People with leprosy are often ostracised from society; this has given rise to leprosy colonies on the outskirts of cities. Currently, there are more than 750 such colonies in India, most of which are built on unused railway lands or on lands donated by individual philanthropists. Many of these colonies date back several decades and were built in reaction to social stigma and forced displacement. People have been living there for generations now. Although they have been able to forge communities and establish local governance systems, they still struggle for many necessities.

After working for approximately two decades across several leprosy colonies in India, Sasakawa-India Leprosy Foundation (S-ILF) has identified some primary challenges that these colonies face. Like other nonprofits supporting people with leprosy, we have had to change our approach in some cases as livelihood patterns shifted, the disease itself became less severe (as disability from leprosy has decreased over the years), and the younger generation got educated and demanded a better life. But there are certain issues that have remained the same.

1. Limited livelihood opportunities

Due to the stigma attached to the disease, even informal employment is a major challenge for people with leprosy. While the situation is worse for those with visible marks on their body, just belonging to the colonies makes the residents targets of discrimination. Until recently, the people from the colonies had difficulty finding opportunities for education, which meant that they had limited options for livelihoods. Many people with leprosy are forced to resort to begging.

Organisations working in these areas have found that livestock rearing, fishery, and other such activities that are usually common in rural areas are also popular here. However, over the years, we have seen a shift towards micro-entrepreneurship, which involves running grocery stores, beauty parlours, food carts, and shops for computer accessories. These businesses require lesser investment in skilling, and allow a self-sustaining, hyperlocal market to be built within the colonies; the residents being the customers also eliminates bias against the vendors. Nonprofits such as S-ILF help the people get loans and registration certificates and provide the entrepreneurs with training on accounting and other aspects of running a business.

Nonprofits and the government have partnered to create awareness against some common myths, such as leprosy being incurable. 

The reduction in cases of Grade 2 disabilities has helped our work because there’s lesser discrimination when the society doesn’t see marks of leprosy on people’s bodies. Nonprofits and the government have also partnered to create awareness against some common myths, such as leprosy being incurable and spreading through touch. I remember, even a decade ago, when we would help vendors set up food carts on the borders of the colonies, we wouldn’t be allowed to use the full name of our organisation on the stalls because people worried that the word ‘leprosy’ would limit their customer base.

We also collaborate with government departments and nonprofits to educate the children in the colonies so that they have more income opportunities when they grow up.

2. Health, hygiene, and the cycle of leprosy    

Many colonies don’t have the appropriate transportation and sanitation infrastructure in place. They lack pukka roads, toilets, clean drinking water, and proper nutrition, which leads to poor immunity that in turn increases chances of contracting the disease. Where toilets exist, they are in dire straits. This results in open defecation, which can potentially spread more diseases in the colony. In the settlements situated in rural areas, nearby fields can be used for defecation, but colonies in cities don’t have that option. This becomes particularly challenging for women and threatens to impact their reproductive health.

The location of the colony plays a key role in determining its condition. For example, the colonies on the outskirts of Delhi are better off because they have access to the government and receive regular funds and donations from individuals and industries too. But that isn’t the case for the large colonies in Purnea district in Bihar, and those in the Northeast. Nonprofits like ours have worked on solving issues such as malnutrition by providing balanced meals. We conduct workshops to introduce the colony to various government schemes related to pension, housing, health, and so on. This not only enhances the residents’ awareness but also gives them confidence to access their rights. We contribute to the well-being of the colony by distributing ration and helping with toilet renovations too.

3. Fear of displacement and rejection

The colonies on railway land were built at a time when land was more abundant. As resources become scarce, populations increase, and railways focuses on repurposing these lands, residents in many of these colonies live in fear of eviction. People are already receiving notices to clear the area and they can’t counter them because they don’t have the land deed that would legalise their claim.

There are still almost a hundred state-based and India-wide laws that discriminate against people with leprosy; these include laws that prevent them from finding employment in university bodies, limit their access to markets and public transport, and stop them from standing for municipal elections. 

In many cases, the residents lack documents, including Aadhaar cards, since they exist outside the framework of formal society.

The National Human Rights Commission (NHRC) and nonprofits have frequently advocated for the removal of such biased laws. Moreover, organisations such as Association of People Affected by Leprosy, an initiative for and by people affected by leprosy, have been working on the ground for capacity building in the colonies so that the residents can recognise and fight for their own rights. Now, these colonies have a local governance system shaped like a village panchayat with elected leaders, who are also part of state-level committees; they help take the communities’ issues to the government, such as the need for better civic amenities like water and electricity.

In many cases, the residents lack documents, including Aadhaar cards, since they exist outside the framework of formal society; we work with the government to help them obtain these. We assist them in getting proper identity cards and acquiring land titles (pattas).

The changes and apprehensions

Since we started, we have seen a decrease in new cases of leprosy—from 1,25,785 in 2014–15 to 75,394 in 2021–22. This has also meant that there’s less conversation about the disease in mainstream media. But the nonprofits that were working in these colonies continue to do so.

There are residents now who don’t carry skin cracks, ulcers, or leprosy-related disabilities, which acted as obvious identifiers of the disease. Many young children in these colonies don’t even have leprosy. This changing situation has necessitated nonprofits like ours to focus on other aspects of the community’s challenges. For example, we work on providing education in the colonies by holding after-school classes and helping people get scholarships to study; many women from these colonies have found employment as nurses after studying on nursing scholarships.

The new generation has more aspirations, some of which can’t be achieved within the confines of the colonies. However, when they step out to nearby places for higher education, they still carry the stigma of leprosy and are looked down upon. Many young people prefer migrating with their families to faraway places where the stigma won’t follow them. Our job has now shifted to conducting skill-building programmes with them to support their ambitions.

The dip in the number of fresh cases has also meant that many funding organisations have diverted their focus from leprosy to other diseases such as HIV, cancer, and tuberculosis, which are considered more life-threatening now. During the peak of COVID-19 too, there was an urgent prioritisation of pandemic-related needs over leprosy. As a result many organisations are struggling for money to continue to do the work they had been doing. It is necessary for funders to realise that the battle against leprosy is only half won until we have also eradicated the stigma and rehabilitated the people into society.

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Know more

• Read this article to learn about life in the last leprosy colony in Kashmir.
• Read this resource to learn more about laws that discriminate against leprosy.
• Read this article to understand how non-communicable diseases in India can be curbed.

Even in the pre-COVID years, Indians depended heavily on private services, but the situation worsened during the pandemic. Many instances of the private sector charging very high prices for providing healthcare came to light in 2020, 2021, and 2022, which had a catastrophic impact on households. On an average, the clinical cost of treating a COVID-19 patient in a private hospital rose to INR 11,000 per day for the general ward. Many were left in debt after their treatment.

India’s healthcare expenditure

This increase in the healthcare burden is, however, not represented in the official data from the government, which paints a different picture. It highlights that government expenditure on healthcare has increased, resulting in people having to spend less money from their own pocket. In order to substantiate this, the government is emphasising that the percent of public expenditure on healthcare in current health expenditure (CHE) has been increasing and within CHE, out-of-pocket expenditure (OOPE) is decreasing.  

According to the National Health Accounts (NHA), CHE refers to “only recurrent expenditures for healthcare purposes net all capital expenditures”. This means expenditure contributed by all union, state, and local government bodies; private entities such as insurance and donors; and so on. The NHA data indicates that the portion of public expenditure on healthcare in relation to CHE was approximately 27 percent in 2016–17. This saw an increase to 33 percent in 2017–18 and further rose to 35 percent in 2019–20. On the other hand, OOPE indicates direct payments made by individuals for any medical service. These are payments not covered by a third party, including the government or any health insurance. The NHA data shows that OOPE in India has been declining steeply. It decreased from 63 percent of CHE in 2016–17 to 55 percent in 2017–18 and has continued to decline. In 2019–20, it was approximately 52 percent.

This trend suggests a rising investment in India’s healthcare by the government, seemingly relieving the burden on the public. However, a closer inspection reveals that this is a simplistic reading.

What is NHA and how does it calculate health data?

Since these health trends are derived from data provided by NHA, it is important to understand what NHA is and how its estimates are calculated.

NHA is an accounting framework that estimates the annual health spending of an economy through a methodology that makes the estimates internationally comparable. It follows the globally used standard framework called System of Health Account (SHA), designed by the World Health Organization.

NHA produces estimates of public expenditure, private expenditure, OOPE, and so on by using the following mechanisms:

1. Government expenditure: NHA uses both union and state budget data and the data collected from the official documents of local bodies such as panchayats and municipal corporations for estimating government expenditure.

