The National Digital Health Mission (NDHM) and Health Data Management Policy (HDMP), and the United Health Interface (UHI) have also received criticism and suggestions in part from relevant sections of society. These issues don’t stem from specific acts or policies but rather from the lack of a comprehensive data protection bill that can cater to our modern needs.
On 27th September, 2021, Prime Minister Narendra Modi launched the Pradhan Mantri Digital Health Mission (PM-DHM). This rollout of PM-DHM coincides with the National Health Authority (NHA) celebrating the third anniversary of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY). On this occasion, we shall examine how and where the scheme can make an impact, and where it needs to focus.
Personal Health Data can include an individual’s data consisting of detailed information about their health condition and treatments. It can further include any data with personally identifiable information of stakeholders like information about their healthcare professionals. On the other hand, Non-Personal Health Data is aggregated health data (e.g., number of covid cases) and anonymized health data where all personally identifiable information has been scrubbed. It can also include information about health facilities, drugs, etc., that do not involve personally identifiable information.
The current legal framework governing the protection of e-health data and Sensitive Personal Data or Information (SPDI) is covered under the combined readings of the Information Technology Act, 2000 and the Information Technology (Reasonable Security Practices and Procedures and Sensitive Personal Data or Information) Rules, 2011. These offer only a limited degree of protection to the collection, disclosure, and transfer of sensitive personal data, including medical records and history. The current policies, which were once considered modern, haven’t been updated with the advancements in the field. Legislation has not kept pace with developments in the field of e-health, especially when healthcare has transcended hospitals and clinics and manifests in different ways such as telehealth apps. Such services existed even before Covid-19, but the lockdown resulted in a surge in their popularity, as doctors could be consulted while at home.
To progress with changing times, the Government introduced DISHA (Digital Information Security in Healthcare Act) and the Personal Data Protection Bill, 2019 (referred to as PDP hereafter). PDP makes some additions to what constitutes health data –
Section 3 (21) of the PDP 2019 – ‘data related to the state of physical or mental health of the data principle and includes records regarding the past, present or future state of the health of such data principle, data collected in the course of registration for, or provision of health services, data associating the data principle to the provision of specific health services.’
On ‘sensitive personal data’ Section 3 (36) of PDP 2019 refers to such data that personal data, which may reveal, be related to, or constitute – (i) financial data; (ii) health data; (iii) official identifier; (iv) sex life; (v) sexual orientation; (vi) biometric data; (vii) genetic data; (viii) transgender status; (ix) intersex status; (x) caste or tribe; (xi) religious or political belief or affiliation; or (xii) any other data categorised as sensitive personal data under Section 15.
NATIONAL DIGITAL HEALTH MISSION AND ITS DATA MANAGEMENT POLICY
Announced by Prime Minister Narendra Modi on the 74th Independence Day, the NDHM is a complete digital health ecosystem. To improve the quality of medical care, along with its access to vulnerable sections and achieve Universal Healthcare Coverage, NDHM introduces measures such as a Health ID. This health account will include details on every test, disease, doctor’s visit, prescribed medicines, and diagnosis. Even if the patient shifts or changes doctors, this information will be easily accessible because it is portable. NDHM is a voluntary healthcare program, unifying doctors, hospitals, pharmacies, and insurance companies to create a digital health infrastructure. The unique Health ID card is created with Aadhar details and the mobile number of the user. Under the ambit of NDHM, one can also find coverage of services such as telemedicine and ePharmacy.
Despite positives such as a focus on consent, privacy, and user autonomy, concerns were raised about the data management policy of this scheme. The Internet Freedom Foundation and the Centre for Health Equity, Law and Policy’s working paper titled ‘Analysing the NDHM Health Data Management Policy’ highlights the background of digital health data frameworks in India. It also details the need for NDHM, the foundations required by such undertakings, the governance framework, and the areas where it is lacking. Its relevance lies in the fact that it reflects the current framework to the policymakers and provides certain insights into how the policy can be improved. Some of the learnings are listed below.
