Essay Class 03: Healthcare (Brijendra Singh)

Four Fundamental Principles

1. Accessibility
Healthcare should be universally available. Patients should be able to access good quality
healthcare, from trained health care professionals, within a defined time frame.

2. Health Promotion
It involves education and awareness about nutrition, sanitation, maternal and child health
care, immunization, mental-health problems etc. Health promotion focusses on preventive
care, to reduce the demands for curative care. Individuals and families are taught skills to
maintain their physical and emotional well-being.

3. Health Equity
It refers to the absence of unfair, avoidable or remediable differences in health among
population groups. Pursuing health equity requires special focus on the needs of those at
greatest risk of poor health.

4. Medical Ethics
Medical practitioners must ensure that their actions are based on the right values and
principles. Further, the laws and rules governing such issues should be based on the principle
of Primum Non Nocere (First, do no Harm).

Principle One: Accessibility

I. Dimension: Geographical
Ideal Condition: Universal coverage.

Concern:
i. Lack of access to medical services in rural and remote areas. In rural India, only 37 per
cent of people have access to In-Patient Department (IPD) facilities within a 5 km
distance and only 68 per cent have access to an Out-Patient Department (OPD). Nearly 75
per cent of dispensaries and 60 per cent of hospitals are located in urban areas, serving
less than 1/3rd of India’s population.
ii. Rural population forms a disproportionately large share of unhealthy population.

Recommendation:
i. Improve physical reach. Physical reach is defined as “the ability to enter a healthcare
facility within 5 km from the place of residence or work”.
ii. Increase presence of frontline health workers. Frontline health workers are those who
directly provide health services where needed, especially in remote and rural areas.
They often belong to and are based in the community they serve e.g. community
health workers, midwives, local pharmacists, nurses etc.
iii. Promote community based-care, especially in rural areas, through Out-reach
programs. Such programs facilitate access to quality health care, provide health
education, bring culturally-relevant health care directly to communities,
increase community awareness etc.

Evidence:
i. China runs a medical outreach program called “Barefoot Doctors” – it involves part-time
health workers who provide basic health services in rural areas.

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 ii. In India, Anganwadi and ASHA workers provide community health services in rural areas.
ASHA( Accredited Social Health Activist) refers to a trained female community health
activist. Selected from the village itself and accountable to it, the ASHA workers are trained
to work as an interface between the community and the public health system.
iii. India has operationalized 1.5 lakh Ayushman Bharat - Health & Wellness Centres (AB-
HWC), where medical care can also be provided through outreach services, Mobile Medical
Units etc. Further, NITI Aayog, in its 2022 Health Care Strategy, advocates the integration of
AYUSH services in 50% of Primary Health Centres (PHC), 70% of Community Health
Centres (CHC), and 100% of district hospitals.
iv. In 2022, the Jharkhand govt., in collaboration with the Rockefeller Foundation, launched
“Swasthya Sawari”. It is a mobile-health pilot programs that uses specially designed vans to
provide medical services to under-served communities.
v. Doctors without Borders, also known as Médecins Sans Frontières (MSF), is an international
humanitarian organization that provides medical assistance to people in need, particularly in
regions affected by epidemics, natural disasters, and exclusion from healthcare. It was
founded in 1971 and is composed of medical professionals who volunteer their time and
expertise to deliver medical care and emergency aid in over 70 countries worldwide.

vi. The Comprehensive Rural Health Project (CRHP) is a non-governmental organization located
in Jamkhed (Maharashtra). The organization works with rural communities to provide
community-based primary healthcare through a variety of community-led development
programs, including Women's Self-Help Groups, Farmers Clubs, Adolescent Programs,
Sanitation Programs etc. The work of CRHP has been recognized by the WHO and UNICEF,
as well as being introduced to 178 countries across the world.

CRHP’s model, known as the “Jamkhed Model”, focusses on mobilizing and building the
capacity of the community. The model works on two mutually supportive components:

1. Village Health Workers and Community Groups: The Village Health Worker (VHW),
usually illiterate and of low caste, is the key change agent in CRHP’s model. Selected by the
communities themselves and trained by CRHP, VHWs not only act as health workers and
midwives but they also mobilize their communities to achieve better sanitation, family
planning, and maternal and infant health.
2. Mobile Health Team (MHT): CRHP brings healthcare to villagers who have not had the
resources to approach a hospital for care. It organises weekly clinics in the villages, and uses
its MHTs to provide a broad range of medical services at the doorstep of villagers.

II. Dimension: Economic

Ideal Condition: Affordability of medical services.

Concerns:
i. Stark difference between haves and have-nots w.r.t. affordability of health services. For
instance, 95.5% of births occurring in the richest 20% of households in India are attended
to by skilled birth attendants; for the poorest 20% of households, the figure is 64%.
ii. Catastrophic household health care expenditure, which is defined as health expenditure
exceeding 10% of its total monthly consumption expenditure or 40% of its monthly non-
food expenditure. In India, about 7% of the population is pushed below the poverty line
every year because of such expenditure.

Recommendation:
i. Ensure free, comprehensive primary health care services.
ii. Provide free or affordable health insurance.

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 Evidence:
i. The National Health Service (UK) provides comprehensive healthcare services to all
residents of the UK, regardless of their ability to pay. It is funded through general
taxation and offers a wide range of services, including primary care, hospital admission,
mental health services, cost of medicines etc.
Similarly, Medicare (Australia) is an insurance scheme that gives Australian citizens and
permanent residents access to healthcare, including a wide range of health and hospital
services at no cost or low cost. Medicare is funded by Australian taxpayers who pay 2%
of their taxable income to finance the scheme.

ii. Pradhan Mantri Jan Arogya Yojana (PMJAY) is the world’s largest health insurance
scheme fully financed by the government. It aims to provide financial protection for
secondary and tertiary healthcare to about 40% of India's households (50 crore people,
10.7 crore families). It provides a cover of Rs. 5 lakhs per family per year for
hospitalization across public and private empanelled hospitals in India.

iii. The Govt. of India will soon launch the ‘One Nation, One Dialysis’ programme, which
will enable any patient to get an affordable dialysis facility anywhere in the country.

III. Dimension: Medical

Ideal Condition: Access to qualified and trained health professionals.

Concerns:
i. Shortage of medical personnel. India has a shortage of an estimated 6 lakh doctors and 20
lakh nurses. According to the Economic Survey (2019-20), India has only 1.7 nurses per
1,000 population and a doctor to patient ratio of 1:1456 — this is well below the WHO
norm of 3 nurses per 1,000 population and a doctor to patient ratio of 1:1000.
ii. Brain drain of qualified medical professionals to foreign countries.
iii. Skewed distribution of health workforce between rural–urban areas and the public–
private sectors.
According to the British Medical Journal, govt. colleges in India produce 50% of all
doctors but 80% of doctors and 70% of nurses work in the private sector.
Further, 63% of all allopathic doctors are self-employed, which creates concerns
regarding the affordability of their treatment.
Similarly, only 20% of doctors are operational in rural India while 80% are concentrated
in urban India. Urban areas also have 3 times the number of nurses as rural areas.
iv. A 2016 WHO report on the health workforce in India revealed that more than 57% of
those practising allopathic medicine did not have any medical qualification. Such
practitioners, called quacks, fill the gap created by the absence of trained doctors. But
their diagnosis and treatment can not only be wrong but even fatal.

