Editorial 1 : Policy paralysis, a weakened public health sector
Context
Primary care is weak while there has been a boost to the growth of the private sector in secondary and tertiary care.
Introduction
The public health needs of a population are diverse and perception and prioritisation vary across the social strata. Public health policies are those decisions made by the government based on the resources available to address people’s health needs. Public health needs include those felt by people (felt needs) based on their lived experiences and those projected upon (projected needs) them by experts — the architects of public health policies. The recent Union Budget has been critiqued for its inadequate focus on the social sector, specifically the public health sector. Public health policies of the government in the last decade indicate that there has been a severe paralysis when it comes to public health policies without any real prescription that addresses the felt needs of people.
What are the felt needs in public health?
Public health needs can be broadly categorised into three groups:
- The diseases of poverty: such as tuberculosis, malaria, undernutrition, maternal death, bouts of illnesses due to food and water-borne infections leading to typhoid, hepatitis, and diarrhoeal diseases faced by the poor and the vulnerable.
- These problems attain greater significance as attempts to prevent these also pose challenges of addressing livelihood and are non-negotiable from a rights perspective.
- Environmental issues: The problems of the middle class and those better off on issues that are related to environmental pollution — air, water, waste management, lack of drainage facility and failure to ensure healthy foods and eateries that pose threat to everyday lives, most of which are due to poor infrastructure development and poor market regulations.
- The list goes on if we add road traffic accidents, climate change and the rise of chronic illnesses.
- The curative care needs of a population: Provisioning of curative care is the most critical and controversial policy question in public health.
- The three levels of curative care envisaged are primary, secondary and tertiary.
- The poor and the vulnerable rely on primary health-care institutions of the public sector for primary-level care, as it is the most affordable and is closer to their places of residence.
- Secondary-level care was historically neglected and is still inadequate against population norms.
- Shortage of infrastructure including health professionals in these facilities aggravates the problem.
- Tertiary-care needs for curative care among the poor are the focus of the Pradhan Mantri Jan Arogaya Yojana (PMJAY) under Ayushman Bharat.
What has been the history of Indian public health policies in the last decade?
- Commercialisation of healthcare: It shows that the National Rural Health Mission, which was started in 2005, and followed by the National Health Mission (NHM) of 2013, were a clear departure from the then existing National Health Policy of 2002, which proposed the commercialisation of health care.
- Architectural correction: It was the NHM’s focus on strengthening public sector health care through architectural correction that has revived an otherwise sinking health system after the reform period of the 1990s.
- Capacity building efforts: Were taken to follow the principles of primary health care while strengthening the institutions of primary health care by implementing the national health programmes through them, thus building goodwill and trust among the people about public sector health care.
- This was obvious from the health infrastructure available in India, which was reported as 1,53,655 sub centres, 25,308 primary health centres (PHC) and 5,396 community health centres (CHC) as per the rural health statistics, 2015.
- Financial support: The impetus created by NHM would have been capitalised had subsequent policies strengthened the secondary- and tertiary-level health care in the public sector.
- The focus has shifted entirely on publicly funded health insurance schemes (PFHI) such as the PMJAY under Ayushman Bharat since 2018.
- Implementation by states: PFHI schemes were implemented by the governments of Maharashtra, Andhra Pradesh, Tamil Nadu, Kerala, and others as an add-on to the overall strengthening efforts under the NHM then.
Why is private health care system the real beneficiary?
The real beneficiary of PFHI schemes in the Indian context is private sector health care.
- A health insurance cover: Ideally implies covering all health-care expenses, globally. It is unique that India’s health insurance scheme covers only hospitalisation expenses under the scheme.
- This is based on the market logic that if 50 crore people (12 crore households are the beneficiaries of PMJAY) are enrolled in the scheme; only 2.5 crore people will have an actual need for hospitalisation annually as per epidemiological data.
- The outsourcing of secondary and tertiary-care services: to the private sector at market rates under the scheme is an open acknowledgement by the government of its failure and a lack of intention to strengthen secondary- and tertiary-level public sector health care in the country.
- The implication is that the remaining 100 crore population who are not covered under any government schemes are forced to have highly commercialised medical care for their illnesses, incurring an expenditure at market rates.
- Thus, by monopolising the market for health care, private hospitals pretend to offer services to the government at market rates, at the same time ensuring that the remaining two-thirds of the population must depend on them by making sure that public sector health care is weakened.
- The transformation of sub centres: PHCs and CHCs into health and wellness centres (HWC) in February 2018.
- The highlight was to declare that 1,50,000 HWCs were established as new institutions in rural areas, when numbers more than that were already in existence (RHS 2015).
- The proposal was to have a community health officer, expected to render treatment to a rural population by completing a bridge course.
- This has transformed the original mandate of sub centres from rendering outreach activity to that which provides curative care.
- Doctoring gained its acceptance through its act of diagnosis, prognosis, and treatment. Instead, the proposal to equip a community health officer to practise medicine minimally results in the new professional becoming a dignified chemist.
The latest of this was in a 2023 directive to rename all the HWCs (sub centres, PHC and CHC) to ‘Ayushman Arogya mandir’. The failure to offer curative care in its entirety by any institution will shatter the trust of people in those institutions.
Threat to public health system
Public health challenges are diverse in a country such as India and there is a need to address these across social groups without fail.
- Concern for the vulnerable and the poor: prevention programmes and health promotion activities become a luxury when their day-to-day livelihoods are not addressed. It is basic primary- and secondary-level curative care that are their felt needs in public health.
