Issues Relating to development and management of Health

The WHO defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The determinants of good health are: access to various types of health services, and an individual’s lifestyle choices, personal, family and social relationships.

Health is central to human happiness and well-being. It also makes an important contribution to economic progress, as healthy populations live longer, are more productive, and save more. Many factors influence health status and a country’s ability to provide quality health services for its people.

At present, India’s health care system consists of a mix of public and private sector providers of health services. Networks of health care facilities at the primary, secondary and tertiary level, run mainly by State Governments, provide free or very low cost medical services. There is also an extensive private health care sector, covering the entire spectrum from individual doctors and their clinics, to general hospitals and super speciality hospitals.

India’s Standing on Health Parameters
Parameter	India’s Standing	Targets (SDG/NHP)
Infant Mortality Rate (IMR) (deaths/1000 live births)	28	12 (neonatal deaths/1000)
Maternal Mortality Rate (MMR) (deaths/100000 live births)	103	70
Life Expectancy (yrs)	69 years and 4 months	70
Under 5 mortality (deaths/1000 live births)	32	25
Total Fertility Rate	2.0	2.1
Stunting	35.5%	Reduce by 40% (By 2025)
Wasting	19.3%	Reduce to < 5% (By 2025)

Sources:

1. The Sample Registration System (SRS) Statistical Report, 2020 released by the Registrar General of India (RGI).
2. Global hunger Index 2022, by Concern Worldwide and Welthungerhilfe

Ranking in Global Indices

• Global Hunger Index (Welthungerlife) (2022) – 107/119
• Healthcare Access & Quality Index (Lancet) (2019) – 145/195
• Healthiest Country Index (Bloomberg) (2019) – 120/169

Health Care Infrastructure in India

• Government Spending (%GDP) – 2.1% in 2021-22 (Target 2.5% by 2025 – National Health Policy 2017, World Average – 6%).
• 62% out of pocket expenditure – pushed 5 Cr people into poverty in a year (A study by three experts of Public Health Foundation).
• Doctor: Patient ratio – 1:1600 [WHO ideal 1:1000].
• Bed: Patient ratio – 0.9:1000 [WHO recommended 3:1000].
• Infrastructure paradox:

	Urban	Rural
Population	30%	70%
Health Infra	70%	30%

Issues and Challenges

Primary Healthcare

Supply Side:

• Doctor & Infrastructure shortage (above data): Only 1/6^th Primary health centers meet public health standard (according to MHFW report). This reduces supply of basic essential service providers.
• Less government funding: Only 2.1% GDP, while target is 2.5% by 2025 – National Health Policy 2017, and World Average – 6.
• Connectivity issue: Besides poor doctor and hospital ratio, such miniscule facilities remain inaccessible due to infrastructure issues like roads, ambulance etc.
• Poor linkage to medical pluralism: Over stress on allopathic medicine make traditional medicine like Ayurveda, homeopathy, Unani, Naturopathy etc.
• Less use of technology: Modern technology usage like digitization of health record, satellite communication, ICT, modern equipment etc., remain minimal.

Demand Side:

• Affordability: 60% out of pocket expenditure pushing 5 Cr people into poverty. High medicine costs making healthcare prohibitive for poor.
• Less awareness about lifestyle diseases: Awareness about healthy lifestyle is dismal. 60% deaths in India are due to non-communicable diseases like Diabetes, Cancer, respiratory illness etc., which can be easily prevented by adoption better lifestyle – eating habits, physical activities.
• Irrational use of medicine: Over-use of prescriptive over-the counter drugs like antibiotics is rendering medicine impact useless e.g. New Delhi metalloB-lactamase-1 (NDM-1 disease) due to bacteria developing immunity against over-use of medicine.

Secondary healthcare- (Additional points):

• Rural-Urban divide: Infrastructure paradox shows 70% population residing in rural area while only 30% of healthcare infrastructure is available in the same regions.
• High cost of treatment and medicine: Secondary, Tertiary care still remain distant dream to majority of population due to affordability issue. E.g. Heart Stent pricing issue.
• Lack of regularization of private sector: Private hospitals working outside government vigilance and exploiting customers. E.g. Fortis Hospital (Guru gram), Max Hospital (Delhi) controversy.
• Weak health insurance: Only 44% of the 1.3 billion people in India have a health insurance policy as of 2017, according to a report by consulting firm Milliman – ‘Indian Life and Health Insurance Sectors’.

National Health Policy

National Health Policy 2017

It is successor to The National Health Policy of 1983 and the National Health Policy of 2002.

Need for new NHP

• It has been 15 years since last National Health Policy.
• The health priorities are changing. Although maternal and child mortality have rapidly declined, there is growing burden on account of non-communicable diseases and some infectious diseases.
• Emergence of a robust health care industry estimated to be growing at double digit.
• The growing incidences of catastrophic expenditure due to health care costs, which are presently estimated to be one of the major contributors to poverty.
• A rising economic growth enables enhanced fiscal capacity.

Key Principles

• Professionalism, Integrity and Ethics, Equity, Affordability, Universality, Patient Centered & Quality of Care, Accountability, Inclusive partnership, Pluralism, Decentralization, Dynamism and Adaptiveness.

Objectives:

• Progressively achieve Universal Health Coverage.
• Reinforcing trust in Public Health Care System.
• Align the growth of private health care sector with public health goals.

