Childhood immunisation checks in low-income countries
Doctors in Pakistan check an infant for a scar showing signs of Bacillus Calmette-Guerin (BCG) vaccination – used to protect against TB in high-burden countries. 

Routine childhood immunisation across 57 low income countries declined slightly for the second consecutive year in 2021, following massive pandemic-related interruptions in vaccine coverage in 2020, according to Gavi, the Vaccine Alliance.

Vaccine coverage stood at 77%, one percent less than in 2020. 

Preliminary data between January and May 2022, however, shows signs of improvement in childhood immunisation coverage, according to preliminary WHO data contained in Gavi’s 2021 Annual Progress Report. 

In 2021, 65 million children were immunised in the 57 Gavi-supported countries, generating economic benefits equivalent of more than $18.9 million. Gavi-supported countries also contributed $161 million in co-financing to advance national commitments to childhood immunisation, and ensure programme sustainability. 

Gavi countries also administered more than two billion Covid-19 vaccines in 2021. 

“Since 2019, we have seen the biggest sustained drop in routine immunisation in a generation, and millions of children are still missing out,” Catherine Russell, UNICEF’s executive director said. “Immunisation is one of the world’s most effective and cost-effective public health interventions.” 

This is not the first time that global health organisations have flagged this issue. In July, WHO and UNICEF sounded the alarm on the largest sustained decline in childhood vaccinations across the globe in 30 years. As per their estimate, around 25 million infants missed out on routine lifesaving vaccines due to many factors like increased conflicts that blocked immunisation access and Covid-19.

Signs of improvement in 2022

Though childhood immunisation numbers declined in 2020 and 2021 due to the Covid-19 pandemic, preliminary data from the World Health Organization (WHO) shows early signs of improvement in 2022. Data collected from January to May 2022 from 16 countries suggests a 2% increase in the basic vaccine coverage among children. 

In December 2021, Gavi also approved funding to support the world’s first malaria vaccine roll-out in sub-Saharan Africa in 2022-2025. 

Expressing disappointment over the continued decline in 2021 in childhood immunisation rates, Gavi’s CEO Dr Seth Berkley said that the early indications on the 2022 data still provides grounds for optimism. 

“There is no higher priority for the Alliance in 2022 than keeping routine immunisation progress on track,” he said. 

Focus on zero-dose children

The number of children who received no vaccine doses in the 57 low income countries increased by 570,000 in 2021, Gavi reported, pegging the total at 12.5 million children. Cumulatively, this is a 34% increase when compared with the 2019-figures – reflecting the much more massive drop in coverage that occurred in 2020, the first year of the pandemic. 

‘Zero-dose’ children are infants who have not received their first dose of the DTP1 vaccine, which protects them from diptheria, tetanus and pertussis. It is one of the first vaccines administered to infants.

In July’s report, 18 million infants out of the 25 million who missed out on lifesaving vaccines did not receive even a single dose of the DTP1 vaccine, thus increasing their risk of dangerous diseases like diptheria, tetanus and pertussis.

Prof José Manuel Barroso, chair of the Gavi Board, said that leveling out of the decline shows signs of recovery by countries’ “heroic” immunization programmes. “As we move forward, we must maintain our focus on supporting routine immunisation and reaching zero-dose children with life-saving vaccines,” he added.  

Added Russell:  “…we need to…make sure lost ground does not become lost lives.”

Image Credits: CDC Global, Public domain, via Wikimedia Commons.

Public goods
A panel discussion at the WTO’s Public Forum on “Creation and Protection of Public Goods for Health (the Experience of COVID-19)”.

At a World Trade Organization Public Forum this week, public health advocates argued for the creation of a new WTO framework to stimulate voluntary offers by countries to supply more ‘public goods’ to trading partners and the world, including investments, assets and know-how critical to protecting the world against future pandemics and other health or environmental crises.

A panel discussion at the World Trade Organization’s Public Forum on Friday took up the topic of a novel trade-based initiative that they say could help incentivize countries to share new technologies, assets and know-how more readily – not only for meeting health emergencies, but other types of health and environmental challenges.

The idea, says James Love, director of Knowledge Ecology International (KEI), is to create a new framework for recognizing ‘public goods’ within the WTO trade rules, whereby governments can make voluntary, but binding, offers to supply such goods to other WTO trading partners – including, but not limited to public health products, investments and know-how.

Examples of ‘Public Goods’ – KEI Presentation at WTO Public Forum.

The initiative on public goods is modeled on the modeled after the General Agreement on Trade in Services (GATS), a landmark deal from the Uruguay Round negotiations in 1995.

