HEALTH

HEALTH

HEALTH SECTOR — GENERAL POINTS

Challenges of Indian Public Health System

1. Accessibility
   • Deficient health Infrastructure: According to NITI Aayog report District hospitals have avg 24 beds per 1 lakh people, Bihar lowest at 6.
   • Shortfall in Health personnel: The doctor-population ratio in India is 1:1456 against the WHO recommendation of 1:1000 and 172.7 nurses and midwives per 1,00,000 people in 2017.
   • Inadequate healthcare services: Non-communicable disease [Between 1990 and 2016, the contribution of NCDs increased 37% to 61% of all deaths [Economic Survey 2020-21], mental healthcare etc. barely have adequate healthcare services.
2. Affordability
   • High out of pocket expenditure: 65% of Health expenditure in India is out of pocket [Economic Survey 2020-21].
   • Expensive Private hospitals: which make it impossible for poor people to access services of private sector.
   • Low Insurance Penetration: As of 2019, penetration for life insurance in India is 2.82%, and for non-life insurance it is 0.94%. Globally, insurance penetration was 3.35% for life segment and 3.88% for non-life segment [Economic Survey 2020-21].
3. Availability
   • No proper healthcare services in rural areas: especially of tertiary care.
     • For example: Only one fifth of the hospitals are in rural areas. Also, doctors are in the ratio of 3.8:1 (urban

).

• Manpower crisis: where medical personnel are unwilling to serve in rural areas.
• Inter-state variations: While Kerala has 65,685 doctors for 35.6 million people, Jharkhand has 6,837 doctors for 38.6 million people. Karnataka has 130,698 doctors for 67.6 million people, while Gujarat has 69,746 doctors for 63.9 million people.

1. Governance related
   • State Subject: Health is a state subject and with less fiscal space and expertise, it suffers due to lack of uniformity and consistency.
   • Absence of single regulator: leading to poor quality of services by hospital, sub grade medical education etc.
   • Inadequate Funding: which is just around 1.2-1.3 % of GDP, as compared to 6% of world average.
   • Poor Coordination: Between ministries of Women, rural and health leading to inefficiencies.
   • Poor Research and development (R&D): in areas like genetics, stem-cells, new vaccines etc.
   • Misdirected efforts: excessive focus is given to curative healthcare with 51% of the spending as compared to just 6% on preventive healthcare.

 

Way Forward

1. Accessible Health Care
   • Incentivising Public Health: Only 10% of graduates join public hospitals, incentives to medical students upon joining the public sector can narrow the public-private gap.
   • Policy Focus: Focus should be shifted to preventive healthcare from curative healthcare.
   • Empowering Local Bodies: Local bodies must be empowered for a decentralized approach to health access.

• Community Approach: Community approach involves the community in direct involvement in addressing issues alongside NGOs to decrease the burden on the government.
• Private Sector Incentives: In form of tax cuts and holidays for setting health centers in rural and underserved areas.

1. Treatment Costs
   • Ayushman Bharat: Leveraging the coverage and funds from Jan Arogya Yojana can reduce expenses for poor sections.
   • Price Regulation: Regulation of the inflating cost of care in private hospitals, via excessive use of consumables or through needless procedures and investigations.
   • Insurance Penetration: Increasing penetration is a key requirement to reduce out-of-pocket expenditure.
2. Governance
   • Implementation Bottlenecks: Bottlenecks in various healthcare schemes must be removed to make it more equitable and consolidated.
   • Special Focus: Upon weaker and vulnerable sections like the elderly and children.
   • Increasing Budget: The healthcare budget must be increased in line with around 2.5% of GDP.
   • PPP: Collaborated approach and combine the welfare aspect of the government and the quality of the private sector.
   • Dedicated Emergency Response: In line with 911 in the US and 999 in the UK for robust emergency systems.

 

Examples from around the world

• New Zealand: Healthcare system in New Zealand is state-sponsored and very good quality. It is funded through taxes and provides free or subsidized medical treatment for residents.
• Denmark: The Danish universal healthcare system provides Danes with mostly free medical care and is predominantly financed through income tax. All permanent residents are entitled to a national health insurance card, and most examinations and treatments are free of charge.
• Australia: The government pays for at least 85 percent of outpatient services, and for 75 percent of the medical fee schedule for private patients who use public hospitals.

 

MENTAL HEALTH

Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices.

Data Worldwide Data: Worldwide, WHO says that there are 300 million people with mental health issues. Disorders: According to WHO, stress and depression cases increased by 18 percent in a decade. Suicides in India: Estimates suggest that 60 million to 65 million persons have common mental health issues in India. Between 6.5% and 7% of the Indian population have mental health issues. Need of Psychiatrists: Between 65,000 and 75,000 Psychiatrists are needed in India. Mental Health Issue: Between 1 crore and 2 crore persons in India have severe mental health issues such as schizophrenia and bipolar disorder. Expenditure on health: According to various estimates, expenditure on mental health is 0.06% GDP of India. Lack of Resources: Low proportion of the mental health workforce in India (per 100,000 population) includes psychiatrists (0.3), nurses (0.12), psychologists (0.07), and social workers (0.07).

 

Reasons of Increasing Cases of Mental Illness

1. Changing lifestyle patterns: In the last two decades, there have been many changes in lifestyle. Busy lifestyle and lack of time for self-care lead to neglect of mental health, which itself came at last.
2. Career-driven mindset of parents: Parents see unfulfilled dreams of theirs in their children. Hence, they push children to achieve the desired goals of the parents without taking into consideration the will of their children. This leads to mental health issues in many students.
   • For example: This could be one reason for India having the highest number of suicides among youth.
3. Stigma and discrimination: People do not accept the fact that they are suffering from mental illness. This mindset helps aggravate health issues related to mental distress.
4. Extensive use of digital gadgets: Extensive use of mobile phones affects the sleep pattern of a person, which indirectly leads to mental stress. Younger generation is mostly the victim of this.
5. Demographic factors: Gender inequality, racial, regional, and ethnic discrimination, etc., could lead to mental health problems.
6. Environmental factors: Natural hazards, industrial disasters, armed conflict, displacement, and disasters triggered by ecosystem hazards due to climate change or increased population.

 

Issues

1. Economic

• High costs: Mental health is neglected due to its high specialized cost of treatment.
• Resources: India has just over 3,800 registered psychiatrists against the need of at least 13,500 and has only about 900 clinical psychologists [MoH&FW].
• Decreasing Budget: The share of mental health in the health budget is less than 1% in 2021-22.
• High Burden: Mental health disproportionately impacts the weaker sections who find it hard to afford treatment.
• Lack of healthcare centers: There are not enough centers to cater to mental patients.
• Rise in Severity: Mental health problems tend to increase during economic downturns, therefore special attention is needed during times of economic distress.
• Disproportionate impact: It is the poor, dispossessed, and marginalized who bear the greatest burden of mental health problems, but historically, their sufferings are dismissed as a natural extension of their social and economic conditions.

2. Social

• Stigma: Families avoid seeking help due to related social stigma and ostracization.
• Awareness: Lack of awareness leaves patients untreated and in extreme pain.
• Irrational beliefs: Families resort to irrational practices like the occult or rituals, which further aggravate the situation.
• Abuse: Mental patients, especially women, are prone to abuse and assault.
• Nuclear Families: Isolated families and persons are often left alone to fend for themselves without proper care.

• Elderly: Without care and support, most elderly mental patients are evicted and abandoned.
• Post-Treatment gap: There is a need for proper rehabilitation of the mentally ill persons post their treatment, which is currently not present.
• Psycho-social factors: Institutions like gender, race, and ethnicity are also responsible for mental health conditions.
• Neglected Area: Mental health, which forms the core of our personhood, is often neglected, which impedes the development of an individual to full potential.
• Suicidal tendencies: Suicidal behavior was found to have a relation with female gender, working conditions, independent decision-making, premarital sex, physical abuse, and sexual abuse.
• Vulnerability of the ills: Mentally ill patients are vulnerable to and usually suffer from drug abuse, wrongful confinement, even at homes and mental healthcare facilities, which is a cause of concern and a gross human rights violation.
• Gendered nature: Females are more predisposed to mental disorders due to rapid social change, gender discrimination, social exclusion, gender disadvantage (like marrying at a young age), concern about the husband’s substance misuse habits, and domestic violence.

3. Political

• Policy Focus: Policy focus has been weak upon the implementation front.
• Centralisation of welfare: Urban bodies and state governments are missing out on policy formulation.
• Violations of human rights: Have been reported in mental asylums and also at homes and places of traditional healing. In India, mental hospitals still practice certain obscure practices that violate human rights.
  • Further poor infrastructure such as closed structures, lack of maintenance, unclean toilets, and sleeping areas clearly violate the basic human right to a life with dignity.

 

Impact

1. Economic

• Human Resources: A severe loss of human resources as persons become ineligible to work productively.
• Burden of Disease: With a large number of patients, the healthcare sector is overburdened and short on skilled staff.
• Falling back into Poverty: Families may fall back into poverty due to high treatment costs.
• Budgetary burden: High burden upon financial resources.

2. Social

• Isolation: Mental health isolates persons due to the stigma associated.
• Rise of Godmen: Poor sections take refuge in fraudulent godmen claiming to cure illnesses.
• Abandonment: Many mental patients find themselves abandoned by families, especially the elderly and women.
• Sexual Abuse: Many children and women afflicted by mental disease are often abused and sexually assaulted by caregivers and healthcare staff.
• Drug Abuse: Without care and treatment, many patients drift towards drugs and alcohol.
• Suicidal tendencies: Suicidal behavior was found to have a relation with female gender, working conditions, independent decision-making, premarital sex, physical abuse, and sexual abuse.
• Gendered nature: Females are more predisposed to mental disorders due to rapid social change, gender discrimination, social exclusion, gender disadvantage (like marrying at a young age), concern about the husband’s substance misuse habits, and domestic violence.

