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No doubt the pandemic has exposed the fragility of India’s health sector. The shortage of doctors hospital beds ventilators oxygen medicine etc. is the stark reality of the day. The story is true across all over India. Incidentally none of the metros have stood apart in this pandemic disaster even though health infrastructure is quite well developed in metros than small towns. 

Frankly speaking few of us are aware of the ground realities in peri-urban/small towns as India media hardly covers them in their stories as most of their clientele are located in metros/urban India. Unlike in west very few papers are published from small towns.

In recent years the health sector reform in the Indian context has basically given push for bigger role for the private health sector provider to curb out inefficiencies in the government health systems. In earlier times the under privileged used to go to public hospital for medical care. However this trend has now been reversed. 

While the privatisation of the health sector has been going on since quite some time it got a big push with the introduction of Ayushman Bharat a flagship scheme of Government of India to achieve the vision of Universal Health Coverage (UHC). This initiative has been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment which is to “leave no one behind”.

Ayushman Bharat has adopted a continuum of care approach comprising of two inter-related components which are (a) Health and Wellness Centres (HWCs) and (b) Pradhan Mantri Jan Arogya Yojana (PM-JAY). HWCs basically involved in transforming the existing Sub Centres and Primary Health Centres. These centres are supposed to deliver Comprehensive Primary Health Care (CPHC) bringing healthcare closer to the homes of people. They cover both maternal and child health services and non-communicable diseases including free essential drugs and diagnostic services.

On the other hand PM-JAY was launched in 2018 as the largest health assurance scheme in the world which aims at providing a health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalization to over 10.74 crore poor and vulnerable families (approximately 50 crore beneficiaries) that form the bottom 40% of the Indian population. 

The scheme provides cashless and paperless access to services at the point of care. Till January as per the provisional report over 40000 beneficiaries were treated for covid-19 under the scheme. Also over 400000 diagnostics tests for covid-19 were performed.

However when the pandemic struck in India and continued for more than a year we observe that privatisation by itself did not lead to capacity augmentation in the domain where it is the need of the hour. All over India the government/army has to step in for human well-beings. The access to insurance does not automatically lead to access to health facility even in urban India. If in the end the government has to step in what is the point of this privatisation push? Or are we overlooking crucial issues in health eco-system?

Firstly the private health service provider is purely governed by profit motive. They are more inclined to invest in capacity augmentation where there is chronic demand and profit per person is high. By the same logic they would not like to increase their capacity of beds with ventilator support significantly as these asset will not be in demand when pandemic is over. For this reason even though private health service provider have got a year time to increase their capacity of Covid related treatment they did not invest on same. 

Also as many of the State governments have capped the rate on Covid related treatment private health service provider have limited leverage to spike their charges on Covid treatment. Thus private health service provider has played safe: it is best not to build up health assets which are primarily used for Covid treatment.

If in the end government has to step in what is the point of privatisation push? Are we overlooking crucial issues in health eco-system?

Secondly how does the profit per patient in case of Covid treatment stands vis-a vis other diseases? This is the other yard stick which private health service provider takes into account while deploying resources for augmenting health infrastructure. Of course profit numbers are hard to obtain. We are thus tempted to draw our inferences based on cost numbers which are publicly available.

Typically on an average 10 days treatment cost of a normal Covid-19 carrier with ICU ventilators ranges between 1 lakh to 3 lakh depending on the States and capping of expenditure in private hospital by state governments. Of course the treatment in most patients continue on an average for 14 days. By contrast the treatment cost in India of cancer treatment can go upwards of ₹10 lakh for heart ailment the expenses can easily reach ₹3-5 lakh or even more.

On the other hand a kidney transplant costs around Rs 7 lakh whereas dialysis can cost you anywhere between Rs. 18000-20000 per session. Moreover the cost can go up to Rs 20-30 lakh if you choose to take treatment at reputed private hospitals. And in case one chooses to go for a Robotic surgery – which is becoming quite popular in India – the cost of treatment may further increases by Rs 5-7 Lakh. 

Moreover the private health service providers are not at all regulated in their costing structure in these diseases unlike in case of Covid treatment. Thus it make sense for them to invest their resources for capacity augmentation in these diseases than solely for Covid related infrastructure (ventilators etc.) which may be of little use once the Covid phase is over.In sum insurance-led private health care is not a remedy in times of pandemic and especially if the treatment cost is not in par with other critical diseases. This is very true even in case of metros. May be the government need to have rethink on the health policy and the role of government in the same.

The writer Sanjib Pohit professor at the National Council of Applied Economic Research. Views are personal.

Using tech to monitor river water quality real-time will help.

India is a home to 4 per cent of the world’s freshwater resources and it ranks among the top 10 water-rich countries of the world. In spite of being home to the major river systems both perennial and non-perennial India is a designated water stressed region (NITI Aayog 2019). The river basins suffer from the pressure of an ever-growing population and rapid industrialisation and urbanisation across the country. All these factors make the basins vulnerable to the incessant release of effluents in the form of sewage and large volumes of solid and industrial wastes. Over the years this discourse on water pollution has made their way into policy-making. 