Consent is a big part of data collection. The current policy framework operates on a one-time, opt-in consent framework where a “yes” is a “yes to everything”. For example, the mandatory requirement of taking informed consent is limited to the collection and processing of personal data and is not explicitly extended to the creation of a Universal Health ID (UHID). However, there are reports of the Central Government generating UHID numbers for all individuals getting their COVID-19 vaccines by presenting their Aadhaar, without their consent. Users can also not withhold or refuse consent to the digitization of specific information, such as abortion, substance use/dependence, HIV status, mental illnesses, etc.
Government and private institutions make UHID mandatory, thus contradicting the voluntary status. For example, the Caravan reported on doctors in Chandigarh being forced to register for what is supposedly a voluntary National Health ID. Citizens residing in Chandigarh hoping to avail of the COVID-19 vaccine were asked to generate UHIDs, with the compulsion of linking Aadhar to it (also not mandatory).
HDMP allows health data companies (insurance and pharmaceutical companies) to share health data with entities for research purposes. This research must not use personal health data in individual patient care, and individual data processors can’t grant access. However, the collection and usage of aggregated health data by private commercial entities poses the risk of market abuse and unfair competition. For example, insurance companies may use digital health records to profile and score individuals in a bid to offer individualized insurance contracts and premiums, potentially leading to coverage denial for high-risk individuals. For others, there may be volatility in premium amounts depending on their health data.
There are concerns regarding the re-identification of anonymized data. A study from Washington State shows researchers were able to re-identify 43% of known patients by matching de-identified data sets against news reports. Adequate addressing of this issue is required for data to be safe.
As mentioned above, a health data management policy must be built on the bedrock of certain prerequisites. These prerequisites mentioned in the IFF-CHELP paper include having a robust legal foundation that can protect against identity fraud, data theft, reidentification, state surveillance, and commercial profiling. Data that can’t be kept secure shouldn’t be stored. In January 2021, a technology portal reported the leaking of COVID-19 test results and the personal information of thousands of patients from multiple Indian government departmental websites. Without a statutory foundation or an independent regulatory authority, implementing a digital health records system that shares data with diverse entities across digital technology services runs the risk of violating rights to informed consent and confidentiality. Data breach threats loom over any data management entity. Health data is always sensitive, and the inclusion of Aadhar when healthcare sector executives recognize the cybersecurity risks posed by the NDHM makes a patient’s data more vulnerable without a personal data protection bill.
Another prerequisite is a robust state capacity to manage and store healthcare data. An internal audit of capacities and capabilities for managing data and assessment on-ground for data collection is required before undertaking data documentation. India currently suffers from several deficiencies in relation to the quality of data being recorded. It is further hindered by poor internet connectivity, power outages, and a lack of technical support. Thus, the outcomes from these policies will be negatively affected. A digital health records system can revolutionize healthcare in India, especially for those living in rural areas. It can help them transfer their medical records across doctors and locations and potentially avail services of better doctors elsewhere. However, implementing the system hastily, at a national level, is a complex process and must be approached strategically.
The United States Federal Trade Commission’s Fair Information Practice Principles, or FIPPs, have widely accepted guidelines and concepts concerning fair information practice in an electronic marketplace. In the context of healthcare and data, some of these principles include:
(i) a notice about what data will be collected, why and how it will be used, and with whom it will be shared;
(ii) using data for appropriate purposes;
(iii) emphasis on individual choice, including an opt-in and opt-out system to avoid “yes-to-all” kinds of consent;
(iv) access and correction of stored data, and;
(v) security to protect stored data.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is an American federal law responsible for national standards intended to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. Best known for its privacy practices, it lists a number of measures, Covered Entities (entities engaged in facilitating treatment between the patient and the doctor, be it from a healthcare perspective, data storage/transmission, or billing/financial perspective). It appropriates FIPPs and lays down focused, stringent measures, such as having 20 elements required to be listed in Notices, an acknowledgment receipt that requires consent, mentions choices available to patients in terms of with whom the data can be shared, etc. It is not absolute, and certain limitations to privacy exist in cases of social order and public safety, but these are highly regulated by the courts and require specific court mandates.