Recommendation:
i. Retention and better utilization of good quality medical personnel.
ii. Regulation & penalization of quacks.
iii. Address push and pull factors that lead to migration of medical personnel to foreign
countries or their preference for the private sector. Push factors include low wages, lack
of opportunities, delayed appointments, lack of investment in public hospitals etc. Pull
factors come in the form of incentives generated by foreign countries and private
companies to attract qualified medical personnel.

Evidence:
i. The National Health Policy 2017 advocates optimum use of existing manpower and
infrastructure available in the health sector. This can be achieved through collaboration with
non-government sector for delivery of health care services. Health services can be linked to a

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 health card to enable every family to have access to a doctor of their choice from amongst
those volunteering their services.
ii. Since 2014, the Govt. of India has stopped issuing No Objection to Return to India
(NORI) certificates to doctors migrating to the US, if they seek to extend their stay beyond
three years.
Similarly, to introduce transparency in nursing recruitments, the Govt. of India has included
nurses in the Emigration Check Required (ECR) category.
iii. Compulsory rural service for medical graduates: 11 Indian states have made it compulsory for
all medical graduates to serve in rural areas for a duration varying from 1 - 5 years.
iv. The most common strategy used by states to attract and retain skilled health personnel in rural
areas is to provide financial incentives- doctors serving in rural areas are given a “difficult
area allowance”, in addition to their regular salaries.
v. Chiranjivi yojana, launched in Gujarat in 2005, empowers the govt. to purchase medical
services directly from the private sector, mostly in the area of maternal care. It involves
purchasing maternity services from private providers through a voucher system, so that
women below the poverty line can access antenatal and post-natal care without paying
anything out-of-pocket.
vi. The National Medical Commission is empowered to impose punishment of up to one year
imprisonment and upto Rs 5 lakhs as fine on any individuals found practising medicine
without a license.

IV. Dimension: Technological

Ideal Condition: Leverage technology to overcome geographical, financial and knowledge-
related barriers.

Concerns:
i. Inability of people to access healthcare services due to remote location, mobility
limitations or transportation problems.
ii. Multiple consultations with doctors and diagnostic tests, which significantly increase
the cost of treatment.
iii. Lack of preventive healthcare habits and interventions.

Recommendation:
i. Promote telemedicine to facilitate access to qualified medical professionals, through
remote consultations between healthcare providers and patients, eliminating the need
for in-person visits.
ii. Establish digital infrastructure for Electronic Health Records (EHR). EHRs enable
healthcare professionals to access patients' medical histories, test results, and
treatment plans, irrespective of location or time. This reduces redundant tests, enable
better continuity of care, and empower patients to share their health information with
multiple providers easily.
iii. Use remote monitoring tools and wearable devices to allow healthcare providers to
remotely monitor patients' health conditions and vital signs. These devices can track
parameters such as heart rate, blood pressure, glucose levels, and activity levels,
providing valuable data for monitoring and early detection of health issues.

Evidence:
i. Telemedicine in India recorded an impressive growth during the COVID pandemic.
The eSanjeevani OPD (a patient-to-doctor tele-consultation system started in April
2020) recorded over a million consultations in the first year itself; by December 2022,
8.5 crore teleconsultations had been conducted at AB-HWCs.
Further, the Ayushman Bharat Digital Mission (ABDM) aims to develop integrated
digital health infrastructure in the country. This will bridge the gap between different
stakeholders and improve accessibility.

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 ii. Digitization of health records: The National Digital Health Mission aims to digitize
the health records of all Indians. This will allow the delivery of tailored, value-added
services to citizens. Further, such data would prove invaluable for medical
practitioners in the “Golden Hour” of medical emergencies.
Similarly, the National Health Stack (NHS) seeks to seamlessly link national health
electronic registries, a claims platform, a personal health records framework, a
national health analytics platform etc. The stack will facilitate single-point access to
individual health records.
iii. Platforms such as Practo, mfine, Niramai etc. enable people to search for doctors
using criteria that suits the patient, such as location, consultation fees, the option of
teleconsultation etc.
iv. Mobile health applications can provide individuals with access to healthcare
information, self-management tools, and remote monitoring capabilities. These apps
can offer features such as symptom tracking, medication reminders, health education,
and access to virtual consultations. Examples include the India Fights Dengue app,
Swasth Bharat mobile app, National Health Portal, E-RaktKosh etc.
v. Many digital platforms host Health Support Communities for individuals facing
specific health challenges. These platforms provide emotional support, and
opportunities for knowledge exchange among patients. They are particularly helpful
for individuals with rare diseases or chronic conditions, who may not have support
networks.

Principle Two: Health Promotion

I. Dimension: Economic
Ideal Condition: Adequate healthcare funding.

Concerns:
i. Low public health-care expenditure.
Even after the COVID pandemic, in 2021-22, India spent just 2.1% of its GDP on
health (pre-pandemic, it was 1.8% in 2020-21 and 1.3% in 2019-20).
The severity of the situation can be better understood by the fact that India ranks 170
out of 188 countries in government health expenditure as a percentage of GDP, as per
the Global Health Expenditure database of the WHO. In contrast, govt. spending on
health (as a proportion of GDP) was 18.3% in the USA and 6.7% in China. The
global average is 6.52%.

ii. Although health is a State subject, limited financial and institutional resources at the
State level have assigned this responsibility upon the Centre. Poor Centre-State
coordination has a negative impact on the provision of health services.

Recommendation:
i. Increase budgetary allocation for healthcare sector.
ii. Explore alternatives for generating additional revenue, such as medical tourism.
iii. Establish a dedicated cadre of health service personnel.

Evidence:
i. The National Health Policy 2017 proposes the raising of public health expenditure to
2.5% of the GDP in a time-bound manner. The States would be incentivised for
increasing State resources allocated for public health expenditure. The Government could
consider imposing higher taxes on commodities such as tobacco, alcohol and foods that
have a negative impact on health.
ii. As per National Health Accounts Estimates, the per capita spending by the govt. on
healthcare was Rs. 1042 in 2013-14. This has increased to Rs. 1815 in 2018-19, an
increase of 74%.

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 Further, the government’s share in health expenditure has increased from 23.2 % in 2013-
14, to 40.6 % in 2018-19.
iii. During the 11th Plan, 90% of the budget allocation for the National Rural Health Mission
(NRHM) was spent on family welfare programs, leaving only 7.7% for disease control.
iv. In June 2021, as part of the Ayushman Bharat program, the Govt. of India announced a
loan guarantee scheme of Rs 50,000 crores for ramping up health infrastructure in Tier 2
and Tier 3 cities. The scheme will provide loans upto Rs. 100 crores, with the interest rate
capped at 7.95%.
v. “Heal in India, Heal by India” is a Govt of India project that is expected to be launched in
2023. It focusses on two elements- promote medical tourism in India and encourage
healthcare workers to provide services abroad.
Medical tourism in India attracts approximately 2 million patients each year from 78
countries, generating $6 billion, which is expected to reach $13 billion by 2026.
vi. The Constitution of India, under Article 312, permits the establishment of All India
Services. Demands for the creation of an Indian Medical Service have increased after
the COVID pandemic.

II. Dimension: Social

Ideal Condition: Good quality of human capital.

