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- The poor condition of healthcare in the country is not a secret, especially in India’s villages where infrastructure is in a dilapidated state. Government hospitals often fail to provide necessary health services to the poor, with private hospitals being out of the reach of most people. The country’s growing population and lack of resources has made matters worse. According to the 2011 census, India’s population is over 1.2 Billion, make it the second most populous nation in the world after, China.
- Many organizations, including the United Nations have estimated that by 2025, India would be the most populated nation in the world, surpassing China.
- More than 32% of total deaths in India are due to heart-related ailments. According to the Global Burden of Disease study, India is ranked low in the Healthcare index; India stands at a rank of 154. This index is out of 194 countries. But despite this, the budget allotment on healthcare services is extremely low.
- India spends less than 2% of her GDP on public healthcare. But now the Government is working on improving public healthcare services. The National Health Protection Mission or Ayushman Bharat Yojana, launched by the Government is the first major step in this direction. Ayushman Bharat Yojana is a program which aims to create a healthy, capable and content new India. It will also focus on the poor and weaker sections of the society. It aims to provide insurance of upto 5 lakh rupees to each family. The new scheme also intends to improve secondary and tertiary healthcare services for crores of Indians.
There are two flagship initiatives under Ayushman Bharat:
- The first is to create a network of health and wellness centres that will bring the healthcare system closer to the people. The centres will provide comprehensive healthcare, including treatment for non-communicable diseases and maternal and child health services. Besides this, they will also provide free essential drugs and diagnostic services; also Rs. 1200 crore have been allocated for this flagship programme.
The scheme will cover more than 10 crore poor families, which is approximately 50 crore persons. It will also setup wellness centres which will give poor people OPD facility near their homes.
- The second flagship programme under ‘Ayushman Bharat’ is the ‘National Health Protection Scheme’. The National Health Protection Scheme will cover over 10 crore poor and vulnerable families. It will provide coverage up to 5 lakh rupees per family, per year for secondary and tertiary care hospitalization.
- Universal health coverage is getting prioritised as a part of political reform with the launch of two pillars.
The pillars are the
- Pradhan Mantri Jan Arogya Yojana (PMJAY): Ayushman Bharat (AB)
Under this scheme, 1.5 lakh health sub-centres are being converted into health and wellness centres.
- The National Health Protection Mission (NHPM)
This aims to provide health cover of Rs. 5 lakh per family, per annum, reaching out to 500 million people.
- It is important to note that the “best health care at the lowest possible cost” should be: a) inclusive
- make health-care providers accountable for cost and quality
- achieve a reduction in disease burden, and
- eliminate catastrophic health expenditures for the consumer.
A Critical Analysis:
- Currently, the NHPM is pushing for hospitalisation at secondary, and at tertiary-level private hospitals, while disregarding the need for eligible households to first access primary care, prior to becoming ‘a case for acute care’.
- Thus, we are in danger of placing the cart (higher-level care) before the horse (primary care).
- It is important to note that without the stepping stone of primary health care, direct hospitalisation is a high-cost solution.
- Recently, the Union Minister for Health and Family Welfare, J.P. Nadda, said that while the PMJAY would help improve availability, accessibility, and affordability for the needy 40% of the population, the Prime Minister was looking for one additional requirement.
- This requirement is that the PMJAY must continue to maintain credibility.
Problem of constraints:
- Public sector health capacities are constrained at all levels.
- Further, forward movement is feasible only through partnerships and coalitions with private sector providers.
- It is important to note that these partnerships are credible only if made accountable.
- It has been suggested that Health-care providers (public/private) should be accredited without any upper limit on the number of service providers in a given district.
Further, the annual premium for each beneficiary would be paid to those service providers, for up to one year only (renewable), as selected by beneficiaries.
- It is believed that the resultant competition would enhance quality and keep costs in check.
- Further, upgrading district hospitals to government medical colleges and teaching hospitals will enhance capacities at the district level.
- Service providers will become accountable for cost and quality if they are bound to the nuts and bolts of good governance.
A look at primary care:
Experts believe that the elimination of health expenditures for the consumer can come about only if there is sustained effort to modernise and transform the primary care space.
It is believed that one must bring together all relevant inter-sectoral action, linking health and development, so as to universalise the availability of:
- clean drinking water,
- garbage disposal,
- waste management,
- food security,
- nutrition and
- vector control.
Further, the Swachh Bharat programme must be incorporated in the PMJAY. These steps put together will reduce the disease burden.
The Way Forward
- It is believed that at the 1.5 lakh health and wellness clinics, one must register households to provide them access to district-specific, evidence-based, integrated packages of community, primary preventive and promotive health care.
- Further, a public education media campaign could highlight the merits of personal hygiene and healthy living.
- The States of Kerala and Tamil Nadu have demonstrated that high-performing, primary health-care systems do address a majority of community/individual health needs.
- The health and wellness clinics must connect with early detection and treatment.
- It is believed that robust delivery of preventive, clinical and diagnostic health-care services will result in early detection of cancers, diabetes and chronic conditions, mostly needing long-term treatment and home care.