In Europe, the General Data Protection Regulation, or GDPR, gives EU citizens enhanced control over their personal data. It streamlines the regulatory environment for business so both citizens and industries in the European Union can fully benefit from the digital economy. From a health data perspective, it provides for Breach Notifications in events of data breaches and hacks. In essence, if the name, address, date of birth, health records, bank details, or any personal data about customers is breached, the breached organization is obliged to inform the compromised as well as the relevant regulatory body so action can be taken to mitigate the damage. Breach notifications are often public, putting the reputation of the company on the line. Such laws put down stringent measures to place privacy first.
DISHA IN INDIA AND ITS FEATURES
DISHA, while still tabled, provides a new turn for how healthcare data can be secured. The Draft Bill defines Digital Health Data (DHD) as ‘an electronic record of health-related information about an individual’. Its provisions deal with physical and mental health information of an individual, health services provided and collected while providing said services to an individual, donation, testing, and information obtained from the act, and details about the clinical establishment accessed by the individual.
Provisions to regulate the generation, collection, access, storage, transmission, and usage of DHD and associated Personally Identifiable Information (PII) are provided. The latter is information that can uniquely identify, contact, or locate an individual specifically, using sources like name, address, date of birth, financial information, etc. The Draft Bill states that health data such as physical, physiological, mental health conditions, sexual orientation, medical records, medical history, and biometric data qualify as information that can only be the property of the person it belongs to.
DISHA hails from the Ministry of Health and Welfare’s attempt, in 2015, to establish the National Electronic Health Authority (NeHA) to regulate the usage of electronic mediums in healthcare and maintaining e-Health records and digital health information across India. Prior legislation such as the Clinical Establishments (Registration and Regulation) Act 2010 mandated the maintenance and provision of EMR (Electronic Medical Records). Similarly, EHR (Electronic Health Records) were covered under a uniform standard-based system for the creation and maintenance by the healthcare providers, rules courtesy of MoHFW. At a point when data was increasingly stored in the electronic format, there was a need to protect said data as well. It is the bridge that DISHA seeks to build.
A few features of DISHA are as follows –
The legislation calls for creating a central regulator – NeHA, accompanied by various State Electronic Health Authorities (SeHA) to execute the provisions of DISHA. These authorities will be responsible for defining protocols to safeguard data from possible breaches and provide data security measures, establish protocols for digital health data transmission, to and receiving it from other countries, and more.
It establishes Digital Health Exchanges for the secure transmission, access, and communication of digital health information across doctors, nurses, pharmacists, and other healthcare providers and patients. It can enhance the speed, quality, safety, and cost of patient care. Standardization of digital health information through eHealth record standards will be followed. Indian data centers are required to facilitate this. DHIEs will be monitored and controlled by their respective Chief Health Information Executive, and they’ll be responsible for appropriate storage of data breach notification, etc.
The Need for DISHA and What it Should Aim For
DISHA needs to be complemented by an overarching personal data protection bill, protecting SPDI (such as financial information, biometric information, physical, physiological, and mental health conditions). In April of 2020, the Kerala High Court, in the interim order in the case of Balu Gopalakrishnan v State of Kerala (Kerala High Court, WP (C) Temp No. 84 (2020), 24 April 2020), warned against a ‘Data Epidemic’. From such cases, it is evident that anecdotal-based cases can pave the way for better data protection measures, but there is a need for a comprehensive law.
DISHA’s emphasis on anonymization and de-identification rules, actions on obtained data being subject to explicit consent, and the right to correct inaccurate digital health data are steps in the right direction but are subject to proper enforcement on the ground level. A point that needs special attention is the absolute prohibition of access to digital health data (whether anonymized or otherwise) to insurance companies, employers, human resource consultants and pharmaceutical companies, or any other entity as may be specified by the Central Government. It directly covers up one of the flaws that the NDHM-HDMP suffers from.
One possible flaw that emerges out of DISHA is that it permits NeHA to use the information for certain limited purposes such as public health research, as long as the confidentiality of the data owner is not compromised. In theory, this seems suitable, but precautions need to be taken as national databases of sensitive information have been breached in the past. Additionally, internal security measures should be taken to ensure that data is only under the purview of relevant figureheads. Minimization of data access can go a long way in preventing insider leaks.