GATS is meant to provide a reliable system of international rules for trade in services, and to facilitate the progressive liberalisation of services markets.  But a unique feature of the GATS framework is the opportunity for countries to make voluntary, but binding, “offers” to liberalize domestic trade rules around services provision  – usually in exchange for another type of trade concession. For instance, a country can voluntarily pledge to drop domestic restrictions against foreign firms’ provision of any kind of services – from credit card management to hospitals administration.  But either directly or indirectly, it might obtain, in exchange, commitments from other countries for benefits or concessions – on issues ranging from agricultural subsidies to tariffs on vehicles.

Make ‘public goods’ part of the international trading environment

Excerpted from: KEI presentation at WTO Public Forum.

In a similar vein, a GATS-like framework for ‘public goods’ could allow, for instance, rich countries to pledge to share money or know-how on vaccines or medicines – in exchange for a developing countries’ pledge to reduce tariffs on electric car imports or even to conserve a biodiverse ecosystem of global significance – as part of the wheeling and dealing that anyways takes place around more conventional trade agreements.

“The idea is to make the public goods part of this trading environment,” said Love and one of the leaders in the novel effort to forge such a new WTO trading framework on such ‘public goods’.

“We’re not picking a fight with the drug companies or the energy companies or anyone else,” he added.

“The decision to supply a public good can be used to get something else you want from other countries at the WTO, or avoid something that you don’t want to do,” said Love. He says that the GATS framework has been highly successful in incentivizing trade liberalization of services precisely because it is heterogenous, but still rules-based.

“It’s not a winners versus losers situation,” Love said of his proposal. “It’s a clever hack at the WTO that has a path forward.”

Public goods debate at the World Health Organization

The question of how and if medicines, vaccines and other public health products could be redefined as ”public goods” also lies at the heart of World Health Organization talks on a proposed new pandemic accord, which began with broad agreement over the summer that a new legal instrument should complement but not repeat provisions of the existing WHO International Health Regulations, while respecting national sovereignty in terms of public health responses.

In those debates and hearings that have since followed, including a new round of public hearings on Thursday and Friday, a significant number of civil society organizations, as well as Asian, African and Latin American nations have stressed that public health responses to the pandemic and investments in R&D for countermeasures should be treated as, and accounted for as public goods- e.g. requiring more public sector investments with the resulting products then freed from profit-based constraints on pricing and distribution.

However, while the campaign to redefine essential medicines and vaccines as “public goods” has been a longstanding aim of many public health advocates – in the realities of the marketplace, it remains that private, not public investments, still drive much critical health related R&D.

Public goods
A slide shown by Antony Taubman, WTO’s director of intellectual property, government procurement and competition division, at a Public Forum discussion

Speaking at the WTO public forum panel, the French virologist Marie-Paule Kieny, a former high-ranking WHO official who now chairs the Medicines Patent Pool, argued “it is really the time to advance” the idea of public goods over “private goods and private profits.”

But making public health resources more broadly available, she said, “will need to be supported by sustainable financing.”

Against those hard realities, incentives for countries to offer up certain kinds of “public goods” in exchange for other types of trade concessions, could be an attractive proposition, panelists argued.

Antony Taubman, WTO’s director of intellectual property, government procurement and competition division, told the forum he believes “it’s a proposal that is quite fertile, in terms of making us all think.”

“More broadly it is a discussion about what it takes to deliver public goods sustainably,” he said. “But it’s also a refection … on how multilateral negotiations work.”

Taubman joked that sometimes “it’s tempting” to call WTO “the World Trade-off Organization,” because of the need to accommodate so many competing interests.

But the “concept of global public goods,” he added, “is in its own a valuable organising idea.”

–Elaine Ruth Fletcher contributed to the reporting of this story. 

Image Credits: John Heilprin, KEI .

EU

“This is really a historic meeting,” said Dr Ilona Kickbusch, co-chair of the European Health Forum at Gastein (EHFG). “Twenty years ago was the very first time there was any talk of a European global health strategy, and it took place right here at Gastein.”

“It was in 2003 that global health first became a part of the EU’s health strategy,” Kickbusch recalled. “But then it disappeared, only to come back in 2010 as the first global health strategy, and now we are working on a second one.” 

Two decades down the road, with public consultations formally closed last week, the European Union (EU) is set to release its second Global Health Strategy before Christmas this year.

“The consultations have taken us from Stockholm to Madrid, but also from Abuja to Columbia,” said Francisco Perez-Cañado, a senior expert at the EU’s Directorate-General for Health and Food Safety (DG SANTE). 

“It has been one of the widest consultations to date, not only including what our stakeholders feel in the member states, but also across the world, and in particular in the Global South.”

The EU plan aims to outline how the region will respond to future pandemics and health threats, and reflect a policy vision that embodies the bloc’s values. In light of the COVID-19 pandemic, EU officials hope to impress upon member states that ensuring more equitable global access to health products worldwide will safeguard global health.