Concerns:
i. Poor diet and nutrition. India is home to around 4 crore stunted children, as per the
Global Nutrition Report 2022; 34.7% of children below the age of 5 years are stunted;
53% of women between 15-49 years are anemic; 17.3% of children under 5 years of
age are affected by wasting (low weight-for-height), which is almost double the
average for the Asia region (8.9%); almost half of child mortality under the age of 5
years in India is attributable to under-nutrition.
India ranks 107 out of 121 countries in the Global Hunger Index 2022, down from
101 out of 116 countries in 2021 and 94 out of 116 countries in 2020.
ii. Cultural influences can create challenges in managing health. Two different types of
medicine, traditional and allopathic, generally work in parallel. Often, there is a
preference for traditional cures over allopathic methods. The issue here is not about
lack of education, because even articulate, well-educated people can express
preferences for traditional forms of medicine. Delays in seeking professional help as
well as non-compliance with the prescribed therapy are common.
iii. Lack of mother’s education, which is a factor that significantly affects her own and
her children's health and nutrition. Probability of stunting among children is 51% if
the mother is uneducated, 33% if the mother has received primary education and 21%
if the mother completed her secondary education.
iv. Micro-nutrient malnutrition, also known as “Hidden Hunger”. India faces a severe
crisis in micronutrient deficiency-more than 6,000 children below the age of 5 die in
India daily; more than half of these deaths are caused by micro-nutrient deficiency.

Recommendation:
i. Improve & integrate provision of healthcare and nutrition.
ii. Overcome taboos and resistance to modern medicine.
iii. Fortification of food, which refers to deliberately increasing the content of essential
micronutrients in a food so as to improve its nutritional quality.

Evidence:
i. POSHAN Abhiyaan, or the National Nutrition Mission, was launched in 2018 to improve
nutritional outcomes and ensure attainment of a Zero Hunger status by 2030. In 2021, the
Supplementary Nutrition Programme and Scheme for Adolescent Girls were merged under
Anganwadi Services and the POSHAN Abhiyaan- they are now re-aligned as Saksham
Anganwadi and POSHAN 2.0.

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 Each year, the month of Sept. is celebrated as Rashtriya Poshan Maah. It focusses on Social
Behavioural Change and Communication (SBCC). The broad themes include antenatal care,
anaemia, growth monitoring, girls’ education & diet, right age of marriage, hygiene and
sanitation, eating healthy food etc.

Other govt schemes include:

- The Zero Hunger Program, launched in 2017, to intervene in farms by organizing nutrition-
focused farming systems, providing zero hunger training, and establishing biofortified plant
genetic gardens.
- The Eat Right Movement, to transform the country's food system, in order to ensure safe,
healthy and sustainable food for all Indians.
- The National Food Security Mission, launched in 2007, to improve the production and
productivity of wheat, rice and pulses on a sustainable basis.

ii. Integrated Child Development Services (ICDS) is a government programme which provides
food, primary healthcare, immunization, health check-up and referral services to children
under 6 years of age and their mothers.
These services are delivered in an integrated manner at the Anganwadi, or childcare centre.
Each centre is run by workers who undergo institutional and community-based training.

iii. In April 2022, the Govt. of India announced the supply of fortified rice through government
schemes such as PDS, ICDS and PM-POSHAN to address malnutrition among the poor. It
allocated Rs. 2700 crores per annum for this scheme.
In May 2023, a United Nations report indicates that the provision of fortified rice has led to a
significant drop in the prevalence of anaemia among schoolchildren.

iv. Rashtriya Kishor Swasthya Karyakram covers adolescent health programmes in India. It
focusses on nutrition, injuries and violence, non-communicable diseases, sexual and
reproductive health, mental health and substance abuse. The strength of the program is its
health promotion approach. It is a paradigm shift from the existing clinic-based services to
promotion and prevention and reaching adolescents in their own environment, such as in
schools, families and communities.
v. The ultimate goal of Mission Indradhanush is to ensure full immunization with all available
vaccines for children up to two years of age and pregnant women. The government has
introduced Intensified Mission Indradhanush 2.0 to accelerate immunization coverage
and ensure greater coverage of all available vaccines.

III. Dimension: Environmental

Ideal Condition: Health should be considered as a value; it should be understood as a
necessary precondition for social justice, economic prosperity and good human capital.

Concerns:
i. Globalization has had a complex influence on health. While globalisation can improve
international sharing of medicines and medical practices, it can also cause faster disease
transmission (e.g. Covid, Ebola, Zika), air and water pollution etc. It has also influenced
cultural norms and led to a shift towards sedentary lifestyles and unhealthy diets.
ii. Urbanisation gives rise to big human populations, large geographic size, high human
density, and a variety of economic activities. These, in turn, create air, water and
noise pollution, mental health challenges etc. Areas of high human density have
limited access to potable water, sanitation and other basic services. As a consequence,
urban health indicators are often worse than those in rural areas.

Problems that are more common in urban areas include respiratory diseases due to air
pollution, vector borne disease such as dengue, diarrhoeal diseases due to unsafe
drinking water and sanitation, increased exposure to toxins etc.

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 Recommendation:
i. Recognize that the relation between health and the environment is direct-the worse the
environment, the more the need for healthcare.
ii. Build comprehensive health ecosystems, that enable a holistic approach to healthcare.
iii. If globalization is properly managed, it can lead to significant health gains. Global market
forces work efficiently in settings where domestic markets are competitive, regulatory
institutions are strong and access to public health services is widespread. In nations that have
good human and physical infrastructure, globalization improves welfare by facilitating the
spread of healthcare facilities.
iv. Urbanization requires comprehensive urban planning and public health interventions.
Strategies such as improving urban infrastructure, promoting physical activity, enhancing
access to healthcare services, implementing pollution control measures etc. can help mitigate
the negative health consequences of urbanization. Additionally, creating healthy and
sustainable urban environments can contribute to overall well-being in urban populations.

Evidence:
i. The Kayakalp scheme, an initiative under the Swachh Bharat Abhiyaan, aims to improve
cleanliness, hygiene, infection control and waste management practices at public health
facilities. The initiative has brought significant improvement in sanitation and hygiene
through a behavioural change in the staff of the hospitals as well as patients and their
attendants towards cleanliness.
ii. The “Swachh Swasth Sarvatra” initiative is based upon the objective of building upon the
achievements of two complementary programmes – Swachh Bharat Mission
(SBM) and Kayakalp. The aim of this scheme is to promote behavioural change, to achieve
higher levels of cleanliness and hygiene, with the goal of making India free of open
defecation.
iii. Human diets can be both healthier and more environmentally sustainable. Many studies
support the conclusion that reduced consumption of meat and dairy products, and increased
consumption of fruit and vegetables, would have a positive impact on both the environment
and health. For example, meat-based meals were found to generate on average 9 times higher
greenhouse gas emissions than plant-based meals.
iv. Switching from motorized to physical and from high-carbon to low-carbon forms of transport
would have beneficial effects on the environment while also potentially leading to a
significant reduction in cardiovascular and other diseases. The reduced disease burden would
result from the combined effects of increased levels of physical activity and reduced air
pollution, and also from decreased injury risk.
v. According to a 2022 study by the Univ. of Chicago, air pollution has shortened life
expectancy in New Delhi by up to 10 years, and across the country by five years. The study
ranked Bangladesh as the world's most polluted country overall, followed by India, Nepal,
and Pakistan.
vi. In its 2018 Article IV report, the IMF has said that India can boost its human capital’s
productivity by investing in education and healthcare. It identified poor public health as the
12th most important hurdle for ease of doing business, ahead of crime, tax regulations and
policy instability. Healthcare is a key recommendation in its suggestions for labour market
reforms. Increase in GDP does not guarantee better health but improvement in health
does relate positively to GDP.
vii. The Human Capital Index (HCI), created by the World Bank, quantifies the contribution of
health and education to the productivity of the next generation of citizens. India ranked 116
out of 174 countries in the 2020 HCI. The HCI is a part of the Human Capital Project (HCP),
which aims at the pursuit of policies towards Universal Health Coverage (UHC) – quality,
affordable healthcare for all without financial compromise. The HCI is creating the realisation
that good population health, nutrition and education are the foundations for sustainable
economic growth.
viii. India is working towards a ‘One Nation, One Health System’ by 2030, which would integrate
modern and traditional systems of medicine like allopathy, homoeopathy and Ayurveda. The

