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Underlining the state of health-Economic Survey, 2021-22

The Economic Survey, tabled in the Parliament, one day before the Union Budget by the Finance Minister is a much-awaited document.  Primarily authored by the principal economic adviser and his team, the Survey is a Department of Economic Affairs (DEA) document that underlines the state of the economy and outlines suggestions for policy actions.

Key highlights from the Economic Survey 2022 for the health sector.
Vaccination has played a critical role (Box 1) in minimizing loss of lives, boosting confidence in the economy toward resumption of activity and containing the sequential decline in output due to second wave. As India completed one year of its COVID-19 vaccination drive on 16th January, 2022, it crossed the historic milestone of administrating more than 156 crore doses of vaccine (Figure 26). More than 88 crore people (93 per cent of the adult population) have received at least one dose of which around 66 crore people (70 per cent of the adult population) stands fully vaccinated. With vaccination drive further extended to the age group of 15-18 years starting 3rd January, 2022, more than 50 per cent of India’s population in this age group have received their first dose of the vaccine as on 19th January.

India’s vaccination drive
Vaccination has been an integral pillar of the comprehensive strategy of Government of India for containment and management of the pandemic. On 16th January 2021, India commenced the world’s largest vaccination program with an ambitious target to inoculate its entire eligible population by 31st December 2021, with at least the first dose. In the first phase, the vaccination drive was sequentially expanded to cover Health Care Workers and Front Line Workers. The second phase started on 1st March (for above 60 years) and 1st April 2021 (from 45-59 years) making all persons aged 45 years and above eligible for vaccination. This cohort had accounted for more than 80 per cent of the COVID-19 mortality in the country. The third phase began on 1st May 2021 to vaccinate people in the age group of 18-45 years. From 3rd January 2022, the vaccination drive has been further extended to include those in the age group of 15-18 years. Taking cognisance of the recent global surge of the Omicron variant, the Variant of Concern declared by WHO on 26th November 2021, booster doses to healthcare and frontline workers as well as senior citizens above 60 years of age with co-morbidities have been allowed by Government from 10th January 2022. Vaccination access and pricing have been deregulated to quicken the pace of vaccination across states and all age groups. The latest available data at the time of writing shows that 99 per cent of the registered Health Care Workers and 100 per cent of the Front-Line Workers, 87 per cent of the population aged between 18- 44 years, 95 per cent of the population aged between 45-60 years and 89 per cent of the population above 60 years have been covered under the first dose. Vaccination drive continues to gather speed and breadth with the number of days taken to achieve an additional 10 crore doses reducing significantly from 86 days during the initial phase to 15 days now (Figure 1A). The average daily vaccination rate has increased four-fold from 19.3 lakh in May 2021 to 75.4 lakh as of 16th January 2021. As on 16th January 2022, eligible population (18 year and above) vaccinated in India with first dose was 93 per cent and with second dose 69.8 per cent (Figure 1C).

With India witnessing a resurgence in daily new cases since end-December 2021, marking the onset of Omicron variant induced third wave, rapid progress in vaccination coverage and further strengthening of testing and health infrastructure assume critical importance in protecting lives and containing the spread of the infection.

At the time of writing, a new wave in the form of the Omicron variant was sweeping across the world, inflation had jumped up in most countries, and the cycle of liquidity withdrawal was being initiated by major central banks.

While restructuring expenditure is a significant aspect of fiscal policy, enhancing the efficiency of Government spending is also important. Public procurement, which involves purchase of goods and services by the Government with an aim to not only carry day-to-day tasks but to also create social and economic infrastructure, is an important component of the Government expenditure. Government has undertaken consistent efforts to boost the efficiency of public procurement policy.

Government e-Marketplace (GeM)
The Government in 2016 had set up a dedicated e-market known as Government e-Marketplace (GeM) for purchase of certain standard day to day use goods. This is a simple, transparent and completely digital process for procurement. The General Financial Rules 2017  mandates all Ministries and Departments to procure Goods and Services available on GeM from GeM. The procedural changes in the procurement method after the introduction of GeM are given below.

Anecdotal evidence suggests that prior to GeM, government procurement prices were much higher than the prices prevailing in the market and there were constant complaints about inefficiency and rent seeking. The use of this e-marketplace has resulted in a substantial reduction in prices in comparison to the rates used earlier, with average prices falling by at least 15-20 per cent, up to 56 per cent.