“It is clear that no single government or institution can address this threat of future pandemics alone,” said Paul Zubeil, Deputy Director-General for European and International Health Politics at the German Ministry of Health. 

“The challenges of global health and our reality have changed dramatically since the last EU strategy plan in 2010, so it is a good sign the new European strategy is taking shape. It is absolutely necessary.”

While the draft strategy to be delivered later this year is sure to be ambitious, its  proposals will be at the mercy of the EU’s deliberative processes, and the final plan – expected sometime in the first half of next year – will reflect the views and priorities of its 27 member states.

“You will need to be very lucid that what will come out of the global health strategy will also be a composition of geopolitical agendas,” said Sandra Gallina, Director-General of DG SANTE. “My heart is with Africa, but our member states have many different geopolitical priorities.”

Nevertheless, the inclusive approach to consultation undertaken by the EU has raised hopes that the final plan will ensure that the region retains the role it assumed during the pandemic as a global health leader.

“Global leadership by the EU starts at home,” said Perez-Cañado. “The global health strategy must no longer be only about development, but a truly holistic health approach.”

North-South cooperation: partnerships, not charity 

EU
Sandra Gallina, Director-General of the EU’s DG SANTE.

While the previous EU global health strategy was crafted in European capitals, the new consultative approach has placed an emphasis on the inclusion of partners from across the Global South. 

“It’s been amazing how the EU has really consulted in a different sort of way,” said Catherine Guinard of the Wellcome Trust. “I think the values and ethos of the strategy – equity first and foremost – are so important to its salience and its ambition, and it is quite exciting to think about global health 10 years from now, where the EU has got a comprehensive, coherent roadmap for global health with this strategy as its kind of North Star.”

This inclusion of the views of stakeholders in low and middle-income countries (LMICs) in the drafting process is key to the new plan’s legitimacy, and to many, represents a watershed moment for the transition from charity dynamics to those of partnership. 

“The fact that we’re here is, in itself ,an indicator of some success,” said Dr Ayoade Alakija, member of the Africa Union’s African Vaccine Delivery Alliance and WHO Special Envoy for the Access to COVID-19 Tools Accelerator. “It’s an indicator that the world is listening, that we’re progressing from where we were, to where we should be.”

Alakija was the host of one of the consultative meetings held in the Nigerian capital of Abuja between European Commission officials and delegates from 17 African countries. 

“I remember when that invitation from the ambassador was sent out, there were gasps from some countries saying, ‘Oh my goodness, this is now fully beginning to indicate true inclusion and partnership as opposed to tokenistic participation’,” Alakija said. “Instead of inviting us to the table and saying, here’s what we made earlier, you invite us to co-create.”

Clemens Martin Auer, president of the European Health Forum at Gastein, stressed: “We must stop thinking in terms of charity, and we must begin to think in terms of empowerment.”

Health and climate

Europe’s understanding of the relationship between climate and health is key to the region’s strategic vision. 

“I would love to see the EU really step up and use this strategy as an opportunity to articulate how it will lead on climate and health,” Guinard said. “There’s real awareness across governments now that climate-health is a real issue, but I think there is a gap in leadership.”

To make progress, Guinard explained, the plan needs to push for a transdisciplinary approach in which health policy is integrated with climate, transport, energy and other associated policy areas. 

“On climate and health, this is a real chance to show how the EU can bring together its unique capabilities across policy, science, and politics to really drive effective change to populations in Europe, but also in the Global South,” she concluded.

No future without a health workforce 

Clemens Martin Auer, President of the European Health Forum at Gastein, says global health policy focus must shift from charity to empowerment.

Shortages in the health workforce are perhaps the most critical silent crisis threatening progress on global health agendas worldwide, and the EU strategy is no exception. 

For low- and middle-income economies, staff shortages in rich countries can have devastating knock-on effects for the progress of their health systems, causing medical talent to be frequently poached by high-income economies. 

“This year alone, the UK has hoovered up about 60,000 medical professionals from Nigeria – from Nigeria!” said Alakija. 

“How on earth are we going to have healthy societies in those countries? If we’re going to have a global health strategy, it has to address the difficult questions.”

“We have a lot of – I would say hoovering – of talent from Romania, from Bulgaria, that come over to Western Europe,” Gallina said. “That doesn’t work in Europe, and what we absolutely don’t want is a depletion of the health workforce in Africa.”

Furthermore, the physical and mental well-being of health workers around the world after years on the front lines of the pandemic – an oft-ignored consideration and major contributor to current and future shortages of medical staff – are reaching a crisis point. 

“The health workforce is at the end of its tether,” said Gallina. “That is the crude reality. They are very tired. There is a crisis.”

As one health worker advocate said: “We cannot magically pull a doctor out of a bag. If we are going to put an end to this endless crisis of shortage of health workforces by 2030, we have to start building the pipelines now.”

