate health and safety policies,
poor communication and management practices, low control over one’s area of work and low levels of
support for employees as laid down by WHO.
 Thus, Corporate India must detect and recognise depression among its staff, intervene at the right time,
support them with all kinds of programmes and help them to be productive.

National Health Authority

iasparliament
December 13, 2018
12 months
1934
0
Why in news?
The NITI Aayog has recently proposed the creation of a new National Health Authority.
What is the proposal?
 National Health Authority(NHA) is proposed to administer the Pradhan Mantri Jan Arogya Yojana
(PMJAY) and will be chaired by the Health Minister with the Aayog as its administrative body.
 It is envisioned as an autonomous body that could initially be formed by an executive order.
 This is because, with health and public health being state subjects, two or more state legislatures will
need to pass resolutions before Parliament enacts a law for the constitution of the NHA. (Article 252)
 The NHA will report directly to the Prime Minister’s office, making the Union Health Ministry to have
little say in the PMJAY scheme.
Why is there a demand for a separate authority?
 PMJAY will target about 10.74 crore poor, deprived rural families and identified occupational category
of urban workers' families as per the latest Socio-Economic Caste Census (SECC) data covering both
rural and urban.
 PMJAY is currently administered by the National Health Agency which is a registered society under
the Health Ministry.
 While the Health Ministry is not responsible for the day to day running of the scheme, it does have a
say in policy matters.
 For example, the package rates were decided by the Directorate General of Health Services.
  However, since PMJAY caters to around 40% of the population, setting the price for the targeted
people could artificially inflate health costs for the remaining 60% who are not covered under the
scheme.
 Hence, there is an argument for a distinct authority, without government intervention, to administer
the price modalities of the scheme.
What will be its purpose?
 The NHA will address the shortage of capacity in many states at the administrative level that could
manage the extra monitoring and supervision involved.
 Also, NHA could lay down uniform standards and access rules that could allow free movement b/w
different jurisdictions without losing access to health care or to health information.
 Internal migration from labour-surplus areas to those parts of the country where wages are higher is
raising in India and hence NHA should ensure that they are not left out.
 NHA will have penal powers and can issue orders to its state counterparts rather than mere advisories
and it can also act against errant hospitals.
 The NHA will also have full say over the package rates and the mandate to negotiate with the private
sector for the strategic purchasing of services.
 The NITI Aayog proposal also envisages the formation of an advisory board.
What are the concerns?
 The crucial determinants of any scheme’s success lie at the state government level.
 The experience from previous centrally-sponsored schemes is that line ministries have often created
too many requirements and required excessive standardisation.
 These have meant that the administration of schemes is not as accountable or efficient as it would be
otherwise.
 This must not be repeated in the case of the NHPS.
 Thus, NHA as an independent authority provides for the chance of less interference from the
government.
 But it should ensure that the NHPS does not turn into a purely central scheme with little involvement
from the states.

Concerns with Generic-Only Model

iasparliament
December 12, 2018
12 months
1491
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What is the issue?
 There is an increased push by the government for generic drugs, for affordable healthcare.
 But the concerns with quality of the generics call for a relook on this 'generic-only model'.
What are generics?
 A generic drug is a copy of drug medication created to be the same as an already marketed brand-name
drug.
 It equals in dosage form, safety, strength, route of administration, quality, performance characteristics,
and intended use.
 Generics do not involve repetition of extensive clinical trials over the years, unlike brands that undergo
extensive R&D procedure.
 Hence, generics' manufacturing cost is less, and so are their prices.
Why is the emphasis on generics?
 The government, to cut down on out-of-pocket expenditure and ensure affordable healthcare, is relying
on a generics-only model.
 In the Indian market, generics hold a whopping 75% share.
 The push for generics witnessed a boom under Pradhan Mantri Bhartiya Jan Aushadhi Pariyojana
(PMBJP).
  It is a campaign launched by the Department of Pharmaceuticals to provide quality medicines at
affordable prices to the masses.
 PMBJP stores have been set up to provide generic drugs, which are available at lesser prices.
What are the concerns?
 India ranks third in the global pharma market (10% in global sales) but the domestic scenario is less
encouraging.
 A 2016 study on Spurious and Not of Standard Quality (NSQ) medicines in the supply chain in India hints
at this.
 More than 10% samples were declared NSQ in the supply chain, of medicines procured by government
agencies, compared to the all-India average of 4%.
 Central Drugs Standard Control Organisation (CDSCO) report shows that a range of commonly
consumed generic drugs fall short of standard quality-control criteria.
 In 2017, five drugs were recalled from Jan Aushadhi stores over quality lapses.
 Another six drugs were rolled back in the first four months of 2018.
 Most of India’s generic drugs manufacturers do not follow US Food and Drug Administration (US FDA)
guidelines for domestic distribution.
 India has more than 67,000 drug formulations.
 But the quality control mechanism of all the Central Drugs Testing Laboratories can ascertain the quality
of only 15,753 drugs annually.
 But branded generics follow regulatory mechanisms like US FDA and WHO Good Manufacturing
Practices, making them more reliable.
What is the inherent risk?
 Come 2020, the NCD burden will be responsible for 73% of deaths and 60% of disease burden in India.
 A low-quality drug delays recovery time, weakens the immune system by a longer duration of dosages,
and invites comorbidities.
 Substandard medicines may promise affordable healthcare in the present, but in the future results could
be catastrophic.
 Thus, relying on generics alone can be counter-productive in the mission to make India disease-free.
What does it call for?
 Medicine procurement and distribution should be driven by global best standards, not lowest price.
 For the goal of universal health coverage by making medication affordable, superior-quality drugs are a
prerequisite.
 The ‘generics-only model’ approach needs a critical reassessment for dealing with India’s disease
burden.

