Lurking in the BLIND SPOT
Below par budgetary allocation for the health sector and abysmal emphasis on serious healthcare issues during the first two phases of election are emblematic of the government’s lacklustre approach in this direction—a situation that should change in the r
The first two phases of the seven-phase general elections are over. Till now, the election issues have remained focused mainly on: Ram temple, electoral bonds, hate speeches by the leaders, EVMVVPAT, politicisation of judiciary, Citizenship Amendment Act (CAA), misuse of government agencies like CBI and enforcement directorate (ED) to harass opposition leaders etc.
Though high unemployment among educated youths has been often mentioned in the political rallies, issues like pathetic medical infrastructure, rising prices of medicines, declining health budget, total breakdown of national health system during the pandemic, predicament of millions of migrant workers — due to sudden, unplanned lockdown — who had to walk thousands of miles to return back home, have not yet received due importance in the ongoing election debates. The long schedule of seven phases of election during this scorching heat also highlights the indifferent attitude of the political establishment of the world’s largest democracy towards the health issues of its citizens.
Against this background, this piece will briefly discuss the proposed pandemic treaty, which is expected to be signed by India and other WHO members very shortly. It is reported that in the ninth meeting of the Intergovernmental Negotiating Body (INB9) which ended on 28 March, the WHO member states agreed to resume negotiations aimed at finalising a pandemic agreement between 29 April to 10 May, 2024.
The pandemic treaty
The International Monetary Fund estimated that the global economy suffered losses of at least USD 13.8 trillion as Covid-19 lockdowns and supply-chain disruptions tipped the world into recession. Governments then spent trillions more responding to the crisis. As scaling up of investments in prevention is preferable — in terms of health, prosperity, and justice — to incurring the costs from a crisis that has spun out of control, the WHO council pointed out, “it is more cost effective to prevent than to cure.”
Apprehension about another pandemic will create a huge market for preventive drugs and vaccines.
A World Health Organisation (WHO) report from May 2022 estimated that nearly 4.7 million Indians died from COVID-19, more than any other country. This figure was nearly 10 times that of the government’s official count for 2020 and 2021, reports The Hindu. In October 2020, India and South Africa asked the World Trade Organisation (WTO) to do away with patent enforcement for all COVID-19 medicines, tests, and vaccines for the duration of the pandemic. The proposal was backed by more than 100 mostly developing countries. However, the proposal was stonewalled by a small number of governments — including the US, EU, the UK, Switzerland, Japan, Norway, Canada, Australia and Brazil.
In 2021, the 194 member states of the World Health Organisation (WHO) began negotiating a new international agreement to replace the existing International Health Regulations (IHR) — a treaty governing global health emergencies adopted in 2005 — and the TradeRelated Aspects of Intellectual Property Rights (TRIPS) agreement governed through the WTO. A study by Neil Sircar (2018), shows that the two treaties have long been at odds in times of emergency. Nevertheless,
TRIPS allows for the use of a patented product without permission during national or global emergencies. But the COVID-19 pandemic has underscored how reluctant rich nations were to actually share vaccines and drugs, even in emergencies. It is reported that Pfizer, BioNTech, and Moderna made combined profits of USD 65,000 a minute during the pandemic. On February 1, 2023, the Intergovernmental Negotiating Body (INB) of WHO released a “zero draft” of the “pandemic treaty.”
The pandemic treaty aims to prepare for the next global health emergency and prevent a repeat of what South Africa called “vaccine apartheid,” where countries had vastly unequal access to COVID vaccines and drugs. The draft treaty aims to save lives and protect livelihoods through strengthening the world’s capacities for preventing, preparing for, responding to, and health system recovery from pandemics.
Major concerns
Experts are of the opinion that while the current draft suggests the importance of IP rules that do not limit affordability and access, it merely “encourages,” rather than requires, measures aimed at knowledge sharing and limiting royalties. Moreover, a misplaced drive to preserve current IP rules is complicating the negotiations. Another obstacle to the pandemic treaty’s success is that it currently seems to be delinked from clear funding commitments, reports Business Standard. The proposed pandemic treaty has no indications that the developed countries are willing to accept a binding framework that can deliver results in future.
Moreover, the current draft fails to enshrine core human rights standards protected under international laws, most notably the right to health and the right to benefit from scientific progress. In a joint statement, dated November 7, 2023, four human rights organisations, including Amnesty International, appealed to all WHO member states to push for clear commitments to human rights protections in the negotiated text.
Healthcare experts believe that the treaty has serious implications for the Global South, the pharma industry, sovereignty, democracy, and health administration, reports National Herald. According to them, the WHO is an unelected body and is totally unaccountable to anyone. Nevertheless, it wants countries to cede part of their sovereignty so that WHO, despite its poor record, can control future pandemics, bio-terrorism and climate change. WHO has failed to trace the origin of the Covid-19 virus so far, and is yet to conduct an audit of its own handling of the Covid pandemic.
Once the countries sign the treaty, they will hand over all regulatory control of future pandemics (Disease X) to World Health Organisation that will declare the onset of fresh pandemics and protocols to be followed (lockdowns, vaccines), prescribe medicines and their dosage, demand surveillance prescribed by it, and decide on which medicines and vaccines are acceptable and which are not. What is more, WHO will also have the power to censor scientific papers, scientists, and research, and also decide what disinformation is and what is not.
Experts pointed out that ‘one size does not fit all’. Demographics differ from country to country, as do conditions. India is a young country with an overwhelming percentage of its population below the age of 70 whereas Europe is ageing faster. Obesity and comorbidities are major health issues in the West but not so much in Asia. In Africa, mortality from Covid was higher in South Africa, where people are more obese than in other countries. While obesity is a problem in the West, malnutrition is a more serious problem in poorer countries like India.