- This would further minimise the demand for hospitalisation.
- In conclusion, investment in primary care would very quickly reduce the overall cost of health care for the state and for the consumer. Technology and innovation are further reducing costs. AI-powered mobile applications will soon provide high-quality, low-cost, patient-centric, smart wellness solutions. Currently, the scaleable and inter-operable IT platform being readied for the Ayushman Bharat is encouraging. Finally, as we integrate prevention, detection and treatment of ill-health, the PMJAY will win the hearts of people.
- Currently, the discretionary powers of the Governor are once again at the centre of controversy. This assumes importance based on the recent decision on the remission of seven convicts in the Rajiv Gandhi assassination case.
- It is important to note that Article 161 of the Constitution provides the Governor with the power to “remit or commute the sentence of any prisoner”.
- However, the Governor’s decision will be subject to judicial review by the constitutional courts.
- Currently, the immediate question is whether there is an independent, discretionary power vested with the Governor with regard to Articles 161 and 163 of the Constitution.
- In the Nabam Rebia and Bamang Felix v. Deputy Speaker (2016) case, the Supreme Court, speaking through a five-judge Bench, viewed that the discretionary power of the Governor is extremely limited and entirely amenable to judicial review.
- As a matter of fact, time and again, the courts have spoken out against the Governor acting in the capacity of an “all-pervading super-constitutional authority”.
- Pertaining to the exercise of discretion, in Samsher Singh v. State of Punjab (1974), a seven-judge Bench of the Supreme Court had held that the Governor may do so only “in harmony with his Council of Ministers”.
- In an effort to do so, the Governor is prevented from taking a stand against the wishes of the Council of Ministers.
- Currently, the domain being traversed in this case is alien to the Constitution of India, not having envisaged a situation where the Governor exercises his power under Article 161 against the express recommendation of the Council of Ministers.
- As a matter of fact, such a decision may drastically alter the Constitution and its founding principles such as
a) the federal structure,
b) Cabinet responsibility and
c) accountable governance.
- This might also be interpreted as the Governor having lost faith in the State government with regard to the performance of its executive functions.
- Either which way, it is believed that to stay true to the spirit of the Constitution, the Governor should desist from conferring discretionary powers to his office where there are none.
- The World Happiness Report (WHR) 2018, which ranked 156 countries, placed India at the 133rd place on the index of global happiness
- There’s no denying the fact that there is an intrinsic relationship between law and people’s happiness
Link between the state of happiness and rule of law
- Experiences from several nations confirm that the countries with higher GDP and higher per capita income are not necessarily the happiest countries and there exists a link between the state of happiness and rule of law
- The WHRs, over the years, confirmed that people tend to have poor mental health, a low score of subjective well-being and poor perception about the governance and law and order, despite high-income levels
Factors responsible for low happiness in India
- 3.3 crore cases pending in various courts in the country
- Each case is not a mere number — it involves tension, anxiety and deprivation to all those associated with it
- A group of people — family members, relatives, friends and others of the parties involved — are necessarily affected because of such cases
- If we presume that there are about 20 persons in each case belonging to one or the other parties, we get a number of about 64 crore
- None of them would be in a state of happiness on account of being linked to the case
- Moreover, not more than 30 per cent people approach the courts in India. There is a visible decline in civil litigation, which suggests that a large number of people in the country are living with unresolved conflicts
- This too dents the state of happiness in general
- Criminal justice administration
- Criminal justice has far-reaching consequences for the lives of people — it brings difficulties when it does not act, it causes turbulence when it does
- Millions of accused, victims, suspects, witnesses and others have poignant tales about the actions and inactions of the criminal justice administration
- The satisfaction level of people is far too low in India when it comes to the police and courts
The relationship between crime and happiness
- Making people happy is the best crime prevention
- The connection between crime and happiness is understandable from the experience of Bhutan, which introduced Gross National Happiness (GNH) as a measure of good governance
- The data show that a great majority of the Bhutanese population are happy (of whom 41 per cent are extremely happy), and only 4 per cent reported being victimised by crime over the last 12 months
- Further, the crime rate in Bhutan is extremely low
Does rule of law make you happy?
