The National Exit Test (NExT) has emerged as a pivotal reform in the landscape of medical education in India. As outlined by the Parliamentary Standing Committee on Health and Family Welfare in its recent report, NExT aims to unify the evaluation of medical graduates across the country.
Current Examination Structure
At present, the responsibility of conducting final-year MBBS examinations lies with medical colleges.
Postgraduate licensing and qualifying examinations like NEET PG and FMGE fall under the National Board of Examinations (NBE), monitored by the Director-General of Health Services within the Health Ministry. This bifurcation of responsibilities has led to a disparate evaluation system.
Objectives of NExT
The National Medical Commission Act has paved the way for NExT with the intent to enhance the competence of MBBS graduates. By replacing the final MBBS examination and serving as a licentiate exam, NExT aims to standardize the assessment of medical graduates, facilitating a more practical and skill-oriented evaluation over the traditionally theoretical NEET-PG.
Implementation Challenges and Recommendations
Despite its well-intended objectives, the implementation of NExT has faced challenges, leading to its deferment in July 2023. The Parliamentary Committee emphasizes the importance of meticulous due diligence before its introduction. To this end, the Committee recommends:
Moderate Evaluation Criteria: For the inaugural round of NExT, the evaluation criteria should be moderated to prevent any undue advantage or disadvantage among graduates, ensuring a fair and equitable examination process.
Standardization of Medical Education: Beyond evaluating graduates, there is an urgent need to standardize undergraduate and postgraduate medical education across India to maintain a uniform quality of medical training.
Mentor Institutes: Recognizing the variance in the quality of medical education, the Committee suggests the division of India into zones with premier institutes like AIIMS serving as mentor institutes. These mentors would oversee and elevate the standard of education in new and private medical colleges within their zone.
Preparation and Transparency: The government is urged to provide sufficient preparation time for candidates and early release of the exam schedule and details. This approach is aimed at facilitating a smooth transition to the new examination format for the first batch of candidates.
Conclusion
The introduction of NExT represents a significant shift towards improving the quality and consistency of medical education in India. While the initiative holds great promise, its success hinges on careful planning, inclusive consultation with stakeholders, and equitable implementation strategies. By addressing these challenges, NExT has the potential to transform medical education and healthcare standards in India, ensuring that future medical professionals are well-equipped to meet the challenges of their profession.
Context: Uttar Pradesh is a remarkable example of the importance of women’s empowerment in tackling malnutrition by supporting community-based micro enterprises led by self-help groups.
About Malnutrition:
According to the World Health Organisation:
It refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients.
The term malnutrition covers 2 broad groups of conditions:
One is ‘undernutrition’: Includes stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals).
The other is overweight, obesity and diet-related noncommunicable diseases (such as heart disease, stroke, diabetes, and cancer).
Conditions such as celiac disease and infections like h. pylori or worm infestations can disturb the digestive system, leading to nutrient deficiencies.
Malnutrition caused by micronutrient deficiency has inter-generational impacts - anaemic mothers are known to give birth to anaemic babies.
Severe acute malnutrition (SAM) is defined by a very low weight for height, severe visible wasting, or the presence of nutritional oedema.
Extent of malnutrition in India:
According to UNICEF, India was at the 10th spot among countries with the highest number of underweight children, and at the 17th spot for the highest number of stunted children in the world
According to National Family Health Survey 5, from 38.4% to 35.5% of children under age five years are stunted, 21.0% to 19.3% are wasted, 35.8% to 32.1% are underweight and 3% are overweight.
7.7 percent of children in the country are affected by SAM.
Among adults, 23% of women and 20% of men are considered undernourished in India. On the other hand, 21% of women and 19% of men are overweight or obese.
Government initiative to tackle malnutrition:
National Nutrition Strategy by Niti Aayog: To reduce all forms of malnutrition by 2030, with a focus on the most vulnerable and critical age groups. The Strategy also aims to assist in achieving the targets identified as part of the Sustainable Development Goals related to nutrition and health.
Integrated Child Development Services (ICDS) Scheme: To improve the nutritional and health status of children in the age-group 0-6 years;
Prime Minister’s Overarching Scheme for Holistic Nutrition Abhiyaan (POSHAN Abhiyaan 2.0): To strengthen nutritional content, delivery, outreach and outcomes with focus on developing practices that nurture health, wellness and immunity to disease and malnutrition
Mid-Day Meal Scheme: It provides that every child aged six to fourteen years, attending classes I to VIII, shall receive a free, hot cooked meal every day except on school holidays.
Indira Gandhi Matritva Sahyog Yojna (IGMSY): To contribute to a better enabling environment by providing cash incentives for improved health and nutrition to pregnant and lactating mothers.
National Food Security Act (NFSA): This act aims to provide subsidized food grains to a majority of the population, including children, to ensure access to adequate food.
Challenges in tackling malnourishment in India:
Issues with ICDS: Lack of quality food supply and uniform distribution of food.
Anganwadi workers' effectiveness in addressing malnutrition is hindered by low wages and inadequate training.
Non- availability of instruments for child development: Height and weight measuring instruments in Anganwadi Centres (AWCs).
More than 80% of Anganwadi centers in rural areas of the state lack proper sanitation facilities and access to clean drinking water, contributing to the prevalence of diseases that exacerbate malnutrition, such as diarrhoea and parasitic infections.
Less than 50% of the total allocated funds for the Integrated Child Development Services (ICDS) were utilized in 2018-19, indicating underutilization of funds.
Lack of credible data on a year-to-year basis: There was a 10-year gap between NFHS 3 and NFHS 4 surveys.