Population density and cultural differences, too, can play a role in pandemics. In India, 80 per cent of the population did not take a booster dose. They did not have to. More Indians died of other diseases than of Covid-19, and yet the government spent 50 per cent of the total health budget on securing vaccines to deal with Covid. Neglect of other diseases has led to resurgence in cases of TB and dengue, and about 2,000 children in India continue to die every day of diseases other than Covid.
Though WHO claims to be an independent body, it cannot remain independent as a large amount of its funding comes from the pharma industry. When big pharma increasingly funds medical and health research, medical journals, and offers more grants than governments, it cannot retain its freedom.
Status of healthcare system in India
Death of nearly five million people during the Covid pandemic has exposed the pathetic healthcare system in India. The Lancet (April 18, 2023) has rightly pointed out that “India’s woes with an underprioritised and hence underfunded and understaffed public health system continue to plague public healthcare delivery”. Here are a few major findings of the study which reveals a wretched condition of India’s public health system even after 75 years of independence. This study also explains why the Indian Prime Minister suggested to beat drums and utensils while chanting ‘Go corona go’ to tackle the pandemic!
It is reported that among all health workers, 66.91 per cent were serving in urban areas where 33.48 per cent of the population is based; and 33.09 per cent were serving in rural areas where 66.52 per cent of the population resides. In terms of numbers, as of 2018, there were 25,89,417 health workers in urban areas and 12,80,583 in rural areas, with an urban–rural ratio of 2.0 whereas, contrastingly, the urbanrural population ratio was 0.5.
The World Health Organisation (WHO) recommended a doctor to population ratio should be at least 1 per 1,000 and the ideal nurse density should be 3 per 1,000 people. As per the National Health Workforce Accounts Data (2020) portal, 0.73 doctors are available per 1,000 population and 1.74 nurses per 1000 population in India. However, as per National Sample Survey Office (NSSO) 2017-18, the availability of doctors and nurses in India in 2018 were 0.5 and 0.6 (accounting for adequate qualifications) respectively.
Large-scale variations also existed among Indian States with regards to the population served by a doctor; for example, a doctor in Bihar served 28,391 people whereas a doctor in Kerala served 6,810 people.
The Rural Health Statistics 2019–20 reported that as of March 2020, only 3.4 per cent of the 1.55 lakh Sub Centres (SCs) were functioning as per Indian Public Health Standards (IPHS). A lowly 13 per cent (3,278) of the 24,918 Primary Health Centres (PHCs), and 8.4 per cent of Community Health Centres (CHCs) adhered to basic standards. More than 37 per cent of the health assistant positions, 19 per cent of pharmacist positions, 34 per cent of laboratory staff and 21 per cent of nurse positions lay vacant.
Also, there were nearly 24 per cent vacancies in rural PHCs for the sanctioned medical officer positions in the year 2020. As compared to 2019, there was a reduction of 4.3 per cent in the number of doctors available in rural PHCs and there were disaggregated shortfalls of 24 per cent, 29 per cent and 38 per cent for SCs, PHCs and CHCs, respectively.
The other problems lay with the prevalence of superstitions and myths related to healthcare, making people further resistant to modern healthcare providers and therapies.
Another issue has been the presence of unqualified practitioners (local superstitious healers and quacks) who falsely claimed to possess medical knowledge and went about providing unscientific and unproven treatment to patients.
As an outcome of such a broken healthcare system, the quality of maternal health services remains a major concern. With a stillbirth rate of 5 per cent, India bears the burden of having the highest number of stillbirths globally; nearly 0.34 million of the 1.9 million global stillbirths happened in India in 2019. Moreover, nearly 35,000 women continue to die due to pregnancyrelated complications which are largely preventable.
There is limited access to reproductive health services, especially among people living in interior rural areas and among marginalised young people. Access to sexual and reproductive health services is particularly limited among adolescents and young people. Moreover, India faces a high burden of both communicable and non-communicable diseases. Tuberculosis, lower respiratory infections, diarrheal diseases, malaria, and typhoid continue to be leading causes of communicable illness. There is a major upsurge in neglected tropical diseases including dengue and chikungunya, while kala azar, visceral leishmaniasis and leprosy continue to pose major health challenges, particularly in certain geographical areas. Emerging and re-emerging diseases such as H1N1 flu virus, SARS, Ebola and Zika pose a major health security threat, as do natural and man-made emergencies. Prevalence of cardiovascular diseases and diabetes are also a cause of concern, highlights an UN report on India.
The pandemic treaty has serious implications for the Global South, the pharma industry, sovereignty, democracy, and health administration
Observations
Though for years, experts have suggested that the health budget should be at least 3 per cent of gross domestic product (GDP) and even the National Health Policy, 2017, put the target for increasing the budget to at least 2.5 per cent of GDP by 2025, the Finance Minister allocated only Rs 90,171 crore to the health sector for the FY 2024-2025. The health allocation at 2.5 per cent should have been Rs 8,19,000 crore, given the projected GDP for 202425 of Rs 3,27,71,808 crore. It indicates the government’s lacklustre approach towards the public health care system.
During the first two phases of election campaigns, millions of deaths during Covid pandemic, increasing price of nearly 800 essential drugs and growing dependence of citizens on unaffordable private health care systems have not attracted the attention of the political leaders. The proposed pandemic treaty is another important issue which has not been deliberated. It deserves urgent debate in the country before making any commitment by the government. Hopefully, during the next five phases of election these important issues will receive proper attention.