Prelims Focus Fortification: It refers to the practice of adding micronutrients (like vitamins and minerals) to the food. Examples of fortification around the world: India fortifies wheat. Recently, the government announced plans to distribute fortified rice through mid-day meal scheme. South Africa fortifies Maize meal. China fortifies soy sauce. Vietnam fortifies fish sauce. Fortification of Salt in India: Recently TATA chemicals and Indian Council of Medical Research (ICMR) – National Institute of Nutrition, Hyderabad, Telangana have partnered to deliver fortified salt to the people. The salt will be fortified with Iron and Iodine and will help to prevent the spread of Anemia and Goitre in the country. Problems associated with Fortification: Fortification needs to be effective throughout the duration of its application to the time it takes to reach the target citizens. This might be quite long in India. Also, fortified food needs to retain the micronutrients even during cooking at high temperatures, which is the practice in the country.

Some More Unequal

Topics covered from the syllabus: GS-3: Indian Economy and issues relating to planning, mobilization, of resources, growth, development and employment. GS-3: Inclusive growth and issues arising from it.

 

Prelims Facts  World Inequality Report 2022: It is released by the World Inequality Lab, a global research initiative. Main Findings w.r.t. India: India is one of the most unequal countries. The number of poor is growing, while the rich are becoming more affluent. The richest 1% of the Indians own 22% of the assets. Top 10% of the Indians own 57% of the assets. Top 1% of the population owns 20% of the national income, while the bottom 50% account for just 13% of the same. Bottom 50% of the people of the country own only 13% of the total assets of the country. Bottom 50% of the people in India earn Rs. 53,610 annually, while a person in top 10% earns 20 times this amount. Average wealth of a household in the country is approximately Rs. 9.8 Lakh. However, bottom 50% of the population holds just Rs 66,280, which is hardly 6% of the national average.

 

Context: According to the World Inequality Report 2022, India has seen an increase in inequality after the advent of New Economic Policy of 1991 in India. India remains one of the most unequal countries in the world.

State of Inequality

• Inequality among People: Inequality in the world has risen at a faster pace in recent decades. This is manifested in the fact that almost half of the world’s population does not have necessary capital or wealth to lead a decent life. Paradoxically, at the same time, it is true that the global wealth has grown and countries are richer than ever.
• Share of Wealth: Though the global wealth has grown at a faster pace, the governments have actually seen their wealth decrease. This is due to the increasing adaptation of the western policies of liberalisation, privatization and globalisation around the world. The governments’ assets have actually decreased over the recent period of time.
• Effects of Recession: The world has seen multiple periods of recession in recent times, viz. the Global Financial Crisis of 2008 and the COVID-induced economic slowdown in the last couple of years. This has led to a rise in poverty at the lowest rung of the society, while the combined wealth of rich has been touching new heights.
• Increase in Debt: This is further complicated by the onset of pandemic, which has put a heavy burden on the exchequer. On one hand, due to Corona-induced Lockdown, revenue collections of the government have taken a hit, while on the other hand, governments have had to increase their spending on healthcare infrastructure as well as social welfare schemes, to handhold the poor through the crisis. Therefore, the governments have been induced to borrow from multiple sources, leading to an increase in their overall debt.
• Concentration of Wealth: From the above points, it is clear that the assets of governments have been transferred to private individuals in the recent period of time, resulting in an unprecedented increase in the wealth of private individuals. For instance, top 1% of the global population control one-third of the global wealth.
• Comparison of wealth over time: Though the exact amount of wealth has kept on changing, yet the overall shares of wealth have remained fairly constant over a considerable part of civilized human history. For e.g. in the two previous centuries (i.e.1820 to 2020), top 10% of the population has controlled 50-60% of the wealth, while the bottom 50% have had just 5-15% of the same.
• Wealth and Income: The total wealth of the world stands at around $575 trillion. Major part of this belongs to the private individuals, with governments sharing a lesser part of the wealth and controlling a lower share of the assets.