Poverty and income inequality: Malnutrition arises from the vicious cycle that starts with poverty. Low-income families have less access to resources to attain healthy meals, leading to insufficient nutrients in their diets, which subsequently leads to malnutrition.
Rice wheat-based policy: India’s food security policy gave excessive focus to rice and wheat for many decades.
Poor feeding practices: Malnutrition among children can be attributed to poor feeding practices, which encompass various factors such as premature weaning, insufficient exclusive breastfeeding, and inadequate complementary feeding.
Climate change impact: Erratic rainfall and increasing frequency of extreme events have impacted agricultural activities everywhere creating unfavourable conditions for food production.
Corruption: Corruption in PDS is widely recognised. PDS a food distribution scheme is mired with inefficiencies and corrupt practices denying food to many. E.g: NAN scam of Chhattisgarh.
Suggestive measures to tackle malnutrition:
Need to invest in the infrastructure of ICDS and the Anganwadi centres as well as improve their coverage.
Promoting breastfeeding: Emphasizing exclusive breastfeeding for the first six months and sustained breastfeeding up to two years enhances the nutritional well-being of infants and young children.
Enhancing dietary diversity: Encouraging a balanced and diverse diet incorporating fruits, vegetables, whole grains, legumes, nuts, and animal-source foods helps address nutrient deficiencies. For example: Haryana is providing financial incentives of ₹7,000 per acre to farmers for shifting from paddy to pulses, oilseeds, and cotton.
Need to implement Buddy Mothers Model, the mother of a healthy baby guides the mother of a malnourished child at an Angandwadi centre every week in the all over India so that children can enjoy their right to stay healthy.
Social audit of Mid-day meal scheme: The mid-day meal scheme should undergo a social audit in every district by the states and union territories.
Establishing an Agriculture-Nutrition Corridor: Can be pivotal in addressing India's nutritional challenges, particularly in its undernourished villages. This initiative aims to develop mechanisms to ensure the nutritional security of villages.
Cash transfers: Especially in regions experiencing acute distress, where household purchasing power is very depressed. It can also be used to incentivise behavioural change in terms of seeking greater institutional support.
Take home ration model
Collaboration between United Nations World Food Programme (WFP)and the Department of Women and Child Development aims to boost the nutritional value and utilization of supplementary nutrition in Uttar Pradesh's ICDS scheme. Focus on enriching take home ration products to promote diversity and increase consumption.
Women’s empowerment in tackling malnutrition by supporting community-based micro enterprises led by self-help groups. These enterprises produce fortified and nutritious foods for pregnant/breastfeeding mothers and children, provided as take home ration through the Integrated Child Development Services (ICDS) programme.
Engaging women from the community to run the take home ration production units. They have been provided with machinery and raw materials such as wheat at subsidised rates to produce and distribute take home ration, this unique gender-transformative approach provides livelihood opportunities to local women, empowering them economically.
The model involves the production of different variants for ICDS beneficiaries. This is done by a 20-member women group that uses automated equipment with a capacity of five metric tonnes per day.
Once the rations are delivered to Anganwadi centres by the women’s groups, the women are reimbursed according to ICDS cost norms.
National Accreditation Board for Testing and Calibration Laboratories-accredited laboratories test the products before dispatch to Anganwadi centres to certify the requisite calorie and protein values and ensure food safety.
India has the problem of identical brand names being used for different drugs to treat different medical conditions. This issue has been a concern for the medical community for many years. E.g.,
Two different drugs had identical brand names — ‘Linamac’.
‘Linamac 5’ is used to treat multiple myeloma (a type of cancer), the other drug bearing the name ‘Linamac’ is used to treat diabetes.
The problem is not limited to identical names but also extends to similar names that are phonetically and visually similar to each other. E.g.,
‘Medzol’ is a drug used as a sedative.
‘Medpol’ is a brand that sells paracetamol.
‘Medrol’ to sell a corticosteroid.
‘Metrozole’ to sell an antibiotic. These names sound phonetically similar to ‘Medzole’ and also similar to each other, with only a letter or two substituted.
Concerns:
Potential risk to patients: The use of such identical or similar names can lead to confusion and potential harm for patients in India for two reasons.
The packaging of all drugs in India bears the name and prescription advice in the English language, a language spoken by less than 10% of the population.
Indian pharmacies are poorly regulated. Not only do many pharmacies in India routinely dispense drugs without prescriptions, but several also do not comply with the legal requirement to operate only with trained pharmacists who are registered with the Pharmacy Council of India.
These factors increase the possibility of errors in dispensing drugs. Hence, identical or similar sounding brand names of drugs, and the possibility of prescription errors increases even further.
Lackadaisical approach by MoH:
The Supreme Court of India (2001) and the Parliamentary Standing Committee on Health and Family Welfare in its 59th report (2012) urged the Ministry of Health (MoH) to put in place processes to prevent the use of names for drugs that are confusingly similar.
Even the Registrar of Companies and the Office of Registrar of Newspapers for India have systems in place to ensure that no two companies or publications have identical or similar names.
However, the recommendations of the Court and Parliament have largely been ignored by the Ministry of Health.
Lack of database of pharmaceutical brand-names: The Ministry of Health brought in the Drugs and Cosmetics (Thirteenth Amendment) Rules, 2019.
These rules require pharmaceutical companies to provide an “undertaking” to State drug controllers, along with their applications for manufacturing licences, that the brand name of the drug for which they were seeking a manufacturing licence was unlikely to cause “confusion or deception in the market”.
The rules required pharmaceutical companies to carry out a search for similar names in trademarks registry, central database for brand name or trade name of drugs maintained by Central Drugs Standard Control Organisation (CDSCO), literature and reference books on details of drug formulations in India, and internet.
