1.Reforming the pulse regime (Live Mint)

2.Healthcare models to be learnt (Indian Express)

3.Curing the cancer (Indian Express)

1.Reforming the pulse regime (Live Mint)

Synoptic line: It throws light on the need of policy interventions in the pulses sector. (GS paper III)

Overview

  • The story of pulses from last year is a stark illustration of what ails agriculture policy. India is the world’s largest producer, consumer and importer of pulses. That may sound contradictory, but isn’t, because domestic production is unable to meet the large and growing domestic demand.

 State of pulses

  • Last year, India’s production was 23 million tonnes (MT), the highest ever, 40% more than the previous year. This was owing to good rains, higher minimum support price (MSP) and higher acreage. High production should have meant lower imports. No such luck. Last year’s imports were at an all-time high of 6.6 MT, that too at zero import duty.
  • This caused prices to crash, in some places to half of the MSP. Farmers faced ruin. In barely 18 months, the price of tur dal has gone down from Rs200 to Rs30 a kilo. In its desperation, the government initiated an unprecedented procurement of pulses, and bought 1.6 MT to support prices. That didn’t help because of the glut; besides, the government was running out of storage and fiscal space.
  • Due to the misfortune of pulses prices this year, we can be sure that its acreage will fall drastically, and we may have a shortage and high prices next year.

What can be learnt?

  • Firstly, there is no instrument for using future price information. Farmers plant crops based on anticipated future prices, not past prices. If futures trading in pulses was allowed, it may have helped in reducing volatility, and garnering some benefits for farmers.
  • Secondly, there are arbitrary stock limits for private traders, which can inhibit inter-period smoothening of prices. In the absence of futures trading, the volatility in tururadmoongand chana has been as high as 48, 54, 72, and 28%, respectively, since July.
  • Thirdly, for the past 10 years, all exports of pulses have been banned. This was presumably for food security and price stability. But this export ban has hurt farmers, who couldn’t take advantage of high prices. It got worse, because when prices did shoot up, the government panicked and started importing at zero duty. The imports didn’t stop despite a record harvest. When prices of food crops go up, the Central government swings into action, clamping down on exports, bringing in zero-duty imports, imposing stocking and storage limits, and so on. But when the opposite happens, that is when prices crash, often, there is no corresponding reverse rescue. This is an example of the inherent urban bias in India’s agriculture policy, which persists to this day.
  • Indeed, among all World Trade Organization members, India is among a handful of countries with negative protection of agriculture.
  • Lastly, one more policy lesson is that pulses continue to be in the Agriculture Produce Marketing Committee (APMC) Act. Thus farmers are not free to sell to any buyer they wish but must go through the APMC.

Importance of pulses in Agriculture

  • Pulses are an important source of protein in India. Almost one-fifth of total acreage is used to grow them. They are also an important source of soil fertility since they provide nitrogen through fixation. Indeed, a pulses plant is called a mini fertilizer factory. Pulses were part of the six technology missions created in the 1980s (they were added to the oilseeds mission), to greatly enhance their production, use of technology and processing. But despite the mission-mode approach, India is still not self-sufficient in pulses production. And farmers continue to be at the mercy of nature, markets, pests and government policies.
  • The story of pulses is repeated across various crops. In cashew, India’s Kollam used to be the world’s capital, but has lost out to Vietnam due to its failure to adopt technology and due to excessive government control. India pioneered the Green Revolution, but scores very poorly in the global hunger index. The monolithic nationwide policies of promoting and procuring wheat and rice have ultimately proved harmful to health, nutrition and environment (through soil salinity). Coarse cereals, the staple of most rural folk, were largely ignored by the public distribution system, and are only now being introduced in the midday meal schemes.
  • Agriculture is an arena where policy-induced distortion is the rule, not an exception. For instance, the maze of subsidies in credit, inputs, outputs, water and electricity is a patchwork to act as an antidote to various price and quantity controls, which have an urban/consumer/anti-farm bias. Even policies like prohibition of foreign direct investment in retail hurt the farmer. Farm distress is chronic, and occasionally manifests in its most acute form as farmer suicides. Loan waiver to farmers is yet another reaction to policy-induced indebtedness, which has much deeper roots.