Targeted interventions – Ending TB epidemic

iasparliament
December 11, 2018
12 months
807
0
What is the issue?
There is a need to provide rights-based interventions for TB patients instead of mere surveillance
technologies.
What are the concerns with technological interventions?
 Tuberculosis (TB), being a curable and preventable disease, is becoming the leading cause of adult
deaths in most of the global south, which kills nearly two million people a year.
 The United Nations recently made a declaration, through which heads of state and government have
reaffirmed their commitment to end the global TB epidemic by 2030.
 However, emergence of surveillance technologies has threatened to detract from an effective
response to TB that is anchored in human rights and has a human touch.
  For example, Directly Observed Treatment, short course (DOTS) strategy requires patients to report
every day to a health authority, who watches them swallow their tablets.
 However, in recent times, governments use a strategy of video, tablets, phones and drones to carry
the old DOTS strategy into the technology era.
 India also planned recently to implant microchips in people in order to track them and ensure they
complete TB treatment.
 The response through these interventions seems to be not with and for people who have TB but rather
against them.
What should be the targeted areas?
 Providing new treatment - New guidelines by the WHO recommend the use of bedaquiline and
delamanid against drug-resistant TB, which are proved to be effective.
 However, only about 30,000 people have received these new drugs, though over 500,000 people get
sick with drug-resistant TB every year.
 Exorbitant prices for these drugs is one of the reasons for the exclusion of vast majority of people
from accessing it.
 Thus, International institutions, donors and countries need to focus and collaborate on the urgent
production and distribution of affordable generics of bedaquiline and delamanid.
 Engaging community health-care workers – They can lead the response by bringing responsive
care to those regions, where the reach of traditional health-care systems is very low.
 For that, they should be equipped with proper training and dignified conditions of employment.
 WHO should focus on recommendations around this cadre of workers and donors should focus
funding to programmes that make the most of them.
 Ensuring accountability - Community-based structures such as “clinic committees” ensure
accountability while also fostering partnership and trust b/w communities and their health-care
systems.
 Grassroots civil society and community-based organisations also ensure accountability.
 Such organisations are indispensable and would thrive on comparatively small amounts of funding.
What needs to be done?
 The Indian government has made an aggressive resolve to end tuberculosis (TB) by 2025, 10 years
ahead of the WHO’s goal.
 Eliminating TB needs an approach focusing on creating health systems that foster trust, partnership
and dignity.
 Thus, instead of mere surveillance technology, any strategy to eliminate TB should regard people with
TB not as subjects to be controlled but as people to be partnered with.

Effects of Drugs Discharged into the Yamuna

iasparliament
December 09, 2018
12 months
1318
0
Why in news?
A recent study reveals the effects of the discharge of drug-containing effluents into the Yamuna.
What is the study on?
 Human body does not use the entire quantity of the drug when it is taken.
 Resultantly, most of it is excreted and thus end up in aquatic systems via domestic sewage.
 The study thus looks at the occurrence, fate and ecological risks of these compounds.
 It observed nine different pharmaceutical active compounds in the Yamuna river.
 These are six over-the-counter drugs (aspirin, paracetamol, ibuprofen, ranitidine, caffeine, diclofenac)
and three prescription drugs (carbamazepine, codeine, diazepam).
What were the findings?
  The highest concentration of pharmaceutical compounds was located downstream Wazirabad at the
point where Najafgarh drain joins the Yamuna.
 This is one of the largest drains of Delhi and has an average discharge of about 25 cubic metres per
second.
 This drain is the largest polluter of the river contributing more than 50% of the total discharge into the
Yamuna.
 At this site, ibuprofen and paracetamol were found at a high concentration of 1.49 and 1.08 microgram
per litre respectively.
 Previous studies have shown that even small concentration of ibuprofen could cause an antagonistic
effect on aquatic organisms.
 Studies have also shown that ibuprofen exposure could increase cyanobacterial growth in the water.
 Caffeine was found in high concentration in most of the sites.
 Caffeine is used as a stimulant in medicine. Residue from beverages and other food products may also
be a contributor.

What could the impact be?

 The individual levels of the drugs were small and cannot cause acute toxicity to the marine life.
 But the mixture of compounds can “possibly cause chronic toxicity” to aquatic life and to humans who
use this water for drinking purposes.
 This not only affects the biodiversity of the river but can also lead to the rise of superbugs.
 The discharge of drug-containing effluents in rivers and other water bodies can potentially make many
microbes drug-resistant.
 The sewage treatment plants are not designed to take care of these pharmaceutical compounds.
 The study thus highlights the need for the government to bring in the guidelines or specific rules to
arrest and address this.
Inclusive Healthcare
iasparliament
December 03, 2018
12 months
1020
0
What is the issue?
With increasing emphasis on technology in healthcare, it is essential to ensure that it does not leave out the
most in real want of it.
What is the need?
 The need for a healthy relationship b/w technology and medicine is vital in today's world.
 This relationship is determined by the interaction b/w tech companies and the medical profession.
 The entry of technology is believed to close the gap of relative lack of medical professionals to cover
India’s large population.
 The logic is that e-health and phone advice could address this lacuna.
 But on deeper reflection, this view seems to be flawed, given the nature of functioning of the healthcare
system in India.
What are the concerns in India?
 The number of medical professionals for the able-to-pay populace (as against the total population) is
far too many (more than in developed nations).
 So the majority of Indians, who cannot pay, are unable to access the level of medical care available to
the favoured few.
 Tech companies, being corporate bodies and profit-seeking, are driven to focus on the patients who can
pay.
 Notably, this section is the same favoured few served by medical professionals.
 The fact that they want to serve the unattended many is hence suppressed.
 There is lack of effort to elevate the earning capacity, improve the health standards of the people and
improve the quality of public hospitals.
 So the aim of technology should be to help the underserved receive the same quality of care available
to the fortunate few.
 It should complement and improve the ability of professionals to do their assigned tasks.

Source: New Indian Express

Importance of Primary healthcare in India
iasparliament
December 03, 2018
12 months
2736
0
What is the issue?
Developing health and wellness(H&W) centres is a well thought out step for renewing focus on
comprehensive primary care.
What is the importance of H&W centres towards ensuring primary care?
 The Union government announced health and wellness centres under its Ayushman Bharat
programme as the foundation for public health system in the country.
 These centres are intended to provide outpatient care, immunisation, maternal and child health
services, non-communicable diseases (NCDs) and other services.
 These centres will be linked to secondary and tertiary care and will be supplied with adequate drugs
and diagnostic services.
 Once developed, these centres will help ameliorating basic health problems including early diagnosis
and treatment of NCDs, thereby avoiding complications in the latter stage.
 This would translate into lower cost of treatments at the secondary and tertiary-care levels.
What are the advantages of primary healthcare?
 Achieving universal health coverage (UHC) with a comprehensive primary-care approach will ensure
healthcare with higher coverage and at lower cost.
 Higher public spending in primary care alleviate household out-of-pocket expenditure(OOP) to a
large extent.
  It can contribute to realising SDG Goal 3 of promoting Good health and well-being to all with
adequate financial protection.
 Countries like UK have already achieved lower rate of mortality and better health outcomes by re-
orienting their strategies towards primary care.
What more does it need?
 Focus - A higher percentage of primary care expenditure is on personalised, curative care, leaving a
minimum amount for population-based primary preventive care.
 Achieving comprehensive primary care requires a paradigm shift from disease-control vertical
programmes(curative) to community-led, people-oriented primary care(preventive).
 Implementation - Involving nurses and allied health professionals in primary care service delivery
models can lower the burden of a low doctor-strength ratio.
 The role of public health professionals assumes paramount importance.
 They can help design outreach and preventive programmes and implement the continuing health
programme effectively.
 Also a trained pool of social workers, psychiatrists, counsellors with public health orientation can
intensify the reach of public service delivery in India.
 Spending - Approximately, 51% of total government expenditure on health is spent on primary care.
 This needs to be stepped up to at least two-third of the government expenditure as suggested in the
national health policy.
 Role of states - The states have higher responsibility than the Centre in matters related to health.
 Hence, the blueprints of primary care can further be redefined by the states in view of their local
needs.

