Public Health in India

As we had often come back to discussing economic benefits/impact of sports I thought it was about time for an economic discussion forum.
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jayakris
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Re: Public Health in India

Post by jayakris »

Atithee wrote: Mon May 31, 2021 8:52 amLots of words to confuse me. Is the gist that there is no legal requirement but the center did it anyway? I don’t get why center is responsible for even transportation. This way, they will hardly ever be the good guy; they will almost always be the bad guy for poor planning in states’ part.
Yes :) ... The Centre knew they weren't responsible but had to do it anyway. SC also knew they didn't have to obey, but ordered them anyway! :)

The only reason for their being responsible for transportation is that the fastest mode of tanker transportation is trains. But India does not have private goods train companies. The Centre runs the railways, so the states needed them to transport it. (If I am not mistaken the states paid for the transport, too. the railways didn't do it for free). if there was a private operator, they would be doing the routing and logistics for the fastest delivery within time windows as stipulated by the states. So, the centre, as the train operator, becomes the logistics planner too!
What about supply of vaccines? Is that center’s responsibility? If not, why are foreign pharma refusing to deal directly with the state governments? And if yes, how can a state own Health care when the center controls pharma production and distribution?
Centre has authority for standardization and quality control nation-wide on a variety of things (mentioned in the constitution, and it somewhat automatically applies to healthcare too). So they can have ICMR and DCGI determine which vaccines to be used/approved. Technically, I believe, the states can question and not accept national standards (for eg, Kerala tried it on National Highway standards, for narrower land acquisition). But on a health matter the states won't question it. But once the Centre is approving vaccines, they automatically assume responsibility for making its use possible. That would mean facilitating the acquisition. Nobody can stop a state from cutting a deal with SII though. They won't, because they know it will be a cheaper for the Centre to negotiate and purchase in bulk. The main reason for foreign companies to not deal with the states is because they have larger buyers out there. So, to not lose leverage on making Indian Government purchase at a larger volume, they resist dealing with the states. But if pfizer didn't have enough backed up orders, they will surely sell to Indian states, but right now it is a seller's market on vaccines. The foreign companies may also know that the states need import permission from the centre (and that is in the union list!), so they could worry about delays and problems if the Centre has not blessed it.
If India’s healthcare has to be improved, I don’t see how this can remain a state’s responsibility? Just policy making and giving away funds to state for whatever they want to donor will create haves and have nots. And, how do you prevent people from one state going to others?
I agree and that was my point too. Just policy-making and giving away money, or even policy-making and constructing facilities would not be enough. That will be pretty inefficient and a lot of money from the centre could end up getting wasted. Just look at Center buying ventilators and giving to states. A large number of them never got used!! You cannot spend an extra 3 percent of your GDP on that kind of boondoggles.
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Re: Public Health in India

Post by prajgolf »

Atithee wrote: Mon May 31, 2021 4:31 am @Jay: On the topic—if health is a state responsibility, why is central Government responsible for oxygen supply, vaccines, and related meds like Remdesevir?
Centre is responsible for all these, because it has invoked the Disaster Management Act in 2020.

Under the DM Act, the National Disaster Management Authority (NDMA) is the nodal central body for disaster management coordination, with the Prime Minister as its Chairperson. The NDMA establishes procedures, plans, and guidelines for disaster management.

Centre is responsible for providing guidelines related to COVID-19, allocate oxygen, Anti-Covid drugs & vaccines. State governments have the responsibility to transport the allotted materials and distribute it in their respective state and follow the protocols for the Covid management.

Recently, the Centre has given up the vaccines part and has allowed the state & local authorities for the import of vaccines.

More details
https://www.livelaw.in/columns/disaster ... -19-174868
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Re: Public Health in India

Post by prasen9 »

The Centre cannot dictate anything but it can certainly use the strings of the purse to say that it will pay for building more hospitals and/or community clinics that the states have to pay back if these hospitals or clinics are not utilized fully as in their original proposals and in working order for 30 years. Sort of like grants for healthcare infrastructure. I am fully with you in that they cannot just build something and hand it over. It has to be based on proposals that require the states to meet a certain level of service failing which the money will be taken out of their allocations in the future and they can be sued for negligence/dereliction of duty etc. To the extent I know that cannot be unconstitutional; please correct me if I am wrong.