THE PATH FORWARD
Healthcare data management policies are important as we are increasingly becoming the sum of our interconnected data and digital identities. At this juncture, a breach of one kind of data can lead to another being compromised. Password leaks can be very alarming, but what happens when your test reports, health status, and UHID linked to services you avail through your Aadhar are exposed? It is for this very reason that discussions around minimization need to be had. Past experiences with Aadhar leaks serve as sufficient evidence for limiting its usage and integration with health IDs and mandating it equally.
While solutions such as 256-bit encryption for protecting data or blockchain for decentralized data can be utilized, what matters is bringing about a culture of enforcing a process rather than an outcome. Rather than giving a ready-to-go checklist that entities can use for privacy and security, it may be beneficial to create a system where accountability and privacy are ingrained with everything the entities do. At the policy design level, it is important to have privacy principles, or ‘security and privacy by design’ in place. While this is a principle HDMP claims it abides by, there are still concerns related to large-scale data processing and the lack of a data protection bill.
As for the policies mentioned here, it is beneficial to teach people digital literacy, informing them more about how consent works and what their digital rights and choices are. For example, hospital administration employees can explain the terms and conditions to privacy and consent to patients, taking away the fear of long, complex forms. It can be a part of the National Digital Health Mission as an outreach campaign.
The White Paper on Data Protection Framework for India lists certain key principles that all Indian tech policies can utilize in order to keep user’s privacy front and center, all the while providing top-notch coverage. One such principle is that of data minimization. The essential idea is that while data protection is important, data privacy must be valued first as data that isn’t required to be collected and thus never collected doesn’t stand the risk of being breached. To this end, mandates regarding linking Aadhar to UHID and other eHealth documents, whether arbitrary or lawful, must be re-examined.
Medical data doesn’t exist in isolation, and relevant data such as financial information should also be covered under the ambit of personal information. HIPAA covers healthcare clearinghouses (middleman between healthcare providers insurance payers/providers). It is something Indian healthcare data protection policies can also take into consideration. Compliance measures and risk assessments need to account for industry-standard methods, as is the case in HIPAA regulations as well.
As has been mentioned above, a Health ID can be concerning, especially its linkage to Aadhar. While voluntary, institutional mandates could make it compulsory. As the scheme gets ready for implementation, the government should note that despite various positives, there are certain loopholes that should be accounted for in order to make digital healthcare a comprehensive, inclusive revolution.
Since independence, agriculture and allied activities have been the backbone of India’s economy. In recent years, the share of secondary and tertiary sectors has increased in the economy, yet agriculture still plays a prominent role. A large section of the Indian population still depends upon agriculture for sustenance. To satisfy the ever-increasing food demand of the growing population, India had to revolutionize its agriculture sector. The Green Revolution of 1966 laid the foundation for this revolutionizing process.
Before the Green Revolution, India introduced Grey Revolution and Round Revolution in the early 1960s, which focussed on fertilizers and potatoes, respectively. Thereafter, various modernization projects, such as White Revolution in milk production, the Blue Revolution in fish production, and so forth, were initiated. In the 1990s and 2000s, the modernization process was expanded to rejuvenate natural fibres – cotton and jute. To boost overall production in the agriculture sector, the government introduced the Protein Revolution and Evergreen Revolution.
Other agricultural branches such as pisciculture, horticulture, and apiculture also require equal and vital attention. Being one of the top 10 countries for honey production in the world, Indian honey has a high demand in the international market. In this context, Prime Minister Narendra Modi announced Sweet Revolution or Mithi Kranthi to revitalize and enhance honey production through beekeeping.
Sweet Revolution or Mithi Kranthi
So far, the scheme has created more than 10,000 new employment opportunities and 25,000 additional days for honey extraction and fabrication of bee boxes. The KVIC provides the farmers with practical training on examining bee colonies; identify and manage bee enemies, diseases, and bee colonies throughout the year; provide equipment for apiculture, honey extraction, and wax purification. Jharkhand is the target state under the project due to its favourable climate and 30% forest area, which is suitable for honey production. By 2022, the project aims to bring Jharkhand to the list of developed states in the country.