2. OOPE: To estimate OOPE, it uses the National Statistical Office’s (NSO) rounds on ‘Social Consumption: Health’ and ‘Consumption Expenditure Survey’(CES). The report also uses data from the Government of India’s ‘National Family Health Survey’ (NFHS).

A major component of OOPE on healthcare is estimated from ‘Social Consumption: Health’ since the survey collects information extensively on utilisation of and expenditure on healthcare, and gathers details of both inpatient and outpatient services along with types of ailments. CES also collects information on expenditure on healthcare; however, it does not do so on utilisation of services and types and incidences of ailments. NFHS is undertaken by the government; it collects household information with a special focus on maternal and child health and nutrition. Along with these data sets, since 2017–18, sales data from IQVIA (an analytics and technology provider based in the USA) has also been used to capture expenditure on vaccines, vitamins, minerals, and other supplements.

3. Total healthcare expenditure: Unlike CHE, total healthcare expenditure (THE) includes both current and capital expenditure on healthcare. While current expenditure means day-to-day operational costs such as services and medicines, capital expenditure indicates long-term costs such as infrastructure development, which could include machines or buildings. Capital goods typically have a lifespan of a few years. This means that spending money on a machine or a building should not be considered as only that year’s expenditure since these assets will be used in the years to follow. Therefore, one has to annualise expenditure on capital goods factoring in its depreciation cost. Since it is technically not feasible to annualise capital expenditure incurred by the providers every year, and thus not possible to eliminate the risk of overcounting, using estimates in proportion to CHE is considered a good practice.

Why this produces inaccurate data

Due to the absence of any nationally representative updated database on OOPE, it is not possible to estimate indicators without error. The magnitude of error would be higher with more outdated databases. Here are some causes of concern:

1. NSO relies on outdated census data

Since it is not possible to cover the entire population of the country for their survey, NSO carries out a sample survey for collecting data. It uses census data for designing sampling frames (the list of individuals the sample survey is drawn from). However, since no new census data has been published after 2011, it is impossible to have an appropriate sampling design and frame for NSO.

2. No new CES has been conducted since 2011

The last CES was carried out in 2011–12. NHA has been using that same old data set for estimating expenditure on therapeutic appliances. Such old data is bound to estimate utilisation and expenditure incorrectly. One may always argue that the magnitude of error for using such an outdated database will not be huge as the item comprises a very negligible proportion of THE or CHE. However, this imposes different challenges. For example, while estimating expenditure on therapeutic appliances for the state of Telangana, which did not exist in 2011–12 and was formed in 2014, one has to make a series of assumptions. 

3. ‘Social Consumption: Health’ data is from the demonetisation year

 A major chunk of the OOPE is estimated using data from ‘Social Consumption: Health’. However, the last NSO ‘Social Consumption: Health’ round was published in 2018. The survey was conducted in 2017–18 with a reference period of one year. This means that the survey collects information on healthcare expenditure incurred during 2016–17, a year in which demonetisation was imposed. As a result, poor and middle-income families (that primarily spend and transact using cash) didn’t have the money to buy food and other necessities. This had a spillover effect on their ability to spend on healthcare.

The same data set has been used for estimating OOPE for the years since then. Although it has been adjusted for inflation and projected population growth in order to produce the estimates, the data doesn’t reflect changes in the demand for healthcare accurately.

The year 2016–17 was an anomaly because of demonetisation, and any approximation based on it is likely to produce incorrect results. It was a period when people were struggling for cash. For many, the usual alternatives didn’t exist: Their savings in cash had no meaning; there was nowhere to borrow from; and, since the economy as a whole was suffering, they perhaps didn’t even have a market to sell their assets and pay for healthcare.

It would therefore be incorrect to assume that people wouldn’t have accessed these options in the subsequent years. So the OOPE is likely to have increased from 2016–17 to 2019–20.

Is the situation likely to change?

The NHA for FY 2020–21 will be published soon, and this round may show a further decline in the share of OOPE in contrast to the increasing share of public expenditure on health due to the absence of a new round of ‘Social Consumption: Health’ and updated information on public expenditure.

Public expenditure on healthcare is lower than the desired level in India. The Union Government’s expenditure on health hovered around 0.4 percent of the GDP for most of the years during 2014–15 to 2018–19, barring 2017–18 when it increased to 0.55 percent followed by a decline.

There was a miniscule increase in allocation for health emergencies in 2021 due to COVID-19, but this was discontinued after two years.

The latest NHA data builds the illusion that everything is fine with India’s public healthcare. Absence of updated data and inaccurate estimation of OOPE shows the government in a good light and allows it to shrug off responsibility and accountability.

What the government needs to do instead is increase allocation for healthcare and collect and publish data in a timebound manner; this will aid the framing of better policies.

Mampi Bose is a faculty member at Azim Premji University. The views and opinions expressed in this article are those of the author and do not necessarily reflect the views or positions of the organisation they represent.

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Know more

• Read this article to learn how Ayushman Bharat fares in its commitment towards all Indians.
• Read this article to understand why the government’s estimation of OOPE is inaccurate.

One can look at the example of a Muslim Indian who carries the double identity of being an Indian and a Muslim wherever they go. Sometime ago, I was thinking of moving out of my family home due to space constraints; however, the only houses that I was shown by real estate agents were in Muslim-dominated societies or were very dingy, unkempt flats, where the owners were too focused on finding a tenant to care about identities. There was a clear refusal on all the well-ventilated and better-located societies and flats because I am a Muslim. Mine is just one of the many narratives of house-hunting failures that are frequently shared on social media.

People are subjected to state violence every day but, even in these cases, journalists and human rights activists have pointed out a clear prejudice against Muslims in recent times. Their houses have been demolished, they have suffered physical violence, and they are often at the receiving end of hate speeches. Even when they aren’t direct targets of systemic injustice, their multiply marginalised identity increases their struggle. For example, the Supreme Court verdict against the legalisation of same-sex marriages was painful for all queer/trans Indians and their allies, but perhaps it is worse for Muslim trans and queer people because a favourable judgement could have given protection to their interfaith/intercaste unions. Similarly, oppressed-caste Muslims not only bear the brunt of Islamophobia from the outside but also of casteism from within the community.

This has multifold effects on the psyche of the community:

• A Muslim person suppresses their helplessness, suffocation, and rage, which could lead to them feeling low and experiencing numbness and anxiety. In some cases, this frustration can lead to further violence against women and children who are less likely to strike back.
• Being the target of everyday violence in the form of lynching, police brutality, and orchestrated riots can lead to depression, hopelessness, disassociation, and so on.
• Another concern is the lack of opportunities to participate in political and decision-making spaces and, therefore, the internalised guilt that minorities may have of not being able to progress beyond a certain limit. For example, we see how small the number is of Muslims who are part of government bodies or are parliamentary members and judges. Many Muslims feel out of place when aspiring to break free from their predestined lives as determined by discrimination and exclusion.

No government body has specifically recognised the rise of Islamophobia and, thus, there is no record of the mental health impact of the same. In the absence of a formal state response, the question that we need to answer next is, what has been the response of India’s mental health professionals, community mental health organisations, and disaster management bodies to the plight of Muslim Indians?

Denial, stopgap solutions, and political apathy

According to a report by Keshav Desiraju India Mental Health Observatory, India’s mental health budget is 1.03 percent of the health budget, which makes the lack of political will obvious. As the report further notes, most of the money is given to two or three big hospitals and the Tele MANAS helpline (state-level toll-free counseling helplines) only recognises the most debilitating clinical illnesses—such as severe schizophrenia, depression, and OCD. Milder mental health issues (anxiety, mild depression, relationship concerns, body image and self-esteem issues, and so on), prevention, or the contribution of social realities on mental health are not given importance.

The fact that we don’t have clear data on the number of non-upper-caste Hindu providers speaks to how this identity is considered a default.

Even the mental health community has been fixated on seeing individuals in clinical vacuums, devoid of context and social realities. There are many reasons for this. First, as the French philosopher Michel Foucault identified, madness is often understood without context in order to isolate and treat the person rather than to change the system. Second, those who can go to medical school or study psychology need several social and economic privileges to access a college education. The group that forms the profession then is not representative of everyone and, therefore, tends to ignore or not think deeply about the intersections affecting marginalised people. The fact that we don’t have clear data on the number of non-upper-caste Hindu (Dalit/Muslim) providers speaks to how this identity is considered a default and not an issue worth thinking about.