Prices of various commodities on the GeM portal vis-a-vis other online platforms
A comparison of prices of various commodities on the GeM portal with those of company websites or other online platforms such as Amazon, Flipkart, etc. is given in the table below. A similar analysis was included in Economic Survey 2020-21. For a close comparison, sample of same commodities as selected last year, is used to the extent possible. In cases where the exact commodity was not available, the newly available models were chosen. While in the last year’s analysis, GeM prices were on an average 3 per cent lower when compared with other platforms, this time it is around 9.5 per cent lower for the chosen sample. 10 out of 22 commodities in the sample were cheaper on the GeM portal as compared to other platforms.

These results are broadly in line with the assessment of GeM conducted by the World Bank, which found that GeM enabled an average savings of 9.75 per cent on the median price for the period between February 2019 and January 2020. The maximum savings in the top five categories ranged from 23.5 per cent to 60.5 per cent. The study attributed this, in large part, to increased participation per bid and better price discovery.

COVID Related Relief Measures
Several measures were taken by CBIC for facilitating Customs clearances of all materialsrelated to COVID-19 during 2021-22.

CBIC had issued notifications to exempt customs duty on import of Remdesivir injection, Remdesivir API and Beta Cyclodextrin (SBEBCD) used in the manufacture of Remdesivir (up to 31st October, 2021), and also on import of various items related to Oxygen and Oxygen related equipment (for a period of three months).

During the second wave of COVID-19 pandemic, the Customs has facilitated the import of approx. 7.5 Lakh Oxygen Concentrators into the country. More than 75 IAF landings were facilitated for import of 97 Cryogenic ISO tanks for carrying of liquid oxygen across the country. Other products facilitated on high priority includes Oxygen generating plants, equipments, ventilators, Remdesivir Injection and its raw materials, diagnostics kits markers etc.

Social Infrastructure
During the last two years, as India along with rest of the world faced the onslaught of the pandemic, Government’s key focus in India remained on providing a safety-net to the vulnerable segments of society as well as providing a coherent response to the health consequences of the pandemic. India having already faced two COVID-19 waves, with the first peak in September 2020 and the second peak in May 2021, is currently facing the third wave led by the Omicron variant. Indian National COVID Vaccination Program, one of the world’s largest vaccination programs, has not only supported production of COVID-vaccines domestically, but it has also ensured free vaccines to its population – world’s second largest population. Union Budget for 2021-22 allocated ₹35,000 crore for procurement of vaccines under COVID-19 Vaccination Program. From 16th January, 2021, as on 16th January 2022, a total of 156.76 crore doses of COVID-19 vaccines, have been administered: 90.75 crore first dose and 65.58 crore second dose. With these, 93 percent of 18 year and above aged persons have been vaccinated with first dose and about 70 percent with second dose. Vaccination at this scale and speed has enabled swift revival of livelihoods.

The need for a strong and resilient social infrastructure became even more important during the ongoing COVID-19 pandemic that brought into focus the vulnerabilities in social infrastructure across countries. Specifically, pandemic posed the challenge of balancing livelihoods while saving lives. To save lives and livelihoods amidst the COVID-crises, countries have adopted various strategies.

India, the country with the second largest population and a large elderly population, adopted a multi-pronged approach. Given the nature of pandemic, the health response including vaccination strategy remained critical. India, one of the young nations in the world, also faced the challenge to sustain the learning outcomes in schools, building skills and reskilling population, employment and livelihood to one of the largest labour forces in the world.

Government’s response through ‘Aatma Nirbhar Bharat Abhiyan’ packages and other sector specific initiatives have provided the necessary support to mitigate the adverse impact of pandemic.

Like most other countries, India also faced two COVID-19 waves: first in 2020 and second in 2021 (Figure 1). During the first-wave, the cumulative number of COVID-19 cases started rising progressively from the month of May 2020, and peaked in mid-September 2020. Thereafter, the country faced a massive surge in COVID-19 cases starting March 2021, with a peak of more than four lakh daily cases in May 2021 and more than 4400 daily deaths in end of May 2021. A fresh surge of cases and a new variant Omicron had surfaced in December 2021 and was spreading at the time of writing.