Way Forward
Historically, institutions of primary health care were entrusted with this responsibility and were delivering preventive and promotion activities close to their home, by making it culturally and contextually relevant. The major curative care challenge posed across the country is the loss of trust towards health-care providers (private sector due to commercial interests) and public sector due to overcrowding of health care with inadequate infrastructure due to low provisioning. This gap needs to be filled and public confidence needs to be built up.
Conclusion
The government has slashed the limbs of the public health system by not strengthening secondary- and tertiary-level care in the public sector and instead favouring the growth of the private sector. Finally, the institutions of primary health care — the lifeline of India’s public health system — were weakened by projecting them as curative care centres, for popularity and branding, without acknowledging their purpose in health programmes and their interconnections with grassroot-level institutions of health care. This has impacted the vulnerable public from gaining adequate health service. Thus, the comprehensive intervention needs to be there, through policy inclusion and monitoring.
Editorial 2: With or without Chinese companies is the question
Context
India will have to maintain a balance between developing home-grown players and allowing continued Chinese investments and operations in the electronics industry.
Introduction
The launch of the ‘Make in India’ project in 2014, and later the Production Linked Incentives (PLI) scheme to attract domestic and foreign capital, are supposed to be a part of this agenda. The Union Budget for 2024-25 provides a big fillip for the PLI scheme for large-scale electronics manufacturing through the allocation of ₹6,125 crore, an increase from around ₹4,499.04 crore in the 2023-24 Budget (₹4,489.46 crore as per revised estimates). The government’s focus on building expertise within the country is also visible in the allocation of ₹1,148 crore to research and development in the electronics and IT sectors, up from ₹600 crore in the 2023-24 Budget (₹1,000 crore as per revised estimates).
‘Make in India’ and China’s presence
- Boost to the electronics sector: Interestingly, one of the biggest beneficiaries of the ‘Make in India’ project in the electronics industry are Chinese smartphone companies.
- Their operations in India have spanned a decade, during which they have become dominant market players.
- According to the International Data Corporation’s Worldwide Quarterly Mobile Phone tracker, four of the top five best-selling smartphone brands at the end of 2023 were Chinese, with a combined market share of slightly over 50%.
- Contribution of the Indian consumers: They are one of the largest users of smartphones with the android operating system (whose market share as of 2023, is about 70%) has worked to the advantage of these companies.
- Chinese innovation: Chinese brands contain a range of applications catering to the diverse Indian tastes.
- These companies have expanded their production with active support from central and State governments.
- Well-thought out strategies in sales, aggressive marketing, calibrated customer segmentation and brand-building, sponsorships of popular culture entities, celebrity endorsements, and smart advertisement campaigns have powered their operations in India.
- They have penetrated beyond metropolitan regions, becoming easy reference points for Indian consumers.
- Manoeuvring the bilateral clashes: Chinese companies have also been able to withstand the troughs and crests in India-China bilateral relations, until the Galwan valley incident in 2020.
- The subsequent shrill rhetoric in India of boycotting Chinese products intersected with the ‘vocal for local’ narrative of the Indian government.
- Indianizing the operations: In addition to the increased scrutiny of Chinese investments for not adhering to tax-related compliances, the government is also seeking to ‘Indianise’ their operations and management in different ways:
- Induction of Indian equity partners in local operations
- Appointment of Indian executives to top roles
- Involving Indian contract manufacturers for production and assembly
- Expanding exports from India, and hiring only local distributors
- Indian strategy: New Delhi’s directive underscores the long-term strategy of creating a robust network of indigenous manufacturers of sophisticated, precision devices. This approach, in fact, mirrors how China developed its own home-grown supplier companies, which have now expanded their operations into South-East Asia.
Attempts at some Indianisation
- Private players entry: The entry of Tata Electronics as a contract manufacturer of smartphone devices is a noticeable example of growing Indianisation.
- Operations control: It began by taking over the India operations of Wistron, and have covered much ground in their negotiations to acquire Pegatron, both Taiwanese suppliers for corporations including Apple.
- Chinese companies cooperation: Chinese smartphone companies have treaded cautiously, by gradually beginning to comply with the Indian government’s directives.
- Structural streamlining: They have brought in Indian distributors, streamlined their structure by introducing separate sales and marketing operations for each individual brand, teamed up with domestic manufacturers to claim benefits of the PLI scheme, and are now increasingly seeking equity partners.
- This illustrates their adaptability to survive, evolve, and outlast phases of turbulence, while retaining consumer confidence.
- The promise and the potential in the sheer size of the Indian market, encourages this approach and a willingness to prepare for the long haul.
- However, while the Indian government ploughs on with measures to dilute and limit Chinese involvement — this includes attracting Taiwanese investments — there remain serious constraints.
Way forward: Need for capacity building
Manufacturing of all smartphone components entirely in India, along with a robust supplier network, requires development of ancillary industries, clusters for technological knowledge-sharing, uninterrupted power and water supply, and better working and living conditions for the workforce. India needs to boost up this space as Chinese are not ready for equity participation.
Conclusion
The push by India’s Ministry of Electronics and Information Technology and Ministry of Commerce and Industry to ease visa norms for Chinese technicians, within days of the new government taking office, underscores the difficulty for the government in conditioning and controlling both Indian and Chinese companies in the short to medium term. The Government’s Economic Survey, released a day before the Budget advocates promoting Foreign Direct Investment from China rather than being fixated on the China Plus One Diversification strategy of major multinational companies. Clearly, New Delhi will need to maintain a delicate balance between developing home-grown players and allowing continued Chinese investments and operations of Chinese companies in order to achieve its manufacturing objectives. Indianisation through Chinese strategies will help Indian tech to grow and advance.