In the mid-1980s Rajiv Gandhi launched Ganga Action Plan I (GAP-I) with the main objective to improve the water quality of the Ganga to acceptable standards by preventing the pollution load reaching the river. In 1987 the objective of GAP was recast as restoring the river water quality to the ‘Bathing Class’ standard. 

Subsequently the programme of river cleaning was extended to other major rivers of the country under two separate schemes of GAP; the Phase-II and the National River Conservation Plan (NRCP). Yamuna and Gomati Action Plans were approved in April 1993 under the Ganga Action Plan Phase-II. Programmes of other major rivers were subsequently approved in 1995 under NRCP. In recent times Prime Minister Narendra Modi announced the launch of the Namami Gange Clean-up programme with a budget of ₹20000 crore during the period 2015-2020.

The overarching action plans launched under these programmes has introduced multiple interventions. One construction of sewerage treatment plants in towns along the rivers so that untreated sewerage are not dumped into the rivers. Two the large polluting industries along the rivers have been retrofitted with treatment plants or were closed down if the water was not cleaned before dumping to the city sewerage or to the river. 

Three government/municipal authorities took initiatives to construct common effluent treatment plants in industrial clusters to clean discharged water. Fourth slums on the river bed along with their inhabitants are relocated so that their daily usage in the river bed do not lead to pollution of water. These steps have been implemented in the major rivers of India particularly in

Ganga/Yamuna. In spite of all these efforts in 2017 the National Green Tribunal stated that “not a single drop of river Ganga has been cleaned so far.” By and large the same view holds for other rivers of India where investment has been undertaken under the National River Conservation Plan (NRCP).

Who is to blame?

Who is to be blamed for this sad state of affairs? The industries or the industrial clusters located in the cities claim they have installed treatment plants to discharge clean water in the urban drains. The inspectors visit them regularly to check whether these are being operated or not. An adverse report from them lead to penalty or closure of the plant till the problem is sorted out. So where is the problem? 

The crux of the issue lies with the capacity/quality of urban sewerage treatment plants which are unable to cope with the ever increasing sewerage load due to the population pressure in the cities. There is a logic in this argument. Most of the cities in the Ganga basin are in a catch-22 position with respect to their capacity of sewerage treatment plant. They end up discharging polluted drain water in the Ganga river since the capacity of the plant falls short of the sewerage load. This is true also for other cities lying beside other principal rivers like Yamuna Godavari etc. 

However the pandemic related industrial lockdown provided once in a lifetime opportunity to identify the principal contributor of pollution in a river like the Ganga. The nationwide lockdown was imposed on March 25 2020 and within 10 days signs of improvement in water quality started surfacing. According to the real-time water monitoring data of the CPCB out of the 36 monitoring units placed at various points of the Ganga river the water quality around 27 points was found suitable for bathing and propagation of wildlife and fisheries.

On April 4 at Varanasi’s Nagwa Nala the Dissolved Oxygen (DO) values were found increased to 6.8 milligram/litre against 3.8 mg/l on March 6showcasing an extraordinary improvement of 79 per cent in DO values. Ganga water at Haridwar and Rishikesh was reported fit for drinking due to 500 per cent decrease in sewage and industrial effluents. 

This improvement was unprecedented. Given non-industrial pollutant loads are unlikely to change in a short period of time we can safely assume that it is the industrial pollutants that have always been the principal culprit for polluted river water. When most polluting industries are not even allowed to function without treatment plants is it really possible to blame the industries? Or can we assume that there is a nexus between the inspectors and the factory owners to look out for other ways in lieu of a monthly remuneration (speed money)? It may well be that the factory owners get prior information before a surprise raid by higher authorities so that the treatment plants can be kept operational else they keep it switched off to save operation cost.

 Automated sensors

This calls for a continuous in-situ sewerage water quality monitoring systems without human intervention which will provide real-time data on water quality’s health. With advances in technology this is now a possibility and is cost effective.

Recently Water-to-Cloud study of University of Chicago’s Tata Centre for Development (www.Thoreau.uchicago.edu) in collaboration with NCAER has demonstrated that multiple submersible automated sensors attached to a boat can be used to gather high-resolution spatially and temporally varying water data. Dynamic mapping of the river water quality using this high-frequency spatial and temporal data is helping to understand how the water quality is changing with weather pollution fishing and general use.

This mapping can help pinpoint pollution sources and ensure regulatory compliance. Through powerful visualisation the heatmaps can help identify pollution sources that can even contribute in controlling infectious diseases. This type of sensors can be easily attached at the discharge point of polluting industries to measure pollutant loads at real-time basis. This may turn out to be cheaper and more effective than the present system of human-based intervention which often leads to rent-seeking activities.