However, this framework of self-certification did not help as there is no database in India of all pharmaceutical brand-names. The CDSCO would first have to build such a database by collecting data from the 36 different drug controllers in each State and Union Territory.
Further, India has no data on prescription errors. Only after maintaining such a database, the Ministry of Health can start the reform process by replicating mechanisms of regulation such as those that exist in the United States and Europe, to avoid confusion and minimize prescription errors.
Context: The Serum Institute of India (SII) will join a growing Coalition for Epidemic Preparedness Innovations (CEPI) network of vaccine producers in the Global South to support more rapid, agile, and equitable responses to future disease outbreaks, and take it a step closer to achieving the 100 Days Mission.
AboutCoalition for Epidemic Preparedness Innovations (CEPI):
It is an innovative global partnership between public, private, philanthropic, and civil society organisations working to finance independent research projects to develop vaccines against emerging infectious diseases in alignment with the WHO R&D Blueprint for action to prevent epidemics.
Enable equitable access to these vaccines for people during outbreaks.
Also other biologic countermeasures against epidemic and pandemic threats.
It was launched in 2017 at the World Economic Forum (WEF) in Davos by the governments of Norway and India, the Bill & Melinda Gates Foundation, the Wellcome Trust and WEF.
It adopted a vision of 100 Days Mission for delivering a vaccine within 100 days with improved surveillance providing earlier detection and warning, and swift use of interventions such as testing, contact tracing and social distancing to suppress disease transmission.
About Arogya Maitri Disaster Management Cube - BHISHM
It is a cube which will function as world's first portable hospital.
This cube is a part of the broader initiative named “Project BHISHM” – Bharat Health Initiative for Sahyog, Hita and Maitri to develop a world-class disaster hospital.
It is tailored to treat up to 200 casualties, emphasizing rapid response and comprehensive care.
It integrates Artificial Intelligence (AI) and data analytics to facilitate effective coordination, real-time monitoring, and efficient management of medical services in the field.
The Aid Cube is equipped with several innovative tools such as a mini-ICU, an operation theatre, cooking station, food, water, a power generator, blood test equipment, an X-ray machine, and more, designed to enhance disaster response and medical support during emergencies.
The whole unit contains 72 easily transportable components that can be conveniently carried by hand, cycle, or even drone, providing unmatched flexibility.
In the face of mass casualty incidents (MCIs), where requirements range from basic aid to advanced medical and surgical care, the Aid Cube stands out with its ability to be deployed within 12 minutes.
These cubes are robust, waterproof, and light, designed for various configurations, making them ideal for diverse emergency scenarios. From airdrops to ground transportation, the cube can be rapidly deployed anywhere, ensuring immediate response capability.
Two such ‘Aarogya Maitri’ mother cubes combine to form a “brick” to complete the kit. The design of these cubes draws inspiration from the “Rubik’s Cube.
Context: Maharashtra’s Anganwadi workers and helpers have been on strike for 46 days now. They have been demanding basic nutrition for children, whose per-day food cost for two meals has been ₹8 a child since 2014 and increase the rent for centres.
About Anganwadi Services:
Anganwadi means ‘courtyard shelter’, a type of rural child care centre in India.
It was started in 1975 as part of the Integrated Child Development Services program to combat child hunger and malnutrition.
The Anganwadi system, launched under the Anganwadi Services Scheme, renamed as Saksham Anganwadi and Poshan 2.0, is a Centrally Sponsored Scheme under the Ministry of women and child development.
It is one of the flagship programmes of the Government of India providing early childhood care and development of the beneficiaries i.e., children in the age group of 0-6 years, pregnant women and lactating mothers through a large network of Anganwadi workers (AWW) and Helpers (AWH).
Anganwadi workers (AWW) and Helpers (AWH) are the basic functionaries of the ICDS who run the Anganwadi Centres (AWCs), and implement the ICDS scheme.
Anganwadi Centres (AWCs): Provide a platform for rendering all services under the scheme.
A single Anganwadi worker (AWW), chosen from the community, manages one village or area. These workers undergo training in various areas such as health, nutrition, and childcare.
There are a total 14 lakh AWCs sanctioned across the country out of which 13.63 lakh AWCs are operational till 2018(PIB).
Criteria for Recruitment of Anganwadi Workers
As per guidelines, Anganwadi Workers under the Anganwadi Services Scheme are selected from the local village by a Committee constituted by the State Government/ UT Administration.
The minimum prescribed qualification is Matriculation and age limit is 18-35 years for engagement of Anganwadi Workers (AWWs) and Anganwadi Helpers (AWHs).
Anganwadi System: How Does It Operate?
Primarily established for rural development, the Anganwadi system is managed by Anganwadi workers who cater to individual villages within a specified area.
These workers, who hail from the community itself, undergo approximately four months of training in various domains including health, nutrition, and child care.
Each Anganwadi worker is responsible for approximately 1000 individuals and reports to a supervisor known as the Mukhya Sevika.
Services provided by Anganwadi workers:
It is a part of the Indian public health care system.
Basic health care activities include contraceptive counselling and supply, supplementary nutrition, non-formal pre-school education, nutrition, and health education, immunization, and health check-up
The centres may be also used as depots for oral rehydration salts and basic medicines.
Benefits granted to Anganwadi Workers and Helpers
Honorarium: AWWs and AWHs, being honorary workers, are paid monthly honoraria as decided by the Government from time to time, which is uniform in all States/UTs.
AWWs at main Anganwadi Centres (AWCs) are paid an honorarium of ₹ 4,500/- per month and AWHs are paid ₹2,250/- per month.
In addition to the honorarium paid by the Government of India, most of the States/UTs are also giving monetary incentives to these workers out of their own resources.