Goals:

• Life Expectancy
• Increase from 67.5 to 70 by 2025.
• Reduce TFR to 2.1 by 2025.

Mortality

• Reduce Under Five Mortality to 23 by 2025 and MMR from current levels to 100 by 2020.
• Reduce infant mortality rate to 28 by 2019.
• Reduce neo-natal mortality to 16 and still birth rate to “single digit” by 2025.
• Reduction of 40% in prevalence of stunting of Under-Five Children by 2025.

Reduction of diseases

• Achieve global target of 90:90:90, for HIV/AIDS i.e., 90% of all people living with HIV know their HIV status, 90% of all people diagnosed with HIV infection receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression.
• Achieve and maintain elimination status of Leprosy by 2018, Kala-Azar by 2017 and Lymphatic Filariasis in endemic pockets by 2017.
• To reach TB elimination status by 2025.
• To reduce premature mortality from cardiovascular – diseases, cancer , diabetes or chronic respiratory diseases by 25% by 2025.

Health Systems Performance

• Increase utilization of public health facilities by 50% from current levels by 2025.
• More than 90% of the newborn are fully immunized by one year of age by 2025.
• Access to safe water and sanitation to all by 2020 (Swachh Bharat Mission).

Health Finance

• Increase health expenditure by Government as a percentage of GDP from the existing 1.15% to 2.5% by 2025.

National Family Health Survey

The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in a representative sample of households throughout India. Three rounds of the survey have been conducted since the first survey in 1992-93. The survey provides state and national information for India on fertility, infant and child mortality, the practice of family planning, maternal and child health, reproductive health, nutrition, anaemia, utilization and quality of health and family planning services.

Each successive round of the NFHS has had two specific goals:

• To provide essential data on health and family welfare needed by the Ministry of Health and Family Welfare and other agencies for policy and programme purposes, and
• To provide information on important emerging health and family welfare issues.

International Institute for Population Sciences (IIPS) Mumbai, is the nodal agency responsible for providing coordination and technical guidance for the survey under the guidance of Ministry of Health.

History of NFHS

• Objective: The main objective of each successive round of the NFHS has been to provide high-quality data on health and family welfare and emerging issues in this area.
  • NFHS-1: The NFHS-1 was conducted in 1992-93.
  • NFHS-2: The NFHS-2 was conducted in 1998-99 in all 26 states of India.
    • The project was funded by the USAID, with additional support from UNICEF.
  • NFHS-3: The NFHS-3 was carried out in 2005-2006.
    • NFHS-3 funding was provided by the USAID, the Department for International Development (UK), the Bill and Melinda Gates Foundation, UNICEF, UNFPA, and the Government of India.
  • NFHS-4: The NFHS-4 in 2014-2015.
    • In addition to the 29 states, NFHS-4 included all six union territories for the first time and provided estimates of most indicators at the district level for all 640 districts in the country as per the 2011 census.
    • The survey covered a range of health-related issues, including fertility, infant and child mortality, maternal and child health, perinatal mortality, adolescent reproductive health, high-risk sexual behaviour, safe injections, tuberculosis, and malaria, non-communicable diseases, domestic violence, HIV knowledge, and attitudes toward people living with HIV.

National Family Health Survey-5

• The NFHS-5 has captured the data during 2019-20 and has been conducted in around 6.1 lakh households.
  • Many indicators of NFHS-5 are similar to those of NFHS-4, carried out in 2015-16 to make possible comparisons over time.
  • Phase 2 of the survey (covering remaining states) was delayed due to the Covid-19 pandemic and its results were released in September 2021.
• NFHS-5 data will be useful in setting benchmarks and examining the progress the health sector has made over time.
  • Besides providing evidence for the effectiveness of ongoing programmes, the data from NFHS-5 help in identifying the need for new programmes with an area specific focus and identifying groups that are most in need of essential services.
  • It provides an indicator for tracking 30 Sustainable Development Goals (SDGs) that the country aims to achieve by 2030.
• NFHS-5 includes some new topics, such as preschool education, disability, access to a toilet facility, death registration, bathing practices during menstruation, and methods and reasons for abortion.
  • NFHS-5 includes new focal areas that will give requisite input for strengthening existing programmes and evolving new strategies for policy intervention. The areas are:
    • Expanded domains of child immunization
    • Components of micro-nutrients to children
    • Menstrual hygiene
    • Frequency of alcohol and tobacco use
    • Additional components of non-communicable diseases (NCDs)
    • Expanded age ranges for measuring hypertension and diabetes among all aged 15 years and above.
• In 2019, for the first time, the NFHS-5 sought details on the percentage of women and men who have ever used the Internet.