Pandemic Preparedness: “wake up”

Another essential component of the strategic vision pertains to pandemic preparedness. The status quo, Gallina remarked sharply, is far from acceptable. 

“So let me wake you all up,” she told the room. “Either our patterns change, or the next pandemic will find us in the same place that we were with COVID.

“We need to stop being in this reactive mode,” Gallina continued. “I am fed up that we in health are forced into reaction mode all the time. We wait for something to hit us in the head, and only then do we react.”

The primary mechanism the EU has selected to push for this change of posture is the World Bank’s Fund for Pandemic Prevention, a financial intermediary fund (FIF) to finance investments to strengthen pandemic preparedness and response, with a focus on low- and middle-income countries. 

With the WHO signed on as lead technical partner, the fund aims to address critical gaps in country capacities in areas such as disease surveillance, laboratory systems, and health workforce.

“Yes, we put in $450 million, and the US has put in $450 million, but the important thing will be the proof in the pudding,” Gallina said. “The World Bank must not run this as a development project. It is a health project. 

“A health project means that you listen to the health professionals that you have,” she explained. “If it becomes a development project, it’s lost. It will achieve other things, but not the things we want.”

Any successful approach to global health cooperation must also be adaptable. As crises are unpredictable, so too must world health vehicles be flexible to respond to that reality.

“At the Commission, we often don’t have real tools to push what we want to push, so sometimes we are inventing our tools [as we go],” said Gallina. “And at international level, it might have to be the same.”

Towards a better future

EU
Dr Ilona Kickbusch delivers closing remarks.

Though the final form of the new strategic plan will not be known for several months, the feeling in the room was one of optimism.

“The strategy isn’t just written for the challenges and the problems we know about now”, Guinard said. “But by embedding the science, it is also about the challenges that we don’t know about yet.”

If the plan is to succeed, global cooperation – and the interests of all stakeholders – will be critical. 

“For a collective future to be what we all want it to be, a global health strategy cannot really just be about health,” Akidja said. “We all need to begin to say ‘no!’, it’s not just health. It is education. It is the elimination of poverty. It is food insecurity. It is gender. It is about women’s rights.

“It is important if we are going to build partnerships that we talk together, because I think there is more that connects us in that which divides,” Akidja said in concluding. “Your health is my health, and your health security is my health security.”

Image Credits: Arthur Olesch, Urska Erklavec, Urska Erklavec.

A wide range of organisations and individuals took part in the second round of public hearings on future pandemic preparedness.

From bedrooms in China to boardrooms in Geneva, people offered their views on how to protect the world against future pandemics during the second round of public hearings called by the World Health Organization (WHO).

The public hearings are part of the WHO intergovernmental negotiating board (INB) process to develop a pandemic “convention, agreement or other international instrument” to “strengthen pandemic prevention, preparedness and response”, as agreed on at a special World Health Assembly in November 2021 

The call for comments elicited over 250 video submissions, some of which were aired on Thursday via the WHO’s website with the rest due to be released on Friday.

Equitable access to medicines and protective equipment, more support for health workers and an end to pandemic profiteering had wide support for inclusion in a future pandemic accord.

Meanwhile, a flotilla of conspiracy theorists also submitted the comments, condemning COVID-19 vaccines (“gene genocide”, according to one), WHO “global domination”, masks and social distancing. People from Australia, Poland and Switzerland seemed particularly agitated about these issues, as well as any notion that there could be global decision-making about how to address pandemics.

Intellectual property rights

But back to the serious commentary, all delivered in 90-second bites (and often by unnamed presenters). Equity of access to vaccines and medicines was a common theme across most presentations, a principle that member states have also agreed on at the INB.

Oxfam, supported by the People’s Vaccine Alliance, advocated for increased public investment in research and development (R&D) conditional on “sharing of intellectual property (IP) rights and know-how as well as technology transfer, especially with producers in developing countries”.

“This must be delivered by a WHO-led IP and technology pooling mechanisms and mandate governments to find regional manufacturing capacity in the Global South, which secures supplies for developing countries,” said Oxfam.

However, the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) said that the fast development of COVID-19 vaccines had been the result of many years of investment in mRNA and viral vector technologies.

“We need to make sure that the IP-based innovation ecosystem is not undermined,” IFPMA director general Thomas Cueni said.

Strong primary health systems

Rosemary Mburu, representing the community and civil society representatives at the ACT Accelerator, called for significant investment in primary health care and national health systems. 

“We need to put trained, skilled, equipped health workforce protection, recruitment and remuneration at the centre of future pandemic response,” said Mburu. “Without this, detection of new pandemics will be slower and those in the frontline responsible for testing treatments and immunisation will not be able to perform their duties.”

Bill Rodriguez of FIND, the global alliance for diagnostics, stressed that “pandemic preparedness and routine primary health care (PHC) are inseparable”. 