Daily COVID-19 Cases and Deaths in India

To save lives, Government adopted a multi-pronged approach viz., (i) restrictions/partial lockdowns, (ii) building capacity in health infrastructure, (iii) COVID-19 appropriate behaviour, testing, tracing, treatment, and (iv) vaccination drive. Measures were taken to break the chain of transmission in terms of containment and buffer zones; perimeter control; contact tracing; isolation and testing of suspect cases and high-risk contacts, and creation of quarantine facilities. Preventive strategy changed in response to the changing situation observed based on real-time data and evidence. Testing capacity in the country increased exponentially. Tests for COVID-19 were also made free in all government centers. Rapid Antigen Test kits for faster screening were introduced. Manufacturing capacity of N-95 masks, ventilators, personal protective equipment kits, sanitizers were ramped up in a mission mode. Massive infrastructure was created for isolation beds, dedicated intensive care unit beds, and supply of medical oxygen. To meet the exponential rise in medical oxygen demand during second COVID wave, government engaged even railways, Air Force, Navy and industry. In the fight against coronavirus, COVID vaccines emerged best shield against the disease to save lives and sustain livelihood.

COVID Vaccination Strategy
Guided by scientific and epidemiological evidence, World Health Organisation (WHO) guidelines and global best practices, India’s National COVID Vaccination Program has been one of the world’s largest vaccination programs. National Expert Group on Vaccine Administration forCOVID-19 (NEGVAC) on the basis of concurrentscientific evidence guided the program. The program was envisioned to vaccinate all eligible beneficiaries aged 18 years and above in the shortest possible time.

“The Liberalized Pricing and Accelerated National COVID-19 Vaccination Strategy”, was implemented from 1st May to 20th June 2021. Under the strategy, States/Union Territories (UTs) and private hospitals were allowed to procure COVID-19 vaccine directly from manufacturers. Government of India procured 50 percent of monthly vaccine production by the domestic manufacturers, while the State Governments and private hospitals procured remaining 50 percent doses. However, based on real-time feedback, it was changed to “The Revised Guidelines for Implementation of National COVID Vaccination Program” implemented from 21st June 2021, whereby, Government of India procured 75 percent of monthly vaccine production and provided free to States and UTs, while rest could be procured by private hospitals.

Availability of Vaccine: India is among few countries producing COVID vaccines. The country started with two Made in India COVID vaccines. India’s first domestic COVID-19 vaccine, Whole Virion Inactivated Corona Virus Vaccine (COVAXIN), was developed and manufactured by Bharat Biotech International Limited in collaboration with National Institute of Virology of Indian Council of Medical Research (ICMR). The ICMR funded the clinical trials of the COVISHIELD vaccine developed in collaboration with Oxford – AstraZeneca. COVISHIELD and COVAXIN have been widely used vaccinesin India. Every month about 250- 275 million doses of COVISHIELD and 50-60 million doses of COVAXIN have been produced.

COVISHIELD, COVAXIN and COVOVAX have also received emergency authorization approval from WHO. Besides, manufacturing of COVID-19 vaccines viz., Sputnik-V, ZyCoV-D, recombinant (Ad26.COV2-S) have also been given emergency use authorization by the regulatory authority. Moreover, import of COVID-19 Vaccines viz., Sputnik-V, Moderna, and recombinant (Ad26.COV2-S) have also been permitted.

Pricing and equity:At all Government COVID-19 Vaccination Centres (CVCs), COVID-19 vaccine was made available free of cost for all eligible citizens. Except for about 4-5 percent of total doses administered in the country, rest have been administered at Government COVID-19 Vaccination Centres. Union Budget for 2021-22 allocated ₹ 35,000 crore for procurement under COVID-19 Vaccination Program. Distribution of COVID vaccine to all without discrimination has also been important feature of the vaccination program. Out of total administered doses of COVID-19 vaccines, 49 percent have been administered to females; more than 70 percent of vaccine doses have been administered at CVCs located in rural areas.