Sanjib Pohit and Soumi Roy Chowdhury are respectively Professor and Associate Fellow at NCAER. Supratik is Professor Pritzker School of Molecular Engineering University of Chicago. Views are personal.

Children in households without piped water or LPG have lower learning outcomes. This negative impact is greater when women bear a greater share of the burden of unpaid work compared to men.

Inadequate access to safe drinking water and clean cooking fuel leads to serious health concerns. The importance of safe water in preventing water-borne diseases and its role in handwashing and maintaining sanitation and hygiene hardly needs to be reiterated. Exposure to smoke associated with solid fuel burning has also been linked to the prevalence of acute respiratory infections (ARI) disproportionately affecting more women and children. Further as per the US Environmental Protection Agency (EPA) exposure to wood smoke can also leave individuals more susceptible to Covid-19 infections.

All this assumes greater importance in the context of the ongoing pandemic. Unlike the first wave which had left rural areas relatively unscathed the second wave has been less merciful. The poor quality of rural health infrastructure has added to the havoc inflicted by the pandemic. However the effect of lack of clean fuel or piped water is not limited to health consequences but also has a bearing on children’s educational outcomes as per findings from a recent study discussed below.

Coverage for LPG connections has improved vastly in recent years with the launch of the Pradhan Mantri Ujjwala Yojana (PMUY). At the all-India level 94.3 per cent of households had an LPG connection in 2019. But this has not translated into sustained use of LPG. The 2019 NSSO Time Use survey shows that 42.8 per cent of households in rural areas continued to use firewood as their primary source of cooking fuel. This is consistent with a CAG report (2019) that notes that the average refill consumption is not at par with the increase in LPG coverage for PMUY households with the high cost of LPG refill being the primary deterrent.

The economic relief provided in 2020 under the Pradhan Mantri Garib Kalyan Yojana (PMGKY) extended three free LPG refills till September 2020. This may have temporarily increased LPG uptake. But this is unlikely to induce sustained usage as LPG price started spiralling upwards soon after. Provisional wholesale inflation estimates suggest that the rate of inflation for LPG went up by 20.34 per cent in April 2021. However the budgetary allocation for LPG subsidy was reduced to Rs 14073 crore this year from Rs 37256 crore in 2020-21.

While coverage for LPG has improved access to piped indoor water remains elusive in most rural areas. As of May 31 only 38.76 per cent of rural households have indoor piped water connections. Fifteen states have less than 10 per cent of villages reporting 100 per cent functional household tap connection in every rural home. The “Har Ghar Jal” initiative under the National Jal Jeevan Mission (NJJM) aims to provide piped water for all rural households by 2024.

In the absence of such infrastructure access women traditionally play the role of water bearers and firewood collectors. Data from the 2011-12 Indian Human Development Survey (IHDS) suggest on an average women spend nearly 45-50 minutes per day in collecting water or fuel with huge variation across states. This gets magnified for households that suffer from insufficient access to both. Additionally time spent in fetching water often goes up in arid and drought-hit regions and in areas of extreme groundwater depletion.

Women’s time spent in collecting goods leaves her with less discretionary time with conflicting demands from other household chores time available for income-generating activities or child care. Further evidence suggests that children often join parents in undertaking household chores particularly in resource-poor households reducing the time available for studies.

Our research (Lack of access to clean fuel and piped water and children’s educational outcomes in rural India Pallavi Choudhuri and Sonalde Desai) finds evidence of negative linkages between lack of infrastructure access and children’s educational attainment mediated by an increase in the time spent by a mother on unpaid chores. Controlling for a range of socio-economic and demographic factors we find that children in households without piped water or LPG have lower learning outcome along with lower educational investments. Such a negative impact is greater when women bear a greater share of the burden of the unpaid work compared to men.

As schools remain closed during the pandemic learning outcomes have suffered. The ASER September 2020 survey indicates that only 30 per cent of rural children received learning materials. This is in line with the findings from the NCAER – Delhi Coronavirus Telephone Survey (DCVTS-4) conducted in December 2020 where 71 per cent households reporting reduced engagement of children in their studies.

With the pandemic continuing to rage across towns and villages children have remained largely confined to their homes. This amplifies the role played by parental input particularly maternal input in supervising children’s educational outcomes. The demands on parental time in supervising children’s learning activities have continually risen as children get tasked on a daily basis with at-home assignments.

While spending time away from home on paid activities supplements household income and can improve children’s educational attainment as more resources become available our research finds that such a positive transmission does not exist with the mother’s involvement in low-productive unpaid chores.

Providing both physical and financial access to time-saving infrastructure — such as LPG and piped water — that frees up mother’s time to supervise children’s learning outcome is likely to aid children in bridging some of the learning loss that they may have endured during the pandemic.

Pallavi Choudhuri is a Fellow at the NCAER National Data Innovation Centre. Views are personal.