“Pandemic surveillance requires investment in routine PHC based testing programmes. 

If we are not testing for common conditions, we will not detect an emerging pandemic until it’s too late,” said Rodriguez, who also stressed that low and middle-income countries needed the capacity to develop their own diagnostics as pandemics disrupted global supply chains and travel.

The Pandemic Action Network wants the accord to ensure that every country has the capacity to “detect, prevent and respond to outbreaks at their source and fulfil their obligations under the International Health Regulations”. 

Legally binding

Third World Network stressed that equity in international public health response is not possible unless there are “legally binding commitments on WHO and member states to operationalize equity” and that member states should be under an international legal obligation to realise equity. 

“We firmly believe in the need for an article 19 convention which sets out what is required of countries in preparedness, response to outbreaks and management of pandemics,” said Dame Barbara Stocking from the Panel for Global Public Health Convention.

“Countries need to be held to account. There is now strong evidence that treaties without compliance measures are ineffective. We believe the best way to do this is by having an independent assessment body within the treaty structure for at arm’s length of the WHO.” 

The panel also wants to “incentivize countries to be accountable” where, for example, “non-delivery could have implications for a country’s financial stability” in terms of article four of the IMF. 

Sharing of pathogens

A number of submissions stressed the need to share information about the pathogens driving pandemics to fast-track global response.

For the IFPMA, this sharing should form part of a “social contract”.

“The world needs to show more solidarity because pandemics do not respect borders,” said Cueni. 

“The industry has committed to reserve vaccines and treatments for priority populations in lower-income countries, but this will only work if countries commit to a social contract. That means immediate sharing of pathogens and their genetic sequence data, unrestricted trade and open borders, and it also means financial support so that those most in need can have equitable access to vaccines, treatments, and tests.”

Inclusive

“Meaningfully engage civil society and communities in every aspect and structure that is set up to better protect against future pandemics,” said Mburu.

“Civil society needs to be on the governance structures of pandemic response architecture. We need to be part of the decision-making and co-creation at every stage and have a say in financing and resource mobilisation decisions. Nothing for us without us.”

AU AMA Special Representative D Michel Sidibe and AMATA moderator Kawaldip Sehmi

Africa’s most powerful countries need to ratify the African Medicines Agency (AMA) to ensure its credibility – and civil society organisations can lobby them to do so , said Dr Michel Sidibe, the African Union’s (AU) Special Representative on the AMA.

“It is important to have countries like South Africa, Nigeria, Kenya, Ethiopia, the DRC, and other countries on the continent ratifying the treaty. It is important to continue for the credibility of the AMA to drive the ratification agenda, and it is very important to not lose momentum,” Sidibe told a webinar organised by the African Medicines Agency Treaty Alliance (AMATA), a civil society network that supports AMA’s formation.

“We don’t have another way to do it except making sure that we maintain we sustained our advocacy and we mobilise political leaders,” he added, commending AMATA for its advocacy work in support of AMA.

The aim of AMA is to harmonise the regulatory system for medical products across the continent’s 55 nations to enable faster approval processes and to support local pharmaceutical production.

But its establishment has been slow, first starting back in 2009. In February 2019, the  AU adopted a treaty to establish the agency but it took until November of that year before the bare minimum of 15 member state had ratified the treaty, enabling the AU to move ahead to set it up.

In July this year, the AU selected Rwanda as the host for AMA, and Sidibe said that he was confident the process of operationalising the agency would move fast in the hands of Rwanda’s President Paul Kagame.

World Health Organization (WHO) Director General Dr Tedros Adhanom Ghebreyesus met Kagame on the sidelines of the UN General Assembly in New York last week to offer WHO’s support for AMA.

“Our continent cannot be always the second in line when we have a crisis. When I was UNAIDS Executive Director, we waited for seven years before getting the [antiretroviral] drugs to the poor people,” said Sidibe. 

“Global health security will not happen without making sure that we can provide our poor people with quality medicine that is affordable. Almost 95% of our medicines are coming from abroad when India is importing a maximum of 15% and China 5% for the same level of population.”

Sidibe has been lobbying African countries extensively himself to ensure their ratification of AMA, and so far 22 countries have done so “after intensive engagement and interaction”, he said. 

Processes to make AMA functional

Sidibe said that he expected the AMA office in Rwanda to become operational “soon”, but outlined six processes to ensure that the agency is fully functional:

  • Ensuring its ratification by all countries, particularly Africa’s largest and wealthiest countries
  • Articulate the AMA strategy and plan widely to ensure it has the support of the continent
  • Develop a funding strategy and roadmap for fundraising
  • Start to build the skeleton of the organisation, including identifying its major functions and leaders
  • Build AMA partnerships and coalitions. 
  • Identify and deliver three to five major impacts for AMA in order to establish its credibility.