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 policy aims to formulate an Integrative Health System, under which patients would get
treatment from any medicinal system, depending on what ails them.
ix. “Health for All” is a WHO initiative that aims at promoting better health and an enhanced
quality of life. This encompasses elements such as regarding health as an objective of
economic development, promoting universal literacy, removing obstacles to health such as
malnutrition, lack of clean drinking water, improving access to medical services etc.
x. In line with the “Health for All” approach, India has introduced the Swasth Nagrik Abhiyaan
which identifies coordinated action on 7 priority areas:
i. Swachh Bharat Abhiyan.
ii. Balanced, healthy diets and regular exercises.
iii. Addressing tobacco, alcohol and substance abuse.
iv. Yatri Suraksha – preventing deaths due to rail and road traffic accidents.
v. Nirbhaya Nari –action against gender violence.
vi. Reduced stress and improved safety in the work place.
vii. Reducing indoor and outdoor air pollution.

IV. Dimension: Psychological

Ideal Condition: Promote mental health.

Concerns:
i. Stigma and Discrimination: There is a significant social stigma associated with mental
health conditions. This stigma can prevent individuals from seeking help and can lead to
discrimination and marginalization.
ii. Limited Access and Affordability: Access to mental healthcare services can be limited,
especially in rural areas and low-income communities. Additionally, mental healthcare
services can be costly, and many people do not have appropriate insurance coverage for
mental health treatment.
iii. Shortage of mental health professionals, such as psychiatrists and counselors.
iv. Limited research capacities and studies, due to which viable cures have still not been
formulated for diseases such as Alzheimer’s.

Recommendation:
i. Raise public awareness about mental health, its signs and symptoms, risk factors, and
available resources for help. Educate individuals about mental health and the
importance of seeking timely support.
ii. Reduce the stigma associated with mental health conditions, including depression.
Encourage open conversations about mental health to promote acceptance and
understanding.
iii. Early Intervention: Understand the importance of early identification and intervention
and encourage individuals to seek help at the first signs of mental distress.
iv. Promote stress reduction techniques such as regular exercise, mindfulness, relaxation
techniques, and healthy coping strategies. Encourage a healthy lifestyle that includes
regular physical activity, balanced nutrition, adequate sleep, and avoidance of
substance abuse.
v. Social Support: Encourage individuals to maintain strong social connections and seek
support from friends, family, or support groups. Foster a sense of community and
belonging to combat feelings of isolation and promote mental well-being.

Evidence:
i. The WHO estimates that:
a. About 3.8% of the population worldwide experiences depression, including 5% of
adults, and 5.7% of adults older than 60 years.
b. Approximately 28 crore people in the world have depression.
c. Depression is about 50% more common among women than among men.

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 d. More than 7 lakh people die due to suicide every year. Suicide is the fourth leading
cause of death in 15–29 year olds.

WHO’s Mental health action plan 2013–2030 attempts to provide appropriate

interventions for people with mental health disorders.

ii. In India, the National Mental Health Survey 2015-16 revealed that nearly 15% Indian
adults need active intervention for one or more mental health issues and one in 20 Indians
suffers from depression.
iii. According to the WHO, the suicide rate (suicides per lakh population) in India was 11.3
in 2020 and jumped to a record high of 12 in 2021. Russia has a suicide rate of 21.6,
while it is 14.5 in the US.
iv. The Mental Healthcare Act (2017) aims to provide mental healthcare services for persons
with mental illness. It seeks to protect their right to live with dignity by not being
discriminated against or harassed. As such, it decriminalized attempted suicide which was
punishable under Section 309 of the Indian Penal Code.
v. Mental health experts caution that the total budget allocation towards the National mental
Health Programme (NMHP) has remained unchanged at Rs 40 crores per annum for the
past few years. They urge that sesides the apex institutes like AIIMS, NIMHANS and
PGI, a more balanced budget should be allocated to peripheral centres and medical
colleges for the better management of mental health needs.
vi. A study, “Catastrophic Health Expenditure due to Mental Illness in India”, published by
the Journal of Health Management, states that in families where a family member has a
mental illness, nearly 1/5 of the household monthly expenditure is spent on healthcare.
Because of out-of-pocket expenditure on such healthcare, about 21% of these households
drop below the poverty line, highlighting the need for financial risk protection.
vii. To address of mental disorders, the Govt of India has launched the District Mental Health
Programme (DMHP) under the NMHP in 704 districts. The DMHP aims to detect,
manage and provide treatment for mental illnesses through the components of counselling
in schools and colleges, stress management skills, life skills training etc.
viii. Tele-MANAS, a free-of-cost mental health helpline, was launched in Oct 2022-it has
received more than 1 lakh calls in the first six months of its functioning. Approximately
70% were distress calls, 20-25% sought information, and around 5-10% pertained to
mental health disorders and required professional help.

Principle Three: Health Equity

I. Dimension: Economic
Ideal Condition: Income-neutral healthcare services, meaning that financial considerations
should not impact the quality or delivery of such services.

Concerns:
i. High out-of-pocket expenditure. Approximately 59% of the total health expenditure in India
is incurred by the public. Out-of-pocket expenditure, payments made directly by individuals
for services which are not covered under any financial protection scheme, is extremely high.
Out of pocket expenditure is typically financed by household revenues. Due to high out of
pocket healthcare expenditure, about 7% population is pushed below the poverty threshold
every year.
ii. Prohibitive cost of medicines and medical devices. 60% of the population in India does not
have regular access to essential medicines. This is despite the fact that India produces 8% of
the medicines available in the global market. About 60-90% of healthcare spending by poor
people is on medicines. Further, there are significant variations in the prices of medicines
being sold at different outlets.
iii. According to the Niti Aayog, at least 30% of the population, or 40 crore people lack financial
health protection. This segment is termed the "missing middle", because they are not poor

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 enough to be covered by govt. subsidized insurance but are not rich enough to buy private
insurance.

Recommendation:
i. Affordable health insurance (Before the launch of PM-JAY, 90% of India’s poorest 20%
citizens did not have any health insurance). However, private health insurance remains
out of reach for most people and needs to be made more accessible.
ii. Financial risk pooling which refer to the collection and management
of financial resources so that large, unpredictable individual financial risks become
predictable and are distributed among all members of the pool. Risk pooling can
provide financial protection to households in the face of high health care costs.
iii. Making medicines more affordable by publicizing comparative prices of medicines,
increasing consumer awareness, promoting the use of generic medicines wherever
possible etc. Further, strategic purchasing should be encouraged to develop channels of
supply at the lowest total cost, not just the lowest purchase price.