Causes of Rising Inequality

• Democracy: Many experts have tried to connect the adoption of democracy over the world with the rise in global inequality. However, it is to be understood that it is not the democracy per se, but the choices which are made under the democracy which impact inequality. For e.g. world has seen a decrease in direct taxes over the last few decades, leading to a rise in global wealth.
• Liberalisation: Liberalisation has seen a rise in the number of people entering the entrepreneurial class. It has rewarded creativity and innovation and led to replacement of the industrial tycoons with technology billionaires as the wealthiest community. A decrease in regulation has seen a rise in the number of people taking risks in the hope of attracting more wealth.
• Free Market: After the launch of New Economic Policy in India, the previous three decades have seen the sources of capital grow in the country. Therefore, it is easier for an entrepreneur to access capital. This has led to creation of multiple classes, with some people being uplifted at the cost of investment in social infrastructure, thereby decreasing opportunities for the poor.
• Globalization: After gaining independence, initially, most of the countries of Asia and Africa were tilted towards socialism because of their antagonism towards the western imperialist nations. However, later on, the western model of capitalism has seen a rise in global acceptance. This has shifted focus from the social welfare approach towards a market-centric approach. While, earlier, it was the socio-economic planning which dominated the scene, nowadays the policies have been more supportive towards promoting ease of doing business.
• Circle of Poverty: It can be said that opportunities have become much better distributed for the people in comparison to the earlier times. However, it is also true that it has become harder for the poor to survive due to rising consumerism, which has perforated their lives also. The materialistic wants have increased, shifting the expenditure towards such needs at the cost of focus on improvement through better avenues of education and better health.
• Higher Debt Levels: Even in comparatively richer countries, where poor are relatively better off than the global south, people at the lower echelons are much more leveraged. They have high debt levels in the form of credit card loans and sub-prime debts. This is a cause of worry for the future as lesser ownership of the assets would further exacerbate the poverty in the poor people.

Conclusion

• As per the World Inequality Report, India has seen an increase in the levels of inequality after the onset of LPG reforms of 1991. This does not bode well for the future of the country, especially since India is a country with a huge working class population. In the absence of adequate opportunities, the demographic dividend might turn into demographic disaster.

1. Account for the rise of inequality in India and the world in the light of recently relaeased World inequality report. What are the reasons for the rise of inequality in the country?

1. It is argued that the strategy of inclusive growth is intended to meet the objectives of inclusiveness and sustainability together. Comment on this statement.                                                                                              (GS-3: 2019)
2. What are the salient features of ‘inclusive growth’? Has India been experiencing such a growth process? Analyze and suggest measures for inclusive growth.                                                                                                              (GS-3: 2017)
3. Comment on the challenges for inclusive growth which include careless and useless manpower in the Indian context. Suggest measures to be taken for facing these challenges.                                                                    (GS-3: 2016)

Myth of Coverage

Topics covered from the syllabus: GS-2: Welfare schemes for vulnerable sections of the population by the Centre and States and the performance of these schemes; mechanisms, laws, institutions and Bodies constituted for the protection and betterment of these vulnerable sections. GS-2: Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources.

Context: As per a report published by two research institutions, viz. Public Health Foundation of India and Duke Global Health Institute, US, PM Jan Arogya Yojana (PM-JAY) failed to deliver during the COVID-induced pandemic.

PM Jan Arogya Yojana (PM-JAY)

• Objective: The scheme seeks to avoid the burden of catastrophic out-of-pocket expenditure on the people of the country, by providing access to quality health care.
• Launch: The scheme was launched in 2018.
• Details: The scheme provides a coverage of Rs 5 Lakh per family to the poorest 40% of the population. The scheme claims to cover 165 million beneficiaries across the country.
• Coverage of Health Insurance: According to a report by NITI Aayog named ‘Health Insurance for India’s Missing Middle’, 70% of the country’s population is covered by one or the other health insurance scheme, which includes state government insurance and private insurance.
• Missing Middle: A peculiar situation has arisen due to the launch of PM-JAY scheme. The richer class was already proactive as far as the coverage of health insurance is concerned and now the poor citizens have been covered by the scheme. However, it is the middle class which is still not completely covered by any health insurance. According to NITI Aayog, almost 30% of the population, which is almost 40 Crore people, are out of the health insurance safety net.
• High Out-of-Pocket Expenditure: Catastrophic health expenditure is the chief cause of people being pushed below the poverty line in India. In fact, almost 7% of the country’s population is pushed annually towards poverty because of the out-of-pocket health expenditure. This is because out-of-pocket expenditure constitutes 63% of the current health spending of the country’s population. In such a situation, it is essential that health insurance coverage increases to provide better financial protection and better health outcomes.

