Gist of EPW November Week 4, 2018

The Economic and Political Weekly (EPW) is an important source of study material for IAS, especially for the current affairs segment. In this section, we give you the gist of the EPW magazine every week. The important topics covered in the weekly are analysed and explained in a simple language, all from a UPSC perspective. 

Topic covered in this article are:

  1. Ayushman Bharat—Long Live Private Healthcare

  2. War on Air Pollution Will Not Be Won in the Courts

 

Ayushman Bharat—Long Live Private Healthcare

Introduction

  • A healthy population is a key contributor to the development of human capital, which, in turn, is the primary ingredient for growth.
  • According to the World Bank, health expenditure as a percentage of gross domestic product (GDP) in India was 3.8% in 2015. This was 16.8% for the United States and 9.9% for the world as a whole.
  • Fifteen percent of the Indian population is insured, and 94% of the health expenditure is paid by individuals out of pocket.
  • Providing the poor with health insurance not only can improve the health of individuals, but it has much bigger potential positive spillovers. It might be the key to driving families out of the vicious cycle of poverty.
  • Against this backdrop, the Ayushman Bharat—National Health Protection Mission (AB-NHPM), also known as Modicare, generated a lot of interest.

Some salient features of the Scheme

  • The scheme has two objectives – Creating a network of health and wellness infrastructure across the nation (for primary health care services) and providing insurance cover to minimum 40% of India’s total population (for secondary and tertiary health care services)
  • Beneficiaries of health insurance under the scheme will include 50 crore economically weak citizens of India as defined in the social, economic and ethnic census 2011 database. It will cover both rural (8.03 crore) and urban (2.33 crore) families.
  • Ayushman Bharat will subsume the existing Rashtriya Sawasthya Bima Yojna, launched in 2008 and the Senior Citizens Health Insurance Scheme.
  • It will provide a benefit cover of Rs 5 lakh/year/family.
  • Expenses incurred will be shared between Centre and States in 60:40 ratio.
  • The Government aims to open 5 lakh health and wellness centre by 2022 that will be equipped to treat various diseases.
  • Ayushman Bharat will take care of secondary care and tertiary care procedures and also cover pre and post-hospitalisation expenses.
  • Cashless benefits will be allowed from any public or private empanelled hospitals. Such empanelled hospitals will have ‘Ayushman Mitra’ to assist patients.
  • Benefits can be availed from any place in India and no hospital can refuse treatment under this scheme.
  • Guidelines have been given by the Government about families that can’t avail the benefits under the scheme. For example- Families with credit card limit of over Rs 50,000, families where a member has a government job, etc.

Some facts before we analyse the scheme

  • Between 2008 and 2015, public health expenditure (Centre and State Governments combined) remained constant at 3% of GDP.
  • It increased marginally to 1.4% in 2016-2017. But it is still low compared to world average of 6%.
  • The deficient investment in public spending on health has resulted in poor infrastructure and inadequate human resources.
  • About 70% healthcare services are provided by private sector.
  • About 80% of doctors and 75% of dispensaries are serving urban India, which makes up only 28% of the country’s population, leaving the rest in dire need of basic health facilities.
  • There are only 0.9 hospital beds per 1,000 population; whereas the figure is 6.5 per 1,000 population for developed countries. India had access to 0.6 doctors per 1,000 population while the figure was around three for developed countries.
  • As per the World Bank, even in 2015, 15% of the children did not have access to basic vaccines.