Stressing that these six points were his personal views, Sidibe called for the launch of “the first replenishment for an African-based health institution” to secure money for AMA’s future.

“The ratification process has highlighted the importance of critical stakeholders – regulators, researchers, academic institutions, private industry and passionate civil society organisations,” said Sidibe.

“AMA should not be just replacing national regulatory authorities or regional harmonisation processes. I think it will be a huge mistake and it will not work. AMA will just come in complement of those and a strong AMA will depend on strong national capacities,” stressed Sidibe, appealing to academics and civil society to help strengthen ethics committees and the implementation capacity of weaker countries.

Panel members discuss innovative financing

Budgetary efficiency and innovative ways to finance health emerged as key solutions to the problems plaguing the European health systems, according to a panel at the European Health Forum in Bad Gastein on Tuesday. 

Europe’s healthcare system is faced with several bottlenecks, said panelists. The COVID-19 pandemic has exacerbated problems such as a lack of adequate workforce and increased out-of-pocket spending on healthcare for citizens of the European Union (EU). 

The need to ensure equitable healthcare, cope with inflation and muster the political will are also issues undermining the health system. 

Is lack of money the problem? 

Money is hardly the problem. The European Commission EU’s long-term budget, coupled with the NextGenerationEU (NGEU) stimulus to boost post-COVID recovery, is channeling over €2-trillion to its member states to address the most important challenges before Europe and support those in need. 

Its EU4Health programme has a €5.3 billion budget for the 2021-27 period to “build stronger, more resilient and more accessible health systems” that are better able to withstand pandemics.

In the aftermath of Russia’s aggression on Ukraine, the EU budget was mobilised to provide emergency assistance and support in Ukraine and in the EU countries, and to alleviate the humanitarian consequences of the war.

“Different needs are best when addressed at their appropriate levels. We have all painfully realised that viruses do not stop at borders. Highly communicable diseases can only be tackled at the international level,” said Nathalie Berger, the director for support to member states’ reforms at the European Commission. 

Other key messages at the session revolved around improving efficiencies and stimulating innovation.

Efficiency

Tamás Evetovits, head of Health Systems Financing at the WHO Barcelona Office, stressed the need for efficient use of funds to bolster up the healthcare system. 

He urged member state to restrict their citizens’ out-of-pocket spending on health care to no more than 15%, which would avoid “catastrophic expenditure” by households. 

According to 2019 EU data on unmet health needs, around 3.1% of the EU population aged 16 and above reported that they have unmet medical examination or treatment needs. This number varied from 0.3% of the population in Spain to 17.6% in Estonia. ‘Unmet needs’ health care needs that are not met due to reasons like cost, distance or long waiting list to access the care service. 

Innovation – now and beyond

In pursuit of universal health coverage and access, Europe should not sacrifice the quality and affordability of healthcare services, said Anca Toma, executive director of the European Patients Forum. “Equity is really important and we want to make sure that health system reform is really centred around protecting the most vulnerable.”

While the COVID-19 pandemic tested Europe’s socio-economic safety net and health systems capacity, the war in Ukraine and with that, inflation and the food and energy crisis, have worsened matters. 

“The situation is tight as we know and the money will become tighter,” said Francesca Colombo, the head of the health division of the Organisation for Economic Co-operation and Development (OECD). “There is a question of who will absorb the pressure on price increases. Is it going to be the government? Is it going to be households? Is it going to be providers?” 

Post-pandemic, money is being channelled towards sectors other than health to rebuild. However, Colombo said that “countries need to invest 1.4% of their GDP across the OECD countries in health systems, targeted at things like workforce, information systems, prevention etc.” 

Members of the audience had a few innovative solutions to finance health systems. Ricardo Leite, a Member of Parliament from Portugal said countries could ask fast food companies to fund public health as they “are taking away health from our societies”.

He added that empowering health ministers to be part of the highest decision-making body of governments could also bring in more funds to the system. 

“I don’t know any minister of health that doesn’t say I want to do better…and they are always seen as the person bringing costs to the government,” he added.

Man showing signs of workplace stress
Can flexible working arrangements help to reduce workplace stress?

Practices implemented during the COVID-19 pandemic, such as flexible working arrangements and teleworking, could help to reduce work-related mental health challenges, according to a first-ever set of Guidelines on Mental Health at Work released Wednesday by the World Health Organization (WHO).

The COVID-19 pandemic triggered a 25% increase in what was already a high percentage of people suffering from anxiety and depression worldwide, WHO has previously noted. At the same time, the pandemic accelerated the pace of transformations in the world of work, especially in remote work, e-commerce and automation – and now emerging evidence shows that more access to flexi-time and remote work arrangements have mental health benefits.