Source: Financial Express

Need for Relook on Indian Medical Devices Industry

iasparliament
November 30, 2018
1 year
1290
0
What is the issue?
 The International Consortium of International Journalists (ICIJ) recently published the 'Implants Files
investigation' on medical devices. Click here to know more.
 In this backdrop, the Indian medical devices industry is in serious need of examination.
What are the concerns highlighted?
 The investigation has revealed multiple signs of danger in regards with the medical devices industry.
 The number of “medical device adverse events” has gone up from 40 in 2014 to more than 550 in
2018.
 One instance would be the deaths after the installation of a stent.
 Then there is the question of devices that have been recalled elsewhere.
 E.g. As many as 117 devices have been recalled over the past two years by the United States Food and
Drug Administration (or USFDA) because they have led to adverse events.
 But half, perhaps more, of these devices are still on the market in India.
 Medical device manufacturers are not following up on their responsibility to track down the recipients
of medical devices that have been withdrawn.
 They also do not pay the compensation that is consequent upon such withdrawals.
What are the drawbacks in India?
 The global withdrawals are not being followed through in India.
 There is not even a public list maintained by the regulator of devices that have been recalled from the
global or Indian markets.
  In this case, the Central Drugs Standard Control Organisation (CDSCO) has the responsibility.
 Even if regulators are not willing to take action, they must at least serve as information clearinghouses
and broadcasters.
 By this, at least, the recipients, their relatives, or citizens concerned can take action on their own.
 The data maintained by the Indian Pharmacopoeia Commission, or IPC, is also worryingly incomplete.
 This is likely because the reporting standards are too low.
 In general, the incentive structure for doctors and medical centres, particularly in metropolitan cities,
are not supportive.
 So they do not react appropriately to a troublesome medical device and thus problems may not be
reported.
 The close links b/w medical device companies and medical professionals are widespread, a variant of
those b/w pharmaceutical companies and doctors.
What does it call for?
 The medical device industry is a unique blend of engineering and medicine.
 It involves the creation of machines that are then used to support life within the human body.
 Given this, it needs not only careful regulation but also the highest ethical standards.
 Certainly, major changes are needed in the sector.
 It is up to the government to reinvigorate both the IPC and the CDSCO, and to give them more
resources and a clearer mandate.
 The issue of the trustworthiness of the private sector to be relied for the tertiary health care system
also needs attention.
 A large and vibrant public sector in tertiary health care is essential.
 This is possibly the way to counteract the hurtful consequences of information asymmetries and poor
regulation.
 The government should re-examine its plan for universal health care, at this juncture.

Gene editing in a human embryo

iasparliament
November 28, 2018
1 year
1753
0
Why in news?
A Chinese researcher recently made a claim that he had altered the genes of a human embryo that
eventually resulted in the birth of twin girls.
What is the technology behind?
 Genes contain the bio-information that defines any individual.
 The information encoded in the genetic material can be attributed to –
1. Height, skin or hair colour
2. Intelligence or eyesight
3. Susceptibility to certain diseases
4. Behavioural traits
 CRISPR (short for Clustered Regularly Interspaced Short Palindromic Repeats) technology is a
relatively new, and the most efficient tool for gene “editing” developed in the last one decade.
 The technology replicates a natural defence mechanism in bacteria to fight virus attacks, using a
special protein called Cas9.
 The specific location of the genetic codes that need to be changed is identified on the DNA strand.
 Using the Cas9 protein, which acts like a pair of scissors, the specified location is cut off from the
strand.
 A DNA strand, when broken, has a natural tendency to repair itself.
 Scientists intervene during this auto-repair process, supplying the desired sequence of genetic
codes that binds itself with the broken DNA strand.
How useful it has been so far?
 CRISPR-Cas9 is a simple, effective, and incredibly precise technology.
 The most promising use of the CRISPR technology is in treatment of diseases.
 For example, in sickle cell anaemia, a single gene mutation makes the blood sickle-shaped, which
can be reversed using gene editing technology.
 In the case of the new-born Chinese babies, the genes were “edited” to ensure that they do not get
infected with HIV.
 However, leading scientists in the field have for long been calling for a “global pause” on clinical
applications of the technology in human beings, until internationally accepted protocols are
developed.
What is the ethical dilemma involved?
 Verification - Tampering with the genetic material can have unintended and unknown
consequences.
 The scientific community has no way to verify the claims on whether the gene editing was carried
out in the proper manner.
 Precision - There is a possibility that some other genes also get targeted, resulting in unintended
impacts.
 Approval - In most countries of the world, such experiments are banned and are punishable by law.
 Without regulatory approvals, there will be data and information gaps about the experiments on
gene editing.
 Consequence - The recent research has edited the genes of an embryo, which would be passed on
to the offspring and make changes in the genome of the next generation.
 Thus there is a possibility to produce designer babies with very specific traits in the future.

