Why is it in the News?

A scheme fully owned by the state has become a toolkit for privatisation of public health services and continues caste discrimination.

Context:

• India was ranked right at the bottom of 180 countries in the Environment Performance Index (EPI) in 2022.
  • This index evaluates countries based on their performance in addressing climate change, maintaining environmental health, and preserving ecosystem vitality.
  • It assesses 40 performance indicators across 11 issue categories, encompassing areas like air quality, access to drinking water, and sanitation.
• In response to this ranking, the government expressed reservations, citing flaws in the methodology that, according to them, fail to accurately capture the Indian scenario.
• Over the past decade, the Modi government has launched several development campaigns, including the Swachh Bharat Mission, the Atal Mission for Rejuvenation and Urban Transformation, the Pradhan Mantri Awas Yojana, and the National Clean Air Programme.
• These endeavors are geared towards enhancing living standards and addressing various socio-economic challenges.
• However, despite these efforts, there remains a noticeable rise in the population's vulnerability due to environmental issues like air and water pollution.

About Swachh Bharat Mission:

• Swachh Bharat Mission, the world’s largest sanitation initiative was launched by the Prime Minister of India in 2014 to achieve an Open Defecation Free India by October 2, 2019, as a tribute to Mahatma Gandhi.
• The programme led to the construction of over 10 crore individual household toilets, taking sanitation coverage from 39% in 2014 to 100% in 2019 when around 6 lakh villages declared themselves Open Defecation Free (ODF).
  • The second phase of the mission aims to sustain the open defecation-free status and improve the management of solid and liquid waste, while also working to improve the lives of sanitation workers.
• The mission aimed at progressing toward target 6.2 of the Sustainable Development Goal Number 6 established by the United Nations in 2015.
  • By achieving the lowest open defecation-free status in 2019, India achieved its Sustainable Development Goal (SDG) 6.2 health target in record time, eleven years ahead of the UN SDG target of 31 December 2030.
• The mission was split into two: rural and urban.
• In rural areas "SBM - Gramin" was financed and monitored through the Ministry of Drinking Water and Sanitation (since converted to the Department of Drinking Water and Sanitation under the Ministry of Jal Shakti) whereas "SBM - urban" was overseen by the Ministry of Housing and Urban Affairs.
  • The rural division has a five-tier mechanism: central, state, district, block panchayat, and gram panchayat.
• As part of the campaign, volunteers, known as Swachhagrahis, or "Ambassadors of cleanliness", promoted the construction of toilets using a popular method called Community-Led Total Sanitation at the village level.

Critique of the Swachh Bharat Mission (SBM):

Discrepancy between Goals and Outcomes:

• The Swachh Bharat Mission (SBM) and its successor, SBM 2.0, set out ambitious objectives to achieve garbage-free cities, garnering political support across party lines.
  • However, the reality on the ground paints a different picture.
• Despite government assertions of India achieving open defecation-free status, reports from the Comptroller and Auditor General in 2020 raised doubts about the program's effectiveness, highlighting issues such as substandard toilet construction and inadequate waste treatment.
  • In urban areas, certain communities, particularly those residing in slums, continue to lack access to essential sanitation facilities, exacerbating existing inequalities.
  • In rural and peri-urban regions, the lack of integration between toilet construction and waste management has led to environmental contamination and health hazards.

Perpetuation of Power Dynamics and Inequalities:

• Sanitation and waste management in India are deeply entrenched in caste dynamics, historically burdening marginalized communities with sanitation tasks.
  • Despite attempts by SBM to promote the idea of shared responsibility, the underlying power dynamics persist.
• The introduction of capital-intensive technologies aimed at mechanizing waste management processes has not yielded the desired outcomes, resulting in health crises due to improper waste disposal practices.
• The outsourcing of sanitation work to private contractors, often employing members of marginalized communities, has further entrenched caste-based discrimination.
• Government emphasis on procuring expensive machinery for waste management, funded through public resources, has inadvertently facilitated the privatization of public health services, exacerbating existing inequalities.

Technological Solutions and Implementation Challenges:

• While the government has invested in technological solutions such as waste-to-energy plants and biological methanation, their effectiveness remains limited, with few success stories to showcase.
• Challenges persist in the implementation of these solutions, leading to a lack of tangible improvements in solid waste management across many towns and cities.

