Knappily Daily Session 4

Doctor shortage in India| Healthcare Initiatives & Reforms| The fate of Julian Assange

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India’s doctor deficit

Short by a lot • India is 600,000 doctors and 2 million nurses short, as per a

report by the Center for Disease Dynamics, Economics & Policy (CDDEP) in the US. In India, 65% of health expenditure is out-of-pocket, and such expenditures push some 57 million people into poverty each year.

• In India, there is one government doctor for every 10,189 people (the World Health Organization (WHO) recommends a ratio of 1:1,000), or a deficit of 600,000 doctors, and the nurse: patient ratio is 1:483 (WHO recommends 1:8), implying a shortage of two million nurses.

• The majority of the world's annual 5.7 million antibiotic-treatable deaths occur in low- and middle-income countries where the mortality burden from treatable bacterial infections far exceeds the estimated annual 700,000 deaths from antibiotic-resistant infections.

A constitutional right The Constitution incorporates provisions guaranteeing everyone’s right to the highest attainable standard of physical and mental health. Article 21 of the Constitution guarantees protection of life and personal liberty to every citizen. The Supreme Court has held that the right to live with human dignity, enshrined in Article 21, includes protection of health. Further, it has also been held that the right to health is integral to the right to life and the government has a constitutional obligation to provide health facilities Most provisions related to health are in the Directive Principles (Part IV). These are: • Article 38 says that the state will secure a social order for the promotion of welfare of the people. Providing

affordable healthcare is one of the ways to promote welfare. • Article 39(e) expects the state to ensure good health and strength of workers, men and women, and that

children are not abused. • Article 41 imposes the duty to provide public assistance in cases of unemployment, old age, sickness and

disablement. • Article 42 makes a provision for protecting the health of infant and mother by maternity benefit. • Article 47 duty of the State to raise the level of nutrition and the standard of living and to improve public health . • Article 48A protection and improvement of environment and safeguarding of forests and wild life.

A major crisis India’ health care sector is battling a major crisis — inadequate infrastructure and human resource.

• Over 2008-17, shortage of medical staff, especially doctors, claimed lives of 72,000 infants in government hospitals of Madhya Pradesh.

• In Bihar, one government doctor serves 28,391 people. Uttar Pradesh is ranked second with 19,962 patients per doctor, which is followed by Jharkhand (18,518), Madhya Pradesh (16,996), Chhattisgarh (15,916) and Karnataka (13,556).

• Delhi is better in terms of doctor-population ratio (1:2203), but it is still twice the ratio recommended by WHO. The states and UTs that are closest to meeting the WHO standards are Arunachal Pradesh, Puducherry, Manipur and Sikkim.

• As of March 31, 2017, the country had a shortfall of 10,112 female health workers at primary health centres, 11,712 female health assistants, 15,592 male health assistants and more than 6,1000 female health workers and auxiliary nurse midwifes at sub-centres. 15,700 primary health centres are operating with just one doctor.

Where are the doctors? If the entire country wants to achieve 1:1,000 ratio, it will need 2.07 million more doctors by 2030, according to a study published in the Indian Journal of Public Health, in September 2017.

• With the government spending just 1.3 per cent of the GDP for public healthcare, as opposed to the global average of 6 per cent, shortage of government doctors means people will continue to incur heavy medical expenditure in private health care system.

• The success of Ayushman Bharat depends on its ability to provide comprehensive primary health care to communities. India has 492 medical colleges out of which 233 are government-owned, offering more than 62,960 MBBS seats. This is a large number but the perceived scarcity is because most doctors are not in the public health system.

• At the postgraduate level, the ‘lucrative’ options — radiology, orthopaedics and gynaecology — are preferred over family medicine, geriatric care, psychiatry. To get more doctors into the public system, India needs more government colleges with affordable fees. Doctors passing out of private colleges will not come to government hospitals because they cannot afford to as they have to recover their training costs. All government colleges must offer postgraduate courses in under-represented disciplines.