Source: Indian Express

Menstrual Hygiene for Rural Women
iasparliament
November 26, 2018
1 year
927
0
What is the issue?
 Urban India is debating the topic of menstruation and the associated stigma.
 But breaking the mould in rural areas is far more challenging, which calls for an integrated approach.
What does NFHS data show?
 Government data suggest positive developments in the use of hygienic methods of managing menstrual
periods.
 As per NFHS-4 (National Family Health Survey), 42% women in the 15-24 age group uses sanitary
napkins.
 Of this, 16% use locally-prepared napkins, while 62% use cloth.
 In all, at least 58% are estimated to be using a hygienic method of menstruation.
 The data says that nearly 48% rural women in this age group are using hygienic methods.
 However, menstrual age of women goes up to 40-45 years, and a large section of women has still been
left out of the survey.
 The ground reality is a lot different, with several challenges to bring about change in rural areas.
What are the limitations?
 Mindset - In rural India, the outdated value system related to periods, sexuality, etc, are much ingrained.
 The resistance is severe, and much is kept literally under wraps.
 Social structure - The social structure is largely patriarchal; women individuality and needs mostly come
second.
 There is even lesser sensitivity with respect to women’s sexuality and physiology.
  Taboo subject - Menstruation remains one of the biggest taboo subjects, and breaking the notions on
such matters are truly challenging.
 Financial viability - Making sanitary pads affordable for money-starved rural families is a limitation for
promoting its use.
 Media - Till date, sanitary pads’ advertisements use blue as the colour to prove the effectiveness of pads.
 It is essential that platforms as these turn mature enough to show the liquid and gel with what it should
be, the colour red.
What are the notable initiatives?
 Chuppi Todo-Sayani Bano (roughly translated as ‘break the silence and grow up’) is an on-ground
menstrual hygiene awareness initiative in parts of Rajasthan.
 It is a private rural healthcare delivery enterprise for sanitary pads dispensation.
 A key effort includes disassociating morality from menstruation.
 It aims at replacing the 'right or wrong' debate with that on health, education, and development
viewpoints.
 Approaching topics such as menstruation with sensitivity, internal workshops are conducted.
 They sensitise the field workers along with the network of Anganwadi workers from the villages.
 To gain trust, influential people from village neighbourhood are identified and entrusted with
implementation.
 Student groups are also involved, making the efforts of sensitisation more effective.
What lies ahead?
 Poor menstrual hygiene practices have serious health challenges.
 They range from urogenital or non-sexually transmitted infections, to yeast, fungal and urinary tract
infections, to even cervical cancer.
 Thus, the cost of following hygienic practices is far less than bearing the cost for treatment of diseases.
 Initiatives as discussed above should be financed appropriately to be scaled to multiple states and
remote regions.
 For further progress, the discourse on menstruation needs to change in both urban and rural spaces.
 A multi-layered approach focusing on awareness, accessibility, behavioural change, and identifying the
target groups is essential.
 Knowing which group is more approachable helps in drawing out strategies to initiate discourse, educate
and trigger behaviour change.
 E.g. Schoolgirls, literate and educated women are more willing to listen and contribute. Men who are
socially-involved and less politically-invested are easier to convince and engage.

Eradicating TB
iasparliament
November 10, 2018
1 year
1113
0
What is the issue?
Becoming the first nation to eradicate TB will be a giant leap and India can serve as a global leader in this
regard.
Why it is important to focus on TB?
 The Indian government has demonstrated political will to improve the health security of citizens with
two bold announcements recently.
 First, an aggressive resolve to end tuberculosis (TB) by 2025, 10 years ahead of the World Health
Organization’s (WHO’s) goal.
 Second, a step towards achieving universal healthcare through the Pradhan Mantri Jan Arogya Yojana
(PMJAY), touted as the world’s largest government-sponsored health insurance scheme.
 The impact of PMJAY’s performance will largely be contained within India, affecting internal politics
and economics.
  But eradicating TB will factor heavily into India’s image and influencing power in global health
diplomacy networks.
 TB is air-borne and with approximately 300 TB patients per 100,000 Indians, the very process of
breathing puts one at risk of acquiring the disease in lungs, spine, brain or any other organ.
 India is in a precarious position in the world with the highest TB burden, and hence there are
expectations to reduce it before it explodes into a global health crisis.
What are the concerns with private healthcare in TB eradication?
 Private healthcare providers are the first contact points for more than half of the Indian population.
 However, about 50-55% of private practitioners are doctors-by-experience, not degree.
 This is where the search-and-treat strategy for TB is falling through the cracks.
 Early symptoms of TB are non-specific, and quite similar to more commonly occurring conditions,
such as secondary infections resulting from seasonal flu.
 This makes private practitioners to rule out other ailments through antibiotic treatment before
ordering TB tests.
 This paved the way for non-specific antibiotic courses which multiply the risk manifold, causing the
infection to become antibiotic-resistant.
 Also, delayed TB diagnosis is the biggest risk factor for transmission.
 Another widely prevalent behaviour in the private sector is hesitation to notify and refer their TB
patients to public health facilities, despite cash incentives.
 Fear of permanently losing clients and revenue to the public sector is the biggest reason for their non-
compliance.
What are the other such concerns?
 India’s run up to the 2025 deadline requires TB transmission to decline at the rate of 15-20% annually.
 The tests and treatment for TB are available for free across all public health centres.
 Also, patients can claim a nutritional incentive of Rs.500 per month until fully cured.
 But the current decline rate of TB in India is at a mere 1-2%.
 Half of the estimated patients are unaware that they have TB.
 They are also getting unreported in Nikshay, which is the government’s e-registry for TB.
 More than a million hidden carriers of active infection live among us, presenting a covert threat.
 Infected patients infect others in the community while undiagnosed.
 Hence, TB transmission can’t be ended until they are cured.
What are the measures taken?
 The government’s long-standing Revised National TB Control Programme (RNTCP) has now initiated
an active case-finding campaign.
 This was done in selected population segments, those who are socially, clinically or occupationally
more vulnerable than others.
 These are also the people living or working in shanty towns, prisons, red-light districts and shelter
homes, or AIDS patients.
 The first three phases of this screening identified more than 12,000 new patients who might have
remained hidden otherwise.
 In the rest of the population, the hope is that TB cases will be duly reported and treated.
 Also, to allay the concerns with the private sector, a new engagement model of public-private
partnership is being tested in Mumbai and Patna.
 Here, private practitioners are encouraged to manage patients themselves, provided they complete
e-Nikshay case notification and follow the standard of care treatment protocol.
 This new model, even though seemingly more effort-intensive, is actually not more expensive on a
recurring cost per case basis.
 However, for cross-country scaling up, the RNTCP budget would have to increase accordingly.
 The approved budget for 2017-20 is Rs.12,300 crores against the requirement of Rs.16,600 crores.
 However, additional budget consideration may pose an uncomfortable challenge for the government.
What should be done?
 In today’s inter-connected world, a nation’s health is no longer an internal matter.
  Outbreaks such as Ebola, Zika and SARS are jolting reminders of a common threat in the form of
infectious diseases which transcends boundaries.
 Accordingly, health has found its way into diplomacy and foreign policy of many countries, evident
from the agenda of this year’s G8 and G20 summits.
 Thus, it is unquestionably a fair price to pay for attaining leadership in global health diplomacy.
 In addition to new provider-focussed strategies, it is time to galvanise the society to drop the fear of
stigma, and insist on a TB test, if one’s cough persists for weeks.
 India followed this technique to get rid of polio and the same has to be emulated to eradicate TB.
 Eradicating polio was an important step and becoming the first nation to eradicate TB will be a giant
leap.