Way ahead

  • The second death anniversary of the visionary farmer leader Sharad Joshi should be a timely reminder that agriculture needs to be unshackled. Export restrictions must go. Monopoly procurement must go. Essential Commodities Act restrictions must go. Arbitrary stocking limits must go. Compulsory sale through the APMC must go.
  • Prohibition on money-lending to farmers, tenancy farming, land leasing, land transfers, all must go (with reasonable and appropriate safeguards). We also need a comprehensive, well-designed crop and price insurance market for farmers. As Joshi’s famous slogan summarized, the farmer just wants to be left alone, to be unshackled from the government, to earn a decent living from his free enterprise, or to leave farming.

Question Agriculture is an arena where policy-induced distortion is the rule, not an exception.  Comment.

2.Healthcare models to be learnt (Indian Express)

Synoptic line: It throws light on the various healthcare models of the renowned countries. (GS paper II)

Overview

  • Two major hospitals in Delhi NCR Max and Fortis, Gurgaon are currently under fire from two state governments for alleged irregularities. Beyond the politics and optics, whether the use of the stick is appropriate in the regulation of healthcare in the private sector is a matter of debate.

Healthcare trends

  • The basic tenets of regulating private healthcare remain largely the same the world over: no payment at the point of service, governments as the primary spenders in healthcare, robust primary care system, regulation of prices of drugs and diagnostics, and some health cover for every citizen.
  • In the best working global models of regulation of the private sector, governments regulate essentially through control of the purse strings. In India, this is probably the highest barrier currently public spending on health is less than 1% of GDP, and per capita public health spend is about $15, less than in Bhutan, Indonesia, Thailand and the Philippines.

Swedish Model (Competitive Bidding)

  • Private and public health facilities compete for government funding and the right to provide healthcare to citizens. The winning bid, whether public or private, receives funding. There are incentives for providing the quickest and cheapest treatment. It is a level playing field, and if the government health facility does not provide quality service or acceptable hygiene standards, it stands to lose out.
  • In a 2008 article in the Canadian Medical Association Journal that looked at the Swedish Model (after it was cited by the Canadian Supreme Court in its 2005 decision to strike down prohibitions against private health insurance in Quebec), Swedish researcher Christopher Mason wrote: “It (the Swedish government) has allowed the nine private, fee-for-service hospitals to open for business, with little handwringing.
  • But the largest role for private medicine is in the public sector, where the privately run facilities receive public funding to provide citizens much the same services they would at government hospitals. Within that system, citizens in government-funded clinics are charged user fees that account for about 5% of overall health funding, while the government contributes the rest. Hospital stays cost about $ 13 a day. Patients are charged about $ 20 for each doctor visit, and about twice that to see specialists. But after $ 150 in one year, visits are free, and no citizen pays more than $ 300 per year including prescription drugs.
  • Most drug stores were government- owned then, but private pharmacies have opened since.
  • In India, medicines account for 70% of out-of-pocket medical expenditure, according to the report of the High Level Expert Group on Universal Health Coverage.

Thailand Model (Capitation Fee) 

  • Thailand’s Universal Health Coverage has earned global appreciation. Under the National Health Security Act, the Universal Coverage Scheme (UCS) covers roughly 75% of the Thai population. Other schemes are a compulsory Social Security Scheme for government employees and dependents (similar to CGHS in India) and the Civil Servant Medical Benefit Scheme for private employees.
  • UCS, which is tax-funded, pays annual capitation fees to hospitals based on how many beneficiaries visit them. Public and private hospitals are treated on a par, and the beneficiary chooses where she goes. This encourages the development of competing provider networks, and the capitation payment approach helps contains costs capitation means a hospital is paid the same money for heart surgery or for containing diabetes-hypertension before they add up to a cardiac or other event requiring catastrophic expenditure. There is no incentive for a hospital or a doctor to do cardiac surgery.