Key Findings of NFHS-5

• Sex Ratio: NFHS-5 data shows that there were 1,020 women for 1000 men in the country in 2019-2021.
  • This is the highest sex ratio for any NFHS survey as well as since the first modern synchronous census conducted in 1881.
  • In the 2005-06 NFHS, the sex ratio was 1,000 or women and men were equal in number.
• Sex Ratio at Birth: For the first time in India, between 2019-21, there were 1,020 adult women per 1,000 men.
  • However, the data shall not undermine the fact that India still has a sex ratio at birth (SRB) more skewed towards boys than the natural SRB (which is 952 girls per 1000 boys).
  • Uttar Pradesh, Haryana, Punjab, Rajasthan, Bihar, Delhi, Jharkhand, Andhra Pradesh, Tamil Nadu, Odisha, Maharashtra are the major states with low SRB.
• Total Fertility Rate (TFR): The TFR has also come down below the threshold at which the population is expected to replace itself from one generation to next.
  • TFR was 2 in 2019-2021, just below the replacement fertility rate of 2.1.
    • In rural areas, the TFR is still 2.1.
    • In urban areas, TFR had gone below the replacement fertility rate in the 2015-16 NFHS itself.
  • A decline in TFR, which implies that a lower number of children are being born, also entails that India’s population would become older.
  • The survey shows that the share of under-15 population in the country has therefore further declined from 28.6% in 2015-16 to 26.5% in 2019-21.
• Children’s Nutrition: Child Nutrition indicators show a slight improvement at all-India level as Stunting has declined from 38% to 36%, wasting from 21% to 19% and underweight from 36% to 32% at all India level.
  • In all phase-II States/UTs the situation has improved in respect of child nutrition but the change is not significant as drastic changes in respect of these indicators are unlikely in a short span period.
    • The share of overweight children has increased from 2.1% to 3.4%.
• Anaemia: The incidence of anaemia in under-5 children (from 58.6 to 67%), women (53.1 to 57%) and men (22.7 to 25%) has worsened in all States of India (20%-40% incidence is considered moderate).
  • Barring Kerala (at 39.4%), all States are in the “severe” category.
• Immunization: Full immunization drive among children aged 12-23 months has recorded substantial improvement from 62% to 76% at all-India level.
  • 11 out of 14 States/UTs have more than three-fourth of children aged 12-23 months with fully immunization and it is highest (90%) for Odisha.
• Institutional Births: Institutional births have increased substantially from 79% to 89% at all-India Level.
  • Institutional delivery is 100% in Puducherry and Tamil Nadu and more than 90% in 7 States/UTs out of 12 Phase II States/UTs.
  • Along with an increase in institutional births, there has also been a substantial increase in C-section deliveries in many States/UTs especially inprivate health facilities.
    • It calls into question unethical practices of private health providers who prioritise monetary gain over women’s health and control over their bodies.
• Family Planning: Overall Contraceptive Prevalence Rate (CPR) has increased substantially from 54% to 67% at all-India level and in almost all Phase-II States/UTswith an exception of Punjab.
  • Use of modern methods of contraceptives has also increased in almost all States/UTs.
  • Unmet needs of family Planning have witnessed a significant decline from13% to 9% at all-India level and in most of the Phase-II States/UTs.
  • The unmet need for spacing which remained a major issue in India in the past has come down to less than 10% in all the States except Jharkhand (12%), Arunachal Pradesh (13%) and Uttar Pradesh(13%).
• Breastfeeding to Children’s: Exclusive breastfeeding to children under age 6 months has shown an improvement in all-India level from 55% in 2015-16 to 64% in 2019-21. All the phase-II States/UTs are also showing considerable progress.
• Women Empowerment: Women’s empowerment indicators portray considerable improvement at all India level and across all the phase-II States/UTs.
  • Significant progress has been recorded between NFHS-4 and NFHS-5 in regard to women operating bank accounts from 53% to 79% at all-India level.
  • More than 70% of women in every state and UTs in the second phase have operational bank accounts.

Steps to be taken in Healthcare Sector

• Public funding on health should be increased to at least 2.5 per cent of GDP as envisaged in the National Health Policy, 2017.
• Institute a public health and management cadre in states:
  • To train officials in public health related disciplines including epidemiology, biostatistics, demography and social and behavioral sciences.
  • To provide training in hospital management to suitably equip personnel responsible for managing large facilities.
  • Create a career pathway up to the highest levels within the state health departments for those trained in public health, as well as for those with clinical specialties.
• Create an environment, through appropriate policy measures, that encourages healthy choices and behaviors:
  • Make the practice of yoga a regular activity in all schools through certified instructors.
  • Increase taxes on tobacco, alcohol and unhealthy foods such as soda and sugar sweetened beverages.
  • Co-locate AYUSH services in at least 50 percent of primary health centres, 70 percent of community health centres and 100 per cent of district hospitals by 2022-23.
  • Operationalize a network of 150,000 HWCs on priority by 2022-23 in order to ensure sufficient coverage of affordable primary care and lower the burden on secondary and tertiary care.
• Create a primary healthcare system with following features:
  • A primary health care nucleus comprising five to six upgraded sub-centers coupled with a primary health centre, and population outreach.
  • A team led by a mid-level health service provider, 3 auxiliary nurse midwives (ANMs), accredited social health activists (ASHAs) and a male health worker responsible for comprehensive primary health care services for a population of about 5,000.
  • Planning of health facility distribution in districts to ensure that a continuum of care is available on the principles of ‘time to care’ through a strong referral linkage.
  • Digitization of family records and information from the community to the facility level.
  • Use of real-time data to guide public health action and implementation monitoring.
  • Undertake a well-funded research programme to find the best pathways for effective and context specific scaling up of primary health care. This is critical because it is well-known that a single model of primary health care may not work for all districts/states in the country.
• Reform the governance of medical, nursing, dentistry and pharmacy education in the country:
  • Revamp the AYUSH, nursing, dentistry and pharmacy councils.
  • Establish a Council for Allied Health Professionals to ensure standardization of education and putting in place quality control mechanisms for educational institutions, teaching methods, clinical protocols and workforce management.
  • Put in place an updated curriculum for medical and allied professions that keeps pace with the changing dynamics of public health, policy and demographics.
  • Establish a nursing school in every large district or cluster of districts with a population of 20-30 lakhs as per the National Health Policy, 2017.
• Enhance production of doctors (especially specialists and super- specialists):
  • Link at least 40 per cent of district hospitals with medical colleges.
  • Meet faculty shortages in new AIIMS with an active search strategy, visiting/adjunct faculty system (from India and abroad), and other methods.
  • Create pathways for training of doctors in specialties and super-specialties at private hospitals. (Certification, short courses, exchange programmes, etc.)