Analysis of the Scheme

  • One of the major departures from previous schemes like the Rashtriya Swasthya Bima Yojana (RSBY) is that the AB-NHPM will also provide primary care assistance by upgrading the government health centres.
  • The insurance amount has also been increased to ₹ 5 lakh from ₹ 30,000. There are also plans of digitisation of the entire process, which would be largely borrowed from the Rajiv Aarogyasri Health Insurance Scheme in Andhra Pradesh. The government aims to cover 40% of the entire population.
  • One of the major issues with the scheme is how to make it sustainable. It will further add to the fiscal burden. The government has claimed that it would be able to finance it through the savings generated from direct benefit transfer (DBT) that amounts to ₹ 90,000 crore. However, this money has already been taken into account in fiscal calculations.
  • Also, since state governments have to bear 40% of the costs, this would further add to the fiscal burden of the states and they might ask the central government for more resources. This would be a problem parti­cularly for poorer states with a large population of people below the poverty line. Hence, this policy would be taxing the poorer states.
  • The state of health infrastructure might prove to be a major problem. This is particularly important in peripheral areas.
  • Lack of government health services would result in dependence on the private sector. It is well known that in regions where the public health sector is well developed, the cost of the private health facilities is lower. For example, in Tamil Nadu, the private hospitals have to compete with the government health services and hence the costs are relatively lower given the quality of services offered. In contrast, in the northern states, the costs in private hospitals can really skyrocket.
  • There are no credible monitoring agencies watching out for medical malpractice in such hospitals.
  • Monitoring of doctors in public hospitals is also required. It is common knowledge that government doctors indulge in private practice, which is much more lucrative. Given the fact that the health insurance covers private facilities, this might be an encouragement for government doctors to go in for private practice or set up private nursing homes.
  • It might also encourage people to save less and indulge in more risky expenditure like on cigarettes and tobacco.
  • We require monitoring agencies that will look into all these aspects. It is not clear if these problems have been anticipated by the implementing agencies and whether they have taken steps to curb these.

Conclusion

  • One can say that the AB-NHPM has a lot of potential, but it might turn into a nightmare if not carefully implemented. These issues need to be kept in mind by the policymakers. We also need better data so that the various dimensions can be analysed.
  • If implemented properly, the scheme will bring the nation closer to the Sustainable Development Goal of Universal Health Coverage.
  • The healthcare services available in India need to be developed and their affordability for its citizens has to be improved. As the public spending on these services are quite low compared to the world average, schemes like Ayushman Bharat are a welcome step.
  • The Government and private hospitals need to cooperate so that a scenario of universal health coverage in India may get closer and poor people are able to get better and affordable health care services.

War on Air Pollution Will Not Be Won in the Courts

Context

  • Despite certain measures adopted in the last 12 months, the air pollution problem across northern India has re-emerged this winter, and only worsened after the Diwali festival.
  • The conversations, however, continue to be dominated by Delhi, and revolve around finding quick fixes, mostly pushed by courts, without looking at the deeper, underlying problems or addressing state capacity to deal with air pollution.

Supreme Court and Firecrackers

  • In Arjun Gopal v Union of India (2018), the Supreme Court attempted to regulate the bursting of firecrackers while refusing to impose an outright ban on such firecrackers across the nation.
  • The Court’s judgment directed that bursting of crackers on Diwali be limited to two hours a day as determined by the state government, that only “green firecrackers” (those not containing barium salts) be sold in Delhi and the National Capital Region, that chain firecrackers be banned, and that the police will be responsible for the enforcement of the order.
  • Needless to say, the order was hardly implemented. The Air Quality Index post Diwali was worse than that of the previous year in Delhi, suggesting that the judgment had no serious impact on improving the air quality.
  • Given that air pollution is the result of a number of factors, including the wind conditions, rains, and other sources of pollutants, perhaps, the comparison is not entirely fair since it needs to be checked if all other factors remained the same across the two years.
  • Though there is a good case to be made for regulating the use of firecrackers, getting an understaffed and overstretched police force to try and police lakhs of people bursting firecrackers seems a misguided directive to say the least.
  • The most befuddled by this measure are the police themselves. What provision in law were they supposed to cite to stop the bursting of firecrackers? Of course, this could have been avoided if the concerned governments identified the problem and stepped in with appropriate legislation.