The Centre can do mobile immunization camps throughout the year, preventive care awareness, etc. I doubt any state will sue the center for encroaching in their efforts. They are doing some of this already and nobody is stopping them. Things need to be coordinated and done at a larger country-wide scale with more intent and focus.

All I am saying is that using the Constitution to hide and say healthcare is a state item is sort of an excuse. Much can be done despite it. It is what it is. Let us not go back to what cannot be done and talk about what can be done despite it.
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Re: Public Health in India

Post by prasen9 »

Here is a direct quote from the Constitution:
47. Duty of the State to raise the level of nutrition and the standard
of living and to improve public health.—The State shall regard the raising of
the level of nutrition and the standard of living of its people and the
improvement of public health as among its primary duties and, in particular, the
State shall endeavour to bring about prohibition of the consumption except for
medicinal purposes of intoxicating drinks and of drugs which are injurious to
health.
Part V.

And Part III defines "State" as:
“the
State” includes the Government and Parliament of India and the Government
and the Legislature of each of the States and all local or other authorities within
the territory of India or under the control of the Government of India.
In other words, the constitution directly mentions that both the GoI and the states are responsible for public health. Yes, I know the State List has "Public health and sanitation; hospitals and dispensaries." whereas the Union List does not have anything related to public health. But, given the explicit directive to both the GoI and the states, a case could be made that in the public interest, the GoI doing things will not be unconstitutional.

My argument is as follows. The Constitution says it is the job of the State explicitly. But, it also says that all governments are responsible for public health. The constitution does not say that the Union cannot do things. In fact, given article 47, a reasonable interpretation would be that if the state does not do things then the Centre should do it. Only when there is a conflict or difference of opinion that perhaps the state will have primary responsibility. In reality, no State will be moronic enough to sue the Centre when state is doing nothing and no judge will actually support a do-nothing policy given article 47 clearly mentions things being the responsibility of all governments together. They will find a way to uphold the centre's doing things. "Sanitation" is also mentioned in the same item. How did the Centre then get away with building the toilets then? I do not see a constitutional prohibition especially when the states are not doing anything in that area.

Instead of blaming things are not their job, the Centre should use the Constitutional powers bestowed upon it to improve public health and get things done.

Why do I say the Centre must do things? Simply because most of our taxes are going there. I would be fine with the states being responsible if the states got a whole lot more of our taxes. The states simply don't have the money. The Centre may not have the money either but if they stop the stupid energy subsidies, fertilizer subsidies, etc. maybe there will be some money to do something if not the whole enchilada.
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Re: Public Health in India

Post by jayakris »

prasen9 wrote: Mon May 31, 2021 1:13 pmInstead of blaming things are not their job, the Centre should use the Constitutional powers bestowed upon it to improve public health and get things done.
Well, the Centre (neither this Governmenet, not the earlier ones) have never blamed anybody for not getting done. They didn't have to, because nobody asked till now!! At best, they have pointed out things like "Look at Kerala and Goa. Why can't you do it, UP and Bihar?"... But they haven't said they have no role in it. And because money comes from them, they are responsible. All I said was that, if all these good PMs, who all were aware and wanted to do something, didn't do a damn thing, it must be some systemic reason. We may be able to make the case that that Indian voters simply didn't know how bad it has been for them and didn't react. That means politicians never saw the benefit in doing something, in comparison with doing something in any number of other areas, though.
Why do I say the Centre must do things? Simply because most of our taxes are going there. I would be fine with the states being responsible if the states got a whole lot more of our taxes. The states simply don't have the money. The Centre may not have the money either but if they stop the stupid energy subsidies, fertilizer subsidies, etc. maybe there will be some money to do something if not the whole enchilada.
Right. Why do they not do it, but do stupid things instead? Plain economics, I think. It seems the planners and economists show the direct cost/benefit of energy and fertilizer subsidies but can't show clear benefits from longer life span or fewer diseases.