Current Issues

Ayushman Bharat (Pradhan Mantri Jan Arogya Abhiyaan)

• World’s largest government funded healthcare program: Integrated approach covering primary, secondary and tertiary healthcare through:
  • Access to Health and Wellness centres (HWCs) at the primary healthcare level.
  • Financial protection for accessing curative care at the secondary and tertiary levels through Pradhan Mantri Jan Arogya Yojana (PMJAY).

Key Features

• The government-sponsored health insurance scheme will provide free coverage of up to Rs 5 lakh per family per year at any government or even empanelled private hospitals all over India for secondary and tertiary medical care facilities.
• Modicare will be available for 74 crore beneficiary families and about 50 crore Indian citizens. Under the process, 80 percent of beneficiaries, based on the Socio-Economic Caste Census (SECC) data in the rural and the urban areas, have been identified.  
• There is no restriction on the basis of family size, age or gender.
• Ayushman Bharat is unlike other medical insurance schemes where there is a waiting period for pre-existing diseases. All kinds of diseases are covered from day one of the Ayushman Bharat policy. The benefit cover includes both pre and post hospitalization expenses.
• The expenditure incurred in premium payment will be shared between Central and State Governments in a specified ratio. The funding for the scheme will be shared – 60:40 for all states and UTs with their own legislature, 90:10 in Northeast states and three Himalayan states of Jammu and Kashmir, Himachal and Uttarakhand and 100% Central funding for UTs without legislature.
• The NHPS will draw additional resources from the Health and Education Cess and also depend on funding from States to boost the Central allocation. The premiums are expected to be in the range of `Rs 1,000 – ` 1,200 per annum.
• The NHPM (National Health Protection Mission) will pay for the hospitalisation costs of its beneficiaries through strategic purchasing from public and private hospitals.
• Wellness Centres: The 1.5 lakh sub-centres that are converted into wellness centres will cater to majority of services such as detection and treatment of cardiovascular diseases, screening for common cancers, mental health, care of the elderly, eye care, etc.
• The wellness centres will also offer a set of services including maternal and child health services, mental health services and vaccinations against selected communicable diseases.

Benefits of Ayushmaan Bharat

• Pan-India portability: Nationwide coverage to the beneficiaries as benefits can be availed anywhere in the country.
• Pradhan Mantri Aarogya Mitras: A cadre of certified frontline health service professionals called Pradhan Mantri Aarogya Mitras (PMAMs) who will be primary point of facilitation for the beneficiaries to avail treatment at the hospital.
• Use of technology: Cashless, paperless system promoting digitization of healthcare and eco-friendly as well.
• Holistic Coverage: Primary through Health & Wellness Centres and Secondary, tertiary care through National Health Protection Scheme (PM-JAY) making all health aspects covered. The cover includes many items typically excluded in standard medi-claims such as pre-existing diseases, mental health conditions, and internal congenital diseases, among others.
• Cooperative federalism: Coordination of Centre with states as Health is a State subject.
• Pubiic-Private partnership: Private hospitals empanelled to ensure quality and greater accessibility.
• Helps reduce catastrophic expenditure for hospitalizations, which pushes 5 crore people into poverty each year.
• It could help country move towards universal health coverage and equitable access to healthcare which is one of the UN Sustainable Development Goals (SDG3: Good health and well-being).
• Market for insurers: For insurers and third-party administrators, this is a large new market that will open

Challenges of Ayushman Bharat

• Practical feasibility:
  • One size fits all – All 10 Crore families given blanket benefit of Rs. 5 Lakh while economic conditions, disease requirements might vary.
  • Number of hospitals empanelled are around 8500 while actual need to cater to all intended beneficiaries are 30-40000 hospitals.
  • Within selected empanelled hospitals the existing bed ratio is poor.
• Regulatory vacuum:
  • Quality of hospitals is not ensured as only 1-3% hospitals are accredited.
  • Minimalist approach – 40% poor selected from SECC 2011 data, there is scope of inclusion and exclusion error.
  • Misuse by hospitals by overcharging for treatments, tests.
• Financial inadequacies:
  • Payments model: There is lack of clarity about what financial model is to followed for funding – Trust v/s Insurance mechanism.
  • Dismal evidence based policy making as there is lack of data on existing health insurance.
  • Fiscal burden: Theoretically, 2-3 Lakh crore is needed to fund the scheme while only 10000 Cr allotted in the budget.
• Human Resource:
  • Public sector healthcare remains in doldrums due to poor quality of human resources, which is forcing patients to go to the private sector.
  • The most critical issue remains the limited and uneven distribution of human resources at various levels of health services, with up to 40% of health worker posts lying vacant in some states.
• Primary healthcare negligence: With greater emphasis on secondary and tertiary healthcare, the scheme pays little attention to primary healthcare which is fundamental for sustainable quality preventable healthcare.
• Technical: There is absence of a large-scale Information Technology network for cashless treatment.
• Administrative: The secondary and tertiary public hospital infrastructure suffers from severe efficiency and accountability problems. Since, majority of the beneficiaries will be families from rural areas, this is a worrisome scenario.