 

Government initiatives

• Mental Health Care Act, 2017: It is an Act to provide for mental healthcare and services for persons with mental illness and to protect, promote, and fulfill the rights of such persons during the delivery of mental healthcare and services.
• National Mental Health Programme: To ensure the availability and accessibility of minimum mental healthcare for all, and to encourage the application of mental health knowledge in general healthcare and in social development; and to promote community participation in the mental health service development.
• The National Institute of Mental Health (NIMH): It is the lead federal agency for research on mental disorders. NIMH is one of the 27 Institutes and Centres that make up the National Institutes of Health (NIH), the largest biomedical research agency in the world.
• ManoDarpan Initiative: An initiative of the Ministry of Education for psychosocial support of students, teachers, and families for mental health.
• Rights of Persons with Disabilities Act, 2017: The Act acknowledges mental illness as a disability and seeks to enhance the Rights and Entitlements of the Disabled and provide an effective mechanism for ensuring their empowerment and inclusion in society.
• Kiran Helpline: Ministry of Social Justice and Empowerment (2020) launched a 24/7 toll-free helpline.
• SAATHI: It is a South-Asian Mental Health Outreach Program of ASHA International that aims to promote awareness about mental health and emotional wellbeing; improve access to care.
• RAAH app: It is a mobile application that provides free information to the public on mental health care professionals and mental healthcare centers. The National Institute of Mental Health and Neuro-Sciences (NIMHANS) has compiled a one-stop source online mental health care directory.
• MANAS App: MANAS stands for Mental Health and Normalcy Augmentation System. It is a comprehensive, scalable, and national digital wellbeing platform. It has been developed to promote the mental well-being of Indian citizens.

 

Way Forward

• Digital health: Internet can provide counseling and telemedicine to the most inaccessible regions.
• Infrastructure: There is a need to create more mental care centers with quality staff.
• Training: Ordinary healthcare workers need to be trained in a specialized manner to deal with mentally afflicted patients.
• Stress relieving exercises: Stress, a key cause of degrading mental health, must be addressed through proper exercise and yoga.
• Policy implementation: The mental healthcare bill must be implemented properly in all states.
• Decentralized: Mental healthcare must be decentralized to include local and village levels.
• Increase Funding: State governments need to scale up their psychosocial interventions through community health workers.
• Role of Community: Civil society groups and community must be roped in to provide assessment and treatment.
• Curbing drug use: Drugs are a leading cause of mental illness; thus, their supply must be curbed.
• Regulating costs: Treatment and rehabilitation packages must be regulated to encourage treatment.
• Digital initiatives: To help improve rural India’s mental health through telemedicine, initiatives like Schizophrenia Research India’s (SCARF) mobile bus clinic is being run by an NGO. There is a need for scaling up such initiatives through public-private collaboration to bridge the rural-urban divide.

 

UNIVERSAL HEALTH COVERAGE 

UHC means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course.

Importance of UHC

1. Social benefits:
   • Access to services: Enables everyone to access the services that address the most significant causes of disease and death.
   • Quality of services: Ensures that the quality of those services is good enough to improve the health of the people who receive them.
   • Human Capital formation: Providing affordable, quality health services to the community, in particular to women, children, adolescents, and people affected by mental health issues, represents a long-term investment in human capital.
2. Economic benefits:
   • Financial benefits: Protects people from the financial consequences of paying for health services out of their own pockets.
   • Reduces poverty levels: Reduces the risk that people will be pushed into poverty because unexpected illness requires them to use up their life savings, sell assets, or borrow—destroying their futures and often those of their children.
   • Long term economic development: Good health allows children to learn and adults to earn, helps people escape from poverty, and provides the basis for long-term economic development.
3. SDG Goals: Especially SDG 3.8, which aims to “achieve universal health coverage.”

 

Barriers to achieving UHC

1. Economic:
   • Imbalance in resource allocation: Less than 2% of GDP is allocated to the health sector.
   • Poor infrastructure: Rural-Urban divide in terms of manpower as well as physical infrastructure.
   • Lack of skilled professionals: Doctor-patient ratio in India is 1:1456, below the WHO standard of 1:1000.
   • High out of pocket health expenditure: 65% of Health expenditure in India is out of pocket [Economic Survey 2020-21].
   • Stop profiteering: Containing costs is a major challenge with social insurance, as patients and healthcare providers have a joint interest in expensive care—getting better healthcare for one and earning for the other.
2. Social:
   • Gender inequality: Women are less likely to be in paid employment than men, which further reduces their chance of availing health benefits.
   • Rising ageing population: Creates a higher burden of diseases and more dependent population.
   • Social determinants of health: Poverty, illiteracy, and alcoholism are also impediments to achieving UHC.
3. Governance:
   • Policy paralysis: Lack of inter-sectoral coordination and political pull and push of different forces and interests.
   • Management issues: Commercialized, fragmented, and unregulated healthcare delivery systems.

• State Subject: Health is a state subject, thus, lack of coordination.
• Unavailability of Public Health Centres: The absence of public health centers, dedicated to primary healthcare and preventive work, creates the risk of patients rushing to expensive hospitals frequently, making the whole system wasteful and expensive.
• Identification of services: Another big challenge remains in identifying what services are to be universally provided initially and what level of financial protection is considered acceptable.

1. Technological

• Digital deficiency: Lack of processed healthcare data, digital storage, and dispersal media.
• Equipment: Low availability of basic medical equipment.
• Research: Inadequate multisectoral research to achieve healthcare for all.

 

Status in India

1. Constitutional
   • Fundamental Rights: Article 21 imposes an obligation on the state to safeguard the right to life of every person.
   • DPSP: Articles 41, 42, and 47 directly state the duty of the state to ensure health and nutrition of citizens, especially women, children, and weaker sections.
2. Policy Measures
   • Jan Arogya Yojana: Ayushman Bharat PM-JAY is the largest health assurance scheme in the world, which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crore poor and vulnerable families, forming the bottom 40% of the Indian population.
   • National Nutrition Strategy: The strategy aims to reduce all forms of malnutrition by 2030, with a focus on the most vulnerable and critical age groups. It also aims to assist in achieving targets identified as part of the SDGs related to nutrition and health.
   • Pradhan Mantri Swasthya Suraksha Yojana: It aims to correct regional imbalances in the availability of affordable and reliable tertiary healthcare services and to augment facilities for quality medical education. It has two components: Setting up of AIIMS-like institutions and upgradation of Government Medical College (GMC) institutions.
   • National Health Policy 2017: It encompasses two Sub-Missions: NRHM and NUHM, envisioning the achievement of universal access to equitable, affordable, and quality healthcare services that are accountable and responsive to people’s needs.
   • Pradhan Mantri Bhartiya Janaushadhi Pariyojana: It is a campaign to provide quality generic medicines at affordable prices to the masses through special kendras known as Pradhan Mantri Bhartiya Jan Aushadhi Kendras.

 

Healthcare as an Optional Public Service (HOPS)

• Routes to achieve UHC

• Public service: In this approach, healthcare is provided as a free public service, like the services of a fire brigade or public library.
  • For example: This socialist project has worked not only in communist countries such as Cuba but also in the capitalist world.
• Social insurance: It allows private as well as public provision of healthcare, but the costs are mostly borne by social insurance funds so that everyone has access to quality healthcare.
• Models: One where insurance is compulsory and universal, financed mainly from general taxation, and run by a single non-profit agency in the public interest (Canada). Other models of social insurance include the one that is based on multiple non-profit insurance funds instead of a single payer (Germany).

• HOPS framework: Framework that builds primarily on healthcare as a public service. The idea is that everyone would have a legal right to receive free, quality healthcare in a public institution if they wish.
  • For example: In Kerala and Tamil Nadu, most illnesses can be satisfactorily treated in the public sector, at little cost to the patient.

 

Significance of HOPS

• Behavioural move: If quality healthcare is available for free in the public sector, most patients will have little reason to go to the private sector.
• Cover procedure: Social insurance could also play a role in this framework by helping cover procedures that are not easily available in the public sector (e.g., high-end surgeries).
• Giant step towards UHC: Although HOPS would not be as egalitarian as the national health insurance model initially, it would still be a big step toward UHC. Moreover, it will become more egalitarian over time, as the public sector provides a growing range of health services.
• UHC does not mean unlimited healthcare: There are always limits to what can be guaranteed to everyone. HOPS requires not only healthcare standards but also a credible method to revise these standards over time. Some useful elements are already available, such as the Indian Public Health Standards.

 

Way Forward

1. Economic
   • Per Capita Expenditure: Improving outlay on health to 5-6% of GDP at the rate of Rs. 2000/capita/year.
   • Non-Medical preventive health: Removing constraints like unemployment, income, food security, water, and sanitation.
2. Social
   • Women Empowerment: Women empowerment has a direct correlation with the health of the family.
   • Ending Social Evils: Campaign drives to reduce social ills like alcoholism, abuse, and elderly neglect.
   • Addressing the regional disparities: Rural areas must be incentivized for healthcare infrastructures.
3. Governance
   • Augmenting Health-Cadre Management: Improved management through the creation of a public health management cadre.
   • Performance Incentives: Rewarding the states financially for recording improved health outcomes.
   • Shifts in Education curricula: Reorienting medical undergraduate education toward public health.
   • Policy focus: Targeting neglected areas like rural, tribal, and inaccessible areas.
4. Technological
   • Digital Health: Doctor on call, telemedicine can bridge geographical gaps.
   • Innovation: Machine learning and AI can transform how healthcare is provided.

 

Best Practices

• Chile: UHC is financed through a mandatory tax.
• Ghana: Revenues from a 2.5% increment in consumption taxes.
• Japan: To increase equity in the system, the government subsidizes payments on plans that incur higher costs.

 

ANGANWADI WORKERS (AWW)

The Anganwadi worker is the most important functionary of the Integrated Child Development Scheme. Anganwadi worker is a community-based front-line worker of the ICDS Programme. She plays a crucial role in promoting child growth and development.