After the attack on Meo Muslims in Nuh and the incident where a Railway Protection Force officer opened fire at four passengers in Maharashtra, I wrote to many psychology/psychiatry bodies such as the National Academy of Psychology, Indian Psychiatric Society, and the Google group called Indian Psychologists to take cognisance of how hatred against Muslims takes a toll on their mental health, provide guidelines for therapists to work with the vulnerable community, and publish a statement in solidarity with them. I did not get a reply from most of them, and the moderator of Indian Psychologists told me that they can’t share my e-mail among the members as the letter was not ‘neutral enough’. They said that the opinion in the letter is more likely to further hate because it is assuming a political position. I was not sure if I should feel worse about the organisations not willing to take a political stand or the apathy of the group that responded.

There have been times when the mental health community has come together to support multiply marginalised people. During the Shaheen Bagh protests, pro bono service provision was organised by well-meaning therapists and community organisations, just like there was some disaster intervention by members from the field during the Bhuj earthquakes and other tragedies. However, overall, the field is quite dormant and not organised enough to respond to these problems.

It will require the coming together of the government, mental health community, researchers, and even faith-based institutions to change this scenario.

Building a mental health ecosystem that recognises intersectional violence

Here are some steps to build a system that recognises the effect of Islamophobia on the mental health of the Muslim community and also makes proactive interventions:

1. Hiring, sensitising, and training better professionals

India doesn’t have enough mental health professionals to cater to its vast population, and thus the community functions with limited resources. Even the available professionals lack adequate training, and don’t go through proper licensing processes and quality checks.

The mental health profession in its current form fails to see social realities and respond in real time. While there are organisations addressing specific issues of inequality (gender rights, queer rights, etc.), it is optional for mental health professionals to be aware or integrated with their work, which is why they do not feel this engagement to be useful. We can learn from the good practices in the West such as the Stanford Muslim Mental Health pages on social media—run by the Muslim Mental Health and Islamic Psychology Lab—that are addressing the issues of mental health of Muslims in real time, or the work done by Lucy Johnstone and colleagues in the UK where they created the ‘power threat meaning framework’ as an alternative and more contextual understanding of mental health that centres lived experience.

2. Conducting contextual research that informs therapy 

While there is worldwide research on the impact of disparity on mental health, the unique contexts of Indian minorities’ mental health is largely missing. In recent times, there have been attempts at correcting the balance. For example, a report by Bebaak Collective (a coalition of autonomous women’s groups) investigates the physical and emotional impacts of extremist violence on Muslims and a paper written by Diane Coffey, Aashish Gupta, and Meghana Mungikar shows that caste minorities and Muslims have the worst mental health in India. However, these are still in the sociology–academia realm and have not percolated into clinical and practice literature yet. They do not, therefore, touch upon the training of therapists and psychiatrists in a large way. There is a requirement for more clinical research that looks at the variables of caste, gender and minority religion status, the mental health impact of living in India for such populations, as well as their mental health needs, and interventions need to be designed accordingly.

The most important part is that this research needs to reach students of psychology and psychiatry and professionals in the field. These studies should be included in the mental health curriculum and we also need a licensing structure in place where, in order to retain one’s license, professionals must continue education credits that help them catch up with new concepts they have not learned.

3. Collaborating with faith-based institutions

Masjids, Islamic boards, and Islamic committees within the country should recognise mental health and social disparity and address these issues at meetings and seminars. They can also help in raising funds for research, intervention, and advocacy in order to bring the lived experience of the average Muslim to the fore.

Faith-based organisations have a far wider reach for Muslims across the country.

Recently, I was invited by the Jama Masjid board in Mumbai to be part of their mental health initiative. While the conversation is still at the planning stage, it seems to be a good attempt at conducting a very important collective dialogue. Faith-based organisations like these have a far wider reach for Muslims across the country. The family counseling centre run by Jama Masjid is an excellent initiative to look at domestic disputes and the need for psychological services, and the Dawa Dua project that functions from within dargahs to provide psychosocial services in cooperation with the shrine mujawars (priests) is another great idea.

4. Making Muslims in India feel included

Dr Akhtar suggests that minorities can be made to feel a part of society by restoring their civil rights, recognising the fact that minority cultures have their own vitalities, and making sure that they are part of the social iconography—statues, street names, currency, holidays, and so on. We can see the opposite happening, with Muslim names and histories being erased by the current government in India.

People from the minority communities, including social and cultural activists and media professionals, can play an important part in helping the community reclaim its place in society. While feelings of victimisation are understandable, they can take cues from reformers such as Fatima Sheikh, the Phules, and Dr Ambedkar to educate, agitate, and organise. There have been some laudable attempts by civil society organisations such as Bebaak Collective, podcasts like ‘Main Bhi Muslim’, and virtual communities like The Queer Muslim Project (QMP). For example, QMP works for the visibility of queer Muslims, and routinely highlights the conflict queer Muslims face while balancing their religious/spiritual identity and sexual/gender identity.

Reinventing India’s shared social fabric

In India’s current political landscape, it is possible that no one—neither the majority nor the minority—is feeling well integrated. We have a lot of unprocessed trauma from pillaging rulers and especially from the British times, famines and wars, and, most importantly, the Partition. Instead of healing these wounds, those with vested interests keep poking at them to rip apart collective unity. 

We need to bring back concern for others and thoughtfulness in how our actions impact others, especially if they are from a marginalised background. Apart from system changes within the mental health space, perhaps the well-being of minorities and the country as a whole depends on the reinvention of a common shared fabric of decency and on us being able to talk to and care for each other.

This article was updated on November 14, 2023, to change India Mental Health Observatory to Keshav Desiraju India Mental Health Observatory.

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Know more

• Read this transcript of a podcast on the future of mental health for the Muslim community.
• Read this article on how mental healthcare is failing marginalised populations.
• Read this article calling for the mental health community to take cognisance of the social suffering of Muslims.

As we near the tapering end of the population growth period, with rise in life expectancy and faster decline in fertility rates, India is experiencing one of the fastest ageing populations and share of older people are expected to rise (8.6% in 2011 to 21% in 2050).

By 2031, elderly count will be 194 million in 2031, compared to 138 million in 2021. The growing older people are posing significant challenges for social welfare, economic and health policies in India. 

Growing share of the oldest-old 

Even more concerning are the trends in the population growth of different age groups among the elderly. The share of elderly aged 80 years and above, in total population, was 0.4% in 1950; which was doubled (0.8%) in 2011 and is expected to increase up to 3.3% by 2050. These demographic shifts indicate a rapid transformation of India’s population composition, where elderly citizens will constitute a significant portion of the total population and it imposes multi-faced challenges form a policy formation point of view especially health care, economic, social and emotional support provision.

Two major challenges associated with increasing ageing population are the health of and the care-giving to the elderly. As age is a predominant determinant of deterioration of health, it limits an individual’s economic productivity, increases chronic morbidity and need for care. An article recently published in The Lancet using their new measure “health adjusted dependency ratio” states that the elderly are largely dependent on others due to their poor health rather than for economic reasons.  

Disability and functional limitations

Mobility associated disabilities are almost inevitable after attaining a certain age. Complete immobility in older ages necessitates round-the-clock assistance to carry out activities of daily living. The latest Longitudinal Ageing Study in India reports that, around 44% of elderly aged 80 years have some kind of activity limitation either in bathing, dressing, eating, using the toilet, getting out of bed or walking across the room.

The numbers from the recent National Sample Survey also suggest that just among 70 years and above population, around 44 lakh elderly are completely bed ridden. Moreover, the number is much higher (19% for elderly aged 80 years above) if we count those who may not be completely bed-ridden but are confined to homes. These numbers can increase to an alarming level in the coming years owing to the rate of population ageing in the country. 

With the advent of a longer life span, there would be a substantial increase in the need for care as elderly population are more vulnerable to possess poor health and non-communicable diseases. Consequently, these multiple health issues contribute to a growing dependence of the elderly upon the younger population as well as on the state for economic, healthcare services and physical support. 

Who will care for the elderly: A big future concern

Hitherto, a majority of living support for elderly had come from children. Only 6% of individuals aged 60 years and above live alone, while 20% live only with their spouse without the presence of their children, but this number can increase significantly in the coming days and might pose a big challenge for household-based informal care-giving. 

In particular, with declining birth rate, migration of young children for education and jobs, splitting of families with growing individuality and the consequent rise in left-behind elderly is a great threat to informal care support for the older population. More importantly, a rise in longer life span for females and growing number of widows pose a serious challenge for later age support for them. Thus, in the future, absence of adequate informal caregivers would significantly hamper the elderly’s access to essential services, particularly for those with poor health conditions.