Report on Mental Health – Lancet

iasparliament
October 10, 2018
1 year
1003
0
Why in news?
The medical journal Lancet recently published a report at the first ministerial on global mental health hosted
by the UK.
What does the report say?
 Mental ill health is on the rise worldwide and it causes massive amount of disability, early deaths and
fuelling cycles of poverty.
 Most people with mental health problems do not receive care, which prolongs suffering and leads to
colossal societal and economic losses.
 They are also often subjected to human rights abuses and discrimination.
 No other cause of suffering has been so profoundly neglected.
 The situation in India is on par with amongst the worst country-level mental health indicators in the
world.
 In India, suicide is now the leading cause of death of young people.
 Alcohol use is blatantly promoted by commercial interests and its abuse has been relegated to a moral
issue to be addressed by primitive, punitive policies rather than through a public health approach.
 People with severe mental health problems languish in horrific conditions in mental hospitals or on the
streets.
 They were also severely deprived from under-nutrition to neglect that affect the development of the
brain in childhood.
 There are virtually no community-based mental health services in the country.
What does it recommend?
 The Sustainable Development Goals (SDGs) made specific references to mental health and substance
use as targets within the health goal reflects this transformative vision.
 To help achieve these targets and the SDGs, the Commission outlines a comprehensive blueprint for
action.
 Focus - Our approach to mental health must cover its full spectrum, from day-to-day wellness to long-
term, disabling conditions.
 Knowledge to promote mental health, prevent mental disorders and enable recovery has to be used to
benefit entire populations.
 Early intervention - Mental health is the product of psychosocial, environmental, biological and genetic
factors interacting with neurodevelopmental processes, especially in the first two decades of our lives.
 Because our experiences in childhood and adolescence shape our mental health for life, it is crucial that
these years unfold in nurturing environments, which promote mental health and prevent mental
disorders.
  Rights based approach - Mental health should be respected as a fundamental right by putting people
living with mental health problems at the centre of planning services.
 Everyone should be entitled to dignity, autonomy, care in the community and freedom from
discrimination.
How should it be achieved?
 Mental health services must be scaled up as an essential component of universal health coverage.
 Barriers and threats to mental health, such as the pervasive impact of stigma, must be assertively
addressed.
 New opportunities must be enthusiastically embraced, in particular those offered by the innovative use
of community health workers and digital technologies to deliver a range of mental health interventions.
 Substantial additional investments must be urgently made, with special focus on research and
innovation.
 This could be made by redistribution of budgets from large hospitals to district hospitals and
community-based local services to efficiently use existing resources.
 Initiatives like Rashtriya Bal Swasthya Karyakram to the Mental Health Care Act provide a robust policy
foundation for realising these aspirations in India.
 A genuine partnership of a diverse range of groups from the mental health and development
communities to policy makers and civil society coming together could transform mental health across
the country.