Evidence:
i. A 2021 report by Oxfam India (“Securing the Rights of Patients in India”) revealed that 12%
of respondents could not get vaccinated because they could not afford the price of the
vaccine. 9% of the respondents had to lose a day’s wages to get vaccinated.
ii. In 2021, the Insurance Regulatory and Development Authority of India (IRDAI) proposed a
“pandemic risk pool” to address various risks which have been triggered by the Covid-19
pandemic and offer protection to people in case of a similar crisis in the future.
iii. The Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP) provides quality medicines at
affordable prices to the masses. PMBJP stores provide generic drugs, which are available at
lesser prices but are equivalent in quality and efficacy as expensive branded drugs.
iv. The National Pharmaceutical Pricing Authority (NPPA) has expanded the list of medicines
under price control from 74 in 1995 to 860 by 2019. This has significantly reduced prices of
many essential medicines and medical devices such as coronary stents, which have become
almost 80% cheaper.
The NPPA has also launched a mobile app called “Pharma Sahi Daam” for consumers to
compare the prices of medicines and lodge complaints where needed.
v. A 2022 market study by the Competition Commission of India (CCI) on the pharmaceutical
industry reveals as many as 2,871 formulations are being sold in India under 47,478 brands.
On an average, there were as many as 17 brands for one formulation.
It found that in the pharmaceutical sector, consumers do not compare prices or buy the
cheapest prices but go by what the doctor has prescribed. Hence, drug companies push their
brands by offering incentives to doctors and high profit margins to retailers.
The study found that the price of an antibiotic sold by 217 companies under 292 brand names
ranged between Rs 40 and Rs 336 for a pack of six tablets. Price variations went up to 120%
for some medicines.

II. Dimension: Social

Ideal Condition: Egalitarianism, meaning that people should be treated the same.

Concerns:
i. Discrimination on the basis of caste, community etc. which leads to differential treatment
and sometimes even denial of treatment.
ii. Gender bias, which leads to women being deprived of medical facilities or not given a
quality of treatment comparable to their male counterparts.

Recommendation:
i. Identify groups that have been historically marginalized and are currently vulnerable to
inequality in health care, such as women and backward classes. Without social justice, we

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 cannot ensure good health. As Amartya Sen says, it is important to distinguish between a
“good health policy” and a “policy for good health”.
ii. Promote gender equality and reduce class elitism.
iii. Conducting more research involving women. Many research studies into diseases and
treatments are skewed with a higher number of male participants. Ensuring women are
properly represented in medical research will help address the gender bias.

Evidence:
i. The Musahar community is one of the most disadvantaged of the scheduled castes in Bihar
and eastern Uttar Pradesh. This community has a disproportionately large percentage of cases
of kala-azar in the country, and the disease is endemic to this territory. Kala-azar came into
the region in the 19th century and is a major killer within the Musahars. The hundred-year
long history of modern epidemic forms of kala-azar is an example of a path of discrimination
towards marginalised communities, through an absence in research priorities and treatment
options, and a lack of interest in more effective methods of cure and control.

ii. A 2021 report by Oxfam India revealed that 33% Muslims and 20% of Dalits and Adivasis
face discrimination and denial of treatment because of their religion or caste.

iii. The “Untouchability in Rural India” survey (2001-02) was conducted by ActionAid across
565 villages in 11 states. It revealed that Dalits are discriminated to such an extent that they
were denied entry into private health centres or clinics in 21.3% of villages. It also revealed
that healthcare workers do not go into 65% of Dalit communities, thus leaving many Dalits
without any healthcare.

iv. Gender budgeting can bring improvements in women’s education and employment, lower
health costs due to targeted diagnosis and treatment etc.

For instance, the task of cooking is often exclusively entrusted to women. Indoor air pollution
due to unclean fuel kills millions of women from heart disease, stroke and lung cancer.
Experts say that cooking on an open fire in the kitchen is like burning 400 cigarettes an hour.

v. Gendered health governance: Earlier schemes like the Rashtriya Swasthya Bima Yojana
(RSBY) excluded women from seeking health services. Such schemes have now been re-
engineered to be free of any gender-bias.

The Pradhan Mantri Jan Arogya Yojana (PM-JAY) allows households without any adult male
members to be considered eligible for the scheme. It has also done away with the cap of five
beneficiaries per family, because it became a tool for excluding women in larger families,
owing to male preference. Additionally, PM-JAY supports a substantial number of health
benefits packages that are either women-centric in nature or are overwhelmingly common to
both men and women.
vi. More than 30% of direct medical costs faced by U.S. Blacks, Hispanics and Asian-Americans
can be tied to health inequities. Because of inequitable access to care and other health
resources, these populations are often sicker and incur higher medical costs. In addition,
studies have shown that doctors tend to have more negative attitudes toward these races.

III. Dimension: Senior Citizens

Ideal Condition: Customized healthcare.

Concerns:
i. Senior citizens face many age-specific challenges in accessing healthcare services, such as
financial constraints, limited availability of geriatric healthcare professionals, limited
mobility, social isolation etc.

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 ii. Lack of comprehensive insurance policies due to
a. Higher insurance premiums
b. Age limits imposed by insurance companies
c. Limited coverage and exclusion of pre-existing conditions from the insurance
policy
iii. Older adults may face ageism and discrimination in healthcare settings, leading to disparities
in the delivery of healthcare services. Negative stereotypes and biases against older
individuals can result in under-diagnosis, under-treatment, or inadequate attention to their
specific health needs.

Recommendation:
i. Develop a robust geriatric healthcare infrastructure that includes specialized geriatric clinics,
hospitals, and long-term care facilities.
ii. Expand the use of telemedicine and remote monitoring technologies, especially for those
living in remote areas. This can improve access to healthcare, reduce travel burdens, and
enable remote consultations with healthcare professionals.
iii. Establish community programs and counselling services that address the social and emotional
well-being of older adults. This can help reduce social isolation and improve mental health
outcomes.
iv. Develop targeted health promotion campaigns for older adults, emphasizing healthy lifestyles
and preventive screenings.
v. Affordable and comprehensive insurance policies.

Evidence:
i. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in India
provides free screenings for breast and cervical cancer to women between the ages of 30-65
years.
While the program aims to detect cancer at an early stage and provide timely treatment, it
excludes senior women above the age of 65 from accessing these screenings. This exclusion
overlooks the fact that older women are also at risk of developing cancer and denies them the
opportunity for preventive care and early detection.
ii. The Longitudinal Ageing Study in India (LASI), conducted by the Ministry of Health and
Family Welfare between April 2017 and December 2018, found that 30% of the 10.3 crore
Indians above the age of 60 display symptoms of depression. It estimated that 8.3 %, or 1 in
12 people, of the country's elderly population have probable major depression.
iii. The Kerala government is planning to launch a comprehensive geriatric care scheme to
provide healthcare services, including preventive, curative, and rehabilitative care, to senior
citizens. It includes medical, nutritional, and psychosocial support for senior citizens.
iv. The World Health Organization and the UN have designated 2021-2030 as the Decade of
Healthy Aging, as a good step for elderly empowerment.

IV. Dimension: People with Disabilities

Ideal Condition: Access to healthcare.

