The Health Collective 

Health News: Air Pollution and You

India holds the unenviable distinction of having half of the world’s top twenty most polluted cities.

2015 World Bank report on air pollution had highlighted the magnitude of the disease and economic burden caused by atmospheric pollutants the world over.

Key findings included that as far back as 2012 over 3.7 million people died worldwide from the acute effects of breathing atmospheric pollutants. When the effects of household pollutants were added, the number rose to a staggering 7 million. Of these, 88% deaths were in the developing world.

The socio-economic costs of air pollution are tremendous. The World Bank estimates that the economic cost of the health damage caused by air pollution range between 0.1 to 3.2% of GDP. This number can reach up to 9%, when the costs of environment related malnutrition and its long-term adverse impacts are taken into account. 

Air pollution remains a global and rising phenomenon – with the World Health Organization estimating that over 92% of the world’s population is living in places whose air does not meet its criteria. Further, according to the OECD’s calculations, global air pollution-related healthcare costs are projected to increase from USD 21 billion (using constant 2010 USD and PPP exchange rates) in 2015 to USD 176 billion in 2060. By 2060, the annual numbers of lost working days, which affect labour productivity, are projected to reach 3.7 billion (currently around 1.2 billion) at the global level. The effects of air pollution are therefore crippling the economy and are putting our long-term wellbeing and productivity in serious jeopardy. 



The effects of air pollution on our health are well documented.

Long-term exposure include mortality due to cardiovascular disease; chronic respiratory disease incidence like - asthma, chronic obstructive pulmonary disease (COPD); lung cancer; and intrauterine growth restriction, for example, low birth weight. Experts agree that a rising number of patients with these conditions are making their way through the health system.

This disease cohort may all be categorised as Non-Communicable Diseases (NCD’s), a grouping on which a lot of awareness, investment and preventive initiatives are being undertaken in India. NCD’s contribute an overwhelming 60% of deaths in India. While conditions like diabetes and cardiovascular disease have received adequate attention, diseases that can be attributed to air pollution rank lower on the priority list. And even in cases where awareness is rising on conditions like asthma, COPD or lung cancer, the obvious linkage with air pollution is stated less often.  Be that as it may, there is no denying a clear linkage.

The 2013 assessment by WHO’s International Agency for Research on Cancer (IARC) concluded that outdoor air pollution is carcinogenic to humans. Further a clear trend on the rising number of respiratory conditions can be linked with an (dis) proportionate increase in air pollution and PM levels of any city. The need is to therefore mainstream air pollution, like tobacco, sugar, inactivity and other causal agents into the public health mainstream. 

Currently, no Government assessment on health of a population lays adequate or any co-relation to air pollution. No estimates of the number of days missed at work or school due to pollution or related conditions is maintained. No air quality-versus- disease incidence is being carried out for our major towns and cities. The need is to therefore move towards a new paradigm. State Governments must be encouraged to measure air pollution and index it against rise in diseases that can be attributed to it. The economic cost of the disease burden due to air pollution must also be maintained. A tax on polluting industries that can be used for public health awareness and treatment is also a possible move.  These would need to be coupled with proven policy interventions like reducing end of pipe emissions, increasing public transport, better waste management infrastructure, use of cleaner fuels and renewables etc. to make a real difference. Many great examples of such interventions in places like Peru, Mexico, Mongolia and Thailand exist. 

The dangers of not being proactive will be catastrophic. The OECD estimates that the number of cases of bronchitis is projected to increase substantially, going from 12 to 36 million new cases per year for children aged 6 to 12, and from 3.5 to 10 million cases for adults. These increasing cases of illness can be translated into an equivalent number of hospital admissions, which are projected to increase from 3.6 in 2010 to 11 million in 2060.  Per capita welfare costs from illness and restricted activity days due to outdoor air pollution for India projected to be $400 by 2060. By the end of the day today, over 500 lives worldwide would be lost to air pollution. These are lives that cannot be hindered or costs that can easily be truncated. 

 (Views expressed are personal.) 


About the Author


Karan Thakur is a healthcare administrator, whose interests include health policy, healthcare systems and management.

He tweets @karanthakur and is one of the earliest Friends of the Health Collective.