Issues with the Scheme

• Coverage during the Pandemic: As per the report, PM-JAY covered only 14.25% of the people hospitalised for COVID-19, despite its claims of covering 40% of the total population of the country. Also, according to a reply by the Union Minister for Health and Family Welfare in Lok Sabha, PM-JAY paid for only 0.52 million COVID-19 hospitalisations across the country.
• Illegal Cash Demands: Media reports have claimed that hospitals extracted cash from the patients illegally during the pandemic. As the occupancy rates were high and the availability of beds was low during the pandemic, many hospitals demanded cash in lieu of security from the desperate patients and their relatives.
• Refusal to Admit Patients: Again, it was found that many patients were turned back by the hospitals citing overflowing wards and the lack of beds. Many reports attributed this to the profiteering culture in the private hospitals as PM-JAY cardholders are poor people and their paying capacity is limited. On the other hand, richer and middle classes have higher paying capacity which can be milked by the private institutions.
• Failure to prevent Catastrophic out-of-pocket expenditure: The scheme failed to meet its objective of preventing catastrophic out-of-pocket expenditure, which has led to slippage of many families below the poverty line. It was reported that many families had to sell or mortgage their assets like house or farmland in order to pay for the treatment costs of their relatives. This led to an increase in non-institutional debts with usurious interest rates.
• Exclusions: Media reports have pointed to the exclusions in the scheme, which has limited the access to healthcare for many deserving sections of society. For e.g. sex workers have been left out, despite being one of the most vulnerable sections of the society. In fact, they suffered the twin aspects of lack of business as well as constant fear of contracting the disease during the peak of the pandemic. Similarly, many rag pickers and destitute were unable to get the coverage under PM-JAY, leading to higher incidence of deaths in the community.
• Delay in Coverage announcements: Many states like Madhya Pradesh and Telangana took time to include COVID-19 in the PM-JAY package, leading to a lack of clarity and unavailability of appropriate treatment for the beneficiaries of the scheme.

Other Issues

• Health being a State Subject: Health, being a state subject, the power to manage the pandemic rested with the states. This led to a lack of uniformity in the policies of different states and made it difficult for the people to move and access healthcare.
• High Occupancy Rates: Though it is true that private hospitals charged the patients exorbitantly, but at the same time, it is to be understood that actually the pandemic was a ‘once-in-a-century’ crisis and nobody could have predicted it. The health infrastructure was overwhelmed by the sudden inflow of patients and was unable to cope with the overload. This points to the structural deficiencies in the healthcare infrastructure as well as the lack of properly trained healthcare professionals in the country.
• Lack of Resources: Pandemic also exacerbated the deficiencies in supply management as well as the availability of critical resources. This was manifested in the lack of availability as well as sudden increase in the prices of medicines like Remdesivir and oxygen cylinders. This also points to the failure of the PM-JAY in covering and ensuring the supply of critical life-saving inputs.
• Lack of adequate knowledge about the treatment: At the onset of COVID-19, there was a lack of clarity about the treatment of the disease, even in the medical fraternity, which was also testing the efficacy of different methods of treatments. This was also a major challenge in fighting the pandemic.

 

Way Forward

• Universal Health Coverage: Experts have pointed to the futility of trying to update inclusions and exclusions in the government welfare schemes, especially in crucial sectors like Health Care. They have advocated Universal Health Care with coverage for all citizens, under an umbrella scheme of insurance-based healthcare covering secondary and tertiary healthcare.
• Strengthening of the Public Health Care institutions: The focus of PM-JAY is on creating a competitive environment wherein any institution, public or private, needs to prove its worth by providing quality health care to the patients. However, private hospitals cannot be a substitute for the public health infrastructure as the main motive behind private institutions is profit. This is contradictory to the very foundation of healthcare, which focuses on access to all.
• Frequent Review of the Scheme: PM-JAY is a much-needed scheme with good intent. However, any good scheme needs to be reviewed constantly to overcome the challenges posed in its implementation. Similarly, in the case of PM-JAY, it is important that the officials in charge of implementing the scheme, have constant interaction with the affected individuals and supporting organisations (like NGOs).
• Adequate Remuneration to the Private Hospitals: As stated above, it was found that many private hospitals refused treatment to the patients. This points to the dissatisfaction of the private hospitals with the current remuneration structure of the scheme. For better implementation of the scheme, it is critical that the private hospitals are adequately paid for the services they offer to the beneficiaries of the scheme.
• Disseminating knowledge about the Scheme: Many people have lamented the lack of knowledge about the details of the scheme. For e.g., many citizens said that they were not aware of the list of empanelled hospitals under the scheme. This needs to be corrected by widespread dissemination of adequate information. This is especially relevant in the times of COVID, when hospitals saw an increase in their occupancy rates.

Conclusion

• The current pandemic has increased the need for urgency in strengthening the health infrastructure of the country. In such a situation, it is important to review and address the current structural deficiencies in the country.
• Though a scheme with good intent, PM-JAY manifests lacunae and challenges which need to be addressed in a haste. Otherwise, exorbitant out-of-pocket health expenditure will lead to further increases in the levels of poverty in the country.

1. Do you think the pandemic has exposed the structural deficiencies in the health infrastructure in the country? Discuss, in light of the implementation of the PM-Jan Arogya Yojana in the country.

1. Appropriate local community-level healthcare intervention is a prerequisite to achieve ‘Health for All‘ in India. Explain.                (GS-2: 2018)
2. Public health system has limitations in providing universal health coverage. Do you think that the private sector could help in bridging the gap? What other viable alternatives would you suggest?             (GS-2: 2015)