The Sweet Revolution or Honey Mission is a project to increase the production of quality honey and other beehive products through scientific methods. The Mission, announced in 2016, also focuses on doubling the income of the farmers by 2024. It was formally launched by the Khadi and Village Industries Commission (KVIC) in 2017. Under the Atma Nirbhar Bharat Abhiyan, the initiative allotted ₹500 cores for beekeeping, wherein farmers growing crops such as fruits, vegetables, pulses, cereals, etc., that make good hosts for bees and help in pollination, can opt for beekeeping which can generate additional income apart from the main crops they produce. Along with increasing the income of farmers, crop production can be increased by 15%. As part of the National Beekeeping and Honey Mission, the National Bee Board, a body that works on research and development, production of honey bee colonies, etc., has created four modules for the training program under the Mission. Around 30 lakh farmers have undergone training in beekeeping. Besides farmers, the Mission targets creating employment for Adivasis, unemployed youth, and women while also increasing honey production in the country.
Impact and Challenges of Honey Production
Beekeeping is one of the world’s oldest occupations and is also expensive. Locally produced honey can be costlier, but it doesn’t spoil easily and has many health benefits such as soothing coughs, boosting memory, treating wounds, etc. The wax produced through beekeeping can be used for manufacturing cosmetics and candles. Other products produced by bees, such as pollen, propolis, royal jelly, and bee venom, can have great economic benefits. As the bees help in pollination, it makes plants healthy and benefits agriculture. New innovative technology and methods can help in boosting high-quality honey production.
Organic products attract more consumers and have little impact on the environment. It also generates direct and indirect employment through allied activities for people, especially in rural areas. Since beekeeping is a profitable practice, it can ensure a stable income for women, especially in rural areas. Adopting technology like Flow Hive, a technique developed in Australia to collect honey on tap directly from their beehives could ease the process of gathering honey from hives.
However, the sector faces many challenges which could be a threat to the bees and honey production. Current climate change conditions are affecting the temperature around the bees that determine their activity. Degradation of floral resources and the spread of diseases and parasites in bees can affect honey production. The application of insecticides to control insects and pests in large quantities can impact bees. While these insecticides are used for a short period to eliminate pesticides and other insects, in the long term, it affects hives, the long-term viability of bee colonies, and pollination. As more people are choosing organic products, the use of large-scale insecticides can affect the promotion of organic honey.
Colony Collapse Disorder (CCD), a phenomenon that results in the disappearance of worker bees, is another risk factor in beekeeping. At times, dead bees are found in and around the hives. Poor nutrition, lack of genetic diversity, migratory bee-eaters which prey on the bees, and habitat loss can also affect bee colonies badly. The degradation of beehives could also result in the production of honey and the income of beekeepers. While adopting new technologies in beekeeping, many beekeepers find it difficult to afford new equipment because of their high prices. Lack of awareness on beekeeping and allied activities in other parts of the country is a challenge in implementing the Sweet Revolution.
India’s Honey Market
Beekeeping has been historically practiced in India. Since honey is the purest form of food, it is a key ingredient in many cuisines, especially in Asia-Pacific. With centuries-old beekeeping practices, Indian honey has an upper hand in the international market. High floral diversity and availability of different bee forges make the Indian honey market competitive along with its innovation and quality. As people are preferring more natural products over artificial sweeteners and there is a growing awareness about the benefits of honey, the demand for Indian honey in the world is rising. Its proven antibacterial, anti-microbial, and anti-inflammatory properties are benefiting it to gain popularity. The food and beverages, pharmaceuticals, and cosmetics industries have also been using honey. Multiflora honey has the largest share in flavours of honey followed by eucalyptus, ajwain, sidr, and others. Maharashtra, Tamil Nadu, Karnataka, Punjab, and Rajasthan are the largest producers of honey in the country.