Concerns:
i. Physical barriers, such as the lack of appropriate infrastructure with regard to accessibility to
buildings and equipment.
ii. Communication barriers, when people with hearing disabilities are unable to convey their
concerns to healthcare providers due a lack of sign language interpreters.
iii. Health-related information, including pamphlets, brochures, and websites, is often not available in
accessible formats such as Braille, large print, or audio. This exclusion prevents individuals with
visual impairments or reading difficulties from accessing essential health information.

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iv. Greater vulnerability to diseases. The WHO estimates that people with certain disabilities die up
to 20 years earlier than those without disabilities. People with disabilities have twice the risk of
developing conditions such as depression, asthma, diabetes, stroke, obesity or poor oral health.
v. Negative attitudes and biases towards people with disabilities. Healthcare providers may have
limited knowledge or understanding of disability issues, leading to misconceptions or stereotypes.
This can result in inadequate care, lack of respect, or discriminatory treatment.

Recommendation:
i. Accessibility: Improve the physical accessibility of healthcare facilities by providing ramps,
elevators, accessible parking, and disability-friendly examination tables.
ii. Sensitization and Training: Conduct regular training programs for healthcare providers to
raise awareness about disability issues, promote sensitivity, and enhance their knowledge of
the specific healthcare needs of people with disabilities.
iii. Communication Accessibility: Ensure effective communication for PwDs by providing
trained sign language interpreters, captioning services, or assistive listening devices.
iv. Accessible Information: Provide health-related information in accessible formats such as
Braille, large print, audio recordings, and easy-to-understand language.
v. Include health services for specific impairments and health conditions in insurance and
healthcare packages.

Evidence:
i. According to the National Health Profile 2020, there are a total of 5,737 hospitals in India. Of
these, only 1248 (21.6%) have provisions to accommodate people with disabilities. The
majority of these hospitals are located in urban areas. In rural areas, only 12.2% of hospitals
have provisions for people with disabilities, making accessibility to healthcare very difficult.
ii. The National Centre for Promotion of Employment for Disabled People conducted a survey in
May 2020 titled "Locked Down and Left Behind”. It revealed that about 73% of persons with
disabilities (PwD) were found to be facing severe challenges like lack of access to rations and
healthcare in the coronavirus-induced lockdown. The survey showed that 67% PwDs had no
access to doorstep delivery of essentials, 48% had no access to a government helpline, and
63% had not received the financial assistance for PwDs announced by the Finance Ministry.
However, states like Kerala ensured that local self-governments were involved in taking
special care of persons with disabilities. It established common kitchens where cooked food
was served, while dry rations were provided to those who could not reach these kitchens. It
also granted students with disabilities Rs 5,000 as ex-gratia payment.
iii. The term “Missing Millions” is often used for Persons with Disabilities (PwDs) to indicate
their invisibility in govt. policies and budgetary allocation.
The 2023-24 Union allotted Rs 1225 crores to the Department of Empowerment of Persons
with Disabilities (DoEPwD). This is a meagre 0.027% of the total budget. In percentage
terms, the DoEPwD’s allocation has increased by just 1% from last year’s budget estimates.
iv. Apollo Hospitals is one of the first medical chains in India to offer prescriptions in Braille.
v. In Dec. 2022, the Delhi High Court directed the Insurance Regulatory and Development
Authority of India (IRDAI) to design and launch health insurance schemes for PwDs.
It passed this order while hearing a petition from a man who was denied insurance by two
companies because he suffers paralysis from the chest down.
vi. The Covid-19 lockdown left persons with disabilities helpless. The government provided just
Rs 1,000 as a one-time payment in two instalments over three months- a pittance, compared
to what was truly needed.
Policy makers failed to take into account how a person with vision impairment, without
guidance, would be able to spot the exact location of open shops, medical stores or hospitals.
People with cognitive disability need assistance for even accessing government grants from
their bank accounts, but there was no provision made for any such assistance.

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 Principle Four: Medical Ethics

I. Dimension: Women
Ideal Condition: Safety and prevention of exploitation.

Concern:
i. Abortion:
- Right to life of the foetus. An embryo develops a heartbeat at 5 weeks of
pregnancy, after which many believe that abortion amounts to the termination of
an innocent life.
- Woman’s control over her own body, especially when the foetus was conceived
as the result of an assault.
- Sex-selective abortions, where doctors assist parents in terminating a pregnancy
based upon the predicted sex of the child.

ii. Surrogacy:
- Exploitation of women through coercion or financial incentives.
- Commodification of reproduction.
- Emotional and Psychological impact, when the surrogate has to may experience
attachment and emotional bonds with the child she carries

Recommendation:
i. Combat gender bias and discrimination that may contribute to the selective abortion
of female foetuses. This can be achieved through education, awareness campaigns,
and strict legal measures. In India, prenatal sex determination is banned under the
Pre-conception and Prenatal Diagnostic Techniques (Prohibition of Sex Selection)
Act 1994 to arrest the declining sex ratio.
ii. Develop clear legal and ethical guidelines regarding abortion. This can provide a
framework for decision-making and ensure the safety and well-being of women. Such
guidelines should consider factors such as gestational limits, maternal health, fetal
abnormalities, and the woman's right to autonomy.
iii. Ensure that the surrogate mother fully understands the physical, psychological and
financial implications, as well as the potential risks before entering into an
agreement.
iv. Explore alternative options for people seeking parenthood, such as adoption or
fostering, which can provide a loving and stable home for children in need.
v. Establish financial safeguards to prevent the exploitation of surrogate mothers. This
includes setting reasonable compensation rates, ensuring fair contracts, and providing
access to healthcare and insurance coverage for both the surrogate and the child.

Evidence:
i. The Medical Termination of Pregnancy Act (1971) was amended in 2021, to allow
abortions up till a period of 24 weeks of pregnancy in case of foetal abnormalities, risk to
the physical or mental health of the woman, contraceptive failure or rape.
ii. The US state of Texas enacted a law in 2021 which prohibits abortions after a period of 6
weeks. This amounts to an outright ban on abortions, since most women would not even
get to know that they are pregnant within this period. This is especially discriminatory
towards victims of rape, teenagers, people who lack financial resources to pay the
increased cost for the procedure etc. Moreover, it compels women to use unsafe methods
to terminate a pregnancy.
iii. In 2023, a bench of the Gujarat High Court, while hearing the plea requesting permission
to terminate the 7-month pregnancy of a 17-year-old rape survivor, cited the Manusmriti
in their observations. The court in its oral observations said, “Ask your mother or your
great-grandmother, 14-15 used to be the maximum age for girls to get married. The child
used to take birth before the age of 17. 4-5 months here and there doesn't make a
difference. You will not read it, but do read Manusmriti once”. A minor who conceived as

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 result of assault had to deal with such regressive remarks and was stripped of her bodily
autonomy.
iv. About 70% of India’s population lives in rural areas where safe abortion services are not
readily available. More than half the abortion-related deaths in the study are due to a lack
of access to appropriate health care. Women living in rural areas have a 26% higher
chance of an unsafe abortion compared to women living in urban areas
v. Savita Halappanavar, a 31-year-old Indian woman living in Ireland, was 17 weeks
pregnant in 2012 when she experienced a miscarriage. Despite her requests for an
abortion, the medical staff refused to terminate the pregnancy because they believed that
the foetus had a heartbeat. Her condition deteriorated rapidly and she passed away in
October 2012.
Her case sparked significant controversy and highlighted the issue of women's rights in
cases where the mother's life is at risk. It paved the way for the legalization of abortion in
Ireland in 2018.
vi. In India, the Surrogacy (Regulation) Act of 2021 permits only altruistic surrogacy, where
no monetary compensation is given to the surrogate except for medical expenses and
insurance coverage. Commercial surrogacy, where surrogates are paid a fee, is prohibited.
vii. Baby Manji Yamada Case (2008): The surrogate mother, a poor woman from Gujarat,
gave birth to a baby through surrogacy for a Japanese couple. However, legal issues arose
as the intended parents divorced before the child's birth, and the surrogate was left in a
complex legal situation, unable to care for the child or grant parental rights to the
intended parents.
viii. The Gammy case (2014): a Thai surrogate mother gave birth to twins, one of whom had
Down syndrome. The intended parents, an Australian couple, took the healthy twin back
to Australia but left the baby with Down syndrome, named Gammy, in Thailand.