Source: The Indian Express

Quick Facts
Rashtriya Bal Swasthya Karyakram
 The Scheme was launched under National Rural Health Mission to screen and manage children
from birth to 18 years of age for Defects at Birth, Deficiencies, Diseases and Developmental Delays
including disabilities.
 All new-borns delivered at public health facilities and homes are screened for birth defects by health
personnel and ASHA.
 The children in the age group of six weeks to six years include those attending Anganwadicentres and
children in the age group of 6 years to 18 years enrolled in government and government aided schools
are screened by dedicated Mobile Block Health Teams.
 The children identified with any health condition are then referred to an appropriate health facility for
further management and linking with tertiary level institutions.
 The establishment of District Early Intervention Centre (DEIC) is also one of the components of the
scheme.
Cancer Treatment Challenges before India
iasparliament
October 08, 2018
1 year
1049
0
Why in news?
Nobel Prize for Medicine 2018 was given to path-breaking discoveries that led to the latest advances in
cancer therapy.
What is noble prize for medicine all about?
 Alfred Nobel in his last will and testament, specifically designated the institutions responsible for the
prizes he wished to be established.
 By which Karolinska Institute in Sweden is responsible for awarding Nobel Prize in Physiology or
Medicine.
 Per the provisions of the will, only select persons are eligible to nominate individuals for the award.
  These include members of academies around the world, professors of medicine in Sweden, Denmark,
Norway, Iceland, and Finland, as well as professors of selected universities and research institutions in
other countries.
 The Nobel Assembly consisting of 50 professors at Karolinska Institute will elects the Nobel Committee
with 5 members who evaluate the nominees.
 Under 1968, provision of noble prize committee no more than three persons may share a Nobel Prize.
 2018 Nobel Prize for medicine was shared by US scientist James P Allison and his Japanese peer
Tasuku Honjo.
What is the significance of recent discovery?
 The recent research was on proteins that prevented the body’s immune system from effectively
attacking cancer cells.
 The researchers believe that, if these brakes on the immune system are removed, rogue cells can be
efficiently tackled.
 The recent research led to the development of a new class of immunotherapy agents, also called
checkpoint inhibitors.
 This is touted as the most important advance against cancer since the advent of chemotherapy in the
1940s.
 The drugs derived from the work is already available in the market, but this is an expensive form of
treatment and used mainly in terminal stage cancers.
What is the status of cancer in India?
 According to the Indian Council of Medical Research, annual cancer deaths, now at 7.3 lakh, are set to
increase by another 20% to 8.8 lakh by 2020.
 The number of new cases each year is expected to touch 17.3 lakh by 2020.
 The National Cancer Registry Programme, started in the early 80s, maintains registries of 23 different
cancers, generating valuable data for collaborative research.
What are the challenges before India in treating cancer?
 Although medical science has been able to reduce mortality from cancers significantly, the
beneficiaries have largely hailed from the rich countries.
 In India, most cancer research is carried out in tertiary cancer centres and specialised institutions of
biomedical science, against well-developed cancer research networks in high-income countries.
 The rising burden of cancer in India acts as a major drain on research time, particularly for clinical staff.
 According to estimates, there are only 2,000 cancer specialists in India for 10 million patients.
 Besides, infrastructure to support cancer research has a long way to go.
 With the cost of treatment forbidding and most of India’s health spend not covered by health
insurance, cancer not only kills but also drives families into poverty and debt.
Fake Drugs and Block Chain technology
iasparliament
September 07, 2018
1 year
1829
0
Why in news?
Recently the drug regulator of Rajasthan found certain medicines to be fake which is a part of the counterfeit
drugs industry in the country.
What are the problems that arise due to Fake drugs?
 According to the World Health Organization (WHO), around 35 % of the fake drugs sold globally come
from India.
 In low and middle income countries like India, one in 10 medical products (pills, vaccines, injectables) in
circulation are either substandard or fake.
 The substandard or fake drugs promote anti-microbial resistance in people.
 Spurious drugs make pharma companies incur huge revenue losses.
  According to industry body Assocham, in 2015, the value of the counterfeit drug industry in India was
pegged at around Rs 150 billion
 It was almost 25 % of the total worth of the global pharma industry.
What are the ways to check the fake drugs?
 So far the efforts to combat the proliferation of fake drugs have been through traditional means — via
tip-offs and surprise raids.
 The current methods of weeding out counterfeit drugs are quite archaic.
 Still the method of sampling is only used to verify the genuineness of drugs.
What is the latest development?
 Niti Aayog, in collaboration with Oracle Technologies and Apollo Hospitals, is working on a technology.
 The technology will leverage blockchain technology to overcome the counterfeit drug problem.
 Oracle is developing the app through which the consumer will be able to scan the bar code of a medicine
 By scanning we will know about its manufacturer, the date of production, its path of transport and the
date it reached the retailer.
 Hence, the consumer can check if the medicine is genuine or not before buying it.
 The technology will work all long the entire supply chain so as to ensure that no fake drugs enter the
system.
How does it work?
 The tracing and tracking of pharmaceutical products is done with the help of new age technologies
like blockchain and Internet of Things (IoT).
 Fake drugs enter into the supply chain as Pharma sector is heavily dependent on logistics.
 Consignments of drugs will be tracked remotely through the use of IoT to check the entry of fake drugs.
 The data captured through IoT will be sent to the cloud server that will then be entered into the block
chain ledger.
 The block chain digital ledger system records the transactions and tracking of consignments.
 It becomes easy for all stakeholders -drug manufacturers, controllers and hospitals to monitor the
ledger.
 This eliminates the possibility of mixing fake drugs with original drugs.
 In addition block chain process is hack proof because it does not use a centralized system to store data.
 Any revision on the chain requires retrograde action on all associated blocks.
 This process allows users to see transactions in real time.
 The real time monitoring of data across the pharmaceutical supply chain will act as a third eye on fake
drug dealers.
What are the other initiatives in this regard?
 Gujarat has implemented an online drug SMS alert system for retailers for ‘unsafe’ drugs.
 The state drug control authority worked with National Informatics Centre to develop the software.
 Abbott has introduced an SMS authentication scheme for customers.
 QR codes are also used to store product information on packs which will do away with the need to print
leaflets.
 These QR codes can be an effective tracking mechanism.
 It allows the manufacturer to keep tabs on the drug’s circulation in the market.
 Companies are also planning to print a hologram on the packaging and mirco-emboss the product
name on cartons.
What is the way forward?
 As block chain technology evolves, India’s efforts to root out counterfeit drugs will definitely make
headway.
 It will surely lead to a much safer public health system in the country.
Issues with J&J Hip Replacement Treatment
iasparliament
August 30, 2018
1 year
2285
 0
Why in news?
Union health ministry’s panel has recommended Johnson & Johnson (J&J) to pay compensation of $28,500
to hip replaced patients.
What is a hip replacement treatment?
 The hip joint consists of a ball and a socket, which are covered with cartilage and surrounded by a
lubricating membrane to protect against wear.
 In total hip replacement, all components are replaced with prosthetic components.
 These are metal on metal, with cobalt, chromium and molybdenum as major constituents, these were
being manufactured and sold for several years by Deputy International Limited (DePuy), UK, a
subsidiary of Johnson & Johnson.
What is the issue with Johnson & Johnson?
 When the prosthetic ball and socket rub against each other, it causes wear.
 If the implant is metal on metal, this can sometimes releases metallic debris into the bloodstream.
 This can lead to complications, sometimes requiring revision surgery.
 Many patients implanted with ASR worldwide experienced serious adverse reactions, some requiring
revision surgery to replace the ASR implant with another kind.
 Because of this, J&J recalled the product in 2010.
What are the concerns with Indian patients?
 In India, the company got the licence to import the device in 2006. By the time it was recalled
worldwide, an estimated 4,700 ASR implants had been done in the country.
 While more than 3,600 of the 4,700 patients could not be traced, the committee sent letters to 101, of
whom 22 responded.
 Some of the patients had reported that they had to undergo excoriating pain during all these and
more particularly after the implant.
 These patient also informed that the cost of revision surgery was reimbursed either by the company or
the insurance firms.
 The patients are still sceptical about their future with the implant in their body.
What are the recommendations’ of the government panel?
 Amid concerns worldwide, the Health Ministry set up an expert committee in 2017 to examine issues
arising out of faulty ASR implants in India.
 The committee has recommended the company should be made liable to pay at least Rs 20 lakh to
each patient with such complications, and the reimbursement programme be extended until August
2025.
 It has recommended that the maximum amount be at par with the maximum granted for clinical trial-
related death and permanent disability as per rules and guidelines of the Drug Controller General of
India.
 Provisions for compensation should be included in Medical Device Rules if any serious adverse event
or death is caused due to the sole use of a medical device.

