Editorial 1: Debating the ‘healthy longevity initiative’
Context
The divide between the real world and the strategy to be adopted in the healthy longevity initiative is too wide to be ignored.
Introduction
Once in a while, the World Bank publishes a visionary and profound report on an important aspect of human well-being. A case in point is ‘Unlocking the Power of Healthy Longevity: Demographic Change, Non-communicable Diseases, and Human Capital’ that was published in Washington DC in September 2024. A significant demographic transformation is underway with a rapidly aging population. This transformation is accompanied by a shift in most Low-and Middle-Income Countries (LMIC) such that non-communicable diseases (NCD) are the leading cause of deaths. Most NCD deaths occur in LMICs, and the proportion of all deaths caused by NCDs is likely to surge among them.
Global NCD crises and the pathway to healthy longivity
- Projections and current concerns: Projections suggest a global surge in deaths from 61 million in 2023 to 92 million in 2050, as well as related increases in needs for NCD-related hospitalization and long-term care.
- If LMICs can achieve ambitious yet feasible rates of progress, the world could avert 25 million deaths annually by 2050, effectively halving avoidable deaths and meeting the related Sustainable Development Goals (SDG).
- Healthy Longevity Initiative (HLI): Driven by this concern, the World Bank report proposes a healthy longevity initiative (HLI) which takes a life course approach.
- Briefly, healthy longevity entails sharply reducing avoidable death and serious disability throughout the life cycle, as well as increased levels of physical, mental, and social functioning through middle and older ages, and a short period of time before inevitable death (World Bank, 2024).
- Whether this is feasible in LMICs, especially India, is debatable.
- Ideal vs. Real-World Health care scenario: Curiously, it imagines a world in which health care is accessible, doctors and nurses, and para medical staff are competent, honest, and committed to proper patient care, hospitals are well-equipped, the monitoring of patients is systematic and digitised, and there is an awareness of benefits of early detection and treatment of NCDs.
- While the World Bank report discusses catastrophic health expenses and impoverishment, and inadequate state funding of health care, the chasm between the real world and that which is subsumed in the HLI is much too deep to be overlooked.
- Indeed, a world without quacks, corrupt doctors, exploitative hospitals, pharmaceutical companies pushing unsafe medicines, and patients with chronic conditions travelling hundreds of miles is rarefied.
- Objectives and strategy: The objectives and the strategy of reducing the surge in NCDs must, therefore, be modest and feasible.
- A recent study by the writers of this article of the growing burden of NCDs in India is a step in this direction.
India’s elderly population, disease concerns
- Current demographics and trends: The older population of India is currently the world’s second largest — 140 million people who are aged 60 years and above (compared to 250 million people in China).
- Moreover, the average annual growth rate of the older population is almost three times higher than the overall population growth rate of India.
- Consequences of NCD surge among elderly: The swift descent of the elderly in India (60 years-plus) into NCDs (for example, cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes)
- could have disastrous consequences in terms of an impoverishment of families, excess mortality, lowering of investment, and a consequent deceleration of economic growth.
- Worse, the government has to deal simultaneously with the rising fiscal burden of NCDs and infectious diseases.
- SDG and health goals at risk: As a report by The Lancet (2018) emphasizes, failure to devise a strategy and make timely investment now will jeopardise achievement of SDG 3 (‘good health and well-being’) and target 4 of a one-third reduction in premature mortality from NCDs by 2030.
- Rising NCD morbidity and mortality: NCD morbidity and mortality as shares of total morbidity and mortality have risen steadily in India.
- In 1990, NCDs accounted for 40% of all Indian mortality and are now projected to account for three quarters of all deaths by 2030.
- Currently, cardiovascular diseases, cancer, respiratory illness, and diabetes are the leading causes of deaths in India, accounting for almost 50% of all deaths (The Lancet, 2018).
- Common risk factors for NCDs: Underlying these rising shares are growing risks that are common to several NCDs.
- These include tobacco use, alcohol abuse, and obesity due to sedentary lifestyles and diets that are getting to be increasingly high in simple carbohydrates and saturated fats.
- Many populations, particularly in remote rural areas, lack easy or frequent access to primary health-care practitioners who can provide regular screenings for common NCDs.
Impact of social security schemes
- Focus on diabetes and heart diseases: The focus here is on diabetes and heart diseases.