Canada Model (Fixed Charges, Govt Reimbursement)

  • Medicare, which covers all Canadians, is publicly financed and privately run. The Canadian Health Act of 1984 allows medical practitioners to only charge fees fixed by governments something that West Bengal is trying, but without the required level of public financing.
  • General Practitioners are a very important link in the healthcare chain, much like the National Health Service of the UK. They are paid from tax revenue either by the federal or the provincial government. Governments decide fees of primary care physicians and salaries of health professionals. The federal government regulates drugs and diagnostics; provincial governments regulate hospitals, private healthcare professionals and private insurance.
  • Dental care, eye care, prescription drugs, ambulance services, medical devices, upgraded hospital rooms and travel insurance are outside Medicare, and these are provided by the private sector. The government reimburses a portion of these costs. The CGHS set-up is similar, but delayed payments have seen some big corporate hospitals exit the scheme.

Germany (Insurance-Based)

  • After government-funded Social Health Insurance (SHI) and private insurance, less than 1% are left uncovered. SHI operated by more than 200 competing Sickness Funds (SFs), which are self-governing, nonprofit, non-governmental organisations, and funded by compulsory wage-based contributions, matched by employers covers preventive services, in-patient and out-patient hospital care, physician services, mental health and dental care, medical aids, rehabilitation and sick leave compensation. The government delegates regulation and governance to the SFs and medical providers’ associations. To increase efficacy and compliance, the Federal Joint Committee was created in 2004.
  • The patient chooses her SF and provider, who cannot refuse her. There are 30 quality control indicators that hospitals have to report. In a paper on the German health system, researchers from the Manhattan Institute of Public Health wrote: “The Pharmaceutical Product Price Ordinance regulates the price of medications. Prescription drugs are sold at a fixed mark-up. As a result pharmacies earn a profit on both expensive and inexpensive drugs and have no economic incentive to promote sale of expensive drugs.

Question– What are the important chapters for India to be learnt from various other countries in the healthcare?

 

3.Curing the cancer (Indian Express)

Synoptic line: It throws light on why the intervention to cure HPV is not simple and straight. (GS paper III)

Overview

  • A National Technical Advisory Group on Immunisation (NTAGI) has proposed that a vaccine against the human papillomavirus (HPV), which causes cervical cancer, be introduced in India’s Universal Immunisation Programme (UIP). NTAGIs are, according to the World Health Organisation (WHO), a technical resource providing guidance to national policymakers and programme managers to enable them to make evidence-based immunisation-related policy and programme decisions.
  • The medical community in India, however, remains divided over the vaccine’s universal implementation and last week, the Swadeshi Jagran Manch, asked Prime Minister to stall moves to incorporate HPV vaccination in the UIP, saying it would “divert scarce resources from more worthwhile health initiatives to (a) vaccine of doubtful utility”.

Cervical cancer

  • Globally, cervical cancer is the fourth most frequent cancer in women; among Indian women, it is the second most frequent, according to the WHO. A 2012 study published in the Indian Journal of Medical and Pediatric Oncology said, quoting WHO figures, that India accounted for a third of all global cervical cancer deaths, with 1.32 lakh new cases diagnosed annually, mostly in advanced stages.
  • The number of deaths from cervical cancer annually was 74,000. Nearly 366 million Indian girls and women aged 15 years and above are at risk from cervical cancer.
  • While India has seen a fall in the incidence of cervical cancer over the last three decades, the number of cases remains high in rural areas, and where sanitation and hygiene are low. These were among the reasons for the NTAGI to propose the HPV vaccination programme for girls.
  • HPV is a group of viruses known to cause penile cancer in men, and cervical, vaginal, anal and vulvar cancer in women. HPV can also lead to throat or rectum cancer in both men and women. The virus is transmitted through intimate contact, for instance, via sexual intercourse, oral or anal sex. The HPV sub-types 16 and 18 which cause over 70% of cervical cancer cases produce two proteins which turn off tumour-suppressing genes and lead to abnormal growth in the cervical lining. While infection may not always lead to cervical cancer, the virus poses a higher risk for HIV-infected persons, smokers, those with high dependency on hormonal contraceptives and with early initiation into sexual activity.