Conversely, shift work and excessively long working hours adding up to 55 hours or more a week are associated with depression, increased alcohol risk and even suicidal behaviours, the WHO Guidelines review found.

More broadly,  job insecurity as well as a lack of  “job control” also are related to higher risk of depressive symptoms and risk of suicidal behaviours, while having more authority to make decisions about your job role and performance is “protective for depressive symptoms and higher job control is associated with reduced emotional exhaustion burnout.”  A lack of “organizational justice also is associated with “subthreshhold mental health symptoms”, the WHO review found.

Work and mental health closely intertwined

Pandemic lockdowns also imposed a mental health penalty when they confined to their homes for work and socializing – but now the benefits of more flexible work schedules are being recognized in the new WHO guidelines.

Release of the detailed 135-page guidelines was accompanied by a joint WHO and International Labour Organization appeal for concrete actions to address mental health concerns amongst the working population and provided evidence-based global public health guidance on how to do so in a policy brief.

“Work and mental health are closely intertwined,” WHO and ILO wrote in their joint policy brief. “A safe and healthy working environment supports mental health, and good mental health enables people to work productively. An unsafe or unhealthy working environment can undermine mental health, and poor mental health can interfere with a person’s ability to work if left unsupported.”

“As people spend a large proportion of their lives in work – a safe and healthy working environment is critical. We need to invest to build a culture of prevention around mental health at work, reshape the work environment to stop stigma and social exclusion, and ensure employees with mental health conditions feel protected and supported,” ILO Director-General Guy Ryder said of the new advice.

The World Health Organization's guidelines on mental health at work

The WHO Guidelines, the product of a lengthy and exhaustive global review of evidence, provide guidance in the following areas: organisational interventions, manager and worker training, individual interventions for promoting positive mental health, and prevention of mental health conditions. The guidelines also include a section offering recommendations on returning to work following an absence associated with mental health conditions and how to aid people with mental health conditions to gain employment.

The guidelines meet the standards for evidence-based guidelines, although in most cases there is low or even very-low certainty of evidence given that the recommendations are based on research into highly complex psycho-social risks, as compared to randomized-controlled drug trials.

Leap in depression and anxiety

Even before COVID-19, the world of work was experiencing changes, from technological development, climate change, globalisation, and demographic shifts. The pandemic accelerated these changes and forced companies and organisations to restructure both for financial reasons and to keep workers safe.

For many employees, WHO and ILO noted, these changes created new psychosocial risks or worsened existing ones.

Before the pandemic, in 2019, around 15% of working-age adults lived with a mental disorder, WHO found in its World Mental Health Report, released in June. This included 301 million people who were living with anxiety and 280 million individuals suffering from depression.

COVID led to a 25% increase in anxiety and depression, making the situation more acute. According to the reports, 12 billion working days are lost annually due to depression and anxiety at a total loss to the global economy of $1 trillion, predominantly from lost productivity.

“It’s time to focus on the detrimental effect work can have on our mental health,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “The well-being of the individual is reason enough to act, but poor mental health can also have a debilitating impact on a person’s performance and productivity. These new guidelines can help prevent negative work situations and cultures and offer much-needed mental health protection and support for working people.”

Organisational interventions – flexible work among the many examples

Flexi-work and telework are just a few among the many examples of organisational interventions that employers can take to address psychosocial risks at work, WHO found.  Others involve  involving workers more in decisions about their jobs, and changing workloads and work schedules to enable better work-life balance.

More “participatory” organisational strategies that allow workers to have a say in their own job design, workload changes, or break schedules also have positive mental health benefits – as does better feedback on worker performance.

Additionally, improvements to the physical work environment can have a positive impact, addressing issues such as “inadequate equipment availability… lack of space, poor lighting, excessive noise.”

In all cases, there was evidence of in favour of these practices, WHO found, even if the review also classified that evidence as weak in classical terms – where randomized controlled trials of the kind used for new drugs are typically seen as the gold standard.

“The GDG [Guidelines Development Group] concluded that, despite very low certainty of the available evidence, the likely benefits of organizational interventions on reducing emotional distress and improving work-related outcomes outweighed the possible harms of implementing these interventions,” the recommendations state. “This was supported by evidence for risk factors at work which negatively affect mental health outcomes, indicating that interventions to reduce, remove or mitigate risk factors could improve these outcomes.”

Addressing mental health of people with existing conditions

On a cold winter morning these women from Raipur, India are crowded into the back of a truck on their way to work.

The WHO guidelines also include recommended measures for addressing the mental health of humanitarian and emergency workers, as well as for integrating new or returning workers with mental health conditions into the workforce.

Finally, the guidelines map out recommendations for training both employers and workers in mental health literacy – including  strengthening managers’ skills to recognise and act on mental health conditions at work, and empowering workers to seek support.