Gap in Sanitation Inspection Infrastructure:

• A significant gap in the sanitation inspection infrastructure exists within Himachal Pradesh, as revealed during a recent case in the State's High Court.
• On March 30, 2024, it was disclosed that the Shimla Municipal Corporation, consisting of 34 wards, has only five sanitation inspectors.
• Moreover, the decision to declare this cadre dead after retirement raises concerns about the State's commitment to addressing sanitation issues effectively.
• With more than 50 municipal bodies in Himachal Pradesh and only 20 sanitation inspectors available, it is clear that several municipalities lack essential sanitation inspection personnel.

The interconnectedness of Environmental Performance Index (EPI) and Development Campaigns:

• The EPI offers a comprehensive assessment of a country's environmental health and sustainability efforts.
• One critical aspect of the EPI is mapping, which exposes the shortcomings and unsustainability of current development processes.
• In light of a recent Supreme Court judgment acknowledging the links between climate change and basic human rights, it is evident that development models must be reevaluated and adjusted.
• The interconnectedness of the EPI and various development campaigns cannot be ignored, as the consequences of climate change directly impact human well-being and rights.
• With climate scientists attributing current environmental problems to anthropogenic and systemic factors, it is essential to consider the broader implications of the EPI when planning and implementing development initiatives.

Conclusion

To tackle India's environmental challenges, a comprehensive strategy prioritizing sustainability, equity, and social justice is essential. This involves reassessing development strategies, strengthening enforcement, and encouraging community participation in environmental governance. Addressing implementation issues and linking policies to human rights can improve India's EPI performance and foster a sustainable future.

Why is it in the News?

April 1, 2004, marked a significant moment in India's fight against HIV/AIDS as Free Antiretroviral Therapy (ART) was introduced for Persons Living with HIV (PLHIV).

Context:

• April 1, 2004, stands as a landmark moment in India's approach to addressing the HIV/AIDS epidemic, as Free Antiretroviral Therapy (ART) was introduced for Persons Living with HIV (PLHIV).
• This initiative, conceived in response to the pressing issues of access and affordability, has emerged as a crucial intervention in the fight against the disease.
• As we commemorate this day, it is imperative to delve into the progression and significance of India's free ART program, shedding light on its transformative impact on the nation's response to the HIV/AIDS crisis.

HIV/AIDS's Emergence and Initial Challenges:

• Inception of a Global Health Crisis: The emergence of HIV/AIDS in the early 1980s signaled the onset of a widespread health emergency with profound implications for populations worldwide.
  • Originally detected among groups in the United States, the disease swiftly traversed borders, reaching nations like India and beyond.
  • This era was characterized by uncertainty, anxiety, and a lack of comprehension regarding the novel virus, initially dubbed GRID (Gay-Related Immune Deficiency), later renamed HIV (Human Immunodeficiency Virus) and its associated illness AIDS (Acquired Immunodeficiency Syndrome).
• Absence of Effective Treatments Resulting in Dire Consequences: During the initial stages of the epidemic, HIV/AIDS was synonymous with a dire prognosis, largely due to the absence of viable treatment options.
  • Marginalized communities, including men who have sex with men, intravenous drug users, and commercial sex workers, bore the brunt of the disease's impact.
  • However, as time progressed, it became evident that HIV/AIDS transcended boundaries of gender, sexual orientation, and socioeconomic status, affecting individuals from diverse backgrounds.
• Pervasive Social Stigma: In addition to its grave health implications, HIV/AIDS precipitated significant social stigma and discrimination.
  • Individuals living with HIV/AIDS encountered marginalization, employment loss, and social exclusion from both their communities and families.
  • This pervasive stigma compounded the challenges associated with managing HIV/AIDS and impeded effective epidemic control efforts.
• Limited Treatment Accessibility and Exorbitant Costs of Available ART: Despite the escalating recognition of HIV/AIDS as a global health threat, access to treatment remained scant, particularly in low- and middle-income nations such as India.
  • The approval of the first antiretroviral drug, AZT (zidovudine), by the US Food and Drug Administration (US FDA) in March 1987 marked a significant milestone.
  • HAART (Highly Active Antiretroviral Therapy) represented a breakthrough in disease management, combining multiple antiretroviral drugs to suppress viral replication and bolster immune response.
• However, the exorbitant expenses associated with HAART, reaching up to $10,000 annually per patient, rendered it inaccessible to the majority of individuals living with HIV/AIDS, especially those residing in resource-constrained settings.