- The countries scoring high on the Rule of Law Index, a measure used by the World Justice Project, are those who are higher on the index of happiness as well
- The fact that happiness ought to be part of the agenda to improve rule of law, and vice versa, is a new thrust in the emerging policy discourse in many jurisdictions
- The institutionalisation of a happiness framework as a measure of achievement for policy goals is now being debated
- It is probably time to change the narrative — to shift the discourse of policy-making towards the larger satisfaction of the people
- It is, perhaps, time to turn the narrative of law, policy and development, towards building a happier society
- Madhya Pradesh has gone ahead with this and has set up a Happiness Department to achieve such objectives
- Two recent reports related to the reorganisation are being questioned and discussed by India’s military community
- The first seeks the elimination of the one-star rank of brigadier with potentially the two-star rank of major general being considered for the first level of command above the unit level
- It also speaks of the intent to have all officers of the army superannuating at least at the rank of major general, by time scale or selection
- Another report, which appears to flow from the first, relates to the operational and organisational restructuring of the army
- It reflects how a study is being undertaken to remove the division headquarters (HQ) from the hierarchy of formations that exercise command and control
Reasons behind the changes proposed
- The proposals are obviously budget-driven because the current, and potentially future, defence budget (1.47 per cent of the GDP) cannot support an army of 1.3 million without seriously affecting funds for capital expenditure
- The approach appears driven more by personnel management than capability based upon real threats
- The idea is to have more appointments in the rank of major general by tailoring command appointments with resources half-way between what a one- and two-star officer currently commands
- With this, it is intended to have more officers achieving aspirations of two-star rank, with commensurately lower responsibility
Arguments in support of proposed changes
- In view of tactical nuclear weapons being introduced in the battle zone, the parameters have changed
- Smaller formations with just 4-5 infantry battalions with some matching support will present smaller targets and retain the capability to strike up to limited distances, as against the concept of deep thrust
- Another rationale in support of the proposed changes is a doctrine many armies around the world are favouring: Swarming by multiple small forces, thus creating greater deception and forcing a divided response by an adversary
Issues that need to be looked upon
- The command and control of the larger number of TFs than the number of division size forces by the corps HQ
- Many of the support resources currently under the division HQ would revert to the corps HQ
- Pre-location of such resources with the TFs would be necessary, while retaining control at the corps HQ with need-based release
- This will make decision-making far more difficult
- Personnel management
- It will witness the greater complexity
- There will be a need to grade the command appointments of major generals as some will command TFs and others, divisions
- Whether this will provide a level-playing field for further promotion is an aspect bound to come up for legal scrutiny
- Many of the divisions at the northern borders also perform counter-insurgency duties by remaining split
- The TF system will cause numerous functional problems for them
- Increasing the teeth-to-tail ratio
- In 1998, a 50,000 cut in the non-field forces was decided and was under implementation until the Kargil War cut it short
- The approach did not involve any large scale tampering as it only scaled off the bloated strength from organisations away from the battlefield
- If the army leadership is seriously seeking better esteem for its officers the non-functional financial upgradation is a better alternative
- It won’t create undesirable organisational turbulence and the social challenges can be far easier met than the functional ones arising from forced organisational change
- As we approach M.K. Gandhi’s 150th birth anniversary, it is perhaps fitting to revisit the Gandhian approach to rural development
- In this context, an analysis of the idea of women self-help groups (SHGs) as a vehicle to transform the rural landscape would be timely
- These SHGs can act as powerful institutions of participation and can contribute to India’s growth trajectory
- SHGs are essentially diminutive and economically homogeneous groups of rural poor
- Mostly they consist of 10-15 members
- The underlying philosophy guiding an SHG is that members periodically save a small amount of money, unanimously agreeing to make a contribution to a common pool
- United leadership coupled with an informal horizontal network helps to create social capital among the poor, especially among the women
- They act as safety nets to achieve twin goals—economic security and social well-being
Relevance of SHGs
- Women SHGs can be an avenue for achieving the goal of financial inclusion by making women’s access to the banking system easier and hassle-free
- This happens because SHGs filter out the potentially high-risk borrowers through local information
- As a result, banks are more willing to lend as it minimizes their risk
Solving banks problem of selection
- The creation of women SHGs helps finesse the widespread problem of adverse selection that plagues the Indian banking system
- Under normal circumstances, when a bank lends money to a potential borrower, creditworthiness is seen as an essential prerequisite
- More often than not, banks do not have access to relevant local information regarding the creditworthiness of the borrower, which can either lead to denial of credit or increasing number of defaults and bad debts
- However, in the case of women SHGs, women entrepreneurs possess the required local information regarding potential members, which banks do not
- As SHGs are based on the sound principle of joint liability, a woman entrepreneur would be pairing up with a creditworthy and low-risk partner
NPA problem not created
- The problem of a non-performing asset (NPA) arises in two cases
- One, when there is no asset creation, to begin with
- Two, when there is asset creation, but the asset fails to generate enough cash flow because of various reasons
- The SHGs are built on the concept of joint liability, there is a common interest, which ensures the creation of an asset
- Also, as each and every member has joint and individual liability to pay off the loan, the problem of moral hazard (inability of the bank to observe the efforts of the debtor) is circumvented
Reducing socioeconomic disadvantage of women
- It is no secret that women suffer from a vast range of socioeconomic disadvantages in India
- This includes being denied basic rights that range from the freedom to engage in economic activities to the right to choose their calling in life
- The access to credit through the SHG channel helps women to break through these barriers
- By bringing women into the financial net, SHGs act as potent agents of change that go a long way in empowering them and, consequently, their families as well
- Financially empowered, they find themselves in a better position to assert themselves in family matters such as family planning, child education, financial investments
- SHGs are a realistic, viable and sustainable option for achieving rural development objectives
- A greater push for the creation of more SHGs in rural India is needed
- This will help reduce the dependence of women borrowers on informal sources of credit and help work towards their continual inclusion into the formal financial system
- Women SHGs can potentially be a potent means of breaking free from the vicious circle of poverty
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