- The writers of this article examine whether participation in social security measures/schemes reduces the prevalence of two specific NCDs, followed by whether utilization of medical services/hospital visits also reduces the prevalence of NCDs.
- The analysis is based on the India Human Development Survey 2015, supplemented by the Longitudinal Aging Study in India (LASI 2017-18) conducted jointly by the International Institute for Population Sciences (IIPS) and Harvard School of Public Health.
- Impact of social security and medical access: Even though pension amounts are meager, they supplement scanty resources of the elderly poor in covering healthcare expenses and thus reduce the NCDs.
- For treatment of such diseases, hospital visits are unavoidable; however, travel costs, fees, and costs of medicines impose a huge financial burden, resulting in large out-of-pocket expenditure, indebtedness, and immiseration.
- While health insurance is useful in restricting the financial burden, its potential is far from fully realized due to limited awareness of eligibility requirements, elaborate documentation, delays in payments, and rejection of claims.
- Dietary risk factors: Diets high in refined grain intake cause an increased risk of premature coronary artery disease, while rice intake beyond a threshold causes diabetes.
- Higher intake of red meats, such as beef, pork, and mutton, also contributes to higher risks of diabetes and heart diseases.
- Additionally, a rise in the price ratios of fat-dense foods (sugar and oil) aggravates the risk of both diabetes and heart disease.
- Age gradient and lifestyle factors: Confirming the age gradient, the risks of diabetes and heart diseases are positively associated with age.
- Reasons for the rise in diabetes with age include a sedentary lifestyle, high-calorie diet, visceral adiposity, and a high genetic predisposition to type 2 diabetes among Indians, which appears at a younger age and at a lower BMI than in the Western population.
- Ayushman Bharat Scheme and Health Insurance Challenges: Of particular importance is the Ayushman Bharat Scheme, which aims to provide health insurance coverage to the bottom 40% of households.
- However, its potential has been far from fully realized due to inadequate funding, stringent eligibility requirements, and widespread corruption, as revealed by the Comptroller and Auditor General of India (CAG) in 2023.
- Issues included large numbers of ineligible beneficiaries, delays in empaneling hospitals, surgeries performed after discharge, and utilization certificates lacking competent authority signatures.
- Insurance alone might not be sufficient to achieve access to quality care, which also depends on healthcare infrastructure, provider availability, and local culture.
Way Forward: Hospital expenses
- Supreme Court’s Directive on hospital price regulation: As private hospitals are notorious for inflated prices of healthcare, the Supreme Court of India directed the central government in February 2024 to find ways to regulate the rates of hospital procedures.
- The Court emphasized that pricing decisions must be informed by a benchmark for price determination.
- While price caps influence actors’ behavior by enforcing regulations, these effects tend to be temporary when enforcement mechanisms are weak.
- Behavioral and lifestyle factors: Behavioral changes are crucial and equally challenging. Lack of physical activity and high-calorie diets promote weight gain.
- Obesity is a known risk factor for cardiovascular diseases and diabetes and can exacerbate risks of respiratory diseases such as emphysema and bronchitis.
- Limiting tobacco consumption can provide individual health benefits; however, reducing multi-morbidity prevalence at a population level requires taxation on unhealthy products.
Conclusion
In conclusion, if and when these policy reforms will be carried out is anybody’s guess. It reflects the need for both regulatory measures on healthcare costs and broader public health policies that encourage healthy lifestyles to effectively address the growing burden of NCDs in India.
Editorial 2: A mixed report card for the India-Middle East-Europe Corridor
Context
Implementation on the northern part of the corridor, which is mostly in West Asia, is going to move slowly until the conflict subsides, while progress is faster on the eastern leg connecting the UAE and Indian ports.
Introduction
In September 2023, the ambitious transcontinental India-Middle East-Europe Corridor (IMEC) was announced on the sidelines of the G20 summit in New Delhi. The proposed corridor is expected to reduce the transit time between its eastern and western nodes by 40%, and costs by 30%, compared to transportation via the Suez Canal. These numbers may vary as the actual benefits may end up being on the lower side, but there is no denying that the new corridor, once operational, will be a game changer for the international maritime trade. Therefore, it is important to understand how the idea has shaped since its announcement and what lies ahead of it.
Progress on both ends
Challenges and Delays in Project Progress
- Initial optimism and setbacks: Over the past year, various challenges have delayed progress on the project.