Among the existing provision of formal care, a few urban based NGOs have started different start-ups aiming to provide support for different instrumental activities to elderly. But they are restricted to the metropolises, as well as expensive. However, a majority of the elderly (70%) live in rural areas and they are financially more dependent on their family and the state. 

The way forward

To address the increasing unmet need of care for elderly, a crucial step would be to reduce their complete dependency on household members; for financial and day-to-day living support. Moreover, a stronger pension scheme, social security system and affordable health care system can share the burden of over-dependency on family-based care.

The Ministry of Health and Family Welfare (MoHFW) has rightly initiated a programme for training and skilled building geriatric care assistance for hospital, home/old age home based specialised care-giving. Launching and scaling-up of an integrated geriatric health care system can serve as step in the right direction in the longer run. In the meantime, providing affordable options to hire formal care givers can provide a quicker short-term solution to existing needs. However, the country needs to prepare itself for formal institutionalised care-giving services to the elderly, especially in the context of unavoidable and accelerating rise of the oldest-old and the physically disabled, sick and bed ridden older population.

A geriatric care-friendly health system, especially in the bottom layers of system (sub-centres, primary health centres and community health centres or in newly created health and wellness centres) can pave the way for creating a healthy and active elderly population in the country. 

This article was originally published on Science, The Wire.

Electricity is the lifeblood of a public health centre, supporting it in ways both obvious and unseen. It powers the equipment used in diagnosis, treatment, and immunisation (vaccine refrigerators, X-ray machines, baby warmers, sterilisers, and centrifuges), and keeps the centre’s basic utilities such as lighting, cooling, heating, and communications systems running. In addition, it powers the homes of staff living on the premises, securing both their safety and comfort.

Creating resilient energy systems for public health

A facility with an uncertain electricity supply is compromised in its ability to extend routine and emergency healthcare to local communities. Urban clinics typically enjoy a steadier supply of electricity than rural ones, but the farther a rural clinic is from gridlines, the greater its dependence on alternative energy sources such as diesel gensets. Facilities that lack electricity fall short of basic medical equipment and tend to be understaffed. A recent report published by WHO, IRENA, World Bank, and SEforALL estimates that approximately one-eighth of the global population is served by healthcare facilities that have no, or unreliable, electricity supply.

It is not the reliability of power alone that poses a problem for last-mile healthcare delivery, but the quality of it too. Even with uninterrupted supply, fluctuating voltage can damage highly sensitive medical appliances. Immunisation suffers as well, for when cold chains and cold storage facilities are disrupted, temperature-controlled vaccines are rendered ineffective. These vaccines must then be discarded, which causes wastage and delay in time-sensitive vaccination programmes.

In the past decade, the central and state governments in India have made several efforts to strengthen both the energy and public health system infrastructure in the country. However, mounting challenges posed by disruptive climate events put the energy infrastructure at risk and often compromise transportation infrastructure as well. This makes it difficult to maintain and rectify power lines, which can in turn impact health centres.  

The smooth functioning of health facilities like sub-centres (SCs) and primary health centres (PHCs) is critical—especially when extreme weather events and disasters such as landslides, floods, and intense heatwaves occur—because these centres serve as the first point of care and relief to local communities. Each facility caters to 6,000–30,000 people and is often the only medical resource that families—especially those from low-income communities—can rely on.

What it costs 

The sudden disruption of electricity access or uneven power supply drives up costs for a health facility, requiring it to purchase inverters and gensets and maintain a steady supply of diesel. This necessitates frequent and lengthy travel. It also compels healthcare centres to bear the additional burden of replacement and repair of equipment damaged due to voltage fluctuation—a difficult proposition in far-flung places.

On top of these are the social costs. When services are stalled, patients may be asked to wait or return later and even then, there is no guarantee that they’ll be provided what they need, even if it is a simple scan. In such cases, they end up travelling to block or district hospitals, forfeiting the day’s wages and spending more to treat something that could have been diagnosed earlier, when the health concern perhaps posed a lower risk. 

In addition to failing to deliver basic services, poor power supply may prevent healthcare facilities from adding new services, especially when the equipment associated with such services is energy dependent.

Energy assurance is, therefore, one of the key ways to strengthen community healthcare delivery. Designing reliable and resilient energy systems for health facilities will help them function without interruption and ensure basic healthcare for all. The best guarantor of this is the solar decentralised renewable energy (DRE) system—a source of clean, sustainable, and inexpensive power.

The DRE solution in public healthcare

Once costly and riddled with supply-chain bottlenecks, today, solar (photovoltaic) systems are cheaper and easier to set up and maintain than other DRE systems such as micro-hydro and mini-wind, making them the obvious answer to public healthcare’s power problems. 

As part of the Energy for Health initiative, we at SELCO Foundation have designed solar-powered systems that range from 1 kilowatt peak (kWp) to 30 kWp and can work independent of the grid. A health centre will still have power in cloudy weather thanks to a battery unit that can sustain it for three days. Thereafter, the centre can draw power from the utility via a provision in the inverter, until the skies clear up. Depending on the size of the operation, the terrain, local weather conditions, and irradiance, a system is designed to power 100 percent of the facility’s critical load.

That’s the last thing you want during a disaster—for a health centre to fail.

It is vital to factor in the area’s climate, both present and projected, when mounting a decentralised solar system. The disproportionately crippling impact of climate change on marginalised communities—particularly those living in remote and underdeveloped areas—is an acknowledged fact. It’s all the more essential, therefore, to bolster public healthcare facilities in these regions and make them climate-resilient and future-ready. Doing so will not only prepare PHCs to withstand unpredictable weather themselves but will also enable them to serve the healthcare needs of communities affected by extreme weather events.   

Designing DRE systems for extreme weather is one of the key lessons learned during our pilot programme in 2021–22, when we set up solar systems at 2,000 public health facilities across four states. We learned these lessons the hard way. For example, although we worked with local partners, we had not accounted for extreme lightning conditions in parts of Meghalaya. As a result, almost half of the 30 or 40 clean energy systems deployed there stopped working after a single lightning strike that caused the invertors to burn out; we later installed lightning protectors on the invertors.

So it’s important to design and install DRE systems keeping local disaster indicators in mind, whether earthquakes, cyclones, or floods. In states prone to cyclones, such as Odisha, DRE systems had to be designed for high wind speeds. In flood-prone areas such as Lower Assam, batteries had to be elevated to protect them from damage from the rising water level. Once damaged, the batteries would bring down the whole DRE system, and that’s the last thing you want during a disaster—for a health centre to fail!

Who owns the DRE system?

As with the public healthcare facility itself, the DRE system should be owned, operated, and maintained by the state health department. Only when the health department becomes a driver for this model will it work efficiently. This involves assigning funds for installation and for operation and maintenance (O&M). Budgets for O&M, system modification, and upgradation can be obtained from various health funds, including at the panchayat and district level, and the untied funds allocated to every health centre. 

The government is committed to transforming public health centres into climate-resilient, sustainable units. To this end, in April 2023, the Ministry of Health and Family Welfare sent out a circular to 12 states confirming targets and contribution towards clean energy assets for health centres. Whether it’s panels, batteries, or charge controllers, there can now be a line item for clean energy components in the Programme Implementation Plan (the annual health budget created at the state level and forwarded to the central ministry).

From our own experience with the Energy for Health Initiative, solarising a small SC costs INR 1–3 lakh, while a PHC costs INR 5–8 lakh. The outlay varies, depending on whether the centre has diagnostic and immunisation facilities, and delivery rooms for maternal and child care.

A DRE system alone isn’t enough

While renewable energy can help deliver the healthcare goods, it is no magic pill. The public healthcare system is the sum of several parts, and energy can only catalyse or strengthen them; it cannot single-handedly transform healthcare metrics. In certain health centres, for example, despite installing high-quality DRE systems, patient footfall remains unchanged. Here are the additional components that contribute to a sustainable healthcare solution:

• Energy-efficient appliances: The healthcare sector—largely fossil-fuel based—accounts for 5–8 percent of global energy consumption and contributes 4–5 percent of total greenhouse gas emissions. While renewable energy will help reduce the sector’s carbon footprint, it is not enough. A comprehensive energy-efficient solution needs energy-efficient equipment to be fully sustainable.
  