 

Role/Significance/Importance

1. Promoting education, health, and nutrition:
   • Supplementary Nutrition: For lactating mothers and children under 6.
   • Nutrition Education: For women in the 15-45 age group.
   • Immunization & Health check: For lactating mothers and children under 6.
   • Pre-School Education: For children aged 3-5 years.
   • Fighting malnutrition: Instrumental in child development for the role they play in fighting malnutrition [UNICEF].
2. Local health crisis: India’s first line of defense against any local health crisis.
3. Local experience: Since they know their people well and have intimate on-the-ground experience, this legion of Anganwadi workers is extensively employed by district administrations.
4. Resilient workforce: Anganwadi workers are a resilient workforce and can adapt very quickly to difficult circumstances.
5. Agent of social change: She is also an agent of social change, mobilizing community support for better care of young children.
6. During COVID-19 Pandemic
   • Tracking migrants: They helped in tracking migrant returnees during lockdown in villages.
   • Surveying and monitoring: Tasked with surveying villagers and monitoring their health during the ongoing pandemic.
   • Other functions: They distribute dry rations and cooked food, screen people for COVID-19, and spread awareness of the virus.

 

Issues

1. Economic issues

• Underpaid: Low honorarium discourages others from becoming workers.
• Lack of infrastructure: Issues at the centers like lack of running water and electricity.
• Exclusion from Labor Codes: Code on Social Security and Code on Wages does not include Anganwadi workers.
• Non-Availability of resources: Medicines and equipment are sometimes unavailable in interior areas.

2. Social issues

• Lack of community support: Social divisions often affect the employability of the workers.
• Socio situation: Poverty and backwardness often inhibit proper working.

3. Administrative issues

• Lack of training: Skill sets of the workers need to be frequently upgraded.

• Lack of comprehensive manual: They do not have any comprehensive manual on managing their roles. They are taught broad principles and it is left to their native wisdom to flesh out the details.
• Lack of accountability: A systematic lack of accountability remains a key barrier to programmatic effectiveness; only rarely is the staff held accountable for achieving targets.
• Poor work culture: Lack of accountability manifests in a work culture that is not impact-oriented, marked by tardiness and absenteeism, achievement of partial work responsibilities, and significant pilferage and leakage of the aid.

 

Way Forward

• Wages: Incentive-based wages should be provided like in the case of ASHA workers.
• Digitisation: Data must be collected and stored regarding the condition and status.
• Telemedicine: Use of the internet in areas with a low workforce.
• Awareness: Community awareness must be enhanced to make AWW more approachable.
• Incentivisation: Encouraging school dropouts to become AWW to bridge the low workforce.
• Ensuring accountability: Each Anganwadi worker can be individually made responsible for services at her centre, thereby avoiding the problems associated with free-ridership.

 

MEDICAL EDUCATION REFORMS

Need for Reforms in medical education/Issues with earlier medical education system

1. Governance related issues

• Corruption: MCI had been charged with rampant corruption.
  • For example: In 2010, MCI President Ketan Desai was arrested for soliciting a bribe of 20 million rupees for allowing a private medical college in Punjab to enroll students despite the MCI having found the college’s infrastructure inadequate.
• Lack of uniformity in recognition and suspension: Lack of uniformity in the conduct of MCI in granting recognition and permission to medical colleges casts a shadow on the credibility of MCI.
• Issue of transparency and arbitrariness: MCI had been accused of corruption, inefficiency, arbitrariness, and lack of transparency.
  • For example: Many of MCI’s members held office for lengthy periods of time by being re-elected or re-appointed in different positions within the council.

2. Human Resource issue

• Shortage of doctors:
  • Less seats: In 2019, more than 338,000 students competed for over 1,150 open MBBS slots in AIIMS, implying admission to a mere 0.34% of candidates.
  • Less graduates: While India produces more than 64,000 graduates in allopathic medicine a year, that number is vastly insufficient to keep up with demand.
  • Migration: Shortages are further exacerbated by the outmigration of many of India’s most qualified doctors. For example, more than 10% of international medical graduates certified by the U.S. Educational Commission for Foreign Medical Graduates are Indian nationals.
• Doctors in rural areas: There are only 1.8 and 1.9 physicians and surgeons, respectively, per 10,000 people in the underserved northern states of Assam and Himachal Pradesh [British Medical Journal].

3. Quality

Many medical colleges of dubious standards, especially in the private and the self-financing sector, lack patients and faculty of credible standards to impart medical education of reasonable quality.

• Outdated curricula: The curricula have remained mainly outdated, despite tremendous changes happening in the healthcare sector.
• Profiteering: The medical education sector has become a lucrative business due to mounting corruption, high fee structure, etc., leading to a highly unregulated business of medical education in the country.
• Lack of knowledgeable teachers:
  • Compulsory bonds: Even doctors completing their post-graduation from government medical colleges sign compulsory bonds, making it very difficult for them to join medical colleges as faculties.
  • Lack of motivation: Amongst young doctors, becoming medical teachers is another challenge.

 

TRADITIONAL MEDICINE

The sum-total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement, or treatment of physical and mental illness.

Data Usage: According to WHO estimates, 80% of the world’s population uses traditional medicine. Ayush doctor to population ratio: According to a 2021 report by the WHO, India was way below the 44.5:10,000 ratio until 2018, and was just above the 2006 standard of 22.8 healthcare workers per 10,000 population.

 

Current Updates

• Global Centre for Traditional Medicine: Recently, the groundbreaking ceremony was performed for the first-of-its-kind WHO Global Centre for Traditional Medicine (GCTM) in Jamnagar, Gujarat.
• Global Ayush Investment and Innovation Summit: The Global Ayush Investment and Innovation Summit was held later in Gandhinagar, aimed at increasing investments and showcasing innovations in the field of traditional medicine.

 

Major traditional medicines in India

• Ayurveda: A holistic and individualized system having preventive (Svasth-Vritta), curative Aushadhi (drugs), Ahara (diet), and Vihara (lifestyle), as well as mitigative, recuperative (Rasayana), and rehabilitative aspects.
• Unani: Originated in Greece, introduced in India by Arabs and Persians around the 11th century. It treats a patient with diet, pharmacotherapy, exercise, massages, and surgery.
• Siddha: Has close relations with Dravidian culture. It takes into account the patient’s surroundings, age, sex, race, habitat, diet, appetite, physical condition, etc., to arrive at the diagnosis.
• Yoga: Primarily a way of life, propounded by Maharshi Patanjali in systematic form in the Yogsutra. It consists of eight components, namely, restraint (Yama), observance of austerity (Niyama), physical postures (Asana), breathing control (Pranayama), restraining of senses (Pratyahara), contemplation (Dharana), meditation (Dhyana), and deep meditation (Samadhi).

• Naturopathy: It is a cost-effective, drugless, non-invasive therapy involving the use of natural materials for healthcare and healthy living.
• Homoeopathy: Introduced as a scientific system of drug therapeutics by a German Physician, Dr. Christian Frederick Samuel Hahnemann in 1805.
• Sowa-Rigpa: An ancient Indian medical system enriched in the entire Trans-Himalayan region. Its fundamental principles are based on Jung-wa-nga (Panchamahabhuta), Nespa-sum (Tridosha), and Luszung-dun (Sapta dhatu), etc.

 

Advantages of Traditional Medicines

1. Health benefits
   • Immunity booster: Ayurvedic treatments during COVID-19 pandemic helped boost immunity.
   • Mental Well-being: Yogic breathing exercises, such as Pranayam, aid in mental health.
   • Healthy lifestyle: The Unani system considers the most suitable diet and lifestyle for promoting individual health.
   • Non-Toxic: Homeopathic medicines are safe as the crude substances used are processed through drug dynamisation, which removes toxicological effects and enhances dynamic properties.
   • Holistic approach: Treats body, mind, soul, and senses.
   • No side effects: Generally, plants used in traditional medicines are safe due to their long history of use in treating diseases based on knowledge accumulated over centuries.
2. Better health services
   • Availability: Commonly available across regions; allopathic doctors are sparse in rural areas (34%) compared to the rural population (71% of total population).
   • Reliance: 70% of India’s population depends on Traditional Medicine for primary healthcare [WHO].
   • Affordable: Provides low-cost services compared to allopathic medicines.
   • Complementary role: Plays a vital role in treating chronic illnesses and improving quality of life for those with incurable diseases [WHO].
3. Universal healthcare: The doctor-patient ratio is 1:1456 when considering only allopathic doctors; this ratio could improve to 1:800 if AYUSH practitioners are included [WHO-mandated ratio is 1:1000].
4. Research and Development: Traditional knowledge offers valuable guidance in selecting and obtaining plant material with potential therapeutic properties.

 

Challenges

1. Policy Issues
   • Quality control: Poor quality control procedures, lack of regulation, and absence of Good Manufacturing Practices (GMP) for Traditional Medicine.
   • State Subject: Health is a state subject; however, states have not taken proactive steps to promote traditional medicines.
2. Infrastructure related: Lack of processing techniques, sophisticated instruments, utilization of modern techniques, and local facilities for instrument fabrication.
3. Human Resource
   • Untrained practitioners: This can lead to negative or dangerous effects on patients.
   • Lack of human resources: As of 2019, around 52,000 students were enrolled in AYUSH institutes.

1. Financial resources: Budget 2021-22 allocated Rs 2,970.30 crore to the Ministry of AYUSH, while the Ministry of Health and Family Welfare is allocated Rs 2.23 lakh crore.
2. Low acceptance: Only 6.9% of patients seeking outpatient care opted for AYUSH. In the case of hospitalized care, the proportion is less than 1% [National Sample Survey in 2014].
3. Slow results: Unlike allopathic medicines, the benefits from traditional medicines take time to show up.
4. Environmental: There is a need to conserve biodiversity and sustainability, as about 40% of approved pharmaceutical products today derive from natural substances.