The vaccine

  • The HPV vaccine is given thrice within six months to girls aged 9-13 years, before they become sexually active. In India, two vaccines Merck’s Gardasil and GlaxoSmithKline’s Cervarix are available. Cervarix provides immunity against HPV sub-types 16 and 18; Gardasil protects against sub-types 16 and 18 as well as against 6 and 11, which cause 90% of genital warts in men and women. Post-vaccination, a girl should ideally undergo pap smear tests every three years to check for pre-cancerous or cancerous cells.

The Concerns

  • In India, the primary concern is cost, given the huge population and stretched healthcare budgets. A single shot of Gardasil costs approximately Rs 3,000 and Cervarix, about Rs 2,000. Each girl requires three shots. “At present, no data suggests that either Gardasil or Cervarix can prevent invasive cervical cancer as the testing period is too short to evaluate the long-term benefits of HPV vaccination. The longest available follow-up data from phase II trials for Gardasil and Cervarix are 5 and 8.4 years respectively,” a 2013 study by specialists at the Tata Memorial Hospital (TMH), Mumbai, said. The study added that India is already witnessing a declining trend in cervical cancer due to better hygiene, changing reproductive patterns, improved nutrition and water supply.
  • It’s better that we strengthen the reasons behind this trend rather than expose the entire population to the vaccine. It has not been proven to prevent a single cervical cancer death,”. Cervical cancer is declining in urban areas due to better hygiene, and it may further shrink if this extends to rural areas.
  • In his letter Swadeshi Jagran Manch drew attention to the high cost of the vaccine. At three shots of Gardasil at MRP for 6.2 crore Indian girls aged 9-13 years, the cost to the government will be over Rs 56,000 crore.
  • Further, there are over 100 HPV sub-types against which the vaccine does not provide immunity. According to few reports, the vaccine can even cause rare side-effects such as regional pain syndrome. In Japan, the HPV vaccine recommendation was temporarily suspended after reports of this neurological problem.

The Counter-View

  • WHO position paper published in May 2017 noted that the “WHO Global Advisory Committee for Vaccine Safety (GACVS), which regularly reviews the evidence on the safety of HPV vaccines” had concluded in January 2016 that the “available evidence did not suggest any safety concern”. The paper recorded that “by 31 March 2017, globally 71 countries (37%) had introduced HPV vaccine in their national immunisation programme for girls, and 11 countries (6%) also for boys”. The vaccine, the WHO said, should be “administered if possible before the onset of sexual activity, i.e., before first exposure to HPV infection”.
  • Global healthcare professionals have rejected as baseless online campaigns against the vaccine, which have resulted in temporary dips in take-up rates in some countries like Japan, Ireland and Denmark.
  • In a paper published in the Journal of Vaccines and Vaccination last year, principal author argued that fewer than 1% women in India go for pap smear tests to detect cancer after 30. The screening framework in India is not robust, but we do have an immunisation system in place. There is manpower and cold storage to store vaccines. Prevention cost will be much lower than treatment cost.
  • Australia, which was the first country to introduce HPV vaccination in its school programme now has one of the lowest rates of cervical cancer in the world.
  • The Federation of Obstetric and Gynaecological Societies of India (FOGSI) strongly supports vaccination and prescribes it routinely in private healthcare. It is easily available, safe and has good enough efficacy. Cervical cancer is the most common cancer amongst women.

Question–  How India should respond to the challenges of curing the HPV? What has been done by government in this regard?