  The Indian Public Health Standards (IPHS) decree what equipment different types of health facilities should have. Some of these devices, such as X-Ray machines and CT scanners, are energy guzzlers. A single autoclave (or steriliser) consumes energy equivalent to the lighting needs of 24 rural households; an average radiology department consumes energy equivalent to the annual consumption of 852 people in a town. Innovation is urgently needed to make these devices more energy-efficient; this can reduce the energy cost of a healthcare centre by 60–90 percent. 
  
  But innovation is not happening at the required pace. R&D initiatives for medical equipment need to prioritise energy efficiency, and high-risk R&D capital needs to be diverted towards small and medium enterprises and start-ups working on sustainable medical technologies. Public procurement can also start benchmarking and featuring higher efficiency specifications in MedTech to incentivise the industry.

• Energy-efficient buildings: When we talk about clean energy for a healthcare facility, it has to be a combination of energy input, energy efficiency, and building design. When you look at optimising energy from a long-term perspective, all three parameters play a significant role. Green building design optimises heating and cooling solutions such that energy costs decline. Rising heat stress, for one, has made clinic and hospital conditions unbearable for both staff and patients. Doctors find it hard to operate in facilities that lack proper cooling and ventilation, and patients, especially in maternity wards, suffer from dehydration and diarrhoea in peak summer months.
  
  At Yellapur Taluk Hospital in North Karnataka, a model labour and delivery unit improved its overall efficiency by integrating built environment design with energy-efficient equipment and a solar system. The techniques used included thermally insulating the roof with brickbat coba (a traditional brick-based waterproofing method) and installing adequate shading to keep the unit cool and sufficient windows to let in sunlight. The upshot: increased patient comfort and significantly lower energy bills.

Closing the gaps

When all the parameters are in place—skilled staff, energy-efficient equipment, sustainable infrastructure—reliable and clean energy can accelerate the type and range of services offered. It’s important therefore to identify ecosystem gaps and find ways to close them.

Made more resilient and reliable with solar power, these facilities have witnessed improved ease and increased efficiency of health staff as well.

For example, when Ramkumar S, director of the National Health Mission, Meghalaya, wanted to scale up the state’s immunisation programme, we used clean energy to strengthen the immunisation cold chain to complement the state’s efforts at delivering vaccines and training midwives and auxiliary nurses. The programme could then be ramped up in a sustainable and effective manner.   

The benefits of solarising health centres are stacking up everywhere. At a community health centre in Churachandpur, Manipur, the vaccine cold chain was strengthened with an energy-efficient ice-lined refrigerator and deep freezers, which enabled it to swiftly meet its immunisation targets. In Karnataka’s Raichur district, PHCs have been able to improve institutional deliveries by ramping up delivery units and human resources. Made more resilient and reliable with solar power, these facilities have witnessed improved ease and increased efficiency of health staff as well. 

A secondary benefit of DRE systems is the employment and entrepreneurial opportunities they set up. Local last-mile clean energy enterprises that work on installation, servicing, and maintenance for a health facility can just as easily service solar-powered schools, households, and panchayat buildings, equipped as they are with the supply chain and trained workforce. 

At the same time, start-ups working on innovative medical devices and green building technologies also gain from their participation in the clean healthcare ecosystem, their growth assured by the projected growth of the sector itself. Programmes like Energy for Health offer them a foot in the door with state governments, and such partnerships enable them to scale up their technologies and scope out new opportunities.  

Paving the way

India’s initiative to power public health centres via decentralised solar energy has become a test bed for programme design and processes. The assessments, system design, installation, and operations and maintenance models piloted here are relevant for a range of climatic and socio-economic contexts across the globe. Moreover, by dovetailing renewable energy with green building design and energy-efficient technology, we’re attempting to build a holistic and sustainable model of public healthcare that places both local community needs and planetary boundaries at the heart of the plan.  

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Know more

• Read this article to learn about some steps the government needs to take to build a high-quality public healthcare system. 
• Learn about this UN Women programme that aims to make policy-making and entrepreneurship around sustainable energy more gender inclusive.   
• Read this article on the need to prepare our healthcare systems for the tide of illnesses that climate change may usher in.  

Had the Act been implemented, and the benefits raised in tandem with (say) nominal GDP, Indian women today would be receiving cash benefits of about Rs 20,000 in the event of pregnancy, as they do in Tamil Nadu. This would help to ensure that they are not deprived of adequate nutrition, rest and healthcare at this difficult time.

Instead, the central government has used every possible means to evade its obligations under the Act. For a full four years (2013 to 2017), there was no action at all. In 2017, a national scheme of maternity benefits was finally launched—the Pradhan Mantri Matru Vandana Yojana (PMMVY). This scheme, however, restricts maternity benefits to the “first living child”, at a measly rate of Rs 5,000 in three instalments. By the time Covid-19 hit the country in early 2020, even this restricted coverage was still a distant goal.

Meanwhile, pregnancy and childbirth remained a harrowing experience for millions of women. In 2019, the Jaccha-Baccha Survey (JABS) found horrendous levels of deprivation and insecurity during pregnancy in a sample of 700 rural women spread over six north Indian states. Among 364 women who had delivered a child in the preceding six months, less than a quarter had eaten nutritious food more often than usual during pregnancy, and nearly 40% complained of a lack of rest at that time. Weight gain during pregnancy was way below the recommended norms—just 7 kg on average. This is all the more worrying as so many women are severely undernourished to start with. (See “Maternity Entitlements: Women’s Rights Derailed”, by Jean Drèze, Reetika Khera and Anmol Somanchi, Economic and Political Weekly, 20 November 2021.)

How is PMMVY faring today? This is not easy to tell because PMMVY has no public data portal worth the name. In this respect, it stands out among India’s social programmes, and violates the pro-active disclosure norms of the Right to Information (RTI) Act. We had to fall back on RTI queries to rustle up the most elementary statistics on the progress of PMMVY. The latest response of the Ministry of Women and Child Development, in January 2023 (four months after the query was submitted), includes state-wise and year-wise numbers of PMMVY recipients for the last few years.

According to these official figures, the limited progress that had been made under PMMVY by the end of 2019 was largely undone during the Covid-19 crisis. The number of women who received some PMMVY benefits crashed from 96 lakh in 2019-20 to 75 lakh in 2020-21 and 61 lakh in 2021-22—a decline of nearly 40% over two years.

To put this in perspective, assuming a birth rate of 19.5 per thousand (the Sample Registration System estimate for 2020), and a total population of 140 crore, the annual number of births in India today must be around 270 lakh. Barely 23% of these births were covered under PMMVY in 2021-22 (see Chart). Even if we assume, optimistically, that another 10% of births are covered by maternity benefit schemes in the formal sector, overall coverage would still be as low as one third of all births.

These PMMVY coverage figures refer to the number of mothers who received at least one of the three instalments. If we raise the bar and focus on women who received all three instalments, the coverage figures are much lower. In 2021-22, the number of pregnant women who received the third PMMVY instalment was just 35 lakh—about 13% of the annual number of births.

State-wise figures are presented in Table 1. Between 2019-20 and 2021-22, PMMVY coverage declined in all major states except Kerala and Jammu-Kashmir, sharply so in many cases. In West Bengal, it appears that the scheme has come to a standstill—perhaps it is victim of a centre-state dispute there, like the rural employment guarantee scheme? PMMVY also came to a virtual standstill by 2021-22 in several other states, including some “double engine” states like Gujarat. The third instalment eludes most women in most states.

We can shift the goalposts and focus on first births, the official target of PMMVY. When the fertility rate is around two children per woman and most women have at least one child, as is the case in India today, first births account for about half of all births. Thus, the coverage figures would roughly double if we put first births in the denominator instead of all births (see Chart). Even then, they would be quite low—46% for “at least one instalment” in 2021-22 and 26% for the third instalment.

It is unlikely that PMMVY coverage expanded radically in 2022-23. Indeed, central expenditure on the SAMARTHYA package (of which PMMVY is the main component) was barely 10% higher in 2022-23 than in 2021-22. Incidentally, we are talking peanuts—barely Rs 2,000 crore per year, compared with an estimated requirement of about Rs 14,000 crore per year for full-fledged implementation of maternity benefits under the National Food Security Act.

The PMMVY setback in 2020-21 and 2021-22 is a sign of mismanagement of the Covid-19 crisis. PMMVY is just a cash transfer scheme, there was no good reason for it to be so badly disrupted. And there was certainly no excuse for the disruption to continue in 2022-23.