 

Steps taken for promoting Traditional Medicines

1. International initiatives
   • WHO Traditional Medicine Strategy 2014-2023: It has 3 key goals:
     • Building the knowledge base and formulating national policies.
     • Strengthening safety, quality, and effectiveness through regulation.
     • Promoting universal health coverage by integrating Traditional Medicine services and self-health care into national health systems.
   • MoU: At least 32 MoUs for collaborative research and development of traditional medicine have been signed with institutes, universities, and organizations from the US, Germany, UK, Canada, Malaysia, Brazil, Australia, Austria, Tajikistan, Saudi Arabia, Ecuador, Japan, Indonesia, Reunion Island, Korea, and Hungary.
2. National Initiatives
   • Separate Ministry: The Ministry of AYUSH was formed in 2014 to ensure the development and propagation of AYUSH systems of medicine.
   • Offices: Re-establishment of PCIM&H as a Subordinate Office under the Ministry of AYUSH (MoA) by merging it with the Pharmacopoeia Laboratory for Indian Medicine and Homoeopathic Pharmacopoeia Laboratory to optimize the use of infrastructural facilities, technical manpower, and financial resources.
   • Schemes:
     • Ayush Grid: The Ministry of AYUSH has conceptualized this new project for digitization of the AYUSH sector.
     • National AYUSH Mission: The strategy of mainstreaming AYUSH under the National Health Mission and National Health Policy-2017 is implemented to promote and strengthen the AYUSH sector. Under it, AYUSH facilities are being set up in PHCs, CHCs, and District hospitals.
     • Ayushman Bharat: 10% of the Sub-centres are to be upgraded as Health and Wellness Centres (HWCs), which will be developed by the Ministry of AYUSH to provide comprehensive healthcare to needy communities.
   • Traditional Knowledge Digital Library (TKDL): An Indian digital knowledge repository containing information about medicinal plants and formulations used in Indian systems of medicine. It is a database with 34 million pages of formatted information on approximately 2,260,000 medicinal formulations in multiple languages.
   • Protection from patent registration: In just under two years, India secured the cancellation or withdrawal of 36 applications to patent traditionally known medicinal formulations through TKDL.
   • GCTM: The Centre aims to channel the potential of traditional medicine by integrating it with technological advancements and evidence-based research.
   • MoU: The CSIR and the Bill & Melinda Gates Foundation have signed an MoU to identify opportunities for scientific and technological research between researchers within and outside India, including collaborations with foundation-funded entities in areas including traditional medicine as well as beyond.
   • Conferences

• International Conference on Standardisation of Diagnosis and Terminologies in Ayurveda, Unani, and Siddha Systems of Medicine (ICoSDiTAUS) 2020: Jointly organized by the Ministry of AYUSH and WHO.
• New Delhi Declaration on Collection and Classification of Traditional Medicine (TM) Diagnostic Data: Adopted and emphasized the commitment of countries to traditional medicine as a significant area of healthcare.
• WHO Meeting on developing Standardized Terminologies and Benchmarks documents for Practice for Traditional Medicine: Hosted by the Ministry of AYUSH.

 

Way Forward

1. Government side
   • Integrated policy: Both Traditional Medicine and Allopathy along with inter-ministerial coordinated efforts by the MoHFW and Ministry of AYUSH.
   • Finance: Equal emphasis on AYUSH and allopathy systems.
   • Facilitate cross-learning and collaboration: Through integration of research, education, and practice of both systems at all levels.
2. Citizen side
   • Awareness: Proper use and advantages of AYUSH system.
   • Generate interest: This will help in attracting human resources to the AYUSH system.
   • Include traditional medicine as a way of life, not medicine.
   • Use it as preventive cure.
3. Best practices
   • China: Combines Traditional medicine system with modern system, and both are complementary.

 

Use of traditional medicines during COVID-19

• Preventive measure: A homeopathic drug, Arsenicum album 30, was recommended for prophylactic (preventive) use against COVID-19 after the Ministry of AYUSH listed the drug among “preventive and prophylactic simple remedies” against COVID-19.
• Immunity booster: Homemade honey ginger herbal Kadha [a concoction] has been suggested to improve immunity.
• Anti-inflammatory effects: There are anti-inflammatory effects associated with meditation and pranayama. Evidence suggests it can help in the modulation of stress and inflammation, immune system enhancement, and in improving the practice of certain forms of meditation, yoga, and pranayama.
• Improvement in oral and nasal health: Therapies such as nasal application of sesame oil/coconut oil/ghee, oil pulling therapy, etc.

 

NON-COMMUNICABLE DISEASES

Non-communicable diseases are a diverse group of chronic diseases that are not communicable, i.e., they cannot be transmitted from person to person. They are diseases of long duration, generally slow progression, and are the major cause of adult mortality and morbidity worldwide. 

Major NCDs: Cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes.

 

Data Global [WHO data] Deaths due to NCDs: Noncommunicable diseases (NCDs) kill 41 million people each year, equivalent to 71% of all deaths globally, according to WHO. Cause of Death: NCDs now form 7 of the world’s top 10 causes of death. This is an increase from 4 of the 10 leading causes in 2000. Premature death: Each year, more than 15 million people die from a NCD between the ages of 30 and 69 years; 85% of these “premature” deaths occur in low- and middle-income countries. High burden on low and middle-income countries: 77% of all NCD deaths are in low- and middle-income countries. Nature: Cardiovascular diseases account for most NCD deaths, or 17.9 million people annually, followed by cancers (9.3 million), respiratory diseases (4.1 million), and diabetes (1.5 million). These four groups of diseases account for over 80% of all premature NCD deaths. India Related Deaths due to NCDs: 65% of deaths in India are caused by NCDs, with ischemic heart diseases, Chronic Obstructive Pulmonary Disease (COPD), and stroke being the leading causes [Economic Survey 2020-21]. Increasing share of NCD-related deaths: Between 1990 and 2016, the contribution of NCDs increased from 37% to 61% of all deaths [Economic Survey 2020-21]. Economic impact of NCDs: India will lose at least $4.5 trillion before 2030 because of the economic impact of NCDs [World Economic Forum and Harvard School of Public Health]. Risk factors for NCDs: Two in five adults have three or more risk factors for NCD in India. Reduction in premature NCD deaths: India succeeded in reducing premature NCD-related mortalities from 503 to 490 per 1 lakh population between 2015 and 2019 [Global Health Observatory, WHO].

 

Risk Factors/Causes of Non-Communicable Diseases

1. Behavioural factors/Modifiable factors
   • Tobacco use: Tobacco use, smoking, and smokeless tobacco are currently among the leading global risk factors for illness and death from major NCDs.
   • Harmful use of alcohol: Both total consumption of alcohol and drinking patterns (e.g., heavy episodic drinking) cause heart diseases, cancers, liver diseases, and a range of mental and behavioral disorders.
   • Physical inactivity: Insufficiently physically active people have an increased risk of all-cause mortality and increases the risk of stroke, hypertension, and depression.
   • Unhealthy diet: Consuming a diet high in salt contributes to raised blood pressure and increases the risk of heart disease and stroke.
2. Environmental factors
   • Air pollution: Both indoor and outdoor air pollution cause millions of deaths due to ischemic heart disease, chronic lung diseases, and asthma.
   • UV radiation: Depletion of the ozone layer and subsequent penetration of sun radiation is a cause of cancer.

1. Non-modifiable factors: Refers to characteristics that cannot be changed by an individual and include age, sex, and genetic make-up. These affect and partly determine the effectiveness of many prevention and treatment approaches.
2. Metabolic factors: Raised blood pressure, overweight/obesity, raised blood glucose, and raised cholesterol. These are aggravated due to behavioral factors.
3. Other factors:
   • Urbanization: Rapid, unplanned urbanization changes people’s way of living through more exposure to shared risk factors.
   • Globalization: Unfair trade, irresponsible marketing, rapid urbanization, and increasingly sedentary lifestyles also increase the risk of NCDs.
   • Educational levels: In India, tobacco use, hypertension, and physical inactivity are significantly more prevalent in lower education groups [WHO].
   • Poverty: Under-nutrition in utero and low birth weight increase the risk of cardiovascular disease and diabetes. As a result, the poor are more likely to die prematurely from NCDs.
4. Aggravated impact of COVID-19
   • Mental health impact: Due to the stress of trying to avoid infection and respecting physical distancing recommendations, resulting in mental health impacts.
   • Disruption in care: NCD care is impacted by disruptions in routine chronic care, difficulties in accessing medication, and treatment when supplies are disrupted, as health workers are diverted to the COVID-19 response.

 

Impact of Non-Communicable Diseases

1. Economic impacts
   • Poverty: High out-of-pocket expenditure and low productivity create a vicious cycle.
   • Decrease in national income: Large-scale loss of productivity due to absenteeism and inability to work leads to a decrease in national income.
   • Loss of household income: Unhealthy behaviors, poor physical status, and high NCD-related healthcare costs lead to household income loss.
2. Social impacts
   • Social inequity: As most healthcare payments are out-of-pocket (around 65% in India), costs weigh more heavily on those least able to afford them, increasing impoverishment.
   • Impact on hunger and education: NCDs can lead to a drastic cut in spending on food and education, liquidation of family assets, and loss of care and investment in children.
   • Impact on healthcare system: NCDs lead to high rates of hospital admissions and increased healthcare resource consumption, placing a substantial burden on already strained systems.
3. Impact on health
   • Deaths: NCD-related deaths are caused by cancer, diabetes, cirrhosis, etc., constituting a significant portion of India’s disease burden [ICMR-IHME-PHFI’s India disease burden].
   • SDG Fulfillment: SDG 3.4 aims to reduce premature NCD mortality by a third by 2030. Progress on SDG target 3-4 will play a central role in determining the success of at least nine SDGs.