Leave: They are allowed paid absence of 180 days of maternity leave and 20 days annual leave.
Award: In order to motivate AWWs/and give recognition to good voluntary work, a Scheme of Award for AWWs has been introduced, both at the National and State level.
The Award comprises Rs.50,000/- cash and a Citation to AWW and Rs.40,000/- to AWHs.
Uniform: Government has made a provision for a set of two Uniform (saree/suit per annum @ Rs.500/- each).
Insurance coverage: AWWs and AWHs been covered under, Pradhan Mantri Jeevan Jyoti Bima yojana (PMJJBY), Pradhan Mantri Suraksha Bima yojana (PMSY) and Anganwadi Karyakartri Bima yojana (AKBY).
Importance of Anganwadi programme in India:
Accessibility and affordability of healthcare: Providing the right healthcare facilities to the rural population of India especially mother and child remains a significant challenge. Many individuals are unaware of the programs available to them.
Establishment of social connections within the community: These centers offer women a sense of involvement in their communities, providing opportunities for participation in activities they might not otherwise have access to.
Nutritional support: Every child requires proper nutrition for healthy development, both physically and mentally. Adequate nutrition in early childhood increases the likelihood of developing into a healthy adult.
Access to Government programs: Anganwadi workers play a crucial role as the primary source of access to government schemes for rural communities. Through their assistance, mothers and parents become informed about essential health services and benefits.
Providing early childhood care and education: Children are heavily impacted by their surroundings and the people around them during their early life and early childhood care and education (ECCE) is more than just school readiness.
It attempts to develop a child’s social, emotional, cognitive, and physical needs holistically in order to lay a firm and comprehensive basis for lifetime learning and wellbeing.
Awareness and counselling: They provide valuable information to mothers and communities about proper health care practices, nutrition, and hygiene. Additionally, they offer counselling on family planning, immunizations, and the importance of education.
Poverty alleviation: By addressing health and nutritional needs, the Anganwadi programme indirectly contributes to poverty alleviation. Healthy and well-nourished individuals are better positioned to participate in education and employment opportunities, breaking the cycle of poverty.
Women empowerment: The programme involves a significant number of female workers, contributing to women's empowerment by providing them with employment opportunities. It also promotes the active involvement of women in decision-making processes related to healthcare and nutrition.
Government initiative:
Collaboration with MGNREGA: The government, in collaboration with the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS), is undertaking the construction of 400,000 Anganwadi Centers (AWCs) nationwide as part of the Integrated Child Development Services (ICDS) Scheme.
Digitalization of Anganwadi Services: AWCs are digitally strengthened with smartphones for POSHAN tracking systems, and monitoring devices.
Enhanced training approach: The Ministry has developed a thorough training strategy for Anganwadi Services personnel, ensuring regular training sessions. Anganwadi Workers undergo a 26-day job training program, focusing on improving their knowledge, comprehension, and skills pertaining to various Acts, Policies, Programs related to women and children. The training also covers the establishment of dynamic Anganwadi Centers and the effective execution of Early Childhood Care and Education activities.
Challenges in functioning of Anganwadi services:
According to Niti Aayog:
Cramped and poorly ventilated: Many AWCs across all sampled states, especially in urban areas, are cramped and poorly ventilated. They do not have enough space for the children to play and learn properly. Many AWCs do not have equipment like swings, sand/water areas etc. due to lack of space and/or funding.
Insufficient AWCs: Discrepancies exist between the approved and functioning AWCs in different states, with disparities ranging from 2% to 8.37% (PIB).
Lack of basic facilities: More than 80% Anganwadi centres in the rural areas of the state lack basic toilet facilities and do not have access to safe drinking water.E.g.: In Odisha more than 80% Anganwadi centres in the rural areas lack basic toilet facilities.
Lack of awareness: The community lacks awareness about the role of an AWC and the services offered by AWC. Moreover, the AWC has a perception of poor service delivery in terms of Pre-School Education (PSE), especially in rural Gujarat and in Rajasthan.
Operational ineffectiveness: Despite the essential requirement of smartphones for ICDS, numerous AWWs have not been provided with these devices, thereby impacting their operational effectiveness.
Issues with honorarium: AWWs are not officially recognized as government employee status and receive monthly honorariums well below the minimum wage, ranging from Rs. 5,000 to Rs. 10,000. The inadequacy of compensation presents challenges in fulfilling basic needs, affecting their commitment to their duties. There is also the issue of delays in receiving honorariums contributing to financial insecurity and hardships for AWWs.
Issues with budgetary allocation: The scheme experiences inconsistency in the percentage or delays in budget allocations over the years. For example: In Delhi the budget assigned to rent a place for AWCs is insufficient. The rental norms of Rs.6000/- per month do not allow renting a reasonably hygienic room for the functioning of the ICDS, leading to improper planning and implementation, along with non-adherence to financial and physical targets.
Unpaid duties: AWWs are frequently assigned various tasks, including Covid-19 duties, Census duties, or implementing government schemes, without receiving additional financial compensation. The resulting heavy workloads contribute to burnout, impacting the quality of services they are able to provide.
Inadequate human capital: Several States/UTs, such as Telangana, Bihar, and Karnataka, face a significant number of vacant positions for Supervisors, AWWs, and AWHs.
Lack of proper training: The initial training for AWWs lacks sufficient preparation to address the multifaceted challenges they face on a daily basis.
Non- availability of instruments for child development: Height and weight measuring instruments in AWCs.
Measures for empowerment of Anganwadi workers:
Need for Community Hub models for AWCs: Anganwadi Hubs can be developed by combining three to four AWCs in areas with high population density.
Addressing equipment shortages: Immediate attention required for the availability of height and weight measuring instruments in AWCs.