Paradigm Shift for Tuberculosis Control

World TB Day is observed on March 24. India accounts for about a quarter of the global TB burden. Worldwide India is the country with the highest burden of both TB and Multi Drug Resistance (MDR)TB. There are an estimated 79,000 multi-drug resistant TB patients among the notified cases of pulmonary TB each year.

Tuberculosis (TB) remains the biggest killer disease in India, outnumbering all other infectious diseases put together – this despite our battle against it from 1962, when the National TB Programme (NTP) was launched.

Steps so Far

• In 1978, the Expanded Programme on Immunisation (EPI) began, giving BCG to all babies soon after birth and achieving more than 90% coverage. Yet, when evaluated in 1990, the NTP and the EPI had not reduced India’s TB burden.
• Reasons for failure
  • BCG vaccine did not protect against TB infection or adult pulmonary TB, the ‘infectious’ form.
  • The assumption of curing pulmonary TB might control TB by preventing new infections was without validation in high prevalence countries.
• In 1993, the Revised National TB Control Programme (RNTCP) was launched. By 2014-15, the RNTCP was found to be very successful in reducing mortality, but failing to control TB.
  • Reasons for failure
    • Delays in care seeking and diagnosis are the result of lack of universal primary health care.

National Strategic Plan for 2017- 25 for TB Elimination in India:

• The NSP 2017 – 2025 builds on the success and learnings of the last NSP and encapsulates the bold and innovative steps required to eliminate TB in India by 2030. It is crafted in line with other health sector strategies and global efforts, such as the draft National Health Policy 2015, World Health Organization’s (WHO) End TB Strategy, and the Sustainable Development Goals (SDGs) of the United Nations (UN).
• Vision: TB Free India with zero deaths, disease and poverty due to tuberculosis.
  Goal: To achieve a rapid decline in burden of TB, morbidity and mortality while working towards elimination of TB in India by 2025.
• Strategic pillars: The requirements for moving towards TB elimination have been integrated into the four strategic pillars of “Detect – Treat – Prevent – Build” (DTPB).
  • Detect: Find all DS – TB and DR – TB cases with an emphasis on reaching TB patients seeking care from private providers and undiagnosed TB in high – risk populations.
  • Treat: Initiate and sustain all patients on appropriate anti – TB treatment wherever they seek care, with patient friendly systems and social support .
  • Prevent the emergence of TB in susceptible populations.
  • Build and strengthen enabling policies, empowered institutions and human resources with enhanced capacities.

Pradhan Mantri TB Mukt Bharat Abhiyan

• About:
  • It’s an initiative of Ministery of Health and Family Welfare (MOHFW) to accelerate the country’s progress towards TB elimination by 2025.
• Objectives:
  • Provide additional patient support to improve treatment outcomes of TB patients
  • Augment community involvement in meeting India’s commitment to end TB by 2025.
  • Leverage Corporate Social Responsibility (CSR) activities.
• Components:
  • Ni-kshay Mitra Initiative: It is to ensure additional diagnostic, nutritional, and vocational support to those on TB treatment.
    • Ni-kshay Mitra (Donor) are those who can support by adopting health facilities (for individual donor), blocks/urban wards/districts/states for accelerating response against TB to complement government efforts.
  • Ni-kshay Digital Portal: It will provide a platform for community support for persons with TB.

What are the other related Initiatives Regarding Tuberculosis?

• Global Efforts:
  • The WHO (World Health Organisation) has launched a joint initiative “Find. Treat. All. #EndTB” with the Global Fund and Stop TB Partnership.
  • WHO also releases the Global Tuberculosis Report.
• India’s Efforts:
  • India’s National TB Elimination Programme is strengthened to meet the goal of ending the TB epidemic by 2025 from the country, five years ahead of the Sustainable Development Goals (SDG) for 2030.
  • National Strategic Plan (NSP) for Tuberculosis Elimination (2017-2025), The Nikshay Ecosystem (National TB information system), Nikshay Poshan Yojana (NPY- financial support), TB Harega Desh Jeetega Campaign.
  • Currently, two vaccines VPM (Vaccine Projekt Management) 1002 and MIP (Mycobacterium Indicus Pranii) have been developed and identified for TB, and are under Phase-3 clinical trial.
  • Ni-kshay Poshan Yojana: It provides Rs 500 support through direct benefit transfer to the patients.
  • Ayushman Bharat Digital Health Mission: The government has also focused on utilising technology and creating digital health IDs for TB patients under the Ayushman Bharat Digital Health Mission to ensure proper diagnostics and treatment are available.

Tamil Nadu pilot model

• To ensure public participation: A missing element in the RNTCP — the new model will be in public-private participation model.
• The Rotary will ensure the participation of all players (health and non-health) in the private sector.
• Tiruvannamalai TB mantra: Slowing down of infection, progression and transmission simultaneously.
  • Transmission:
    • TB affected should cover their mouth and nose while coughing and sneezing and not to spit in open spaces.
    • Public education for behavior modification, starting in all schools and continuing through to adults.
  • Progression:
    • Giving World Health Organization-recommended short-term ‘preventive treatment’.
    • Cohorts of schoolchildren (5, 10 and 15 years) can be tested and those TST positive given preventive treatment.