 

Steps taken

1. National Steps
   • National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular disease and Stroke (NPCDCS), 2010: It is with the objective to increase awareness on risk factors, to set up infrastructure (like NCD clinics, cardiac care units) and to carry out opportunistic screening at primary health care levels.
   • National Health Policy 2017: Aims at reducing premature mortality from CVDs, cancers, diabetes, and chronic respiratory diseases by 25% by 2025.
   • National Action Plan: India became the first country to adopt a National Action Plan in response to the “WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020.”
   • WHO Framework for Tobacco Control: India has implemented WHO’s Framework Convention on Tobacco Control aimed at reducing the demand for tobacco products.
   • Ayushman Bharat: 1.5 lakh health and wellness centres to be established throughout the country by 2022 to promote early screening, diagnosis, and treatment.
   • Indian Hypertension Management Initiative (IHMI): A collaborative project between ICMR, MoHFW, SGs, and WHO aimed at strengthening the CVD component of the health ministry’s NPCDCS.
   • Awareness initiatives:
     • Eat Right movement by FSSAI
     • POSHAN Maah: A year-long social and mass media campaign on the Eat Right India movement to trigger behavioral changes through a mix of regulatory measures.
     • Total Polar Compounds: FSSAI has prescribed a limit for Total Polar Compounds at 25% in cooking oil to avoid harmful effects of reused cooking oil.
2. International Steps
   • Global action plan for the prevention and control of NCDs 2013-2020: Developed by WHO, it includes nine global targets. It recognizes the role of governments in responding to the challenges of NCDs.
   • Global Compact on NCDs: A group comprising heads of governments has been formed to fast-track the goal to reduce premature deaths from non-communicable diseases (NCDs).
     • It will strategize the reduction of preventable deaths from diabetes, cancer, heart and lung disease, and promote mental health and well-being.
   • Global Non-communicable Disease Network (NCDnet): Formed by WHO in 2009, it consists of leading health organizations and experts worldwide to fight against diseases like cancer, cardiovascular disease, and diabetes.
   • NCD Alliance: A global partnership founded in May 2009 by international federations representing cardiovascular disease, diabetes, cancer, and chronic respiratory disease.
   • The United Nations Interagency Task Force on the Prevention and Control of Non-communicable Diseases (UNIATF): Established by the UN Secretary-General in 2013 to provide scaled-up action across the UN system to support governments, particularly in low- and middle-income countries, to tackle NCDs.

 

Way Forward

Risk Factor/Diseases to be Addressed	Intervention
Reduce Tobacco use	Tax: Increase excise taxes and prices on tobacco products. Packaging: Large graphic health warnings on all tobacco packages. Advertising, promotion, and sponsorship: Enact and enforce comprehensive bans on tobacco advertising. Smoke-free public places: Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places, and public transport. Educate: Effective mass media campaigns that educate the public.
Reduce harmful use of alcohol	Tax: Increase excise taxes on alcoholic beverages. Advertising: Enforce bans or comprehensive restrictions on exposure to alcohol advertising (across multiple types of media). Availability: Enforcing restrictions on the physical availability of retailed alcohol (via reduced hours of sale).
Reduce unhealthy diet	Reformulate food: Reduce salt intake through the reformulation of food products to contain less salt and the setting of target levels for the amount of salt in foods. Supportive environments: Reduce salt intake through the establishment of supportive environments in public institutions (hospitals, schools, etc.). Educate: Reduce salt intake through a behavior change communication and mass media campaign. Packaging: Reduce salt intake through front-of-pack labeling.
Reduce physical inactivity	Educate: Implement community-wide public education and awareness campaigns for physical activity.
Manage cardiovascular disease and diabetes	Drug therapy and counseling: For individuals who have had a heart attack or stroke and for persons with high risks.
Manage Cancer	Vaccinate: Vaccination against human papillomavirus. Screening: Prevention of cervical cancer by screening women aged 30–49.

 

Other Steps:

1. Ensure living and working conditions conducive for all: Clean water and air, income and social protection, and food security, among others.
2. ‘Health-in-all policies’ approach: Gender-responsive and human rights-focused, advancing the core principle of the SDGs: leave no one behind.
3. Community outreach and empowerment: Including women-led organizations can help identify root causes of inequities, find localized solutions, and enhance coordination between health and social services and target communities.
4. Ensure reliable health data: Data should be collected on a disaggregated basis and analyzed by key parameters for inequities such as sex, geography, income, education, etc.
5. Leverage WHO-supported Health Information Platform (HIP): Provides an integrated database of country progress across a range of indicators.

 

Best Practices:

• Zambia: Integrated national HIV services and cervical cancer prevention, screening over 100,000 women for cervical cancer over the last 5 years.
• Tuvalu: Tuvalu Red Cross Society implemented a pilot project to build National Society capacity to deliver a ‘bottom-up’ community-based program that addresses health, disaster, and climate change needs for the community on Funafuti – TeKavatoetoe.

 

NATIONAL DIGITAL HEALTH MISSION
(Ayushman Bharat Digital Mission)

The National Digital Health Mission (NDHM) aims to develop the backbone necessary to support the integrated digital health infrastructure of the country. It will bridge the existing gap amongst different stakeholders of the healthcare ecosystem through digital highways.

THE NDHM ECOSYSTEM

• Central Government
• State Governments
• Program Managers
• Policy Makers
• Providers (Hospitals, Clinics, Labs, Pharmacies, Wellness Centers)
• Healthcare Professionals (Doctors, Nurses, Practitioners of Modern Medicine, AYUSH)
• Allied Private Entities (TPAs, Insurers, Health Tech Companies)
• Non-Profit Organizations
• Regulators
• Associations
• Development Partners/NGOs
• Administrators
  

 

Objectives of NDHM

To strengthen the accessibility and equity of health services in a holistic healthcare program approach leveraging IT & associated technologies, and to support the existing health systems in a “citizen-centric” approach. The NDHM envisages the following specific objectives:

• Establish digital health systems: To establish state-of-the-art digital health systems, manage core digital health data, and the infrastructure required for its seamless exchange.
• Establish registries: To create a single source of truth regarding clinical establishments, healthcare professionals, health workers, drugs, and pharmacies.
• Enforce adoption of standards: To enforce open standards adoption by all national digital health stakeholders.
• Personal health records: To create a system of personal health records, easily accessible to individuals and healthcare professionals based on informed consent.
• Enterprise-class health application systems: To promote the development of enterprise-class health applications, focusing on achieving the SDGs for health.
• Cooperative federalism: To adopt principles of cooperative federalism with States and Union Territories to realize the vision.
• Portability: To ensure national portability in health services provision.
• Use of clinical decision support (CDS): To promote CDS systems usage by healthcare professionals and practitioners.

• Management: To promote better management of the health sector leveraging health data analytics and medical research.
• Better governance: To enhance the efficiency and effectiveness of governance at all levels.
• Quality of healthcare: To support effective steps for ensuring quality healthcare.
• Strengthening health systems: To strengthen existing health information systems by ensuring their conformity with defined standards and integration with the proposed NDHM.

 

Features of NDHM

• Digital health ecosystem: The NDHM is a complete digital health ecosystem with four key features – Health ID, personal health records, DigiDoctor, and health facility registry.
• Implementation by: Implemented by the National Health Authority (NHA) under the Ministry of Health and Family Welfare.
• DigiDoctor: Allows doctors from across the country to enroll, with their details available if they wish to provide them.
• Health ID: A repository of all health-related information of every Indian. Various healthcare providers (hospitals, laboratories, insurance companies, etc.) will be expected to participate in the Health ID system.
• Personal health records (PHR): A collection of information about your health that you compile, update, and keep.
• Health facility registry (HFR): A comprehensive repository of health facilities in the country across different systems of medicine, including public and private health facilities such as hospitals, clinics, diagnostic laboratories, and pharmacies.
• Electronic Medical Records (EMR): A digital version of a patient’s chart, containing their medical and treatment history from a single health facility.
• NDHM Sandbox: Set up to enable any software to integrate with the digital building blocks and test compliance with digital health standards.
• Roping of private sector: Private stakeholders will have equal opportunities to create and integrate their own products for the market.

 

Benefits of NDHM

1. Improvement in quality of health service: The implementation of NDHM is expected to significantly improve efficiency, effectiveness, and transparency in health service delivery.
2. Benefits for patients:

• Storage: Securely store and access medical records (such as prescriptions, diagnostic reports, and discharge summaries).
• Sharing of information: Share records with healthcare providers to ensure appropriate treatment and follow-up.
• Accuracy: Access more accurate information on health facilities and service providers.
• Access: Access health services remotely through tele-consultation and e-pharmacy.
• Informed decision-making: NDHM will empower individuals with accurate information to enable informed decision-making and increase healthcare provider accountability.

• Choice: NDHM will provide individuals with a choice to access both public and private health services.
• Transparency and accountability: It will facilitate compliance with established guidelines and protocols, ensuring transparency in the pricing of services and accountability for health services provided.
• Data portability and mobility: A unique digital health ID will enable chronic patients to carry their medical records on their phones, viewable by doctors on computers anywhere.
• Prevents repetition: As most blood tests, CT scans, MRIs, and ultrasound reports are available on the cloud, patients won’t need to undergo painful and expensive repeat tests.

3. Benefits for healthcare professionals

• Effective health interventions: Professionals will have better access to patients’ medical history (with informed consent), allowing more appropriate and effective health interventions.
• Continuum of care: The integrated ecosystem will enable a better continuum of care.
• Faster processing: NDHM will digitize the claims process, enabling faster reimbursement.
• Ease of providing services: This will streamline service provision among healthcare providers.
• End to Quackery and fake medicines: Only registered doctors will be permitted to prescribe medications on digital prescription pads. With medicine strip barcoding, fake medicines will also diminish.

4. Benefit to policy makers

• Informed decision making: Access to better data enables more informed government decision-making.
• Better preventive healthcare: Improved macro and micro-level data will enhance advanced analytics, health-biomarker use, and preventive healthcare.
• Proper monitoring and implementation: The system will allow geography and demography-based monitoring, fostering appropriate decision-making and strengthening health programs and policies.
• Optimize resource utilization: Digitization has transformed industries; similarly, NDHM can leverage data for effective health program administration.