II. Dimension: Life

Ideal Condition: Right to life.

Concern:
i. Euthanasia:
- Right to life and informed consent of the patient, especially in case of
involuntary euthanasia, where the patient does not have the ability to express
their opinion. This can lead to the exploitation of vulnerable patients for
financial reasons.
- Element of guilt associated with active euthanasia, as compared to the pain
and suffering associated with passive euthanasia.
ii. Do Not Resuscitate (DNR): It is a legal document pre-signed by a patient that
instructs healthcare providers to not perform cardiopulmonary resuscitation (CPR)
in case of a cardiac arrest.
- Potential for misunderstandings or disagreements during emergency
situations. The families of patients may not fully comprehend the
implications of a DNR order, and healthcare professionals may be uncertain
about whether to provide resuscitative measures.
iii. Living will: It is an advance directive detailing a person's desires regarding future
medical treatment, in circumstances in which they are no longer able to express
informed consent.
- Potential for misinterpretation or ambiguity. Living wills outline an
individual's healthcare preferences in advance, but there may be situations
where the document is open to different interpretations.

Recommendation:
i. Develop a comprehensive legal framework that clearly defines the conditions, procedures,
and safeguards for euthanasia, living wills, and DNR orders. The legislation should address
concerns related to abuse, consent, and protection of vulnerable individuals.

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 ii. Provide counselling services to individuals considering euthanasia, living wills, or DNR
orders.
iii. Encourage regular review of living wills and DNR orders to ensure that they align with an
individual's current wishes and medical circumstances.

Evidence:
i. Aruna Shanbaug case (1973-2015): She was a nurse in a Mumbai hospital in 1973, when she
was sexually assaulted and suffered severe brain damage. She was confined to a persistent
vegetative state for over four decades, till the Supreme Court admitted a petition in 2011
seeking active euthanasia for her, based on the fact that continuing life-sustaining
interventions amounted to a violation of her right to die with dignity.
In its landmark 2011 judgment, the Supreme Court recognized the legality of passive
euthanasia (withdrawing life-sustaining treatment) under specific conditions but denied the
request for active euthanasia. The court also established a framework for end-of-life decisions
in India, requiring the involvement of a high-level medical board and authorization from the
judiciary.
ii. Terri Schiavo was an American woman who suffered severe brain damage and fell into a
persistent vegetative state in 1990. Her husband sought to have her feeding tube removed
based on the belief that she would not want to be kept alive in that condition. However, her
parents fought against it, arguing that she could potentially recover and that removing the tube
would be euthanasia. The case resulted in a prolonged legal battle and public debate.
Ultimately, the court ruled in favour of removing Terri's feeding tube, leading to her death.
The case highlights the complexities surrounding euthanasia and end-of-life decisions.
iii. Marlise Munoz was an American woman who was pregnant in 2014 when suffered a cardiac
arrest and was declared brain-dead. Her husband invoked her living will and requested the
removal of life support.
However, a legal complication arose due to a law that stated that life-sustaining treatment
could not be withdrawn from a pregnant patient. Despite Marlise being brain-dead, the
hospital continued to keep her on life support, against the wishes of her husband and her own
documented preferences. The case sparked a debate about the rights of pregnant women and
the interpretation of living wills in the context of pregnancy.
iv. In 2022, the European Court of Human Rights ruled in favour of Tom Mortier, son of
Godelieva de Troyer, who died by lethal injection in 2012, aged 64.
Mortier had sued the Belgian govt., where euthanasia is legal, for allowing his mother to be
euthanised because she was suffering from depression. He also alleged that none of the family
members were consulted before allowing her plea, weakening the basic ethos of family and
societal support.

III. Dimension: Procedural

Ideal Condition: First, do no harm.

Concern:
i. Genetic engineering, which refers to the manipulation and modification of an
organisms’ genetic material. It raises several concerns such as:
a. Human enhancement, which deepens the divide between haves and have-nots
b. Environmental impact, because genetically modified organisms may disrupt
existing ecosystems.
c. Designer babies, which raises questions about the ethical limits of selecting
specific traits in babies, and the potential for creating a society that values certain
traits over others.
ii. Organ trade, which refers to the practice of luring and compelling poor and
uneducated people to donate organs to high paying customers.
iii. Unnecessary tests and inflated medical bills: Many private hospitals, to maximise
profits, use a system of incentives and disincentives to push doctors to over-bill. An
unholy nexus between doctors and pharmaceutical firms is rampant, which leads to

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 prescription of costly drugs. The Income Tax Department reveals that doctors get a
referral fee of 35% for MRI tests and 20% for other diagnostic tests.
Recommendation:
i. Promote organ trade and pledging of organs. This makes it easier for patients to obtain organs
for transplants and reduces the threat of organ trade.
ii. Ban the system of commission for doctors on the basis of referrals. Such a system creates
adverse incentives because the more a doctor recommends diagnostic tests or the longer he
keeps a patient in the ICU, the more he earns.
While it is legitimate for a private hospital to maximise revenue, it implies having a system
which seeks to maximise patient expenditure-this is why societies with good public health
services have strict monitoring on private healthcare providers.
iii. Impose ceilings on medical charges, including the cost of treatment as well as the cost of
medicines and medical equipment.
iv. Develop comprehensive ethical guidelines and standards for genetic engineering procedures.
Regulatory bodies should be established to ensure compliance and prevent the misuse of
technology for non-therapeutic purposes.

Evidence:
i. The Transplantation of Human Organ Act (THO) was passed in India in 1994 to
streamline organ donation and transplantation activities. The act made the sale of organs a
punishable offence. However, doctors estimate that although the annual number of kidney
transplants is over 2000, less than 600 of them are cadaveric transplants. This proves the
existence of a huge quantum of illegal organ trade.
ii. Many Western countries are considering the “opt out” system for organ donations. This
system assumes all citizens to be willing organ donors after death, unless they “opt-out”
of doing so. However, such a policy may not always be sensitive to the families of the
deceased, especially in countries where awareness of organ donation related issues is low.
iii. In 2008, the police arrested Dr. Amit Kumar, known as the “Kidney Kingpin” of India for
operating an organ trafficking network. He used to exploit the vulnerabilities of the
donors and transplanted organs into wealthy patients, including foreigners, who were
willing to pay huge amounts of money.
iv. Similarly, in 2018, several senior doctors at Hiranandani Hospital in Mumbai were
arrested for running an institutionalised kidney transplant racket.
v. CRISPR babies case: In 2018, Chinese scientist He Jiankui claimed to have successfully
edited the genes of twin girls using gene-editing technology. He altered the embryos'
DNA to make them resistant to HIV infection, marking the first reported attempt at
creating genetically modified humans. The case raised ethical concerns about the
potential long-term effects and unintended consequences of gene editing.
vi. In 2020, the Maharashtra govt. put a cap on charges private hospitals can levy on patients.
This step was taken after numerous grievances by patients of exorbitant amount of money
being charged by healthcare providers. In many instances, hospitals were selectively
admitting patients based only on their ability to pay.
vii. In Jacob Mathew vs. State of Punjab (SC 2005), the Supreme Court framed guidelines
under which a doctor can be held criminally liable on account of professional negligence
or deficiency of service. The judgment arose on the basis of a complaint wherein a patient
lost his life because the hospital could not provide oxygen in time.