Granting Limited License to the Medical Practitioners at the Mid-Level

Under the new NMC Bill 2019, the NMC may grant a limited license to certain midlevel practitioners connected with the modern medical profession to practice medicine. These mid-level practitioners may prescribe specified medicines in primary and preventive healthcare. In any other cases, these practitioners may only prescribe medicines under the supervision of a registered medical practitioner.

Pros

• Empowering PHC: Trained community health providers will strengthen preventive and primary care at the health sub-centers at the rural level and substantially reduce out-of-pocket spending on treatment.
• Accessibility: The middle level service providers will help the government in reaching to such areas where there are no qualified doctors.
• Human Resource: It would help India achieve the WHO mandated doctor-patient ratio of 1:1,000 persons in seven years. The ratio today is around 1:1,500.
• Structuring of Healthcare providers: An ideal health workforce is multilayered and multi-skilled, with complementary roles delivering competent, comprehensive, continuous and compassionate care. CHWs act as community mobilisers and trusted links to the organized health services. E.g. Ethiopia, Rwanda used CHW for antenatal care and significantly reduced maternal mortality.
• World best practice: This is similar to other countries where medical professionals other than doctors are allowed to prescribe allopathic medicine. For example, Nurse Practitioners in the USA, after completing some basic course, training and registration, are eligible to provide a full range of health care services. Swasthya Sebikas and Swasthya Kormis have strengthened primary healthcare in Bangladesh. Thailand has CHWs designated as village health volunteers and village health communicators. Brazil’s family health teams, too, have CHWs as an important component.

Cons

• Law legalizing quackery: The term ‘Community Health Provider’ has been vaguely defined to allow anyone connected with modern medicine to get registered in NMC and be licensed to practice modern medicine.
• Technical knack: IMA fears that people who have some connections with modern medicine like pharmacists, practitioners of other systems of medicines, healthcare workers at the Primary Healthcare Centers (PHCs) etc. may not have sufficient background in the study of anatomy, physiology or pathology etc. which form the basis of modern medicine.
• Quality: The Bill does not talk about the renewal of the medical license, as practiced in other countries like UK and Australia.
• Abrupt provision: The courses prescribed for CHW, the institutions which will deliver them, the competencies that will be promoted and the nature of functions they are expected to perform are not clear at this stage.

Way Ahead

• The state governments should incentivize medical practice in rural areas. The government should reserve post-graduation seats specifically for those candidates who work for a certain number of years with the government. For CHPs, the government can start a three-year training programme for physicians, as practiced in Chhattisgarh and Assam.
• The CHPs may not fit well into the NMC but surely they can be accommodated as allied health professionals. That may bring accord between the government and the medical profession.

The National Medical Commission Bill, 2019

Why the Government has gone for regulating Medical Education:

• To ensure that doctors are appropriately trained and skilled to address the prevailing disease burden.
• To ensure that medical graduates reflect a uniform standard of competence and skills.
• To ensure that only those with basic knowledge of science and aptitude get in.
• To ensure ethical practice in the interest of the patients.
• To create an environment that enables innovation and research.
• To check the corrosive impact of the process of commercialisation on values and corrupt practices.

The National Medical Commission Bill, 2019 replaces Medical Council of India to develop and regulate all aspects of Medical Education, Medical Profession and Medical Institutions. The Government considers this as one of the biggest reforms. The Bill seeks to annul the Indian Medical Council Act, 1956 in the wake of allegations of corruption against MCI.

Salient Feature of the Bill

• The Bill envisages defining “Community Health Providers” as persons granted a license to practice medicine at mid-level. These CHPs would be allowed to prescribe specified medicines independently in primary/preventive healthcare.
• The Bill stresses on enhancing the interface between systems of medicine such as Central Council of Homeopathy and Central Council of Indian Medicine.
• Common final year MBBS exam will be called National Exit Test (NEXT) for admission to PG courses and also for obtaining a practice license and it will also act as screening test for students, who graduate in medicine from foreign medical colleges.
• NEET will continue to be the entrance examination for undergraduate courses and premier educational institutions like AIIMS will also have to stick to it.
• It seeks to do away with the practice of yearly inspections. It will ensure the end of the Inspector Raj and will facilitate the addition of undergraduate and post graduate medical seats.
• Medical Council of India did not have the power to regulate fees. The New Commission is envisaged with the power to determine fees in 50% private medical college seats.
• It empowers the Centre to override any suggestion of the NMC.
• Stringent measures have been introduced to punish the quacks.

Positive Aspects

• The measure of issuance of limited licenses to community health providers to practice medicine has already been implemented in many countries, including developed nations.
• A common exit examination is needed for standardization and Post Graduate course selection.
• It opens the path to a long-awaited reform of medical education.
• NMC can encourage and incentivize innovation and promote research by laying down rules that make research a prerequisite in medical colleges.
• NMC has the potential to link the disease burden and the specialties being produced.
• The Bill has virtually given up inspections for assuring the quality of education. With NEXT, a college with the largest number of failed students will automatically close down.