World Bank Report on Stunting

iasparliament
August 18, 2018
1 year
2469
0
Why in news?
World Bank recently released a report on the prevalence and effects of stunting.
What are the highlights?
 A child is stunted if the height-for-age ratio is not proportionate.
 Effects - Children with stunted growth are more prone to enduring adverse outcomes later in life.
 They suffer from impaired brain development.
  This leads to lower cognitive and socio-emotional skills, and lower levels of educational attainment.
 India - The World Bank analysed 140 countries for workers who were stunted as children.
 Of these, only Afghanistan (67%) and Bangladesh (73%) surpassed India’s proportion (66%).
 Around 66% of the working population in India are earning 13% less.
 This is specifically because of lack of skills due to stunting in childhood.
 This is one of the highest proportions worldwide in such reductions in per capita income.
 Others - The average reduction for South Asia was 10% and North America 2%.
 Middle East and North Africa do better, with a reduction of 4%.
 This is better compared to Europe and Central Asia with a reduction of 5%.
 The economic impact of stunting was not limited to Asia and Africa.
 Stunting has affected almost all continents in varying amounts.
 But Indians lost more income than people, on average, from Sub-Saharan African countries.
 Notably, countries poorer than India have handled stunting better.
 E.g. Senegal, with a per capita GDP of half as that of India’s, was able to reduce stunting in its children
by half over 19 years to 2012.
 Peru, too, demonstrated a remarkable decline in its childhood stunting characteristics.
 This was largely due to its nutrition, health and sanitation interventions.
 Returns - The World Bank report calculated that the returns on a national nutrition package outweigh
the costs.
 This is in reference to interventions focussed mainly on maternal and neonatal health.
 But given the time lag b/w childhood and joining workforce, the effects begin to show only 15 years
after implementation.
 After the initial 15 years, the cost remains static and the benefits continue to increase as more of the
workforce begins to benefit.
 The average rate of return predicted for the programme was 17%.
 But for India the returns were forecast at 23%.
What is the current scenario?
 The percentage of childhood stunting in India’s current working-age population does not reflect the
percentage of children currently stunted.
 This is given the gap b/w childhood and joining the workforce.
 Notably, the current number of stunted under-five children in India has reduced drastically.
 Over 26 years to 2014, the percentage of stunted Indian under-five children has reduced from around
62% to 38%.
What are the causes for India's state?
 Stunting is affected by a variety of socio-economic determinants.
 More than the economic development state, it reflects the treatment of women and children.
 The related causes for stunting lie in social inequity with women’s status and health, household wealth,
access to services, etc.
 India clearly has inadequacies in women’s well-being and efforts to reduce poverty.
 The two most influential deciding factors are women’s BMI and women’s education.
 These factors explained the difference in child stunting b/w highly sensitive and less sensitive districts.
What lies ahead?
 In India, Integrated Child Development Services, PDS and mid-day meal schemes address children’s
nutrition.
 The Swachh Bharat Abhiyan and the National Rural Water Drinking Programme address sanitation
needs.
 Despite these, improving women’s well-being remains a challenge for policy.
 A nutrition-specific national programme could significantly tackle stunting.
 The National Nutrition Mission (POSHAN Abhiyan) should thus be promoted to address nutritional gaps
for women.
 There has to be a specific focus in the lower income brackets if stunting is to be truly eradicated.
Source: Business Standard, Financial Express
Issues with Indian Abortion Law
iasparliament
August 16, 2018
1 year
1785
0
What is the issue?
India’s abortion law must be amended to take into account the agency of women.
What is the need?
 Many women, when denied legal abortions, turn to unqualified providers or adopt unsafe methods of
termination.
 Various estimates indicate that unsafe abortions account for 8% of maternal deaths in India.
 15.6 million abortions took place in India in 2015 out of which about 11.5 million took place outside
health facilities.
What is the Abortion law of India?
 Abortion has been legal in India under the Medical Termination of Pregnancy (MTP) Act, since 1971.
 According to the Act, abortion can be provided at the discretion of a medical provider under certain
conditions.
 Currently, the Act allows abortion up to 20 weeks.
 When the Act was introduced, policymakers had two goals
1. To control the population resulting from unintended pregnancies (which even today are to the tune of
48%)
2. To reduce the increasing maternal mortality and morbidity due to illegal, unsafe abortions
What are the concerns?
 The Medical Termination of Pregnancy Act has limitations that pose barriers to women and girls seeking
legal abortions.
 A woman’s right to decide for herself, did not and still does not fall within the intent or ambit of the MTP
Act.
 When it comes to foetal abnormalities and pregnancies resulting from rape, this limit of 20 weeks is
proving to be a hurdle for both the woman and the provider.
 Women seeking an abortion after the legal gestation limit often have no option but to appeal to the
courts for permission to terminate the pregnancy.
What are the pending measures in this regard?
 In 2014, the Ministry of Health and Family Welfare recognised these barriers and proposed certain
amendments to the Act.
 Consequently, the MTP (Amendment) Bill, 2014, was submitted, proposing some changes.
 They include -
i. increasing the gestation limit from 20 to 24 weeks for rape survivors and other vulnerable women
ii. removing the gestation limit in case of foetal abnormalities
 In 2017, these amendments were returned to the ministry with the mandate to strengthen the
implementation of the MTP Act as it stands.
 The amendments are yet to be revised and returned to the PMO.
The Dilemma with e-cigarettes
iasparliament
August 14, 2018
1 year
1666
0
What is the issue?
 There are conflicting claims about health effects of 3-cigarettes.
 Hence, Indian policy makers should tread cautiously in this regard.
How does India’s policy landscape on e-cigarettes look?
 Recently, the Delhi government stated in court that it was planning to ban e-cigarettes in its territory
due to its likely health implications.
 Significantly, Karnataka and Maharashtra have already banned e-cigarettes and the “Union Health
Ministry” has also taken a stand against it.
 But as combustible cigarettes are freely available throughout India, there are concerns on whether an
outright ban against e-cigars is the right move.
 Notably, “e-cigar” is a new technology, and its long term health effects aren’t known yet, but there are
indications that they are better than conventional cigarettes.
What are the health implications of e-cigars?
 Instead of burning tobacco, e-cigars heat a liquid to generate a nicotine-containing aerosol that does
not produce toxic tars.
 But this doesn’t mean they are completely safe, as at high temperatures, e-cigarettes produce
carcinogens such as formaldehyde.
 They also increase the odds of lung disease and myocardial infarction.
 Nonetheless, its carcinogenic and other health implications are believed to be lesser than for normal
cigarettes, although long-term data isn’t available.
What is the dilemma about?
 Positives - Some researchers argued that e-cigarettes must be viewed from a “harm minimisation”
perspective as they are a better alternative.
 Given that combustible cigarettes are more noxious than electronic ones, switching from the former to
the latter can help addicts to lead healthier lives.
 Negatives - But others feel the need to adopt a precautionary approach as e-cigarettes is a young
technology, whose long term effects aren’t known.
 Further, some carcinogens in e-cigarettes have already been discovered to have a non-linear effect (even
small quantities having big effects) on cancer.
 There is also the risk of e-cigarettes acting as a gateway drug for young people and surveys have
indicated that e-cigars are likely to increase addictions.
 Further, due to its branding as a healthier alternative it may end up promoting the habit of smoking.
What is the way ahead?
 Completely banning the technology, while selling normal cigarettes, could take away a promising
smoking-cessation aid.
 A more pragmatic option would be to regulate e-cigarettes tightly, by creating standards for the aerosols
and banning underage and public use.
 This would leave smokers with a therapeutic alternative, while protecting youngsters from a gateway
drug.
 Either ways, conflicting evidence makes it a tough call for policymakers and India should tread cautiously.