5. Benefit to researchers

• Evaluation: Data availability will allow studying and evaluating program effectiveness.
• Comprehensive feedback: NDHM will facilitate a feedback loop for researchers, policymakers, and providers.

 

Issues with NDHM

1. Structural problems

• Lack of statutory value: It is a policy document issued under no statutory framework.
• Federal structure: It impacts India’s federal structure, as health is a state subject.
• Non-binding: Not only can it not bind the state, but it also isn’t binding on the National Health Authority (NHA) that is enforcing it—the policy can be changed.
• Data usage: It is unclear whether individuals will be notified each time their data is used, and it is unclear who will enforce it.
• Erasure of data: The policy provides only specific circumstances where personal data can be erased.
• No right to be forgotten: Patients can request data erasure if they withdraw consent, but the request can be denied, providing no right or control over their data.
• Lack of infrastructure: Digital literacy and accessibility of digital records is a concern in rural areas, as many villages lack the necessary digital infrastructure.
• Data Migration: Data migration and inter-State transfer face multiple errors and data security concerns.

1. Ambiguity: The definition of a consent manager is unclear, leaving ambiguity regarding whether the role will be played by a private firm, NGO, or government body.
2. Privacy issues: Certain clauses suggest that the consent manager may collect and process personal data for unspecified purposes, with unclear access rights.
3. Mass surveillance: The “womb to tomb” health identity aims to improve efficiency in patient care but raises concerns about potential mass surveillance.
4. Misuse of data: Private insurance companies could use algorithms to analyze health data for risk profiling, making affordable insurance access challenging.
5. Increase in cost of patient care: Private hospitals, still onboarding, are unclear about the system’s workings and potential additional investments.

 

HEALTH DATA MANAGEMENT POLICY

The Health Ministry approved a policy under the National Digital Health Mission (NDHM) to protect and manage patients’ personal data via digital services. Data collected across NDHE will be stored at central, state/UT, and health facility levels, adopting the principle of minimality. Health Data Management (HDM), or Health Information Management (HIM), systematically organizes health data digitally—from Electronic Medical Records (EMR) created during doctor visits to Electronic Health Records (EHR) and handwritten notes digitized.

 

Need for Health Data Management

• Create a comprehensive view: Enables a holistic view of patients, households, and groups, providing status and predictive insights.
• Improve patient engagement: Targets patients with reminders and care suggestions relevant to them, based on predictive modeling.
• Improve health outcomes: Tracks health trends across regions or specific populations, predicts trends, and recommends proactive measures.

• Business decision making: Helps healthcare providers make data-driven decisions, such as which types of medical professionals to recruit.
• Analyse physician activity: Analyze data on medical practitioners, including success rates, time invested in treatments, and alignment with healthcare organization goals.
• Greater control of patients: Patients gain more information about their treatment.
• Address fragmented data: Indian healthcare data is fragmented across multiple diagnostic centers, hospitals, and pharmacies.
• Ensure data operability: Lack of interoperability (e.g., system X at one hospital communicating with system Y elsewhere) has led to static data silos.
• Multiple data handling entities: Several systems operate at national and state levels (e.g., the Mother-Child tracking system alongside HMIS), causing redundancy.

 

Objectives of the Policy

• As a guide and framework: Sets a secure framework for processing personal and sensitive data for NDHE members in compliance with laws.
• To safeguard data: Protects digital personal data, including the Personal Health Identifier, electronic health records, and medical records, through technical and organizational measures.
• To provide accessibility to data: Creates a system of digital health records accessible to individuals and providers.
• Awareness generation: Increases data privacy awareness within NDHM members.
• Portability: Ensures health service portability.
• Institutional mechanism for auditing: Establishes auditing mechanisms for NDHE, encouraging adoption of data protection principles.
• Leverage information systems: Integrates existing Indian health systems with defined data privacy standards and the NDHE.

 

Salient Features

• Enabling document: Sets minimum data privacy standards before full NDHM implementation.
• Applicability: Applies to all entities in NDHM and NDHE, including healthcare providers, regulatory bodies, and those with IDs under the policy.
• A single platform: Connects healthcare providers, allowing data retention after meeting prescribed standards.
• Interoperability of data: Uses a federated structure for data exchange among agencies without central storage.
• The consent manager: Manages data requests, verifying identities of data seekers and providers.

• Consent: A person can give full or partial consent, for a particular medical condition, while other medical records remain separate from the initial consent.
• Integration with Ayushman Bharat: The policy aims to integrate data collection and usage with the Ayushman Bharat architecture of Health and Wellness Centres.

 

Draft Health Data Management (HDM) Policy 

1. Features
   • Federated architecture: NDHE follows a federated architecture that enables interoperability between independent and decentralized information systems, enhancing individual data security and privacy.
   • Applicability: Applicable to all entities and individuals in the Ayushman Bharat ecosystem.
   • Objectives: Provides guidance and a framework for secure processing of personal and sensitive data within NDHE, complying with applicable laws.
   • Data privacy: HDM policy aims to increase data privacy awareness, instilling a privacy-oriented mindset within ABDM and ecosystem partners.
2. Significance
   • Setting standards for data privacy protection: A guidance document across the National Digital Health Ecosystem that sets minimum standards for privacy protection.
   • Safeguarding digital personal data: Secures data such as the Personal Health Identifier, electronic health, and medical records through technical and organizational measures.
   • Create a system of digital health records: Ensures accessibility for individuals and healthcare providers, voluntary in nature, based on individual consent.
   • Leveraging existing information systems: Integrates existing health sector information systems with NDHE to conform to defined data privacy standards.

 

Issues with the Health Data Management Policy

1. Lack of data protection law: Without legal support, HDMP lacks adequate protection for sensitive private information.
   • Example: Calls for digitization and data sharing from the Vahan and Sarathi databases led to privacy concerns after reports of targeting vehicles by community during the February 2020 Delhi riots, leading to MoRTH scrapping data sharing.
2. Dispute settlement: Although HDMP details rights such as correction and erasure, it lacks provisions for dispute resolution with data fiduciaries.
3. Penalties: HDMP does not mention penalties for non-compliance with policy standards.
4. Consent manager: Qualifications required for a consent manager role are unclear.
5. Documents for authentication: Although the draft clarifies Aadhaar is not mandatory for health ID, Aadhaar is likely to be the primary document used.

1. Top-down nature: Developing such enterprise architecture systems in healthcare has been a challenge, even in developed nations.
   • For example: National Health Service (NHS) “Connecting for Health” efforts in the UK were abandoned after seven years. The primary reason for failure was its top-down approach and lack of ground-up infrastructure.
2. Health ID creation and handling of sensitive data
   • Against principles of data minimisation: The HDMP mentions that the Health ID will collect Electronic Health Records (EHR), Personal Health Records (PHR), and Electronic Medical Records (EMR). This includes sensitive data such as biometrics, psychological and mental health data, intersex status, sexual orientation, and more. The policy’s mandate that data should be for “a specific, lawful and clear purpose” seems contradictory.
   • Ambiguity regarding data use: The policy is ambiguous on data usage depth, creating mistrust similar to Aadhaar linkages with phones and bank accounts. This over-collection raises privacy concerns.
   • Protection of sensitive data: The policy lacks clarity on how data will be protected, risking patient privacy and creating doubts about healthcare providers’ intentions.
   • Issue with anonymised data: Experts agree that anonymised data can often be reidentified with other data sets.
     • For example: Research shows that 87% of the U.S. population can be identified with only three data points—Zip code, birth date, and gender.
   • Commercialisation of medical data: The digital health mission appears to benefit the private sector, potentially leading to medical data commercialization without expanding on-ground health services.

 

Way forward

• Need for a data protection law: Ensuring that data shared with different entities is protected and secure requires a stringent law.
• Conformity with other legislations: HDMP should align with existing laws like the Right to Information Act and state-specific laws, as health remains a state subject.
• Use of technology: Integrating blockchain into NDHM could enhance privacy for sensitive health data.
• Ensuring confidentiality: Implement checks on data access and introduce anonymization protocols.
• Infrastructure: The policy needs to emphasize an effective regulatory body for securing digital infrastructure, ensuring data protection, and building system confidence.

 

TOBACCO-USE IN INDIA

The most prevalent form of tobacco use in India is smokeless tobacco, with commonly used products including khaini, gutkha, betel quid with tobacco, and zarda. Smoking forms of tobacco used are bidi, cigarette, and hookah.