Apprehensions

• IMA feels that granting non-medical persons licence to practice modern medicine, is nothing but legalising and promoting quackery in India. It opens the floodgates for licensing 3.5 lakh quacks.
• It is not yet clear, what kind of professionals could be certified as Community Health Providers and this gives rise to several apprehensions.
• Though the bill does not openly talk of a bridge course for Ayush doctors, the wording of the interface between systems of medicine is prone for different possibilities.
• NEXT effectively removes the opportunity to reappear for PG selection. Moreover , it is objective in nature, increases the workload and stress level of the students’ manifold.
• There is a need for college-level testing of practical clinical skills as a qualifier for the theory-based National Exit Test.
• States can only advise the National Medical Commission, but the Commission can choose not to accept those advices.
• NMC Bill clearly states that the Ethics Board will exercise appellate jurisdiction with respect to actions taken by the State Medical Councils.
• The bill allows differential pricing with freedom for the college managements to levy market determined fees on 19,000 students, which is called management quota. This is admission for those with the ability to pay.
• NEXT is an idea borrowed from UK, that has for over seven years been struggling to introduce it. In all such countries, the licensing exams are stretched into modules, that are not multiple choice questions type of exam.
• Relying only on the NEXT as the principal substitute for ensuring quality may lead to certain grey areas giving scope for corrupt practices and production of substandard doctors.
• The Bill allows extensive discretionary powers to Government to set aside decisions of the NMC. Hence, it virtually becomes an advisory body.

Way Forward

• The quality and integrity of the people appointed would define the future of the health system in India.
• Mid-level health workers like Community Health Providers are needed and their training programmes, competencies and roles have to be clearly defined to differentiate them from medical graduates.

Surrogacy (Regulation) Act, 2021

• Surrogacy is an arrangement in which a woman (the surrogate) agrees to carry and give birth to a child on behalf of another person or couple (the intended parent/s).
• A surrogate, sometimes also called a gestational carrier, is a woman who conceives, carries and gives birth to a child for another person or couple (intended parent/s).

Altruistic Surrogacy	Commercial Surrogacy
Altruistic surrogacy involves no monetary compensation to the surrogate mother other than the medical expenses and insurance coverage during the pregnancy.	Commercial surrogacy includes surrogacy or its related procedures undertaken for a monetary benefit or reward (in cash or kind) exceeding the basic medical expenses and insurance coverage.

• Defining ‘surrogacy’:
  • It is defined as a practice where a woman undertakes to give birth to a child for another couple and agrees to hand over the child to them after birth. 
• Altruistic surrogacy:
  • The Act allows ‘altruistic surrogacy’ — wherein only the medical expenses and insurance coverage is provided by the couple to the surrogate mother during pregnancy. 
  • No other monetary consideration will be permitted.
• The intending couple:
  • Any couple that has ‘proven infertility’ is a candidate. 
  • The ‘intending couple’ as the Act calls them, will be eligible if they have a ‘certificate of essentiality’ and a ‘certificate of eligibility’ issued by the appropriate authority. 
  • The former will be issued if the couple fulfills three conditions:
    • A certificate of infertility of one or both from a district medical board; 
    • An order of parentage and custody of the surrogate child passed by a Magistrate’s court;
    • Insurance cover for the surrogate mother.
• Eligibility Certificate:
  • An eligibility certificate mandates that the couple fulfil the following conditions:
    • They should be Indian citizens who have been married for at least five years; 
    • the female must be between 23 to 50 years and the male, 26 to 55 years; 
    • they cannot have any surviving children (biological, adopted or surrogate); 
    • However, this would not include a ‘child who is mentally or physically challenged or suffers from life threatening disorder or fatal illness.’
• Surrogate mother:
  • Only a close relative of the couple can be a surrogate mother, one who is able to provide a medical fitness certificate.
    • She should have been married, 
    • with a child of her own, and 
    • must be between 25 and 35 years, 
    • but can be a surrogate mother only once.
• Regulating Body:
  • The Centre and State governments are expected to constitute a National Surrogacy Board (NSB) and State Surrogacy Boards (SSB) respectively. 
  • This body is tasked with enforcing standards for surrogacy clinics, investigating breaches and recommending modifications. 
  • Further, surrogacy clinics need to apply for registration within 60 days of the appointment of the appropriate authority.
• Offences:
  • Offences under the Act include commercial surrogacy, selling of embryos, exploiting, abandoning a surrogate child etc. 
  • These may invite up to 10 years of imprisonment and a fine of up to Rs. 10 lakh.

Why regulations on Surrogacy? 

• India as Surrogacy hub:
  • India has emerged as a hub for infertility treatment, attracting people from the world over with its state-of-the-art technology and competitive prices to treat infertility. 
• Socio-economic conditions:
  • Soon enough, due to prevailing socio-economic inequities, underprivileged women found an option to ‘rent their wombs’ and thereby make money to take care of their expenses.
  • This was often practiced to facilitate marriage, enable children to get an education, or to provide for hospitalisation or surgery for someone in the family.
• Rising middlemen:
  • Once information of the availability of such wombs got out, the demand also picked up. 
  • Unscrupulous middlemen inveigled themselves into the scene and exploitation of these women began. 
  • Several instances began to emerge where women, in often desperate straits, started lodging police complaints after they did not receive the promised sum.
• Other issues:
  • In 2008 a Japanese couple began the process with a surrogate mother in Gujarat, but before the child was born they split with both of them refusing to take the child. 
  • In 2012, an Australian couple commissioned a surrogate mother and arbitrarily chose one of the twins that were born.