The root of this fiasco is that pregnant women count for very little in public policy and electoral politics. Quite likely, a real effort to universalize maternity benefits would have made waves. Instead, the central government took refuge in a lame scheme that didn’t really take off. On three occasions, the Finance Minister ignored an appeal from 60 Indian economists for much higher spending on maternity benefits. The opposition parties, Congress included, did very little to challenge this inertia. The outcome is a lost decade for maternity entitlements.

This article was originally published on The India Forum.

To determine the extent of the impact of air pollution on these occupations, Chintan conducted a survey of 400 participants—constituting safai karamcharis, waste pickers, and security guards—across 15 sites in Delhi. The findings of this survey have been published in a report titled Unfair Quality: The Impact of Air Pollution on Three Occupations. The report uncovers that 97 percent safai karamcharis, 95 percent waste pickers, and 82 percent security guards are prone to exposure to air pollution during work.

Highlighted below are some of the solutions put forth by the report to combat this.

1. Workers need accessible PPEs

The report outlines that approximately 61 percent safai karamcharis, 52 percent waste pickers, and 30 percent security guards are unaware of personal protective equipment (PPE) gear. More than half of these workers also report not having access to them. In the absence of these kits, many workers use a gamchha (cotton cloth) to cover their face and head, but this is not always helpful.

These occupations also subject workers to various other pollutants. For instance, during colder seasons, many workers resort to burning wood or coal to keep warm. However, this practice releases harmful toxins that can amplify respiratory issues and even contribute to cancer. Without PPE kits, the health issues experienced by these workers such as burning of eyes, cough, headache, and breathing problems can worsen. The study revealed that even where PPE is available, there are no incentives in place to promote its use among these groups, highlighting the necessity for additional measures to encourage compliance in this regard.

2. Workers should have access to healthcare

Although majority of the workers are aware of these health hazards, they find themselves compelled to persist in order to ensure financial security. This is particularly concerning for waste pickers, 87 percent of whom report suffering from various ailments since they started their current role. Forty-seven percent of safai karamcharis and 45 percent of security guards also report experiencing migraines, chest discomfort, and respiratory problems since commencing their duties.

Chintan conducted a pulmonary function test (PFT) to learn about the lung health of these workers and found that they suffered from decreased lung capacity when compared to indoor workers. Only 25 percent waste pickers, 14 percent safai karamcharis, and 14 percent security guards exhibited normal lung function. The study also concluded that women’s lung capacities have deteriorated more in comparison to men in all three occupations. Women waste pickers, for instance, are 3.9 times more likely than their male counterparts to have a respiratory disease.

Despite this, healthcare facilities remain inadequate. More than half of the workers surveyed expressed concerns about the lack of appropriate healthcare provisions, and a significant majority cannot avail routine annual health check-ups. Therefore, the need to improve healthcare access becomes imperative.

3. Organisations must promote healthy practices

In addition to offering healthcare provisions, workplaces can also include hand- and face-washing facilities. Gargling in the morning and at night, before and after work, can serve as an effective strategy to minimise the retention of dust particles within the throat and nasal passages.

4. Outside exposure needs to be limited

To safeguard the health of these workers, one of the most crucial steps is to minimise their exposure to pollutants. For safai karamcharis, this can be ensured by shifting their work timings from early in the morning to later in the day when pollution levels are not as high. Sweeping should be avoided when the air quality index (AQI) touches a hazardous level. Security guards must be provided with enclosed spaces to sit. For both, rotation in duty from high-pollution spots to low-pollution areas must be undertaken to avoid long-term exposure. And to prevent waste workers from burning waste in the winter, free gas cylinders should be made available. Dry waste collection centres must also be well ventilated. Waste burning should be monitored and heavily discouraged.

5. Systemic-level shifts are necessary

Although increasing healthcare access, limiting exposure, and promoting the use of PPE and healthy practices can aid in mitigating the impact of air pollution on these workers, achieving long-term sustainability in protecting them necessitates a broader systemic transformation.

• Waste pickers: Waste pickers should be empowered to explore alternative forms of recycling, such as doorstep collection or composting, rather than limiting their work to landfills. Garbage burning must be banned and any organisations or individuals partaking in it must be fined. This is particularly relevant for horticulture waste management. Investments must be made in wet waste composting to prevent landfill fires.
• Security guards: To prioritise the well-being of security personnel working in cities with an AQI higher than 300, it is crucial to offer discounts to organisations that can purchase kiosks for them. This initiative is particularly significant for security guards operating in construction sites, schools, or low-income areas.
• Safai karamcharis: In situations where the AQI exceeds 250, it is crucial to implement measures like spraying mist to mitigate the dispersal of rising dust. To prevent open burning of used tires and e-waste, adequate collection systems should be put in place. This will also increase recycling rates.  

Occupational health protection guidelines should be established and enforced by relevant bodies such as the Pollution Control Board and prioritised by programmes like the Swachh Bharat Mission. These guidelines must be integrated into the practices and policies of organisations involved in all three occupations to ensure the well-being and safety of workers.

Continued exposure to pollutants, coupled with socio-economic challenges, magnifies the damaging impact of air pollution on workers from these occupational groups. Addressing these issues requires a multi-pronged approach, including improved occupational safeguards, enhanced access to healthcare and education, and rigorous air quality management measures.

Komal Daal from Chintan; Dr Randeep Guleria, former director of AIIMS; and Dr Tejas Menon Suri, Assistant Professor, Department of Pulmonary, Critical Care, and Sleep Medicine at AIIMS, also contributed to this study.

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Know more

• Read the detailed report here.
• Learn why the rising temperatures pose a huge risk for gig workers.
• Know more about the health risks faced by India’s workers in the world’s ‘most polluted’ city.

Recognising the growing burden of NCDs in the country, the Indian government launched the National Health Policy in 2017 to prioritise the prevention and control of such diseases. The policy includes measures such as promoting healthy lifestyles, increasing access to affordable and quality health services, and improving surveillance and monitoring of NCDs. However, despite the steps taken by the government, efforts to control NCDs focus more on screening, monitoring, treatment, and referral and less on prevention. India’s primary health system is geared towards screening people in large numbers for diabetes and hypertension and referring them for clinical care and treatment.

While screening and testing for NCDs is important, it is an extremely resource-intensive exercise. Given the numbers—approximately 136 million people in India are pre-diabetic and more than 50 percent are unaware of their diabetic status—it is nearly impossible to focus just on treatment as our way out of the crisis. Therefore, it is essential to manage the problem with the help of prevention-focused interventions—based on behavioural change—that encourage lifestyle modifications and adoption of healthy habits.

This article is based on our learnings from our work on NCD prevention in India, and highlights how programmes can reach the required scale with tech-based interventions and through collaborations among various stakeholders.

1. Take prevention to the doorstep

Early detection and prevention of NCDs is key to controlling them. However, many people still view them as diseases that only affect the elderly and may not even get tested for NCDs such as hypertension and diabetes. It is crucial, therefore, to spread awareness about NCDs and why they need to be taken seriously, as well as educate individuals on healthy behaviours that they can adopt to prevent them. This makes it necessary to take NCD prevention interventions to where the people are—schools, homes, and workplaces.

Keeping this in mind, we launched the MyThali programme to promote healthy dietary choices among urban women, who are more prone to diabetes. Based on the success of MyPlate by the US Department of Agriculture, we translated India’s National Institute of Nutrition guidelines into an easy-to-follow image that we then disseminated through social media. We engaged with micro-influencers in the health and nutrition, lifestyle, food and travel space in order to reach urban women looking for nutrition advice from credible sources. Another reason for collaborating with influencers was to make healthy eating aspirational and accessible while simultaneously increasing awareness about it to prevent lifestyle diseases.

2. Intervene early

Many NCDs have their origin in childhood, and are shaped by lifestyle and environmental factors. According to a study by the Indian Council of Medical Research, the prevalence of diabetes and pre-diabetes among adolescents in India ranges from 12.5 percent to 14.5 percent. The study also found obesity to be a major risk factor for diabetes among adolescents. Research shows that urban adolescents are more likely to suffer from NCDs than rural adolescents, mainly due to lifestyle factors such as physical inactivity, unhealthy diets, and excessive screen time. Adolescents from lower socio-economic groups are also at a higher risk of NCDs, as they have limited access to healthcare services, education, and information on healthy lifestyles.

Peer-led group discussions as well as age-appropriate, compelling games and activities can be used to teach adolescents good lifestyle habits.