MSP and Crop Residue Burning

  • The NGT in Ganga Lalwani v Union of India (2018) directed the state governments of Uttar Pradesh, Delhi, Punjab, and Haryana to come up with a scheme to penalise farmers, who set fire to their fields to clear it of plant residue, by not paying them minimum support price (MSP).
  • There is nothing in the order that indicates any serious application of mind on the part of the court as to the measure it is proposing and its potential effectiveness.
  • However, the NGT incongruously does not blame the state governments or the centre for not being able to curb crop residue burning.
  • Even where there was an attempt at behavioural change, it was done in a ham-fisted manner: the fines for crop residue burning were cheaper for farmers to pay than the losses they would incur as a result of holding it off .
  • Despite the absence of data, studies, or for that matter any empirical proof that withdrawing MSP is a viable means of nudging farmer behaviour, the NGT has simply directed parties to carry out this ill-conceived idea.
  • Having noted that fines were proving to be ineffective, the NGT seems to be persisting with the notion that economic disincentives would work in preventing farmers from setting fire to the crop residue, without actually assessing whether the loss from lack of MSP for crops would deter them.

About the National Green Tribunal (NGT)

  • NGT has been established under the National Green Tribunal Act 2010 for effective and expeditious disposal of cases relating to environmental protection and conservation of forests and other natural resources.
  • Ambit: The tribunal deals with matters relating to the enforcement of any legal right relating to environment and giving relief and compensation for damages to persons and property.
  • Members: Sanctioned strength: currently, 10 expert members and 10 judicial members (although the act allows for up to 20 of each).
  • Chairman: is the administrative head of the tribunal, also serves as a judicial member and is required to be a serving or retired Chief Justice of a High Court or a judge of the Supreme Court of India.
  • Selection: Members are chosen by a selection committee (headed by a sitting judge of the Supreme Court of India) that reviews their applications and conducts interviews. The Judicial members are chosen from applicants who are serving or retired judges of High Courts.
  • Expert members are chosen from applicants who are either serving or retired bureaucrats not below the rank of an Additional Secretary to the Government of India (not below the rank of Principal Secretary if serving under a state government) with a minimum administrative experience of five years in dealing with environmental matters. Or, the expert members must have a doctorate in a related field.
  • The Tribunal is not bound by the procedure laid down under the Code of Civil Procedure, 1908, but shall be guided by principles of natural justice.
  • The Tribunal’s dedicated jurisdiction in environmental matters shall provide speedy environmental justice and help reduce the burden of litigation in the higher courts.
  • The Tribunal is mandated to make and endeavour for disposal of applications or appeals finally within 6 months of filing of the same.

Principles of Justice adopted by NGT

  • The NGT is not bound by the procedure laid down under the Code of Civil Procedure, 1908, but shall be guided by principles of natural justice.
  • NGT is also not bound by the rules of evidence as enshrined in the Indian Evidence Act, 1872. Thus, it will be relatively easier for conservation groups to present facts and issues before the NGT, including pointing out technical flaws in a project, or proposing alternatives that could minimize environmental damage but which have not been considered.
  • While passing Orders/decisions/awards, the NGT will apply the principles of sustainable development, the precautionary principle and the polluter pays principles.

Conclusions

  • While, no doubt, more data is needed on the exact sources of air pollution and the quantum of contribution by each to the problem, the available data is clear that there are multiple sources, all of which contribute significantly, such that tackling any one to the exclusion of others will have no impact on the problem.
  • It is not just road dust, vehicular pollution, dust storms, industrial pollution from power plants, and biomass burning, but a combination of all that has led to the problem.
  • It is also very clear that this is not just a “Delhi problem” or even an urban problem (though India briefly had the 40 most polluted cities in the world), but an international one that affects wide swathes of northern, western, and eastern India.
  • It cannot be tackled through one-off measures by courts, it cannot be handled with piecemeal measures aimed at one source, and it cannot be focused only on the cities.
  • The scale of the task is indeed vast, but—if history is any guide—not insurmountable. London and Los Angeles are among those cities that had a seemingly insurmountable problem of polluted air thanks to a combination of geographic and industrial factors in the last century, but have now made significant progress in improving air quality.
  • No part of this progress, however, was cost-free or an overnight process, but change did come about gradually thanks to governmental interventions.

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