Data Economic Costs of Diseases and Deaths Attributable to Tobacco Use in India, 2017-2018 Total economic costs attributable to tobacco use from all diseases and deaths in India in 2017-2018 for persons 35 years or older: Rs. 1773.4 billion (US $27.5 billion), of which 22% is direct and 78% is indirect cost. Burden on India: According to the Global Youth Tobacco Survey, India has the second-largest number (268 million) of tobacco users globally, with 13 lakhs dying each year from tobacco-related diseases. Gender-wise economic burden related to tobacco: Men bear 91% of the total economic burden related to tobacco, while women account for the remaining 9%. School-going children: Approximately 27 crore people above the age of 15 years and 8.5% of school-going children in the 13-15 age group use tobacco in some form in India. Costs associated with smoking: Ten lakh deaths are due to smoking, over 2,00,000 deaths due to second-hand smoke exposure, and over 35,000 due to smokeless tobacco use. Economic cost of tobacco use: India bears an annual economic burden of over Rs. 1,77,340 crore from tobacco use, accounting for approximately 1% of GDP [As per the WHO Study published in August 2020 titled “Economic Costs of Diseases and Deaths Attributable to Tobacco Use in India”]. Tax revenue from tobacco: In 2016-2017, it was 12.2% of its economic costs. Medical costs from tobacco use: Direct medical costs alone account for 5.3% of total health expenditure. Increase in healthcare costs linked to tobacco use: These have increased by 21% between 2011-2018. Costs vs. earnings from tobacco products: For every INR 100 received as excise taxes from tobacco products, INR 816 in costs is imposed on society due to its consumption. Other data Leading consumer and producer: With nearly 267 million tobacco users (29% of the adult population), India is the second-largest producer, consumer, and exporter of tobacco products [Global Adult Tobacco Survey-India]. 28.6% of adults above 15 years and 8.5% of students aged 13-15 years in India use tobacco in some form. Decrease in prevalence of tobacco use: Dropped by 6 percentage points from 34.6% in 2009-10 to 28.6% in 2016-17 [MoH&FW]. Gender-wise use of Tobacco: The prevalence of current tobacco use among men is 42.4% compared to 14.2% among women. Global Youth Tobacco Survey-4 Decline in Tobacco Use: There has been a 42% decline in tobacco use among 13-15-year-old school-going children in the last decade. Nearly one-fifth of students aged 13-15 have used any form of tobacco product (smoking, smokeless, or any other form) in their life. Use of any form of tobacco was higher among boys, with a prevalence rate of 9.6% for boys and 7.4% for girls. State-Wise Data: Tobacco use among school-going children was highest in Arunachal Pradesh and Mizoram, and lowest in Himachal Pradesh and Karnataka. Initiation Age: 38% of cigarette users, 47% of bidi smokers, and 52% of smokeless tobacco users initiated use before their tenth birthday. The median initiation age for cigarette and bidi smoking, and smokeless tobacco use was 11.5, 10.5, and 9.9 years, respectively. Awareness: 52% of students noticed anti-tobacco messages in mass media, while 18% noticed tobacco advertisements or promotions at points of sale. 85% of school heads were aware of the Cigarettes and Other Tobacco Products Act (COTPA) 2003, and 83% of schools were aware of the “tobacco-free school” policy.

 

Implications of Tobacco Use in India

1. Health Impact:
   • Deaths: Tobacco is a major risk factor for NCDs, causing over 8 million deaths worldwide annually, with 1.3 million deaths in India, averaging 3500 deaths per day.
   • Diseases:
     • Cancer: Tobacco-related cancers accounted for 27% of India’s cancer burden in 2020 [ICMR].
     • COVID-19: Smokers face a 40-50% higher risk of severe disease or death from COVID-19.
   • Mental Health: Tobacco users are prone to emotional, mental, and behavioral disorders.
2. Economic Implications:
   • Micro-level: Expenditure due to medical services and morbidity includes direct and indirect costs related to medical care and other expenses.
     • Direct medical expenditure: Costs like surgeon fees, tests, medicines, bed charges.
     • Indirect morbidity costs: Costs for household income loss during hospitalization or outpatient visits.
     • Indirect mortality costs: Premature deaths attributable to tobacco use.
   • Macro-level: Impact on the nation.
     • Drain on National Resources: Tobacco use is a significant drain on the national exchequer, costing approximately 1% of India’s GDP.
     • Workforce: Tobacco use contributes to a less healthy workforce, leading to reduced productivity and economic growth.
3. Social Implications:
   • Crowding out effect: Expenditures on tobacco smoking can lead to reduced spending on other basic commodities like food, health, education, housing, transport, and energy.
   • Nutritional status of children: Reduction in the nutritional status of children as a consequence of the expenditure on smoking products, mediated via reduced food expenditure.
   • Healthcare system: It increases healthcare expenditure, straining healthcare systems, primarily in developing and under-developed countries, and creating health disparities.
4. Environmental impact

• Land degradation: Tobacco farming is associated with land degradation and desertification, including soil erosion, reduced soil fertility, productivity loss, and disruption of water cycles.
• Impact of smoke: Tobacco smoke has adverse environmental health effects.
  • Example: Tobacco smoke leaves a durable residue on surfaces, building up over time and becoming increasingly toxic.
• Marine pollution: Cigarette butts cause pollution by being carried in runoff to drains and subsequently to rivers and oceans.
• Harmful to marine life: Organic compounds (such as nicotine, pesticide residues, and metals) seep from cigarette butts into aquatic ecosystems, harming fish and microorganisms.
• CO₂ emission: According to WHO, 600 million trees are chopped down annually to produce cigarettes, resulting in 84 million tonnes of CO₂ emissions and using 22 billion liters of water.

1. Others

• Accomplishment of SDGs: Tobacco use hinders achieving SDGs, particularly SDG 1, 3, 5, 10, and 12. Achieving SDG target 3.4, which aims to reduce premature deaths from NCDs by one-third by 2030, is also crucial.

Steps taken to reduce tobacco use

1. Indian Initiatives
   • Legislative measures:
     • Cigarettes Act, 1975: Mandates the display of statutory health warnings in advertisements and on cartons and cigarette packages.
     • Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade, Commerce, Production, Supply, and Distribution) Act [COTPA, 2003]: Aims to provide smoke-free public places and restricts tobacco advertising and promotion.
     • Juvenile Justice Act, 2015: Imposes strict punishment against providing tobacco products to children.
     • Prohibition of Electronic Cigarettes Act, 2019: Prohibits production, manufacture, import, export, transport, sale, distribution, storage, and advertisement of e-cigarettes.
     • Delhi Prohibition of Smoking and Non-Smokers Health Protection Act: Passed by the Delhi assembly in 1997, it became a model for central legislation banning smoking in public places in 2002, following directions from the Supreme Court.
   • Other measures:
     • Tobacco Quitline services: Initiated in 2016 and available in 16 languages and other local dialects from four centers. The quit line receives around 2.5 lakh calls per month.
     • National Health Policy 2017: Sets an ambitious target to reduce tobacco use by 30% by 2025.
     • Global Youth Tobacco Survey: Conducted its fourth round among 13-15-year-old school-going students in India.
     • National Tobacco Control Programme (NTCP) – 2007-08: Launched to ensure effective implementation of COTPA, 2003, and to raise awareness about the harmful effects of tobacco.
     • Pictorial Health Warnings: Covers 85% of the front and back panels of tobacco product packaging.
     • WHO Framework Convention on Tobacco Control (FCTC): India became a party to the FCTC.
2. Global measures
   • Director General’s Special Recognition Awards: Conferred on individuals or organizations for their accomplishments in tobacco control. In 2019, the award was given to Indian Union Health Minister Harsh Vardhan.
   • WHO Framework Convention on Tobacco Control (WHO FCTC): Developed in response to the globalization of the tobacco epidemic, emphasizing demand reduction strategies and supply-side solutions.
   • Firewall by WHO: In 2007, WHO established a firewall to protect policies from commercial and other vested interests of the tobacco industry.
   • The United Nations Global Compact followed suit: Banning the tobacco industry from participation in 2017, flagging the problematic and irreconcilable conflicts between the goals of the UN and an industry responsible for more than 8 million deaths per year.
   • Other UN measures: In 2008, the UN General Assembly adopted a Resolution for Smoke-free United Nations Premises. In 2012, the United Nations Economic and Social Council called for “system-wide coherence on tobacco control.”

 

Way Forward

1. WHO Recommendations
   • Making tobacco products unaffordable: Through comprehensive fiscal and non-fiscal policies, including increased taxes on tobacco products annually to make them unaffordable.
   • Greater investment in the National Tobacco Control Programme (NTCP): To fast-track tobacco control implementation and deploy the broad-based MPOWER package of policies and interventions to curb the tobacco epidemic.
   • Smoke-free laws: Protect the health of non-smokers, are popular, and encourage smokers to quit.
   • Mass media campaigns: Reduce demand for tobacco by promoting non-smoker protection and encouraging tobacco cessation.
   • Comprehensive bans on advertising, promotion, and sponsorship: Reduce tobacco consumption.
   • Tobacco taxes: A cost-effective way to reduce tobacco use, particularly among youth and low-income people.
     • A 10% increase in tobacco prices decreases consumption by about 4% in high-income countries and 5% in low- and middle-income countries [WHO].
   • Helping to quit: Professional support and proven cessation medications can double a tobacco user’s chance of quitting.
2. Other Measures
   • Identifying health effects: Identify, prevent, treat, and monitor health effects among tobacco-growing farmers and workers.
   • Alternate employment: Develop strategies to free tobacco farmers and their children from unsafe agricultural and labor practices.
   • Extended producer responsibility: Implement regulations to reduce, mitigate, and prevent manufacturing and post-consumption tobacco product waste.
   • Recovering cost: Engage in litigation and economic interventions to recover costs from industry misconduct and environmental damages.
   • Community of Concern: Establish a multi-sectoral community (health, agriculture, trade, and environment) to address tobacco production and use’s environmental impacts.
   • Strengthening environmental policies: Increase costs for tobacco products, reduce social acceptance of tobacco use, and drive changes in commonly used tobacco products.

 

RURAL HEALTH

Rural Health Care services in India are mainly based on Primary health care, which envisages attainment of healthy status for all. Being holistic in nature, it aims to provide preventive, promote curative, and rehabilitative care services. The Indian rural health care system is a three-tier system comprising Sub-Centres, Primary Health Centres (PHC), and Community Health Centres (CHC). The lack of clear vision, absence of inclusive strategies, lack of motivation, zeal, and enthusiasm combined with failure of bureaucratic leadership are some of the reasons impairing rural health care delivery.

Statistics

1. Quality of healthcare: Only 11% sub-centres, 13% Primary Health Centres (PHCs), and 16% Community Health Centres (CHCs) in rural India meet the Indian Public Health Standards (IPHS).
2. Shortage of doctors: Only one allopathic doctor is available for every 10,000 people, and one state-run hospital is available for 90,000 people.
3. India’s spending on healthcare: At 1.4% of GDP, India spends among the least on healthcare. The Centre aims to raise it to 2.5% by 2025.
4. According to the Rural Health Statistics Report 2019-20:
   • Shortage of health and wellness centres: There are 38,595 functional health and wellness centres in rural India, against the target of 1,53,000 by 2022 under Ayushman Bharat.
   • Severe shortage of specialist doctors: There is a shortfall of 76.1% in terms of specialists like surgeons, gynecologists, physicians, and pediatricians at the CHCs.
   • Health infrastructure: Over the years, a significant increase has been observed in the number of centres at all three tiers.
5. Good signs:
   • Number of ANMs (auxiliary nurse midwife): Increased from 1,33,194 in 2005 to 2,12,593 in 2020.
   • Allopathic doctors at PHCs: Increased from 20,308 in 2005 to 28,516 in 2020, about a 40.4% increase.