Therefore, it is crucial to intervene when children are in the early adolescent years so that healthy habit formation and lifestyles for the future can be encouraged. In 2011, based on the school education model for tobacco control, we developed a two-year school-based programme for diabetes awareness and prevention. Through a network of teachers and student peer leaders, the programme aimed to educate 11–14-year-olds about the benefits of increasing physical activity and improving dietary intake. We used peer-led group discussions as well as age-appropriate, compelling games and activities to teach adolescents good lifestyle habits. For example, the game of snakes and ladders was used in classrooms to explain the difference between healthy and unhealthy dietary choices, with a bag of chips depicted by a ‘snake’ and eating fruits and vegetables represented by a ‘ladder’.

We realised though that it was first important to build awareness among teachers in schools. For this, we worked with various partners such as CINI and SRU Innovations to conduct workshops and learning sessions about NCDs with teachers. The teachers were encouraged to carry out these games with children in classrooms, and integrate the messaging of healthy eating habits and physical activity through their teaching. 

3. Collaborate with multiple stakeholders

In order to enable the prevention of NCDs in a country as large as India, programmes must be designed keeping scale in mind. A gamut of knowledge, research, and learnings already exists in the form of public and private organisations that work on NCD screening, prevention, and management. These include the Public Health Foundation of India, Madras Diabetes Research Foundation, Indian Council of Medical Research, All India Institute of Medical Sciences, PATH, and The George Institute. Collaboration and coordination among these organisations is essential to maximise resources and impact.

Nonprofits can leverage the networks of NCD organisations to share knowledge, expertise, and resources, and to develop and implement joint programmes and initiatives. This also helps in bridging the trust deficit communities may have when approached by a new organisation.

For example, for the MyThali programme, which was originally developed for urban women, we partnered with PATH—a nonprofit focused on improving health equity in the country—to adapt it for rural adolescent girls. PATH brought in stakeholders—from policymakers to nutrition experts—to deliberate on core elements of the existing programme’s content and tweak it for adolescent girls. We used this to develop an eight-page comic book and activity booklet, which were then disseminated across schools we were working with.  

4. Leverage technology effectively

Technology not only allows for programmes to reach otherwise isolated locations, but also permits the continuous circulation of knowledge. Using technology such as text messages can be an important means of enabling behaviour change. As part of our mDiabetes programme (a text/voice-message-based diabetes prevention programme), the team sent 56 messages twice a week for 6 months to more than one million people. Focused on informing about diabetes and its prevention, these messages were sent in 12 different languages including English, Hindi, Kannada, and Tamil. The content of the messages was developed with the objective of highlighting the benefits of adopting healthy lifestyles and acting as nudges for behaviour change, such as eating two to three fruits and vegetables a day, avoiding fried food, and increasing physical activity. 

When it comes to imagining a future without NCDs, interventions that focus on prevention are key. And in order to address the problem at scale, coordinated and collective efforts are essential, wherein all stakeholders work together to build an environment conducive to healthy living for the population at large. 

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Know more

• Read this article to understand what is causing the growing prevalence of diabetes in rural India.
• Read this article to learn why women and girls are at a higher risk of NCDs.
• Read this study to learn more about public health interventions for prevention and control of NCDs in relation to India.

To commemorate this day, we are looking at ‘Ayushman Bharat’ – a flagship scheme of the Government of India, which was launched as recommended by the National Health Policy 2017 to achieve the vision of Universal Health Coverage (UHC).

Introduction to Ayushman Bharat

The Government of India launched Ayushman Bharat in 2018 to expand universal health coverage, especially to rural and vulnerable populations. This initiative has an underlying commitment, which is to “leave no one behind”, and has been designed to meet SDG 3, Target 3.8, i.e. achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality.

Ayushman Bharat (AB) aims to undertake interventions to holistically address health at primary, secondary, and tertiary levels. The main aim is to provide essential health services throughout the country through four pillars of this programme:

1. Health and Wellness Centres (HWCs)

The first component pertains to the creation of 1.5 Lakh Health and Wellness Centres (HWCs), which brings healthcare closer to the homes of the people. These centres provide Comprehensive Primary Health Care (CPHC), covering both maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services.

In FY 2018-2019, a budget of 1200 crore was allocated as a flagship programme to Ayushman Bharat – Health & Wellness Centres.

A notable landmark of 1.5 Lakh Ayushman Bharat Health & Wellness centres has been surpassed in 2023. These centres were operationalised within India to provide the citizens with easy access to healthcare. Since the establishment of HWCs, the program has achieved more than:

• 86.90 crore screenings for Non-communicable diseases
• 9.3 crore teleconsultations were provided
• 135 crore cumulative footfalls
• 1.60 crore wellness sessions at HWCs.

An important aspect of HWCs was to provide comprehensive healthcare for Non-communicable diseases (NCDs). During the period of Aug 2020 to Dec 2022 (25 months), remarkable progress was seen in the number of screenings for NCDs.

While the total number of screenings went up by 510%, a major jump was seen in screenings for Oral Cancer, which increased by 148 million (570% increase).

2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)

The second important component of Ayushman Bharat is the ‘Pradhan Mantri Jan Arogya Yojana – also popularly known as PM-JAY. This scheme was launched on 23 September 2018, with the vision of achieving SDG Target 3.8 – ensuring financial protection against catastrophic health expenditure and access to affordable and quality healthcare for all.

The year-on-year budget allocation of Ayushman Bharat PM-JAY rose significantly from 2400 crores in FY 2018-19 to 6400 crores in FY 2019-20. Though the budget allocation remained constant for the last 4 years, the budget allocation was increased to 7200 crores in FY 2023-24 – a threefold increase since its inception in 2018-19.

PM-JAY is the largest health assurance scheme in the world, covering over 10.74 crore poor and vulnerable families (~50 crore beneficiaries) that constitute the bottom 40% of the Indian population who will receive an annual health coverage of Rs. 5 lakhs per family, for secondary and tertiary care hospitalisation.

PM-JAY provides the States with the flexibility to choose their implementation. The different modes of implementation are:

• Trust mode – Claims are paid directly by the State Health Agencies (SHA’s)
• Insurance mode – Claims are paid by the insurance company, and SHA pays a premium to the insurance company.
• Hybrid mode – Claims up to a certain amount are being covered by the Insurance company, and claims above the defined threshold are covered by the SHA’s company.

So far, 33 States have adopted the Ayushman Bharat PM-JAY scheme, and these states implement the scheme in different modes. 23 states have adopted the Trust mode, which caters to 63.9% of the beneficiaries in India. Three states viz. Jharkhand, Maharashtra, and Tamil Nadu have adopted the Hybrid mode of implementation, which contributes to 19.5% of the beneficiaries.

Progress of PM-JAY in India

The PM-JAY beneficiaries get an e-card called ‘Ayushman Bharat Card’ that can be used to avail services at an empanelled hospital (public or private) anywhere in the country. As of March 2023, more than 21 crore Ayushman Bharat cards have been created, and 28,561 hospitals are empanelled under PM-JAY in India, and the total amount incurred under PM-JAY is INR 53,942.7 crores.

Since the inception of PM-JAY in 2018, the trend of Ayushman Bharat card creation has been erratic. The impact of COVID-19 can be seen in the trends of both card creation and hospital admissions. While new card creations slowed down during the first wave (Apr – Nov 2020), the number of hospital admissions spiked during the second wave.

As of March 2023, ~21.33 crore Ayushman Bharat cards have been created and ~4.46 crore hospital admissions (~1 admission every 5 cards). More than 50% of the card share is from five large states – Madhya Pradesh (16.6%), Uttar Pradesh (12.2%), Gujarat (8.3%), Chhattisgarh (7.9%) and Karnataka (6.4%).

Share of hospital admission is found to be higher in the Southern states such as Tamil Nadu and Kerala, viz 19.5% and 10.9%, respectively. This indicates that awareness of the benefits of the Ayushman Bharat scheme seems to be higher among the rural beneficiary families in the southern region.

Highly populous states like Bihar and Maharashtra have very low percentages of Ayushman Bharat card creation as well as hospital admissions. In spite of having a higher share of Ayushman Bharat cards in the states of Uttar Pradesh and Madhya Pradesh, the hospital admission shares are low – 4.4% and 5.7%, respectively.

While the majority of the states have very low hospital admissions per 100 Ayushman Bharat cards -ranging between 0 to 25. Tamil Nadu topped with ~331 Hospital admissions per 100 Ayushman Bharat cards followed by Kerala (~68), Rajasthan (~41) and Meghalaya (~32) per 100 cards created.