Coverage: In the first phase (from 16th January to 1st March 2021) COVID-19 vaccines were given to Health Care Workers and Frontline workers. In second phase (from 1st March onward), COVID vaccines were extended to persons over 45 years of age with specified co-morbidities and those aged 60 years and above. From 1st April, 2021, coverage was further extended to all citizens aged 45 years and above. From 1st May 2021, all 94 crore persons of age 18 years and above, were made eligible for COVID vaccination. From 3rd January 2022, COVID-19 vaccine coverage has been extended to age-group of 15-18 years. Till 19th January 2022, 3.73 crore youngsters between 15-18 age group have been vaccinated with 1st dose of COVID-19 vaccine covering more than 50 percent of youngsters. Further, from 10th January, 2022, Health Care Workers, Front Line Workers and persons age more than 60 years with co-morbidities have been made eligible to receive a precaution dose of COVID-19 vaccine, on completion of 9 months or 39 weeks from the date of administration of 2nd dose. As on January 19, 2022, 56.66 lakh precautionary doses have been administered to health care workers, frontline workers and persons over 60 years of age.

Vaccine hesitancy: Misconceptions about the COVID-19 vaccine make people hesitant to take vaccines. To reduce vaccine hesitancy, Government made efforts which include awareness through media channels, radio jockeys, op-eds and articles by identified experts and dissemination of fact-check videos by key expertsto provide correct & factual information. From 3rd November 2021, a campaign, ‘Har Ghar Dastak’, has been initiated to identify and vaccinate those who missed 1st dose and due for 2nd dose through house-to-house mobilisation activity. Vaccine also administered to beneficiaries at their homesthrough mobile teams viz., ‘vaccination toli’ along with ‘prachartoli’. Interstate competition for coverage, conducting vaccination camp at Bazaar Haats, utilization of social media to counter anti-vaccine rumours, messaging through influential persons and other innovative approaches have helped in vaccination.

Technology driven: ArogyaSetu mobile app was launched to enable people to assess themselves the risk of their catching the COVID-19 infection. It calculates the risk of infection based on a person’s interaction with others, using Bluetooth technology, algorithms and artificial intelligence.

Co-WIN 2.0 (along with e-VIN), a unique digital platform, supported the real-time vaccination activities viz., registration for vaccine, tracking COVID-19 vaccine status of every beneficiary, stocks of vaccine, storage, actual vaccination process, and generation of digital certificates.

Vaccination Progress: As on 16th January 2022, a total of 156.76 crore doses of COVID-19 vaccines have been administered: 90.75 crore first dose and 65.58 crore second dose. Vaccination speed increased significantly once the population between ages 18 to 45 years was permitted. Out of total doses administered, largest 60 percent are in the age group 18-45, followed by 25 percent to age group 45-59 year and 15 percent to aged 60 years & above.

Some initiatives taken to fight against COVID-19
Laboratory network: As of 24th November 2021, a total of 1346 government laboratories and 1701 Private Laboratories (3047 laboratories in total) are conducting COVID-19 testing. So far as on 20.01.2022, India conducted 70.93 crore total COVID tests; On 20.01.2022, India conducted 19.35 lakh COVID tests.

Medical Oxygen Plants: Defence Research and Development Organisation (DRDO) was entrusted with installing and commissioning 931 Medical Oxygen Plants in 869 hospitals across the nation within six months, funded through PM-CARES fund. These plants were designed and developed based on the spin-off technology of Onboard Oxygen Generation System (OBOGS) of India’s indigenous fighter aircraft Tejas.

Oxy-Care System: DRDO developed SPO2 based Oxygen Cylinder Controller (SPOCC) based Medical Oxygen Cylinders to optimally use the available medical oxygen for COVID-19 patients. This system supplies quantity of oxygen based on individual’s SPO2 levels. This technology was transferred to M/s Bharat Forge Ltd and M/s UFLOW automation. They have supplied 1.5 lakhs such systems to Government hospitals across the country.

Anti-COVID Drug: An anti-COVID-19 therapeutic application of the drug 2-deoxy-D-glucose (2- DG) in collaboration with Dr. Reddy’s Laboratories, Hyderabad was formulated. Based on results of Phase-II and Phase-III clinical trials, Drug Controller General of India (DCGI) granted permission for Emergency Use of 2-DG as adjunct therapy in moderate to severe COVID-19 patients. The drug comes in powder form in sachet, which is taken orally by dissolving it in water. DRDO has transferred its patented process technology to 13 major Pharma industries.

Although, the pandemic has affected almost all social services, yet the health sector was the worst hit. Expenditure on health sector increased from ₹ 2.73 lakh crore in 2019-20 (pre-COVID-19) to ₹ 4.72 lakh crore in 2021-22 (BE), an increase of nearly 73 percent. For the education sector, the increase during same period was 20 percent.