Though India’s domestic per capita honey consumption is 50 grams per year, globally it ranges between 250 to 300 grams. While Germany tops global honey consumption with 2 kgs per year, in Asia, Japan has the highest consumption with 700 grams per year. With increasing global demand for Indian honey, the experts expect a 207% rise in the coming years. Germany, the US, UK, Japan, France, Spain, and Italy are the main markets of India (Marar, 2019). The number of beekeeping companies and honey societies has also increased in past years. As of January 2019, there are 9,091 registered people in apiary business in India.
The COVID-19 has increased the demand for Indian honey in Japan, South Korea, and Australia, which import mostly from China, which is India’s biggest competitor. The declining rate of indigenous bees and the increasing presence of western bees are reducing local honey production in Japan and South Korea. As per the exporters, a weaker Indian currency also makes Indian honey more attractive. 60% of the total honey produced in India is exported to the US, Canada, Africa, and West Asia. Though honey from China is cheaper than India’s, the superior quality makes Indian honey more demanding. According to the Agricultural and Processed Food Products Export Development Authority-APEDA, compared to 2018-2019, India’s honey export has increased to 61,333.88 tonnes, valued at ₹732.19 crores (Sally, 2020).
Companies are competing in the Indian market to bring high-quality honey at a cheap cost. Recently, leading brands were accused of adulterating which is a major problem for the domestic honey market. Though people are now choosing forest-produced or small-farmers-produced honey over branded ones, these products do not reach mainstream outlets in the country. Bringing the locally produced honey to major outlet chains can boost local consumption. Checking honey adulteration is also important in boosting local demand.
Best Practices: Tamil Nadu
The southern state of Tamil Nadu is producing honey mostly from indigenous bees. Since beekeeping does not need much space, people are investing in apiculture and practicing beekeeping in terraces in big cities such as Chennai, Coimbatore, and Madurai. Apiculturists are providing training for interested people. Tamil Nadu Agricultural University (TNAU) along with the government are conducting workshops for aspiring apiculturists where they get to improve their skills in handling the latest technologies in beekeeping.
Apart from pure honey, traditional medicines such as tulsi honey, garlic honey, and other products like honey mixed cashews and almonds, gooseberry honey has high demand in the market. Tamil Nadu has adopted Meliponiculture beekeeping. Kerala too practices the same method. Tribal people of Western Ghats successfully rear stingless bees. Tamil Nadu government provides grants for the supply of beehives to the Tribal on hill areas, Scheduled Castes /Scheduled Tribes under Western Ghats Development Programmes, Hill Area Development Programme, and Integrated Tribal Development Programme. 40% assistance is given for installing beehives and colonies. Under Rainfed Area Development, an Integrated farming system including honey bee rearing is provided at 50% subsidy.
Beekeeping in China
With long beekeeping traditions and a diverse bee population, China is the leading global honey producer. Japan, the UK, Belgium, and Spain are major honey importers from China. Since honey is an ingredient of traditional Chinese food, domestic consumption in China is high. Beekeeping in China is focused on generating a high yield. So, the beekeepers maintain a balance between the number of frames and the number of bees in a hive-the core Chinese beekeeping technique. Though there is a large production of honey, bee pollination is less in the country. Also, the industry is constantly reviewed by the Ministry of Agriculture.
Being a tech giant, China is now adopting the latest technologies in beekeeping. In 2019, beekeepers in Zhejiang Province introduced artificial beehives which come with a sensor that can monitor and regulate temperature and humidity. These smart hives collect data on the number of times bees enter and leave the hives. The QR code in the hive can help to trace the source and ensure the safety of honey (Yan, 2019). Similarly, in September 2019, Alibaba, the internet giant of China introduced the Ali AI beekeeping system to improve honey production by automatic regulation of temperature and humidity of the hives. It also comes with a GPS that alerts the beekeepers to avoid theft, which is common in China. AI technology is trying to reduce labour power and make it easy to manage the hives (Jingli, 2019).