Assuring the Insured: Quality & Health Insurance Must Align

By Karan Thakur

The country has witnessed a significant increase in health insurance coverage across population groups. A recent study by Brookings India, “Health & Morbidity in India: Evidence and Policy Implications” indicates that in the decade from 2004 to 2014, the number of Indians insured through some mechanism increased from 55 million to over 350 million.

The coverage went from 1% of the population to 15% in a decade. While universal health coverage through insurance remains some way down the road, the increased coverage is welcome. India accounts for some of the lowest health insurance coverage in the developing and low and middle-income countries cohort. This along with low health spends as a percentage of the GDP has meant that over 7% of the population is pushed to poverty on account of catastrophic healthcare expenditures. This is not only unpardonable but also wholly addressable. 



Researchers suggest that universal health insurance along with a strengthened primary healthcare infrastructure are the most important tools to ensure that all Indians have access to an equitable and affordable health system. However, as the Brookings study indicates, ‘public health insurance is not associated with lower out-of-pocket expenditure, probability of facing catastrophic health expenditures or impoverishment caused by health expenditures’.

While it would seem intuitive to assume that increased coverage should lower out of pocket expenses for health needs, this is not what the data alludes to.

It may be conjectured that inadequate coverage, lack of quality at institutions servicing a health insurance policy and asymmetric availability of healthcare facilities mean that out of pocket spending for both inpatient and out patient care remain high. While health coverage itself is the target of most health insurance schemes, adequate and comprehensive coverage for a range of services and diseases has remained elusive. Curative and invasive interventions like surgeries or inpatient care is covered in most public health insurance policies. However, with the rise of non-communicable diseases – now contributing to over 60% of all deaths in India – health insurance schemes seem inadequately planned to meet this disease burden. Lack of coverage for outpatient care and preexisting conditions act as impediments for obtaining a comprehensive and affordable health insurance scheme. Similarly, coverage for diagnostics and health tests remains patchy. The Brookings study indicates that the latter has been the largest contributor to health expenses in urban India. 

More than comprehensive coverage, the lack of quality and outcomes remains a major source of worry. India must move from an output-based to an outcome-based paradigm. Often health insurance policies mandate coverage at pre determined empanelled hospitals for its beneficiaries. These hospitals are selected adopting the “L1” tendering process, where lowest bids are considered “superior” and “cost effective”. Therefore, cost controls, rather than optimal health outcomes, are key considerations for both payers and providers. The lack of co-relation between coverage and out-of-pocket expenses could be explained by this prevalent practice. The insured may look at options beyond the empanelled providers, mostly in the private sector, which could drive up costs to adequately cover their health needs. Therefore, the need to build in quality and outcomes into the coverage regime is an imperative. 

Quality, unlike numerical population coverage remains a challenge. Qualitative assessment of clinical quality and outcomes has been dealt through models like the diagnosis-related group (DRG) reimbursement, pay-for-performance and outcome-based reimbursements the world over. The need to evolve such models in India will be important. Health insurers have relied on price ceiling as their preferred tool for cost controls, especially for reimbursements for private providers. However, this remains inadequate for public providers and also for high-end tertiary care. Similarly, price controls on pharmaceuticals and medical devices are the approach that Governments are taking to control costs. This too remains controversial and inadequate in ensuring overall outcomes and in reducing Disability-Reduced Life Years (DALY) in India. 

Further, quality assurance through institutional certifications like National Accreditation Board for Hospitals & Healthcare Providers (NABH) and National Accreditation Board for Testing & Calibration Laboratories (NABL) have been mandated by insurers for reimbursements. But these serve only as certifications; a more comprehensive evaluation system for outcomes and performance for all healthcare providers needs to be created. Also, quality assurance and outcomes linked performance assessment for the primary healthcare network remains unaddressed. 

Costs and coverage remain twin challenges. We must add quality and outcomes to these overarching pillars on which a 21st century health system for India is to be created. As the Brookings Study indicates catastrophic health expenses continue to rise in India, something that India can ill-afford. But mere price controls and increased coverage alone too shall not address this and other challenges. Quality, outcomes and reliability must all be central to our combined efforts for an accessible, equitable and effective health system. 


Views expressed in this article are personal.

About the Author: Karan Thakur is a healthcare administrator, whose interests include health policy, healthcare systems and management. His other interests are non-fiction reads, impressionist art and history. He tweets @karanthakur and is one of the earliest Friends of the Health Collective.

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