Infrastructure assessment and funding allocation: The Government should set up a committee to identify the AWCs with bad infrastructure that is classroom, kitchen, building and playground and such centres should be allocated more funds to improve their infrastructure.
Priority focus on basic amenities: Prioritizing the establishment of drinking water and toilet facilities in AWCs for improved service delivery.
Corporate partnership for infrastructure enhancement: The Identified AWCs can be referred to big corporations, so that it can be adopted by them to improve their infrastructure.
Promoting awareness and attendance: As the AWs suffer from Low attendance of beneficiaries it becomes a task of the AWCs to promote the services of AW among the needy by rural communities. Pamphlets can be issued to the rural houses about the services rendered by the AWCs.
Context: Indore and Surat were named the joint winners of the cleanest city in the Swachh Survekshan Awards 2023.
About Swachh Survekshan Awards (SSAs) : Urban
Launched in: 2016
Launched as: Part of the Swachh Bharat Abhiyan, to assess urban areas for their levels of cleanliness and active implementation of Swachhata mission initiatives in a timely and innovative manner.
Launched by: Ministry of Housing and Urban Affairs with Quality Council of India as its implementation partner.
Methodology for measuring cleanliness: Citizen feedback and field assessment.
Objective: To encourage large scale citizen participation and create awareness amongst all sections of society about the importance of working together towards making towns and cities a better place to live in.
Theme of the cleanliness survey 2023:“Waste to Wealth”, while for 2024 it is “Reduce, Reuse and Recycle”.
Key findings of Swachh Survekshan Awards 2023 :
Cleanest city (over 10 lakh population):Indore has been named the cleanest city in the Swachh Survekshan Awards for the seventh consecutive year.
Surat, which has been in second place, won the top award for the first time.
Both cities had 100% door-to-door collection of waste, 98% segregation at source and 100%Navi Mumbai was named the third cleanest city.
Cleanest state: Maharashtra was awarded the cleanest state, followed by Madhya Pradesh.
Arunachal Pradesh, Mizoram, Rajasthan, Nagaland and Tripura were ranked the bottom five states.
About Swachh Bharat Mission (Clean India Mission):
Background: It is a restructured version of the Nirmal Bharat Abhiyan launched in 2009.
Launched in: 2nd October 2014
Type of scheme: Centrally sponsored scheme
Objective: To eliminate open defecation and improve solid waste management and to create Open Defecation Free (ODF) villages. Also aims to increase awareness of menstrual health management.
Phases of SBA:
Phase 1 of SBM: Lasted till 2 October 2019. To eradicate manual scavenging, generating awareness and bringing about a behaviour change regarding sanitation practices, and augmentation of capacity at the local level.
Phase 2of SBM: Being implemented between 2020–21 and 2024–25 to help cement the work of Phase 1. Aims to sustain the open defecation free status and improve the management of solid and liquid waste, while also working to improve the lives of sanitation workers.
The mission was split into two: Rural and Urban.
SBA - Rural: Financed and monitored through the Ministry of Drinking Water and Sanitation (since converted to the Department of Drinking Water and Sanitation under the Ministry of Jal Shakti).
SBA- Urban: Overseen by the Ministry of Housing and Urban Affairs.
Salient Features of Swachh Bharat Mission - Urban 2.0
Launched in: 2021
Tenure: Till 2026.
Objective: For creating a “Garbage Free” Urban India.
Focus areas of mission: All households and premises segregate their waste into “wet waste” and “dry waste”.
100% door to door collection of segregated waste from each household/ premise;
100% scientific management of all fractions of waste, including safe disposal in scientific landfills;
all legacy dumpsites remediated and converted into green zones;
all used water including fecal sludge, especially in smaller cities are safely contained, transported, processed and disposed so that no untreated fecal sludge and used water pollutes the ground or water bodies.
Intervention of the mission:
Garbage Free Cities: All statutory towns are certified at least 3-star garbage Free, or higher. Follows a SMART framework – Single metric, Measurable, Achievable, Rigorous verification mechanism and Targeted towards outcomes.
ODF Norms: No faeces should be seen around, and everyone at home and public places should use safe methods to get rid of it.
ODF+ Norms: Nobody should defecating and/or urinating in open areas. All public and community toilets should be kept clean and well-maintained.
ODF++ Norms: Emphasis on mechanized cleaning of septic tanks and sewers. Safe collection & treatment of used water as well as safe management of faecal sludge.
Water+ Norms : The focus is on collection, transportation, treatment, and reuse of both used water and faecal sludge to prevent environmental pollution.
For towns having population more than 20,000, a minimum of 25% households to be connected to sewerage network.
Striving to achieve sustainability.
No untreated used water is let out in the environment.
Context: Central Government is set to roll-out human papillomavirus (HPV) vaccination program for girls in the age group of 9-14 years. The roll-out of HPV vaccination is expected to reduce the incidence of cervical cancer, which is the second most common cancer in women in India. India accounts for one-fifth of the global burden of cervical cancer, recording 1.25 lakh cases and 75,000 deaths each year.
HPV Vaccination Campaign:
The government plans to launch an HPV vaccination drive for girls aged 9-14 years to reduce cervical cancer rates.
This campaign will be carried out in three phases over three years.
The immunisation will be carried out through schools and existing immunization points.
The two-dose HPV vaccine, which will be free under the government's immunization program, protects against various cancers and genital warts caused by HPV.
This safe and effective vaccine can help prevent six HPV cancers. Five of these occur in women: vulvar, anal, vaginal, throat, and cervical. And other is penile cancer.
The campaign aims to immunize one-third of girls in the target age group each year, with an initial phase requiring 6.5-7 crore vaccine doses.