Source: The Hindu

Unequal Access to Healthcare
iasparliament
August 01, 2018
1 year
1381
0
What is the issue?
 While India boasts of having an ultra modern healthcare infrastructure, the masses in India actually aren’t
even able to afford even basic medical facilities.
 Our policymakers have shown no real zeal to provide equitable medical care to all citizens cutting across
classes.
What is India’s vision in the health sector?
  The NITI Aayog’s 3 year vision document has recommended the government to prioritise preventive
care rather than provide curative care.
 The document has advised the government to focus on the public health as whole and not merely restrict
itself to “health care” and hospitals sector.
 Further, it asks the government to better public health infrastructure to cater to the needy who can’t
afford private care.
 Notably, out-of-pocket expenses for medical care are about 70% of all medical expenditure in India
currently.
 While the vision statement spelt out seems ambitious, India’s previous track record in health care has
resulted in serious scepticism.
How entrenched is class based exclusiveness in our health care sector?
 Divide - It is a hard reality that not all medical interventions are available to every citizen who may need
it due shortage of infrastructure and funds.
 The major technological leaps in medicine starting from 1980s have only widened the gap b/w the
private sector and the government hospitals.
 Failures - Every government since Independence has stated egalitarianism as its goal in health care, but
the reality has been rather different.
 Many interventions, especially those which are very expensive, continue to be accessible only to those
who can pay for them.
 Notably, costly interventions are provided in a few government hospitals, but these are merely tokenism,
and an attempt by governments to appear fair.
 Recently - Even the new “Ayushman Bharat Health Scheme” which covers a whopping 40% of India’s
population seems patchy on this count.
 Notably, the scheme seeks to provide secondary and tertiary care to the economically deprived class,
but has a cap of Rs. 5 lakh per family per year.
 While the beneficiaries can access both private and public hospitals for treatment within that limit, it is
unlikely help them access costly treatments.
 Notably, there are indications that an explicit “negative list” for procedures which will not be covered
under the scheme, will be pronounced.
What are the other flaws in India’s health policy?
 Subsidy - In order to promote investments in health, governments have been giving subsidies to private
players in health sector.
 Notably, it is these subsidies that have aided these private hospitals to cater to foreign clients at rates
far cheaper than the western world.
 As subsidies in a way are taxpayer’s money, it is a clear case of taking from the poor to give to the rich
private corporate hospitals.
 Corporatisation - Private hospital chains in India have entered every segment of medical care including
complex tertiary care, and diagnostics.
 Most have large investors from abroad and some are effectively controlled by foreign investors, all of
whom benefit from the government subsidies.
 Privatisation - Successive governments have been increasingly dependent on the private sector to
deliver health care to the masses.
 The new “Ayushman Bharat Scheme” would only further this dependence and hospital chains are sure
to see a significant spike in their profits.
What is the state of our public health institutions?
 As health care is indeed costly and out of reach for most citizens, public hospitals continue to be the
only resort for the masses.
 Successive government policies over the year have been favouring private health players over the public
sector due to various constrains.
 Public health sector has been largely under-funded, under-equipped and under-staffed, and its quality
and credibility eroded over time.
  Consequently, even the morale of the doctors and staff in public hospitals has taken a severe beating in
comparison to their private sector peers.
 If public hospitals are to be bettered, coordinated and sustained action is needed on the part of the
government, which currently seems lacking.

Fairness in Organ Transplantation

 Foreign nationals have been found to be receiving disproportionately more cardiac transplants over
locals in India despite dearth of donors.
 Recently, a controversy has erupted in this regard, opening up a debate that could help in correcting
the faultiness in our transplantation policy.
What are the problems in the India’s current transplant policy?
 India’s organ allocation program currently lacks transparency.
 While Tamil Nadu has one of the best “deceased donor programs” in the country, there are some
concerns regarding alleged preferential allocations.
 Recently, the controversy has heated up due to a leaked communication from the head of the “National
Organ and Tissue Transplant Organisation”.
 As public credibility is vital for the sustenance of any program, faith among the masses needs to be
restored at the earliest.
Why are foreigners getting more transplants done?
 While there is a foreigner skew for recipients across organs (liver, kidneys etc...), the trend is pronounced
in heart transplants.
 This is because, unlike others, heart transplant require a deceased donor, which is difficult to spot in
countries that don’t have dedicated programs.
 So patients with advanced heart failure from countries that don’t have a deceased donor programme
have no option but to try their luck in India.
 As most heart transplants are performed in corporate hospitals, the costs in India are well beyond a large
majority of the local population.
 Hence, as affordability among foreign nationals is more, there is a clear skew that is visible among
recipients.
What needs to be done?
 For ensuring credibility in the deceased organ donation program, mere calls for transparency in organ
allocation won’t work.
 Rampant privatisation has led to a profit oriented approach to health and has thereby financially skewed
organ transplants to the rich.
 We will have to ensure that organs will go to those who need them the most rather than to those who
can pay for them.
 Subsidising transplantation cost (in private) and quota based organ allocation to public hospitals are
some options that can be considered to ensure fairness.
 This would mean, public hospitals should step up their capacity to integrate with ‘deceased donor
programmes’ to catch up with their private counterparts.
What is the way ahead?
 One of the reasons behind Europe’s high donation rates is public trust in their respective nationalised
health schemes.
 To ensure that such aspects are mimicked in India, we need imbibe among the mass, the feeling of
inclusiveness.
 As India has comprehensively embraced liberal markets (even in health), innovative policies are needed
to ensure equity in health access.
 Thus far, Tamil Nadu has led the way in deceased donation and also has a good record of public medical
institutional infrastructure.
 Hence, its model can become an all India template after some alterations.

Source: The Hindu