The load on empanelled hospitals seems to be higher in the states of Bihar and Assam. These states have more than 20 thousand beneficiary families per empanelled hospital. On the other hand, the southern states have approximately only 3 thousand beneficiary families per empanelled hospital.

While there are a total of 28,561 hospitals were empanelled under PM-JAY, a lot of these seem to be inactive. As of Mar ‘23, 22% of these hospitals were inactive, further increasing the load on the active hospitals. ~79% of empanelled hospitals in Arunachal Pradesh and more than 50% of empanelled hospitals in Rajasthan, Andhra Pradesh, and Manipur are now inactive.

While the PM-JAY scheme provides access to comprehensive healthcare, the most popular services availed were General Medicine (40%) followed by services for Infectious Diseases (15.7%).

Among the procedures, the most popular procedure undertaken has been Hemodialysis (~40.5%) followed by screening tests for COVID-19 Infection(~25.8%). 

3. Ayushman Bharat Digital Mission (ABDM)

On 27 September 2021, Ayushman Bharat Digital Mission(ABDM) (earlier known as National Digital Health Mission) was announced with a budget of Rs. 1,600 crore for five years. It aims to develop the backbone to support the integrated digital health infrastructure of the country and create a secure online platform based on open, interoperable digital standards.

4. Pradhan Mantri-Ayushman Bharat Health Infrastructure Mission (PM-ABHIM)

This mission, earlier known as Pradhan Mantri Atma Nirbhar Swasth Bharat Yojana scheme, was provided an outlay of about Rs. 64,180 crores till FY 2025-26 and was launched on 25 October, 2021. This is the largest pan-India scheme for strengthening healthcare infrastructure across the country. The measures under the scheme focus on developing capacities of health systems and institutions across the continuum of care at all levels viz. primary, secondary and tertiary and on preparing health systems for effective response to current and future pandemics/disasters.

Setting up these 4 pillars has paved the path to an underlying commitment of India’s goal for SDG 3 to “leave no one behind” and the coming years will determine whether every rural beneficiary is covered and benefited from this.

Additional resources:

• Ayushman Bharat Digital Mission Dashboard
• Ayushman Bharat PM-JAY Dashboard

This article was originally published by India Data Insights.

Therefore, it is imperative for organisations to prioritise the mental health of their employees. But they must move beyond their current tokenistic approach, shifting the focus from yoga retreats and workshops to thinking of mental wellness as a person’s right. Organisations must focus on developing robust policies and creating safe spaces that encourage conversations on mental wellbeing among employees.

However, does the onus of an employee’s mental well-being lie entirely with the organisation? What role can the employee play in their own well-being? Where does the organisation’s responsibility end and the individual’s begin?

On our podcast On the Contrary by IDR, we sat down with Raj Mariwala, director at Mariwala Health Initiative, and Santrupt Misra, director of Group HR at Aditya Birla Group, to discuss how workplaces can impact an individual’s well-being and productivity, and why mental health policies in the workplace need to be more inclusive.

Below is an edited transcript that provides an overview of the guests’ perspectives on the show.    

We need to rethink the current approach to mental health in the workplace

Raj: Mental health within the country is largely seen in the biomedical paradigm. What this means is that just like physical health, mental health is assumed to be a set of symptoms. There’s a certain kind of treatment given, which could be allopathic medication, or talk therapy at most. And then what is expected is that there [will be] a reduction in symptoms, and then the person [will be] cured. Now this is a very limiting narrative, because what it ends up doing is [focusing] only on a symptom reduction approach. What we’ve seen in COVID-19 is that people are coming to realise that mental health is also very deeply connected to our lives and the environments we inhabit. It’s not enough for one to say, ‘I will provide a psychiatrist or a counsellor,’ especially when it comes to workplace mental health. This is a piecemeal approach. Instead, we should look at our workplace and see the stressors that are born out of this environment.

Santrupt: An organisation’s performance would always be unsustainable and short-term if the [employees] are not at ease. And all evolved organisations realise that. Well-run organisations realise and understand that they are productive because their people are in a state of equanimity, where they are able to bring their best to the job. There isn’t a dichotomy between mental health and productivity. Yes, there will always be tension between the two in terms of how much you need to account for an employee’s mental health and how much you need to meet your obligation to other stakeholders. But [the minute] you integrate well-being and productivity, you start seeing them as two sides of the same coin, not two parallel lines.

It is crucial that the leadership views mental health as a matter of concern.

The challenge is that for far too long, we have refused to recognise mental health as an issue… And it is crucial that the leadership [views] mental health as a matter of concern. You can always provide a yoga instructor, a counsellor, and a supportive infrastructure [at the workplace]. But those can be the icing on the cake, they cannot be the cake. The cake has to be a big commitment for the management, [and they must have] the willingness to understand mental health, and [be capable of seeing the need for creating a] supportive environment to [deal] with these issues.

What can organisations do better?

1. Recognise mental health as an issue of disability rights

Raj: [It is] the organisation’s responsibility to look at the environment [and] to address the structural barriers in society that exclude persons with disabilities. What that means in a larger sense is that your whole workplace, your whole work ecosystem should be accessible to everyone. And you’re not looking at it as a privilege, you’re looking at it as a right.

The focus should be on providing ‘reasonable accommodation’. According to this principle, necessary and appropriate modifications and adjustments, that do not excessively burden the organisation, must be made to ensure that all employees get an equal opportunity to enjoy or exercise their responsibilities and their privileges.

[For example], historically and [even now], employers wouldn’t hire women because they didn’t want to give pregnancy leave. Now, due to advocacy, that has shifted [and] pregnancy and maternity leave are considered an employee’s rights. So what’s stopping us from giving similar mental health accommodation? If your employee breaks a leg, you’re going to make sure the lift is working. Maybe get a nicer chair. That’s what reasonable accommodation is.

2. Enable senior leadership to talk about their mental health

Santrupt: During the course of their work, people can develop many kinds of problems. And employers do have a responsibility to find ways to notice that and help create a sensitive culture. Role modelling [then becomes important]. Most often, senior managers and successful people seem to believe [that] there is a compulsion to always show that you are invincible. [But] if senior leadership can display authenticity and vulnerability, it makes people around them more comfortable to share similar experiences. 

Raj: At Mariwala Health Initiative, we [published] this research on mental well-being in the workplace in 2020. During our research we found that just like anyone else, leaders face certain unique stressors. But they never share this with their co-workers or their peers. If the head of the organisation or the senior leadership of the organisation doesn’t feel safe talking about [mental health], how are you going to expect your employees to talk about it?

3. Develop policies keeping in mind different socio-economic contexts

Raj: Part of this is also looking at your workplace and recognising that it actually mirrors the larger prejudices of society. Workspaces are largely engineered in a way that may be more distressing to women, to LGBTQ persons, to Dalit and Adivasi persons, or to Muslim persons. Does this mean that when we look at mental health, when we look at distress, we are going to be able to treat everyone equally? If the answer is ‘we are not sure’, then we need to look at our different policies. It’s not just about looking at mental health policies, it’s also looking at other comprehensive anti-discrimination policies. It’s also having grievance mechanisms up and running and in place. It’s also having supportive spaces at work.

And you need to look at it under all three categories—the ecosystem, the workplace, and the individual. At the workplace, it could be work hours, it could be toxic supervisors or toxic peers. Second is the individuals themselves. If there’s an individual who undergoes anxiety, and suddenly the job requires, public speaking, what sort of accommodations are you going to make? And third is industry. What are you doing as a larger ecosystem, in terms of policy, to negotiate with unions? How about pushing for mental health within insurance policies?

Employees must also take responsibility for their well-being

Raj: [Employees need to] communicate to the supervisor that they will require an accommodation. A safe space has to be created in order to do that. People often think that this will mean compromising on performance. That is not reasonable accommodation. Everyone who wants reasonable accommodation still requires to be accountable for their work. And that’s as per your negotiations. Also, the employee must realise that if they’re unable to do certain things, it’s likely that another team member would have to do it for them. So, the responsibility for the employee is to communicate [these needs] very clearly, and many employees do not for a variety of reasons.

Santrupt: The health of an employee, whether mental or physical, is primarily the responsibility of that employee. You cannot suddenly become a paternalistic state or company. But having said that, given the fact that you have a larger responsibility to society and your employees are also part of the larger society, if you find that there are issues there, you have a responsibility to help them both.

You can listen to the full episode here.

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Know more

• Read this report by MHI to learn more about structural inequalities and mental health.
• Read this to learn more about mental health in the workplace.
• Listen to this podcast to learn about how leaders can navigate mental well-being.