Plain politics is probably even more a cause. The Indian voter does not care for the number of doctors per thousand population, and the number of hospital beds. They think THEY aren't able to pay for it even if there are more doctors and hospitals. And they are right. They don't think it is because the government doesn't provide hospitals. They think there are enough and more doctors and hospitals. Just not affordable due to their bad luck and bad income.

So the politicians will only think of doing things that give the voters jobs, businesses and income. Hospitals aren't known as employment or income generators for poor people. The voters don't know it, so the politicians don't do it. That is where you need systemic forces driving it due to constitutional requirements or even political ideology behind of socialism/communism/capitalism, none of which was ever allowed in the right form in India. In the absence of systemic forces, what happens or not is directly a result of people's awareness and votes. In Kerala and Goa, education forces in awareness of public health, so they vote with that also in mind. In Bihar and UP, it doesn't happen.

If the Centre simply gives money to states to build capacity, build more medical colleges, produce more doctors and hire them, and build hospitals, all of it will simply go to private sector money-makers and it will all be done. Nobody will be there to use it because people can't afford it. That means, no new votes!

The only way is to give the people money to get healthy, because there are votes for it. If they just spend with a central program and build capacity that people can't pay for, they get no votes for it.

So, Ta-da. We need an insurance program to spend money. That is a vote-generator. Then let the private sector build capacity based on what people are able to pay. Generate demand for medical care that way. Increase the insurance levels and more capacity will be built.

And this is exactly what Congress and Manmohan Singh started. Modi bought it into it and sold it better at election time. They have fine tuned and expanded the insurance scheme too. But that is only 3 or 4 years ago and serious spending into it has not really started. But it is in the right path. It will take 15-20 years and multiple governments spending at 4 to 6% percent of GDP before we will get to a decent level of healthcare and public health. But I see no big reason why the Governmets won't do it. The votes are there. They couldn't do it, pre-2005, when private sector was not too much into healthcare. Now they are. So, here we go. Have hope!!
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Re: Public Health in India

Post by prasen9 »

There are no (net positive, benefit being positive) cost/benefit of energy and fertilizer subsidies. They are just a cheap, populist slogan by the Congress politicians. People like getting something for free. That is as much fo a vote-getting politics as religious populism. Once these things are there, people find it hard to get it off. Modi did try somewhat but not the full way maybe because he was afraid of upsetting the cart too much. Secretary Chu said when I was in Qatar that to take off the free energy benefits to all Qatari citizens, the government had to make them pay and say that the money would be sent back to the people in terms of checks and the entire operation would be made cost-neutral to the budget. That way people would not think you were taking something away from them.

I think Modi and any subsequent PM should make these moves cost-neutral. Take away fertilizer subsidy and put the same amount of money in rural clinics and hospitals. Then, let them argue that paying for fertilizers and wasting things is more important than paying for medicines and life-saving vaccines. Or to open schools. Or things that are useful. Or well, a Rs. 1,000 or whatever that amounts to child bonds for each kid born to be used when they are adults to give them college funds, business capital, or whatever they want to use it for after 18 years.

"good PMs" :-) I think these two words maybe illustrates [the difference between] your and my philosophy Jay. :-) I think they were all varying shades of useless to evil. lol. I hope we get a good PM some day.

Given this divergence, we will forever argue here. :-)
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Re: Public Health in India

Post by jayakris »

prasen9 wrote: Mon May 31, 2021 4:23 pm"good PMs" :-) I think these two words maybe illustrates [the difference between] your and my philosophy Jay. :-) I think they were all varying shades of useless to evil. lol. I hope we get a good PM some day.
I know most Indians will be with you (except on their favorite PM like Modi or Indira)... But really, I think almost no less-developed country has had as many PMs that cared for their country, wanted to do things, and were not corrupt. Very little of their own businesses benefiting and all that. Maybe the Left and the BJP types will point to the Gandhi family, but I don't believe the popular myth that they stole half of India's wealth and took it to Swiss banks! But look at Nehru, Shastri, Morarjee, PVNR, Vajpayee, Manmohan, Modi etc. That is a boatload of well-meaning PMs who were not corrupt. Not just marginally un-corrupt. Most were spotlessly clean and there aren't even rumors otherwise. That's amazing, if you ask me. A prohibitive majority of our PMs, like no other country has had in the third world. I like and respect them all to various extents.
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Re: Public Health in India