Currently, the two-dose HPV vaccine is commercially available for about Rs 2,000 per dose. However, once included in the immunization program it will be made available for free.
Production Capacity Increase for HPV Vaccine:
The Serum Institute of India (SII) is increasing its production capacity for Cervavac, a quadrivalent vaccine that protects against four HPV strains.
The current capacity of 2-3 million doses per year is expected to increase to 60-70 million doses
Cervavac is a quadrivalent vaccine developed to protect against certain types of human papillomavirus (HPV).
Quadrivalent Vaccine: "Quadrivalent" means that the vaccine targets four different types of HPV. Specifically, Cervavac is designed to protect against HPV types 16, 18, 6, and 11.
Targeted HPV Types: HPV Types 16 and 18 are high-risk types that are responsible for the majority of cervical cancers, as well as other types of cancers like anal and oropharyngeal cancers.HPV Types 6 and 11 are low-risk types that commonly cause genital warts but are not typically associated with cancer.
Use and Effectiveness: Cervavac is primarily used to prevent cervical cancer, genital warts, and other HPV-related diseases. The vaccine is most effective when administered before individuals become sexually active, as it protects against HPV types that they have not yet been exposed to.
Administration: The vaccine is typically administered in a two-dose schedule for young adolescents, with the doses spaced several months apart. For older recipients or those with certain health conditions, a three-dose schedule might be recommended.
Development and Availability: Cervavac is developed by the Serum Institute of India (SII), one of the world's largest vaccine manufacturers. It represents a significant advancement in the global effort to combat cervical cancer, particularly in low- and middle-income countries where the burden of HPV-related diseases is highest and access to vaccines can be limited.
Importance in Public Health: By providing protection against key HPV types, Cervavac plays a critical role in reducing the incidence of cervical cancer and other HPV-related conditions. It is an important tool in public health strategies aimed at reducing the global burden of these diseases.
Single-Dose HPV Vaccine Trials:
National Immunization Technical Advisory Group (NITAG) has advised Indian Council of Medical Research (ICMR) to trial single-dose HPV vaccine efficacy in ages 9-15.
While there is no global recommendation for a single-dose schedule, the WHO suggests it can be followed for public health programs. The ICMR is considering an antibody persistence study post-one dose instead of a Phase-3 trial.
Combination of Screening and Vaccination:
Scientists and health experts emphasize the importance of combining efficient screening programs with HPV vaccination to effectively tackle cervical cancer.
About Cervical cancer
It is a type of cancer that occurs in the cells of the cervix, which is the lower part of the uterus that connects to the vagina.
Types of Cervical Cancer:
Squamous cell carcinoma: This type begins in the thin, flat cells lining the outer part of the cervix and accounts for the majority of cervical cancers.
Adenocarcinoma: This type starts in the glandular cells that line the cervical canal.
Causes of Cervical Cancer:
Human Papillomavirus (HPV) Infection: The primary risk factor for cervical cancer is a persistent infection with certain types of HPV/wart virus, a sexually transmitted virus.
Other factors can increase the risk, such as smoking, having a weakened immune system, long-term use of oral contraceptives, and having multiple sexual partners.
Who is Impacted Most: Cervical cancer most frequently affects women over 30 years of age. It's less common in developed countries due to widespread screening with Pap tests which can detect precancerous changes in the cervix.
Symptoms of Cervical Cancer:
Early stages often have no symptoms.
Advanced stages may include irregular bleeding and discharge, pelvic pain, and bleeding after menopause.
Treatment for Cervical Cancer:
Surgery: To remove early-stage cancers or precancerous cells.
Radiation Therapy: Often used along with chemotherapy for more advanced stages.
Chemotherapy: Used to treat advanced cervical cancer, often in combination with radiation.
Current Status of Cervical Cancer in India
Incidence and Mortality: Cervical cancer is the second leading cause of cancer deaths among women in India, after breast cancer with age-specific incidence and mortality rates of 22 and 12.4 per 100,000 women per year, respectively.
Globally: As of now, it is fourth most common cancer among women worldwide, cervical cancer claims the lives of more than 3,00,000 women every year, or one life every two minutes.
9 out of 10 women dying of cervical cancer live in lower- and middle-income countries.
India: India accounts for 25% of all global deaths due to cervical cancer.
Survival Rates: The overall 5-year relative survival rate for cervical cancer in India is 46%. This rate varies significantly with the stage of cancer at diagnosis, dropping to 7.4% for advanced stage disease compared to 73.2% for localized cancer.
Challenges
Limited access to screening and treatment.
Lack of health care infrastructure.
Social and cultural barriers impact awareness and early detection.
Healthcare Disparities: Geographic disparities exist in healthcare access and quality. E.g. rural urban divide Current Global Statistics of Cervical Cancer
Incidence and Mortality: Cervical cancer is the fourth most common cancer in women globally, with 604,000 new cases and 342,000 deaths in 2020.
Geographical Variation: The highest rates of cervical cancer incidence and mortality are found in low- and middle-income countries, particularly in sub-Saharan Africa, Central America, and South-East Asia.
Risk Factors: Persistent infection with the human papillomavirus (HPV) is the primary cause of cervical cancer. Women living with HIV are six times more likely to develop cervical cancer compared to those without HIV.
Strategies and Initiatives by WHO to tackle Cervical Cancer
The World Health Organization (WHO) has set goals, establishing targets of 90-70-90, to accelerate the elimination of cervical cancer with a set of three targets to be met by 2030:
HPV Vaccination:
Vaccination against HPV, particularly targeting 90% girls aged 9–14 years before they become sexually active, is a key preventive measure. As of 2023, six HPV vaccines are available globally, protecting against high-risk HPV types 16 and 18, which cause most cervical cancers.