While India is looking forward to enhancing scientific techniques in beekeeping, it has not yet experimented with AI in full-scale in the field. Last year, Eco Park in Kolkata did a trial with an AI system in beehives that helps to identify diseases and monitor the functioning of hives to improve production (Bandyopadhyay, 2020). By bringing AI startup companies and bee research institutes, this technology can be gradually developed to major honey-producing areas of the states.
Being one of the largest honey producers in the world, the Sweet Revolution is indeed a push for India’s honey industry. As a cottage industry, this initiative can make it a more full-sized industry in the country. However, in India, there is still a lack of application of scientific beekeeping methods. Many apiculturists still follow traditional beekeeping methods. Increased risks due to climate change, insecticides, and other factors make it difficult for beekeepers to maintain the traditional methods. Research and development as part of the Sweet Revolution can bring a change to this. While promoting beekeeping in rural and urban areas, the initiative can focus on tribal areas of the states. Lack of transportation and proper management of produced honey is a challenge for extending the initiative to tribal areas. Establishing a systematic marketing network in these areas could help the producers to take their yields directly to the market.
Self Help Groups (SHG) play a vital role in bringing honey to the market. Leading honey-producing states such as Punjab, Tamil Nadu, Karnataka, and the rest actively include SHGs in marketing honey in the domestic markets. It also generates reasonable income for the SHGs. The Directorate of Beekeeping and Khadi and Village Industries Commission is promoting honey on a domestic level through a store chain. Though there are various international agreements on goods trade, there is no global agreement on the criteria of honey. As for India, it can push for introducing an international criterion for honey to ensure the quality which can further increase the production and export of high-quality honey and other products in the coming years. This can also benefit in expanding honey export through mutual international cooperation and promotion.
Since the early 2000s, we have seen Amitabh Bachchan, the stalwart superstar, actively endorsing advertisements by our Health Ministry for raising awareness towards Tuberculosis. Being a survivor of the deadly disease himself, he has been advocating for better awareness to detect TB early to enable citizens to receive adequate treatment and has been viewed on televisions and heard on radios in all households across rural and urban India for years. It won’t be wrong to say that he has been able to create a tremendous impact on the minds of people due to his immense popularity and we as a public associate him with the campaign and his picture in various roles pop up in our heads when we hear about TB.
Despite the decades-long fight against TB, our nation is yet miles away from succeeding in this endeavor, as we see the maximum number of incidences of TB being reported from our nation, at almost 27 lakhs and around 4.3 lakh deaths being reported annually. TB is one of the major causes of death in India and our government has waged a war against it.
National Tuberculosis Eradication Programme
Soon after Independence, India established various regional and national TB control programs, but the efforts saw serious results only after the Revised National TB Control Programme of 1997. The program uses the Directly Observed Treatment Short Course (DOTS) strategy recommended by the World Health Organisation. Since then, we have come a long way with our commitments to fighting the deadly disease.
Our Prime Minister, Sh. Narendra Modi, in 2018, declared that India will strive to eradicate TB by 2025, which is 5 years earlier than the Global Target set under the aegis of the United Nations. A Revised National TB Eradication Programme has been set up with various new provisions to receive active participation from States, Districts, and other institutes of Local Governance.
The NTEP incorporates various mini-programs under it and works closely with other Ministries and Departments. Various schemes such as Nikshay Poshak Yojana, providing Rs. 500 per month for a nutritious diet, Nikshay Jan Aushadhi, providing drugs/medicines at affordable costs, and other Direct Benefit Transfer plans have been performing closely with NTEP. Healthcare facilities are stressing upon better and regular checkups to diagnose and treat at the right times, and for this, private players in the healthcare sector have been brought in close association to ensure minimal under-reporting and better treatment.
What are the states doing?
The Ministry of Health and Family Welfare releases an annual report on India’s efforts to eradicate TB. On March 24, World TB Day, the Indian states performing well against TB in their respective areas, are facilitated with awards. The island UT of Lakshadweep and the Budgam District in J&K have already been declared TB-free. Recently in 2021, Himachal Pradesh received an award for performing excellently to eradicate TB in the category of States with a population over 50 lakhs. Nagaland, in 2020, was declared as the best state to perform under the category of small states with a population under 50 lakhs.