Can the informal ‘doctors’ plug the gap? 60% PHCs have just one doctor, while nearly 7% are functioning without any. More than a third of them do not have a laboratory technician, a fifth of them do without a pharmacist. This gap has fuelled the proliferation of informal healthcare providers, known pejoratively as “medical quacks.” • These untrained practitioners of medicine provide more than 70% of primary care in rural India. There are an

estimated 1.6 million rural informal providers compared to less than one million licensed MBBS doctors. Policymakers and the Indian medical establishment have resisted the integration of these providers into the formal medical system.

• A National Medical Commission (NMC) proposal in May 2018 in the National Medical Commission Bill and the National Health Policy 2017, of allowing AYUSH (Ayurveda, Yoga and naturopathy, Unani, Siddha and Homoeopathy) practitioners to practise basic and limited allopathy on completion of a bridge course faced strong opposition from allopaths, the Union cabinet withdrew the proposal and passed on the responsibility to states to utilize this as a strategy for addressing human resources gaps in primary healthcare.

• Given the terrible shortage of MBBS doctors in rural areas, it makes sense to leverage the ready availability of a large population of willing AYUSH practitioners. With the availability of appropriate bridge courses, sound regulatory and licensing mechanisms, AYUSH graduates should be given a chance to help serve India’s primary healthcare needs.

• Global models: Physician Assistant (PA) in the US & Physician Associate in the UK. Assistant doctors in China, clinical associates in South Africa, and assistant medical officers in Malaysia. 89% of healthcare delivery in rural areas of Bangladesh is being taken care primarily by sub-assistant community medical officers (SACMO)

The Chhattisgarh Model While most states are struggling to retain doctors to work in rural areas, the Left-wing Extremism (LWE)-affected Chhattisgarh has shown how. It has managed to retain doctors by offering them high salaries, opportunity for career advancement, and good facilities to work in districts where LWE has claimed thousands of life.

• Under a project that started in two districts in partnership with the Public Health Foundation of India in 2015, the state attracted specialists – gynaecologist-obstetricians, general surgeons, paediatric surgeons among others – from Maharashtra, Andhra, Telangana and Uttar Pradesh to live and work in these two districts where there are mine-clearing vehicles and CRPF camps every 5 km of NH-43, but no private hospitals or clinics.

• This was done by giving more autonomy to district collectors in the use of flexi-funds from the National Health Mission (NHM) and district mineral foundation (DMF) to offer specialists salaries that are two to three times higher than what they would earn in an urban hospital. Specialists earn between Rs 2 and Rs 2.5 lakh a month. A senior paediatric and general surgeon, for example, was offered Rs 2.6 lakh – Rs 1.59 lakh from NHM and Rs 1.1 lakh from DMF.

• Money apart, doctors and their families are being given the same facilities as civil servants and army personnel, including homes and incentives for career advancement, such as three marks per year for PG and priority in training programs overseas. Social support in the form of help with their children’s school admission and jobs for their spouses, depending on their qualifications, is also provided.

An eye on healthcare reforms

Towards Universal Health Care (UHC) • India's cabinet passed the National Health Policy in 2017. Its stated aim is to achieve "universal health

coverage and deliver quality health care services to all at affordable cost.“

• A policy known as Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana, launched in September 2018, aims to establish 150,000 health centres across the country. There is no publicly available data on how many of these have been set up.

• Since 2014, three new branches of AIIMS have started some form of operations and a further 12 have been announced or approved, though they are not yet operational.

• The National Medical Commission Bill, which will replace the Indian Medical Council Act, 1956, has yet to be passed by Parliament. Till then, the government has appointed a Board of Governors to supersede the Medical Council of India. Last year, the board finalised a new MBBS curriculum, to be taught from the 2019-20 session.

• The National Health Mission (NHM) budget for 2018-19 (Rs 31,745 crore) barely crossed the spend in 2017-18 (Rs 31,510 crore).

The report card • India's cabinet passed the National Health Policy in 2017. Its stated aim is to achieve "universal health

coverage and deliver quality health care services to all at affordable cost.“ • A policy known as Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana, launched in September 2018,

aims to establish 150,000 health centres across the country. There is no publicly available data on how many of these have been set up.

• Since 2014, three new branches of AIIMS have started some form of operations and a further 12 have been announced or approved, though they are not yet operational.