Criticisms

• Too restrictive regulations: 
  • For instance, it does not allow single women, or men, or gay couples to go in for surrogacy.
  • This Deprives homosexuals and single parents.
• Lack of clarity:
  • Bill doesn’t define “close relatives” as it is hard to regulate commercial surrogacy in this context.
• Reproductive rights:
  • Reproductive Rights of women are restricted as State deciding mode of Parenthood.
  • It Restricts basic human right (of Having a Child) and article 14 because of the discriminatory approach on the basis of nationality, marital status and sexual orientation and Violates freedom of Choice and Declaration of Human Rights 1948.
  • The Act doesn’t address issues like Postpartum problems.
• Rights of women surrogates:
  • The act is criticised for curtailing the rights of women surrogates under the garb of curbing exploitation.
  • Prohibition of payment can lead to more exploitation of Women.
  • Eg., Several villages in Gujarat are known for commercial surrogacy. As per reports, Anand, known for Amul’s dairy factory, has also acquired fame as India’s ‘surrogacy capital,’ offering lucrative monetary opportunities for impoverished women.
  • Such practices have now been thrown into a quandary with the passage of this Act.
• Example of the Transplantation of Human Organs Act:
  • Despite a similar, stringent law — the Transplantation of Human Organs Act — organ commerce continues to thrive in the country. 
  • Brokers continue to operate, though with less temerity and more covertly, sometimes with hospital authorities, to pull the wool over the eyes of the appropriate authority and law enforcement officials.

Way Ahead

• Surrogacy is legal in India. But, making it commercial is illegal. It is a humanitarian act and is recognized by law. 
• Surrogacy comes under the reproductive choices of women and it is included as a fundamental right under the purview of Article 21 of the Indian Constitution.
• If a critical mass builds up, amendments might have to be resorted to in order to resolve the grievances and ensure access for all categories of parents.
• Rather than penalising surrogacy, the person providing a womb for surrogacy must be secured with a contract, ensuring proper, insurance and medical checks.
• The issues like middlemen will have to be handled with a stern visage, even as sensitivities of people are factored in.

Healthy States, Progressive India Report by NITI Aayog

“Healthy States, Progressive India” is a comprehensive Health Index report released by the NITI Aayog. The report ranks states and Union territories innovatively on their year-on-year incremental change in health outcomes, as well as, their overall performance.

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

• About:
  • The State Health Index is an annual tool to assess the performance of states and UTs, which has been compiled and published since 2017.
  • It is a weighted composite index based on 24 indicators grouped under the domains of ‘Health Outcomes’, ‘Governance and Information’, and ‘Key Inputs/Processes’.
    • Health Outcomes:
      • It includes parameters such as neonatal mortality rate, under-5 mortality rate, sex ratio at birth.
    • Governance and Information:
      • It includes parameters such as institutional deliveries, average occupancy of senior officers in key posts earmarked for health.
    • Key Inputs/Processes:
      • It consists of proportion of shortfall in health care providers to what is recommended, functional medical facilities, birth and death registration and tuberculosis treatment success rate.
• Developed By:
  • NITI Aayog, with technical assistance from the World Bank, and in close consultation with the Ministry of Health and Family Welfare (MoHFW).
• Focus of the Fourth Edition:
  • Round IV of the report focuses on measuring and highlighting the overall performance and incremental improvement of states and UTs over the period 2018–19 to 2019–20.
• Ranking of States:
  • To ensure comparison among similar entities, the ranking is categorized as:
    • Larger States:
      • In terms of annual incremental performance, Uttar Pradesh, Assam and Telangana are the top three ranking states.
    • Smaller States:
      • Mizoram and Meghalaya registered the maximum annual incremental progress.
    • Union Territories:
      • Delhi, followed by Jammu and Kashmir, showed the best incremental performance.
    • Overall:
      • The top-ranking states were Kerala and Tamil Nadu among the ‘Larger States’, Mizoram and Tripura among the ‘Smaller States’, and Dadra and Nagar Haveli and Daman and Diu (DH&DD) and Chandigarh among the UTs.

• Significance of the Index:
  • Policymaking:
    • States use it in their policy making and resource allocation.
      • This report is an example of both competitive and cooperative federalism.
  • Healthy Competition:
    • The index encourages healthy competition and cross-learning among States and UTs.
    • The aim is to nudge states/UTs towards building robust health systems and improving service delivery.
  • Helpful in Achieving SDGs:
    • The exercise is expected to help drive state and union territories’ efforts towards the achievement of health-related Sustainable Development Goals (SDGs) including those related to Universal Health Coverage (UHC) and other health outcomes.
  • Role in National Health Mission:
    • The importance of this annual tool is reemphasized by MoHFW’s decision to link the index to incentives under the National Health Mission.
• Limitations of the Index:
  • Not Covered Critical Areas:
    • Some critical areas such as infectious diseases, noncommunicable diseases (NCDs), mental health, governance, and financial risk protection are not fully captured in the Health Index due to non-availability of acceptable quality of data on an annual basis.
  • Limited Data:
    • For several indicators, the data is limited to service delivery in public facilities due to paucity and uneven availability of private sector data on health services.
      • For outcome indicators, such as Neonatal Mortality Rate, Under-five Mortality Rate, Maternal Mortality Ratio and Sex Ratio at Birth, data are available only for Larger States.
  • Without any Field Verification:
    • For several indicators, Health Management Information System (HMIS) data and programme data were used without any field verification due to the lack of feasibility of conducting independent field surveys.