Kerala has become an inspiration and a model for other states as it has been successful in its approach to fight TB. It has engaged the Local Self Governance (LSG) bodies to organize local awareness programs and activities. It has also set an example by effectively including the Private healthcare sector and establishing a single-window system for patients.
India and Tuberculosis: Reality of Healthcare in the Post-Pandemic World
The national battle against tuberculosis has, however, been disrupted by the advent of the COVID-19 pandemic. The healthcare system in India is already reeling under pressure and has been unable to cope up with the deadly virus. The fear caused a sharp decline in TB incidence reports as people stopped visiting healthcare facilities and the healthcare staff, already under pressure, has not been able to focus on its endeavors towards fighting TB. The home care programs undertaken for critical or old patients who cannot visit the healthcare center or hospitals by healthcare staff have also suffered a setback.
The accessibility to hospitals, healthcare institutions, drug stores, etc., stands hampered due to the catastrophe that has struck humanity. Various researches indicate a potential connection between COVID-19 and TB as both generate similar symptoms. The administration has taken various steps like COVID-testing for TB patients and working to resume the welfare programs for TB patients, while also detecting new incidences.
Other than COVID-19, our program in itself suffers from various problems and shortcomings due to the large population in our country and inadequate resources. Jan Aushadhi stores have come under the scanner for supplying fake or substandard drugs. Soon after the launch of the Jan Aushadhi program, various medicines had to be recalled as they were of sub-standard quality. In 2019, India had only 47 drug testing facilities under the National Good Laboratory Practice Programme and only six central labs testing just around 8,000 samples in a year (Livemint).
The Nikshay Poshak Yojana’s many beneficiaries haven’t been receiving the small monthly amount of Rs. 500. In Punjab alone, the 45,000 patients enrolled did not receive any monetary support in their accounts for four months during the pandemic (The Tribune, Jan 7, 2021). The healthcare staff is being blamed for being undertrained, while the administration’s latest experiments of including AI and IT for awareness generation among people have been facing glitches due to poor focus on software.
Striving for better
India needs to learn from its mistakes and from the many successful attempts by various State and local governments to plan a well-rounded program. The healthcare reach needs to be improved, better coordination needs to be there among departments and ministries, the sub-programs need to be monitored effectively and mass awareness for consistent checkups and visits needs to be ensured. Soon after we start recovering from the pandemic, we may witness an unexpected rise in TB incidences and casualties and our healthcare facilities need to be ready for it.
With a poor doctor-to-patient ratio of 1:1456 against WHO recommended minimum of 1:1000 and the highest number of TB cases annually, we are still very far from the already over-ambitious target of eradicating TB by 2025. A realistic target needs to be set based on which our future endeavours in this regard may be planned. Social participation, better medical research to ensure shorter treatment plans, and judicious use of mHealth (mobile health) and eHealth (electronic health) are the key components to win the battle against TB.
WHO acts as a guiding force behind the efforts of a nation fighting a health crisis. In 2002, it developed the ‘onion’ model as a framework for assessing the number of patients who go unreported for TB. According to this model, there are six rings. The sixth or outermost ring consists of cases without access to the healthcare system, while the first layer consists of those diagnosed and reported by providers affiliated to a national tuberculosis program and the only cases captured in case notification data.
On World TB Day in 2019, WHO launched a 1+1 initiative to speed up actions at public levels and amplify youth’s participation. It is a simple initiative aiming that a person can reach another person and make a difference individually and start a chain. WHO South-East Asia Region countries, in 2017 adopted the Delhi Call for Action to end TB by 2030, which is the Global Target and WHO has been assisting India with Universal Drug Susceptibility Testing (DST) guided treatment, addressing problems of Multi-Drug Resistant (MDR) TB and focusing on the social aspects. Various surveys and studies by UN agencies, and WHO have been guiding India and also pushing us for better actions. The World TB Day 2021’s theme, ‘The Clock is Ticking’ is crucial. This is an alarm for the world, especially India, which has set an important, yet ambitious target and it’s our race against time.