• The National Medical Commission Bill, which will replace the Indian Medical Council Act, 1956, has yet to be passed by Parliament. Till then, the government has appointed a Board of Governors to supersede the Medical Council of India. Last year, the board finalised a new MBBS curriculum, to be taught from the 2019-20 session.

• The National Health Mission (NHM) budget for 2018-19 (Rs 31,745 crore) barely crossed the spend in 2017-18 (Rs 31,510 crore).

• India's health ministry released a concept note on setting up a standardised way of digitally storing and using health data. But no legislation has been passed in parliament.

Ayushman Bharat The ambitious scheme offers an insurance cover of Rs 5 lakh, which will cover 10 crore poor families or almost 50 crore persons. In his Independence Day speech, Modi had announced that while the scheme would initially cover 10 crore poor families as per the socio-economic census of 2011, it will also benefit the lower middle-class, middle-class and upper-middle class by way of jobs in the medical sector as new hospitals will open in Tier-2 and Tier-3 cities.

• To ensure that nobody is left out (especially women, children and the elderly), there is no cap on the family size and age under the Ayushman Bharat-National Health Protection Scheme (AB-NHPS). The scheme will be cashless and paperless at public hospitals and empanelled private hospitals.

• The expenditure incurred in premium payment will be shared between Central and State Governments in specified ratio as per Ministry of Finance guidelines in vogue. The total expenditure will depend on actual market determined premium paid in States/ UTs where B-NHPS will be implemented through insurance companies. In States/ UTs where the scheme will be implemented in Trust/ Society mode, the central share of funds will be provided based on actual expenditure or premium ceiling (whichever is lower) in the pre-determined ratio. The scheme will cost Rs 10,000 crore when its rolled out across India this year.

Ayushman Bharat - so far • Instances are being reported of patients not getting the financial support they were entitled to for systemic

reasons, including one Government cover not being recognised in another State.

• Private hospitals and doctors were reluctant to get onto the AB program, as they find it badly designed, not capturing their realities in terms of costs. And for those on the scheme, there was the standard rumble on delayed payments.

• Many healthcare specialists are uncomfortable with the insurance model that takes care of an individual only when hospitalised. They urge the Government, instead, to pursue a universal healthcare approach where out-patient treatments are also covered. The Government needs to ensure a mutual recognition of the different insurance covers across the country.

• As patients get enrolled in Government insurance programs, premiums are paid to companies, but patients still don’t get the benefit of free healthcare. Hospitals across the country should be empanelled to accept any Government-run health insurance programm. The present system of discriminating between different Government-run health insurance programs only takes the country one step away from offering universal healthcare to all its people.

Savings of Rs 1700 crore for citizens

2500 stores by 2020

First things first

First things first

First things first

First things first

Julian Assange fights extradition

Arrested, finally • WikiLeaks founder Julian Assange has exchanged a small room at the Ecuadorian Embassy in central London for a

cell at Belmarsh Prison. • For nearly seven years, Assange lived in the embassy without taking a step outside for fear of being arrested and

sent to the U.S. to be prosecuted. • On April 11, British authorities dragged the Australian native from the embassy, and U.S. authorities announced

charges against him of conspiring to break into a Pentagon computer, setting up what is expected to be an epic legal and political battle over whether to extradite him to the U.S.

• The political debate over whether to extradite Assange is already taking shape, with Britain’s opposition Labour Party urging the government not to hand him over to the Americans. Party leader Jeremy Corbyn tweeted that the U.S. is prosecuting Assange because he exposed “evidence of atrocities in Iraq and Afghanistan.”

• The politicization of the case reflects the clashing views of Assange as either a heroic whistleblower standing up to the mighty United States or a willing stooge who helped the Russians boost Donald Trump’s presidential campaign by publishing hacked emails that embarrassed his rival, Hillary Clinton.

• Assange’s bid to fend off extradition could take years and involve several layers of appeal. He could also face a second extradition request if Sweden decides to pursue a rape case against him that was suspended in 2017, when he was in the embassy, beyond the reach of the law.

• If Assange loses in extradition court, he could appeal several times and ultimately try to have his case heard at the European Court of Human Rights — unless Britain has left the European Union by that time

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