Cervical Screening and Treatment of Precancers:
Regular cervical cancer screening is recommended for 70% of women, every 5–10 years starting at age 30, and every 3 years for women living with HIV starting at age 25. The use of high-performance HPV tests for screening is encouraged.
Self-collection of samples for HPV testing is an option that has been shown to be as reliable as samples collected by healthcare providers.
Awareness and Access to Information and Services:
90% of women detected with cervical pre-cancer and cancer lesions must receive treatment and care.
Boosting public awareness and access to information and services are crucial for prevention and control of cervical cancer.
Other prevention steps include being a non-smoker, using contraceptives.
Human Papillomavirus (HPV) It is a group of more than 200 related viruses, of which more than 40 are spread through direct sexual contact. Among these, several are known to cause cervical cancer.
Types of HPV:
Low-risk HPVs: These types generally do not cause cancer but can cause skin warts on or around the genitals, anus, mouth, or throat.
High-risk HPVs: These types can lead to cancer. Two high-risk HPVs, types 16 and 18, are responsible for the majority of cervical cancers.
Transmission: HPV is primarily transmitted through intimate skin-to-skin contact, most often through sexual transmission. It's possible to contract HPV even when an infected person has no signs or symptoms.
Symptoms: Most people with HPV do not know they are infected and never develop symptoms or health problems from it. In some individuals, the virus can cause genital warts, which may appear weeks or months after sexual contact with an infected partner.
Health Risks: In women, high-risk HPV types can cause cervical cancer. These viruses can also lead to other genital cancers and throat cancer.
Prevention:HPV Vaccination: The best way to prevent HPV is through vaccination, which is recommended for preteens (both boys and girls) and for unvaccinated adults up to age 26.
Safe Sex Practices: Using contraceptive and limiting the number of sexual partners can reduce the risk of HPV.
Screening: Regular cervical cancer screening (Pap smear and HPV test) is recommended for women to detect precancerous changes in the cervix caused by HPV.
Context: According to the Health Ministry, women account for approximately 49% of the total Ayushman cards created and approximately 48% of total authorised hospital admissions.
About Ayushman card:
The national health authority(NHA) issues the Ayushman card, which offers access to a network of public and private hospitals across India.
The health cards are given to the beneficiaries families and individuals. The family health folders are kept at the Health Wellness Centres (HWC) or nearby Primary Healthcare Centres (PHC) in paper and/or digital format.
Beneficiaries can use this card to avail cashless treatment and hospitalisation at these network hospitals.
This ensures that every family knows their entitlement to healthcare through both HWC and the Pradhan Mantri Jan Arogya Yojana or equivalent health schemes of state and central government.
Aadhar card is not mandatory for availing services under this scheme.
About National Health Authority (NHA)
It is the successor of the National Health Agency.
It is an attached office of the Ministry of Health and Family Welfare with full functional autonomy.
Governed by a Governing Board chaired by the Union Minister for Health and Family Welfare.
It is headed by a Chief Executive Officer (CEO), an officer of the rank of Secretary to the Government of India, who manages its affairs. The CEO is the Ex-Office Member Secretary of the Governing Board.
It is an apex body for implementation for AB PM-JAY and National Digital Health Mission.
To implement the scheme at the State level, State Health Agencies (SHAs) in the form of a society/trust have been set up by respective States.
SHAs have full operational autonomy over the implementation of the scheme in the State including extending the coverage to non SECC beneficiaries.
Context: In India, unhealthy eating habits are rapidly growing, and there is a need for higher taxes on High Fat Sugar Salt (HFSS) foods to help reduce their consumption.
About HFSS foods:
It may be defined as foods (any food or drink, packaged or non- packaged) which contain low amounts of proteins, vitamins, phytochemicals, minerals and dietary fiber but are rich in fat (saturated fatty acids), salt and sugar and high in energy (calories) that are known to have negative impact on health if consumed regularly or in high amounts (Ministry of Women and Child Development).
Need to tax HFSS foods:
Public health concerns: According to a World Bank report of 2019, worldwide, 70% of all overweight and obese people live in Low- and Middle-Income Countries.
Economic burden: Obesity’s cost in India was $23 billion in 2017, potentially rising to $480 billion by 2060. This highlights the economic impact of unhealthy diets.
Revenue generation: Can generate revenue for governments, which can be allocated to development of social sector.
Growing consumption: India, the world’s largest sugar consumer, has seen snack and soft drink sales triple, exceeding $30 billion. This indicates a worrying rise in HFSS food consumption.
Initiative taken to reduce consumption of HFSS foods:
Eat Right Movement, 2018 : Launched by FSSAI, to improve public health in India and combat negative nutritional trends to fight lifestyle diseases.
GST rates on ultra-processed foods: Tax on sugar-sweetened beverages (SSBs) with a 28% GST rate and 12% compensation cess.
Kerala’s Fat Tax: In 2016, Kerala introduced a ‘fat tax’, which later merged into India’s Goods and Services Tax in 2017, which later got subsumed into India’s Goods and Services Tax in 2017.
Global Initiative:
Colombia’s “junk food law” on ultra-processed foods, providing a model for other nations.
Over 60 countries have implemented taxes on sugary drinks.
Countries like Denmark, France, Hungary, Mexico, South Africa, the UK, and the US have specific HFSS food taxes.
Way forward:
HFSS taxation in India should prioritize enhancing public health rather than being perceived solely as an economic or fiscal policy.
The promotion of nutrition literacy and effective food labelling is crucial.
There is a need for a nutrient-based tax model, involving higher taxes on products high in fat, sugar, and salt.
HFSS food tax can be both non-regressive and fiscally neutral.