IV. Dimension: Research

Ideal Condition: First, do no harm.

Concern:
i. Although animal research is crucial for medial advancement, animals are not always
treated kindly and their well-being/suffering is not given the importance it deserves.

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 ii. Many humans participate in clinical trials due to financial constraints and only focus
on the payment they receive for participating. This results in many people being
unaware of the risks and long-term health consequences of the trial.
iii. Although research and trials are welcome for scientific and medical innovations,
many trials focus only on cosmetic products and commercial gains.

Recommendation:
i. Adhere to strict guidelines for animal care, minimizing pain and distress, and using
alternative methods whenever possible.
ii. Obtain the Informed Consent of participants by providing comprehensive information
and facilitating participants to make autonomous decisions.
iii. Cosmetics are typically considered to be low-priority as compared to
pharmaceuticals. Therefore, endeavor to use alternative modes such as AI models and
simulations wherever possible and avoid testing on living subjects.

Evidence:
i. Silver Spring monkeys case (1981): It exposed the severe mistreatment and neglect of
monkeys in an animal testing laboratory in the US. The monkeys were subjected to
confinement, forced chemical ingestion, invasive procedures without proper pain relief,
and inadequate veterinary care. This case led to the global emergence of PETA (People
for the Ethical Treatment of Animals), which had been founded just a year back.
ii. The Tuskegee Syphilis Study (1932-1972): The U.S. Public Health Service conducted a
study on African American men who were infected with syphilis. The participants were
not informed about their diagnosis, denied proper treatment, and left to suffer the long-
term effects of the disease, including blindness, organ damage, and even death. The study
violated ethical principles such as informed consent, beneficence, and respect for persons.
iii. Thalidomide Trials (1950s-1960s): Thalidomide, a drug prescribed to pregnant women
for morning sickness, caused severe birth defects. The trials conducted failed to
adequately assess the drug's safety and did not consider the potential risks to developing
fetuses. This tragic oversight resulted in thousands of infants being born with limb
deformities.
iv. Maternal Deprivation Studies: In the mid-20th century, studies were conducted that
involved separating infant monkeys from their mothers at birth and subjecting them to
social isolation and psychological stress. These studies aimed to investigate the effects of
maternal deprivation on development but inflicted severe psychological distress upon the
infant animals.
v. HPV Vaccine Trial (2009): A large-scale trial of the Human Papillomavirus (HPV)
vaccine for cervical cancer was conducted in Andhra Pradesh and Gujarat by Merck. The
vaccine was administered to around 16,000 girls, many of whom were living in state-run
hostels for tribal children.
Dozens of girls fell seriously ill and 7 of them died. A standing committee that
investigated the incident found that out of the 6217 consent forms collected in Gujarat,
3944 had a thumb impression instead of a signature. This indicated the low level of
awareness the children had before consenting to participate in the trials.

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 Quotes on HEALTHCARE

1. The improvement of medicine would eventually prolong human life, but improvement of social
conditions could achieve this result even more rapidly and successfully. - Rudolf Virchow
2. America's health care system is neither healthy, caring, nor a system. ― Walter Cronkite
3. ‘Has access to’ does not mean that they are guaranteed health care. – Bernie Sanders
4. No parent should ever have to decide if they can afford to save their child’s life. – Jimmy Kimmel
5. The best way to reduce the cost of medical care is to reduce the illness. – Arlen Specter
6. Health is like money. We never have a true idea of its value until we lose it.
7. The rich man's dog gets more in the way of vaccination, medicine and medical care than do the
workers upon whom the rich man's wealth is built. – Samora Machel
8. The doctor of the future will give no medication, but will interest his patients in the care of the
human frame, diet and in the cause and prevention of disease. -Thomas Edison
9. Health coverage for regular citizens isn't mandated by the Constitution, but we're obligated to
provide adequate medical care for prisoners, whatever the cost. Jim Riley
10. Health is more than the absence of disease. Health is about jobs and employment, education, the
environment, and all of those things that go into making us healthy. ― Joycelyn Elders
11. A tremendous amount of needless pain and suffering can be eliminated by ensuring that health
insurance is universally available. – Daniel Akaka
12. A good physician treats the disease, the great physician treats the patient who has the disease.
13. Do as much as possible for the patient, and as little as possible to the patient.
14. Medical science is making such remarkable progress that soon none of us will be well. – Aldous
Huxley
15. It is much more important to know what sort of a patient has a disease than what sort of a disease
a patient has.
16. So many people spend their health gaining wealth and then have to spend their wealth to regain
their health. – A.J. Materi
17. Health cannot be a question of income; it is a fundamental human right. – Nelson Madela
18. In the middle of difficulty lies opportunity. – Albert Einstein
19. Medicines cure diseases but only doctors can cure patients. - Carl Jung
20. Health is a state of body. Wellness is a state of being. – J Stanford
21. Just as we practice physical hygiene to preserve our physical health, we need to observe
emotional hygiene to preserve a healthy mind and attitudes.— Dalai Lama
22. Poor health is not caused by something you don't have; it's caused by disturbing something that
you already have. Health is not something you need to get, it's something you have already if you
don't disturb it. - Dean Ornish
23. The power of community to create health is far greater than any physician, clinic or hospital. -
Mark Hyman
24. Medicines cure diseases but only doctors can cure patients- Carl Jung
25. The aim of medicine is to prevent disease and prolong life; the ideal of medicine is to eliminate
the need of a physician- William Mayo

VAJIRAM & RAVI Page 20

 COMPARATIVE HEALTH INDICATORS

INDIA USA CHINA EU BHUTAN PAKISTAN AFRICA

Life expectancy 69 years 76 years 76 years 81 years 68 years 67 years 63 years
(Male)
Life expectancy 72 years 81 years 82 years 85 years 72 years 70 years 68 years
(Female)
Spending on Health 2.1 % 18.3% 6.7% 8.1% 4.37% 2.95% 6.1%
(as % of GDP)
Maternal Mortality 130 32.9 15.4 8 183 186 533
(Deaths per 1 lakh
live births)
Infant Mortality 28 5.7 5.5 3.8 28 66 67.6
(Deaths per 1000
live births)
Number of Doctors 0.9 2.6 2.4 3.2 0.37 0.98 0.2
(Per 1000
inhabitants)
Households using 62% 99% 95% 99% 100% 70% 40%
clean fuel for
cooking (%)
Total Fertility Rate 2.0 1.7 1.5 1.6 2.3 3.0 4.6
Per capita Govt. 22 5,258 130 2,400 120 100 30
Health Expenditure
(In dollars)
OOP expenditure, as 58.7% 11% 30% 15% 50% 45% 40%
share of total Health
expenditure

VAJIRAM & RAVI Page 21