- The announcement of the corridor came with much optimism.
- However, this did not last long, as the very premise which led to the conception of this idea, namely, the normalisation of Arab-Israel relations, came to a sudden halt with the escalation of the conflict between Israel and Palestine on October 7 last year.
- This crisis engulfed the whole of West Asia for the larger part of the year, which put the corridor on the back-burner.
- Impact on stakeholders: As a result of the temporary pause, two key stakeholders, Saudi Arabia and Jordan, have not been able to make any progress on the project.
- Though it may be argued that the official relations between Arab countries and Israel won’t impact completion of work on the ground, the two governments, which will have to work closely with the Israeli establishment for the project, would not want the optics and its geopolitical dimension.
- Therefore, implementation on the northern part of the corridor, which is mostly in West Asia, is going to move slowly until the ongoing escalation subsides.
Progress on the eastern leg of the corridor
- Advancement of UAE-India relations: On the eastern leg of the corridor connecting the United Arab Emirates (UAE) and Indian ports, things are moving forward at a relatively fast pace.
- The economic relations of the two countries are on a northward trajectory, which is also reflected in the increasing bilateral trade numbers.
- Trade Growth Post-CEPA agreement: Post the signing of the Comprehensive Economic Partnership Agreement (CEPA) in 2022, bilateral trade has grown from $43.30 billion in 2020-21 to $83.64 billion in 2023-24 (a staggering 93%).
- Another important feature of the growing bilateral trade is the diversification of the trade basket between the two countries, which is reflected in the growing non-oil trade.
- The non-oil trade between India and the UAE grew from $28.67 billion in 2020-21 to $57.81 billion in 2023-24.
- This represents a healthy shift from an Indian perspective, considering that most of these commodities will be transported further west and north through the IMEC, thereby improving India’s export share in the larger region.
- Virtual Trade Corridor for trade facilitation: Beyond amplifying trade volumes, the two countries are also working on the standardisation and facilitation of trade processes.
- Recently, India and the UAE launched the Virtual Trade Corridor.
- This will be an integral part of the IMEC, aimed at the reduction of administrative processes and time, reduction of logistics and transportation costs, and ease of doing trade.
- The streamlining of trade processes would not only serve bilateral relations, but also pave the way and provide a working model for other countries involved in the IMEC to develop similar frameworks for cross-border trade facilitation.
Differing progress between western and eastern parts
- Uncertainty in the west: After more than a year since the IMEC was announced, we see an uncertain western part of the corridor trying to navigate through the conflict.
- Commitment in the east: A committed eastern part is forging new linkages to ready itself for the new maritime order.
Focus on connectivity amidst regional tensions
- Connectivity aspect as primary focus: Further, given the one-year progress and the situation on the ground, it is clear that only the connectivity aspect of the IMEC initiative is gaining some traction at the moment.
- Paused infrastructure initiatives: Other elements of the corridor, including clean energy export, undersea fiber-optic cables and pipelines, energy grid linkages, telecommunication lines, and clean energy technology cooperation, will have to wait till the situation in West Asia normalises.
- Capacity building in eastern countries: Therefore, the countries on the eastern part of the corridor should use this time to develop their capacity to improve connectivity among them
Way Forward: What India can do
- Port development and economic zones: India, especially, can use this time to prepare its ports, develop specific economic zones along the connectivity nodes, and improve its domestic logistics for seamless integration with the IMEC.
- Enhancing domestic logistics and digital infrastructure: There is a need to improve the digital footprint in the domestic logistics landscape, which will help reduce logistics time and costs, thereby making Indian exports more competitive.
- Strategic importance of global value ihain Integration: Further, the corridor, as ambitious as it may be, is just the means.
- The actual benefits will be seen only if India can improve its integration in the global value chains.
- Positioning as a global supply chain alternative: With IMEC, India aims to position itself as a global supply chain alternative.
- This can only happen if the country takes steps towards enhancing its manufacturing competitiveness.
Conclusion
Finally, it is time to push for the IMEC secretariat, which can make the structure and working of the IMEC more organised. For starters, the secretariat can work on developing the framework for streamlining the cross-border trade processes and empirical evidence-based research on benefits accruing to participating countries. This would help countries in the neighbourhood of the corridor to better understand the project. This may end up generating interest, which could result in them joining it.