The Introduction of Free ART in India and its Impact:

• In response to the pressing issues of limited access and affordability of HIV/AIDS treatment, the Indian government embarked on a significant initiative.
• On April 1, 2004, the government initiated the provision of Free Antiretroviral Therapy (ART) for Persons Living with HIV (PLHIV).
• The introduction of Free ART aimed to dismantle barriers to treatment and extend life-saving medication to all PLHIV, irrespective of their financial means.
• By offering ART at no cost, the government endeavored to ensure that access to treatment would not be hindered by financial constraints, thereby addressing a crucial gap in healthcare accessibility.

Its Role in Curbing the Epidemic

• Enhanced Treatment Accessibility: Over the past two decades, the initiative has undergone substantial expansion, witnessing a surge in the number of ART centers from less than 10 to approximately 700, catering to around 1.8 million PLHIV.
  • This proliferation has facilitated heightened treatment access for individuals living with HIV/AIDS nationwide, including those residing in remote and underserved regions.
  • A notable outcome of the Free ART endeavor has been the remarkable enhancement in health outcomes observed among PLHIV.
• Significant Reduction in Mortality Risk and Transmission Rates: Timely and effective treatment accessibility has transfigured HIV/AIDS from a dire prognosis to a manageable chronic ailment for many.
  • By suppressing viral load and bolstering immune response, ART has not only extended the lifespan of PLHIV but also augmented their quality of life.
  • Moreover, the Free ART initiative has played a pivotal role in curbing HIV transmission rates by ensuring treatment access for PLHIV, thereby thwarting virus dissemination within communities.
  • Research indicates that efficacious ART can substantially mitigate HIV transmission risk, contributing to the overall decline in HIV prevalence.
• Broader Societal Benefits: Beyond its direct impact on individuals grappling with HIV/AIDS, the Free ART initiative has yielded wider societal advantages.
  • By mitigating the disease burden and forestalling fresh infections, the initiative has alleviated the societal and economic repercussions of HIV/AIDS on families, communities, and healthcare systems.
• Supplementary Measures and Patient-Centric Approach: The success of India's ART program extends beyond free medication provision.
  • Complementary initiatives, such as complimentary diagnostic services, prevention of parent-to-child transmission programs, and management of opportunistic infections, have played pivotal roles in curbing the HIV epidemic.
• Furthermore, the program has adopted a patient-centric strategy, furnishing stable PLHIV with two to three months' worth of medicines to minimize clinic visits and enhance treatment adherence.

Challenges and Future Prospects:

• Delayed Initiation and Attrition in Care: A notable portion of patients presents with advanced HIV illness, evidenced by low CD4 counts, impacting treatment efficacy.
  • Furthermore, attrition in care remains a concern, as some patients discontinue treatment upon feeling well, leading to interruptions and potential drug resistance development.
• Logistical Hurdles and Infrastructure Deficiencies: Remote and underserved regions, including those with rugged terrain, encounter hurdles in accessing vital medications and healthcare provisions.
  • Fortifying the logistical network and infrastructure for dispensing ART drugs is imperative to sustain uninterrupted treatment access for all PLHIV.
• Involvement of the Private Sector: While the public sector assumes a pivotal role in HIV/AIDS treatment provision, fostering collaboration with the private sector is crucial.
  • Leveraging the resources and infrastructure of private healthcare entities can expand ART accessibility and reach marginalized populations, including urban dwellers.
• Interconnected Health Program Integration: Augmenting integration with other health initiatives, encompassing hepatitis, non-communicable ailments, and mental health, holds paramount importance.
  • Given PLHIV's propensity for concurrent ailments, comprehensive and integrated healthcare services necessitate intersectoral collaboration within the healthcare spectrum.
• Realization of Ambitious NACP Phase 5 Objectives: The ongoing fifth phase of the National AIDS Control Programme (NACP) sets forth ambitious targets, envisaging an 80% reduction in annual new HIV infections and AIDS-related mortalities by 2025.
  • Achieving these milestones demands concerted endeavors to escalate testing, enhance treatment coverage, and secure viral suppression among PLHIV.

Conclusion

India's free ART initiative has successfully combated HIV/AIDS, demonstrating the power of accessible healthcare. Its achievements emphasize the importance of political will, funding, community engagement, and patient-centered care in tackling infectious diseases. Lessons from this program will guide future public health endeavors, improving outcomes for all