In addition to the National Health Mission, Union Budget 2021-22, announced Ayushman Bharat Health Infrastructure Mission, a new Centrally Sponsored Scheme, with an outlay of about ₹ 64,180 crore in next five years to develop capacities of primary, secondary, and tertiary care Health Systems, strengthen existing national institutions, and create new institutions to cater to detection and cure of new and emerging diseases. Besides, Union Budget 2021-22 provided an outlay of Rs 35,000 crore towards COVID-19 vaccination.

The National Health Policy, 2017 envisaged to increase government’s health expenditure to 2.5 percent of GDP by 2025. In keeping with this objective, Central and State Governments’ budgeted expenditure on health sector reached 2.1 percent of GDP in 2021-22, against 1.3 percent in 2019-20.

Health -Programmes and Schemes
Ayushman Bharat Health and Wellness Centres (AB-HWCs). Vision of Ayushman Bharat is to achieve the universal health coverage. It adopts a continuum of care approach, comprising of two inter-related components. The first component is creation of 1,50,000 Health and Wellness Centres (HWCs) which cover both, maternal and child health services and non- communicable diseases, including free essential drugs and diagnostic services. These AB- HWCs provide Comprehensive Primary Health Care (CPHC), by expanding and strengthening the existing Reproductive & Child Health (RCH) services and Communicable Diseases services and by including services related to Non-Communicable Diseases. It is also envisaged to incrementally add primary healthcare services for mental health, ENT, Opthalmology, Oral health, Geriatric and Palliative health care and Trauma care as well as Health promotion and wellness activities like Yoga. As on January 19, 2022, a total number of 221.99 lakhs Tele-consultations have been provided under e-Sanjeevani tele-consultation platform through functional HWCs of 3017 Hubs & 33,819 Spokes across the country. About 96.27 lakh Wellness Sessions, including Yoga has been conducted at AB-HWCs as on January 19, 2022.

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). The second component of Ayushman Bharat is PM-JAY; it is being implemented by the National Health Authority (NHA) in partnership with state governments. The scheme provides a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and vulnerable families in the bottom 40 percent of the Indian population. As on January 19, 2022, total of 17.5 crore Ayushman Cards have been issued under AB PM-JAY. A total of 2.73 crore authorized hospital admissions worth Rs. 30673 crore have been provided through a network of approximately 25000 hospitals (approximately 10800 Private and 14300 Public hospitals). A massive information, education and communication drive Aapke Dwar Ayushman was carried out in 2021 with the support of grass root resources such as frontline workers, healthcare workers and Panchayati Raj Institutions. This led to the identification and verification of more than 4 crore people under the scheme.

PM-Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) is a mission to develop the capacities of primary, secondary, and tertiary care health systems, strengthen existing national institutions, and create new institutions, to cater to detection and cure of new and emerging diseases. It is the largest Pan-India scheme for public health infrastructure since 2005.

Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) is being implemented to correct regional imbalances in the availability of affordable reliable tertiary healthcare services and to augment facilities for quality medical education in the country. Under PMSSY, construction of 22 new All India Institutes for Medical Science (AIIMS) and 75 Government Medical College up-gradation Projects has been approved and taken up for implementation. Out of this, six (6) AIIMS at Bhopal, Bhubaneswar, Jodhpur, Patna, Raipur and Rishikesh are already fully functional. Another Sixteen (16) AIIMS under various phases have been sanctioned.

Ayushman Bharat Digital Mission (ABDM), erstwhile National Digital Health Mission (NDHM), announced on 27th September, 2021 with the aim to develop the backbone necessary to support the integrated digital health infrastructure of the country. It is to bridge the existing gap amongst different stakeholders of the healthcare ecosystem through digital highways. Services like the issue of Health ID, Healthcare Professionals Registry (HPR), Health Facility Registry (HFR) and Health Records (PHR) have been initiated.

e-Sanjeevani. In wake of COVID-19 pandemic, Ministry of Health and Family Welfare upgraded eSanjeevani application to enable patient-to-doctor tele-consultation to ensure continuum of care and facilitate health services to all citizens in the confine of their homes free of cost. Telemedicine services have been rolled out in 36 States/UTs. To increase the outreach of health services virtually, e-Sanjeevani OPD application has been integrated with 3.74 lakh Common Service Centers (CSCs) thereby facilitating access to equitable health care in the remotest areas of the country.
MB Bureau

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