Post by Atithee »

Please someone explain why creating a road block is ok when private vaccination is allowed? If the idea is to get most people vaccinated, we shouldn’t be in the way. If the person is eligible, where they get the shot shouldn’t be the Union government’s concern. This seems an arbitrary rule, if it can even be called one.

https://timesofindia.indiatimes.com/ind ... 080564.cms

The Union health ministry wrote to all states on Saturday, saying it had come to its notice that “some private hospitals are giving packages for Covid vaccination in collaboration with some hotels, which is against (rules).”

The Centre has pointed out in the letter there are four available options for vaccination — government centres; private hospitals; at government and private offices and “near to home” centres for elderly and differently abled.

“Apart from this there is no other avenue to carry out (Covid) vaccination… therefore vaccination (being) carried out in star hotels is contrary to guidelines and must be stopped immediately. Necessary legal and administrative actions should be initiated against such institutions,” the letter by Union health ministry additional secretary Manohar Agnani says.
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Re: Public Health in India

Post by prasen9 »

Who knows Atithee. What you said makes sense. The only reason this may not make sense is if the star hotels are getting supplies in some way that others are not getting. Then, they make it available at a cost that the rich can only afford. Seems like a fairness issue. But, I am guessing and have no clue.
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Re: Public Health in India

Post by depleter »

Atithee wrote: Tue Jun 01, 2021 12:55 am Please someone explain why creating a road block is ok when private vaccination is allowed? If the idea is to get most people vaccinated, we shouldn’t be in the way. If the person is eligible, where they get the shot shouldn’t be the Union government’s concern. This seems an arbitrary rule, if it can even be called one.

https://timesofindia.indiatimes.com/ind ... 080564.cms

The Union health ministry wrote to all states on Saturday, saying it had come to its notice that “some private hospitals are giving packages for Covid vaccination in collaboration with some hotels, which is against (rules).”

The Centre has pointed out in the letter there are four available options for vaccination — government centres; private hospitals; at government and private offices and “near to home” centres for elderly and differently abled.

“Apart from this there is no other avenue to carry out (Covid) vaccination… therefore vaccination (being) carried out in star hotels is contrary to guidelines and must be stopped immediately. Necessary legal and administrative actions should be initiated against such institutions,” the letter by Union health ministry additional secretary Manohar Agnani says.
It's obviously done because of the outrage from the left yesterday. Even some foreign correspondents were blabbering about some ethical issues about this. Though I can't understand what's so much unethical about it. But yeah, with govt fearing so much about it being called suit boot ki sarkar, they went after them. TBF the hospitality industry is already struggling. This type of vaccination even allows people moving out from the covid hotspots i.e, vaccination centers too. But some people just can't digest some things.
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Re: Public Health in India

Post by prasen9 »

Are vaccines available to anyone who wants it today?
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Re: Public Health in India

Post by suresh »

prasen9 wrote: Tue Jun 01, 2021 1:26 pm Are vaccines available to anyone who wants it today?
No.
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Re: Public Health in India

Post by prasen9 »

Thanks. Then, there should be no special lines for the rich via five-star hotels or whatever. Private vaccination should be allowed but the marking up of a precious public resource to enable private gains is not the right thing. That is, the private hotels can give out private vaccines at reasonable cost but they have to make that available to anyone who is eligible and wants it and not only people who are staying at their hotels. We must oppose such bundling to enable private profits and that should be rightfully banned and whoever made the noise to get it banned should get kudos. Thanks to the government for taking action. In essence, using vaccines to sell hotel rooms is not right.
Last edited by prasen9 on Tue Jun 01, 2021 4:34 pm, edited 1 time in total.
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Re: Public Health in India

Post by jayakris »

Yeah, that seems like profiteering. Using the vaccines as a way to make a profit.
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Re: Public Health in India

Post by Atithee »

This is no different for most things in life including healthcare services. I don’t like it either but the high price paid by others keeps overall prices affordable for many too.
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