 

Significance of Rural Health

1. Economic
   • Financial support: Enables the rural population to pay for services, such as health or dental insurance.
   • Associated services: Means to reach and use services, like transportation to distant services.
   • Economic Stability: The rural sector provides human resources for sectors such as retail, construction, manufacturing, hospitality, education, and transportation.
   • Overcome Health Expenditure: Robust health infrastructure helps in treating diseases at the primary level, saving resources that would otherwise be spent on secondary and tertiary care.
     • Example: Currently, out-of-pocket expenditure in India is more than 60%, which places a heavy burden on the rural poor.
2. Structural Significance
   • Overrides the infra barriers: Rural residents often encounter barriers to healthcare that limit their ability to obtain the care they need.
   • Overrides language barriers: Provides confidence to communicate with healthcare providers, particularly if the patient is not fluent in English or has poor health literacy.
   • Benefits of accessibility to primary care: Preventive services, including early disease detection, care coordination, lower all-cause, cancer, and heart disease mortality rates, reduction in low birth weight, and improved health behaviour.
   • Disease Control and Prevention: Properly equipped healthcare facilities in a proximate range would ensure that common health concerns, such as viral diseases, maternal issues, child health problems, etc., are addressed in an expedited manner.
3. Health
   • Targeted Population: With more than 60% of India’s population living in rural areas, the importance of rural healthcare facilities cannot be over-emphasized.
   • Overall physical, social, and mental health: According to Healthy People 2020, access to rural healthcare is important for detection, diagnosis, and treatment of illness, preventable death, and life expectancy.
   • Higher Vulnerability: The region comprises people who are not as affluent and resilient as their urban counterparts. Their ability to absorb extreme situations like a pandemic is very limited due to inadequate financial cushions.

 

Challenges associated with Rural Health

1. Infrastructural
   • Distance and transportation: Rural populations are more likely to have to travel long distances to access healthcare services, particularly subspecialist services. This can be a significant burden in terms of travel time, cost, and time away from the workplace.
   • Lack of medical infrastructure: The existing healthcare centres in rural areas are under-financed, use below-quality equipment, and have a low supply of medicines.
   • Lack of support infrastructure: Underdeveloped roads, railway systems, poor power supply are some of the major disadvantages that make it difficult to set up a rural healthcare facility.
   • Lack of medical stores: Supply of basic medicine is irregular in rural areas. The fair price shops (PPP model) are located in tertiary care and secondary care hospitals, but they charge differently in different locations.
   • Inaccessibility of PHCs and CHCs: In some cases, e.g., in tribal areas, these centres are quite far from villages, leading people to rely on unregistered local private healthcare practitioners who are rarely open or equipped to address even basic illnesses.
   • Lack of basic facilities: Poor sanitation facilities, shortage of electricity, and water discourage medical graduates from serving in rural centres.
2. Social
   • Lack of Awareness: Proper education on basic issues such as sanitation, health, hygiene, healthcare policies, and the importance of medical services is insufficient in India. Rural residents often avoid seeking care for mental health, sexual health, pregnancy, or chronic illnesses due to taboos.
   • Lack of awareness about the right of patients: Innocent and illiterate patients or their relatives are often unaware of their rights.
   • Nutritional Deficiency: The culture of fast food has penetrated the rural arena, displacing the traditional healthy diet patterns.
   • Dual burden of diseases: Inequality in health care delivery and the changing pattern of disease in India has pushed rural India into a dual burden of communicable and non-communicable diseases.
   • Privacy issues: With very little or no anonymity in rural areas, privacy concerns are more likely to act as barriers to healthcare access due to personal relationships with their healthcare provider or others working in the healthcare facility.
3. Human resource
   • Lack of adequate medical personnel: Less than recommended patient-doctor and nurse-doctor ratios contribute collectively to the inadequacy of the rural healthcare system. Every doctor needs a nurse to cater to their patients.
   • Lack of doctors even in PHCs: PHCs are short of more than 3,000 doctors, with the shortage up by 200% over the last 10 years to 27,421, as per a report by India Spend.
   • Lack of qualified personnel: Most of the centers are run by unskilled or semi-skilled paramedics, and a doctor in the rural setup is rarely available.
   • Unscientific medical practices: The situation of rural healthcare in India has not changed much over the past decade, though it is difficult to gauge from outside. Patients are still in the hands of quacks and unscientific medical practices.
   • Lack of mental health providers and services: Primary care physicians often fill the gap and provide mental health services while facing their own barriers, such as lack of time with patients or adequate financial reimbursement.
   • Lack of substance abuse services: Despite a growing need, there is a definite lack of substance abuse services offered in many rural communities.
4. Economic
   • Lack of insurance avenues: The government has only contributed to about 32% for insurance in the healthcare sector in India, which is insufficient. India has one of the lowest per capita healthcare expenditures in the world.
   • Unaffordability: People cannot afford upmarket health services when they need to visit private hospitals. The cost of diagnostic facilities and advanced technological advancements is going up.
   • Prone to exploitation: Patients, when in an emergency, are sent to tertiary care hospitals where they get more confused and easily cheated by a group of health workers and middlemen.
   • Lower population densities: Economy of scale cannot be achieved by healthcare industry in rural and tribal areas. It discourages investment in rural health infrastructure.

 

1. Administrative
   • Demand-supply mismatch: Peripheral health centers are underutilized, whereas tertiary and secondary-level facilities are often argued to be overloaded with work that could have been done at lower centers, resulting in compromised quality.
   • Reluctance to serve rural areas: Health care personnel are reluctant to work at block or lower level areas due to the absence of reasonable living conditions (e.g., proper housing, 24-hour electricity supply, good school for their children, social isolation, etc.).
   • Corruption: Deep-rooted corruption is prohibiting the smooth flow of the system, especially the prompt purchase of medical equipment and diagnostics.
   • Negligence in treatment: A patient is not always treated on time in rural India since the doctors are less in number.

 

Government Initiatives in Rural Health

1. Ayushman Bharat Scheme: To achieve universal health coverage.
   • 1,50,000 Health and Wellness Centres (HWCs) to deliver Comprehensive Primary Health Care (CPHC) by transforming the existing Sub Centres and Primary Health Centres.
   • Pradhan Mantri Jan Arogya Yajna provides a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and vulnerable families.

1. Ayushman Bharat Health Infrastructure Mission: It envisages increased investments in public health and other health reforms to provide better access to health in rural areas. It has an outlay of Rs. 64,180 crore to be spent till 2025-26.
2. National Rural Health Mission (NRHM): To provide accessible, affordable and quality health care to the rural population, especially the vulnerable groups.
3. Kayakalp award: Given to Community Health Centres, Primary Health Centres and Health & Wellness Centres who have achieved a high level of cleanliness, hygiene, and infection control.
4. eSanjeevani platform: Enabled telemedicine services through Doctor-to-Doctor and Patient-to-Doctor tele-consultations to improve accessibility.
5. Jan Aushadhi Medical Store: Quality medicines are made available at affordable prices for all, particularly the poor and disadvantaged, through exclusive outlets “Jan Aushadhi Medical Store” to reduce out-of-pocket expenses in healthcare.
6. National AYUSH Mission: To promote traditional medicines such as Ayurveda, Siddha, Unani, Yoga, Naturopathy, and Homoeopathy.
7. Pradhan Mantri Shurakshit Matritva Abhiyan: To improve access to specialist maternal care through voluntary participation of private providers.
8. Bridge Programme in Community Health: The trained nurses and Ayurveda practitioners will provide comprehensive promotive, preventive, and curative healthcare services.

Ways Forward:

1. Administrative:
   • Primary healthcare under PMJAY: It would help in promoting access to primary healthcare and reduce the overall expenditure on healthcare by reducing unnecessary referrals, by preventing illnesses, and by treating diseases at an earlier stage.
   • Collaboration: The Medical, Health, and Education Department need to work in synergy to achieve the objective of overall enhancement of health.
   • Instilling empathy: Medical colleges need to encourage students to visit rural areas and understand the healthcare requirements of the poor and downtrodden.
   • Skilling: The primary care team should be adequately supported through regular skilling, incentives, and supervision.
2. Social:
   • Revise undergraduate medical and nursing curriculum: The training of MBBS should be aligned toward producing rural family physicians and nursing graduates to produce rural primary care nurses.
3. Economic:
   • Investments in primary healthcare: The policy commitment to invest 2.5% of GDP on healthcare and 70% of this expenditure on primary healthcare should be tracked periodically. 
4. Infrastructural
   • Village development: RURBAN initiative of developing villages can be gainfully used for innovative medical manpower management in primary healthcare.
   • Use of technology: Appropriate technological solutions should be provided to help them deliver quality healthcare.
   • Affordable healthcare by research: Biomedical scientists in the hospitals, research institutions should come together and translate their knowledge towards indigenous production of affordable medical products.

 

In India, 75% of the healthcare infrastructure is concentrated in urban areas where only 27% of the total Indian population is living. The government’s efforts to provide better healthcare to people in rural areas seem to have resulted in improved utilization of the formal healthcare infrastructure. There is a need to incorporate “cooperative thinking” in the system by diverting efforts towards provision of universal basic care, i.e., “Good for most rather than best for few.” The current national agenda calls for an immediate focus on the rural health delivery systems including tribal and inaccessible areas, which constitute nearly 70% of the population hitherto deprived of the advancements in health and disease management.