Context: Underlining the risks associated with vaping or e-cigarettes, the World Health Organization (WHO) has urged governments to categorize them akin to tobacco, advocating for the prohibition of all flavors and immediate interventions.
What are E-cigarettes?
There are numerous sizes and shapes for e-cigarettes. The majority feature a heating element, a battery, and a liquid-holding capacity.
To create an aerosol, e-cigarettes heat a liquid that typically contains nicotine, the addictive substance found in normal cigarettes, cigars, and other tobacco products, as well as flavourings and additional compounds. Individuals breathe in this aerosol.
There are several names for e-cigarettes like "electronic nicotine delivery systems (ENDS)," "tank systems," "e-cigs," "e-hookahs," "mods," "vape pens," and "vapes."
Vaping is another term for using an electronic cigarette.
What is in e-cigarette aerosol?
The e-cigarette aerosol that users breathe from the device and exhale can contain harmful and potentially harmful substances, including:
Nicotine
Ultrafine particles that can be inhaled deep into the lungs
Flavoring such as diacetyl, a chemical linked to a serious lung disease
Volatile organic compounds
Cancer-causing chemicals
Heavy metals such as nickel, tin, and lead
What are the concerns related to using e-cigarettes?
Nicotine dependence: The most addictive ingredient in traditional cigarettes, nicotine, is also present in most e-cigarettes. Dependency on nicotine can result in cravings, symptoms of withdrawal, and trouble quitting.
Affects brain development: Nicotine has a particularly negative effect on memory, learning, and attention in the growing brains of teenagers and young adults.
Lung damage - EVALI (lung injury related with vaping or e-cigarette use): This dangerous illness may result in scarring, inflammation, or even death. Chest pain, exhaustion, coughing, and shortness of breath are some of the symptoms.
Long-term lung issues: The aerosol from e-cigarettes contains dangerous substances such diacetyl, which has been connected to the deadly lung condition bronchiolitis obliterans. Additionally, vaping exacerbates pre-existing lung diseases like asthma.
cardiovascular disease: Since e-cigarettes can harm blood vessels and the heart, they raise the risk of heart attack, stroke, and other cardiovascular problems.
Mental health: Nicotine usage has been shown to exacerbate depressive and anxious symptoms.
Secondhand aerosol exposure: The aerosol from e-cigarettes includes nicotine and other dangerous substances that can hurt onlookers, particularly young children and expectant mothers.
Are e-cigarettes less harmful than regular cigarettes?
The aerosol from e-cigarettes typically has less harmful compounds than the lethal mixture of 7,000 chemicals found in traditional cigarette smoke. Aerosol from e-cigarettes is not harmless, though. It may include chemicals that cause cancer, heavy metals like lead, nicotine, volatile organic compounds, and other potentially dangerous things.
Regulation of E-cigarettes:
In India, the possession of e-cigarettes and similar devices is a violation of the Prohibition of Electronic Cigarette Act (PECA) 2019, according to the Union Health Ministry.
All producers, manufacturers, importers, exporters, distributors, advertisers, transporters including couriers, social media websites, online shopping websites, shopkeepers/retailers etc. not to directly or indirectly produce or manufacture or import or export or transport or sell or distribute or store e-cigarettes, whether as a complete product or any part thereof.
Context: A new study reveals that a huge volume of unapproved and even banned fixed dose combinations (FDC) of antibiotics are being sold in India.
In 2020, 60.5% FDCs of antibiotics were unapproved and another 9.9% were being sold despite being banned in India.
What are FDCs?
Fixed Dose Combinations (FDCs) of drugs refer to pharmaceutical formulations that contain two or more active ingredientsin fixed proportions in a single dosage form.
These combinations can include drugs from the same therapeutic class or from different classes.
Benefits: FDCs can be useful in the treatment of some diseases since the combination can improve patient compliance.
For instance, if a patient has to take three different medications for a particular treatment, she may forget to take one. But if all three medications are combined into one tablet or one syrup, the chance of her forgetting to take one or two of the drugs is reduced.
For diseases such as AIDS, it is well documented that FDCs have proven to be very useful in improving patient compliance, which at the end of day improves treatment outcomes.
Issues with FDCs:
Increased Antimicrobial Resistance: Inappropriate use of FDCs can contribute to the development of antibiotic-resistant bacteria. This is because the fixed ratio may not be appropriate for all patients, and it may lead to the overuse of one or both antibiotics.
Potential Side Effects: All drugs have side effects and when formulated together, there is a possibility that the active ingredient or even the excipients (inactive ingredients) may affect the way that each drug functions.
E.g., The drugs may interact in a way to reduce the therapeutic efficacy of each active ingredient, or the drugs may interact with each other to create a more toxic element, often called metabolites.
Regulatory Challenges: Pharmaceutical companies in India use FDCs to escape liability under multiple laws without much concern for public health.
Government fixes the prices of individual drugs under the Drugs (Prices Control) Order (DPCO). Since drug combinations are traditionally not covered under the DPCO, it gives the pharmaceutical industry an easy way to escape the remit of the DPCO. As a result, the Indian market consists of various superfluous combinations of FDCs which are not found elsewhere, further being sold at high prices.
Lack of specific FDC regulations and the sheer volume of FDCs available in the market can make it challenging to effectively ensure quality across the board.
While there are no specific standards for FDC testing outlined in the Drugs & Cosmetics Act, 1940, the law empowers the Central Drugs Standard Control Organisation (CDSCO) to formulate guidelines and regulations for the manufacturing, testing, and quality control of all drugs, including FDCs.
The CDSCO has established certain guidelines for FDC quality control, but these may not be as comprehensive or specific as those for individual drugs.