In their joint brief, WHO and ILO call for the creation of an environment with “cross-cutting actions to improve mental health at work” through seven factors they said are “critical for progress:” leadership, investment, rights, integration, participation, evidence, and compliance:

  • Leadership involves the development of a mental health plan and assigning roles based on that plan. Investment centers on allocating the financial and human resources towards implementing such plans, as well as including mental health services in any work benefits package.
  • A “‘rights” based approach calls for employers to develop and implement non-discrimination policies around mental health and take the necessary steps, such as training programs, to stop stigmas around mental health in the workplace.
  • Integration means the embedding of mental health into existing occupational safety and health strategies and participation engage workers – especially those who have lived with mental health challenges – in the decision-making process.

Walking the talk at WHO

WHO’s new headquarters in Geneva – touted architecturally for its modern design but with many staff doubling up on desks in the new atrium open-space.

Ironically, prior to the pandemic, WHO itself was the agency with some of the UN’s most restrictive policies on teleworking and flextime – until COVID which forced most of its 8,000+ workforce to abruptly begin working remotely in March 2020 – the resulting efficiencies triggered a re-evaluation of internal policies.

Until today, most the WHO workforce in its Geneva headquarters is still working off-site much or most of the time – as a massive building renovation project coinciding with the pandemic reduced office space and forced workers to double up on desks – unless they are high-level directors.

More recently, a new WHO policy calling for workers to return to the office for at least one day a week may have been met with relief among some staff happy to reconvene with colleagues again, but resistance among others who say that office work policies need to be fine-tuned in light of workers’ individual status and needs.

In particular, WHO’s new building design, chosen after painstaking review, has received complaints among from critics who say that the modern, open-plan offices reduced privacy and net desk space, leaving almost no room for consultants.  Even some of the regular staff have to double up on desks in a windowless “atrium” area, taking everything home at night.  More private office spaces, featuring windows, run along the sides of the new building, but these are largely taken up by higher-level officials.

WHO’s “atrium offices” in the new building headquarters – windowless cubicles crowded together.

Observed one senior WHO staff member who asked not to be named: “I think that days in the office should be decided upon based on the benefit that can be derived from going to the office relative to the risks/disadvantages.

“For instance, effects on work-life balance would be negative for me, since I would have to waste between 1 hour and around 2 hours of my day on commuting.

“Additionally, some 95% of my work is with people outside Geneva, not to mention that I have a great teleworking set up at home – whereas in the office I have a small desk area with ‘blinders on three sides’ in a hallway (which they euphemistically call ‘atrium’) that I would have to clear every evening since it will be used by somebody else on another day. This is not what I consider a productivity environment.”

Asked for comment, Aiysha Malik, WHO’s lead coordinator of the new guidelines from the Department of Mental Health and Substance Use said: “These first ever guidelines from WHO …mean that employers, and the people responsible for the health and wellbeing of workers, can now be assured in what works for mental health. Like all organizations, WHO will review the recommendations and ensure that this guidance forms part of its way of working.”

–Elaine Ruth Fletcher contributed to this report.

Image Credits: Ciphr Connect, Neil Moralee/flickr , World Health Organization, Prem Kumar Marni/Flickr, Geneve Internationale/WHO and BBK Architekten, Health Policy Watch .

WHO Europe Director Dr Hans Kluge pitches his “moonshot”.

European finance ministers need to recognise that the “permacrisis” of the pandemic, climate change and the war in Ukraine pose as big a danger as a nuclear threat, and double their investment in the health workforce, according to World Health Organization (WHO) Europe director Dr Hans Kluge.

This, added Kluge, was his “moonshot” for a truly European health union – the theme of the European Health Forum in Gastein that he was addressing on Tuesday.

“According to some reports, nine out of 10 nurses would like to quit their job, 80% of the nurses had psychological distress, and 40% of the medical doctors in our region are close to retirement age,” Kluge told the forum.

In addition, health workers were migrating from poorer countries to in the east to the wealthier west.

“We have medical deserts, where you have rural areas where you don’t find any doctors or nurses, and this is a big challenge,” said Kluge.

Resilience and stronger health systems

Stella Kyriakides, the European Commissioner for Health and Food Safety

Stella Kyriakides, the European Commissioner for Health and Food Safety, said that both the COVID-19 pandemic and the war in Ukraine had shown the region that it needed to focus on “resilience and stronger health systems”.

“EU Member States and other countries are supporting Ukraine with emergency assistance to a level that I believe we haven’t seen before. We’re delivering medicines, personal protective equipment, ambulances, food and shelter,” said Kyriakides, adding the EU had also set up a medical evacuation system that had enabled 1,300 patients to get special treatment outside of Ukraine.

“Wars have huge consequences at all levels and so much human suffering. But we are, as an EU, in there for the long haul to support Ukraine, and we need to be prepared for more difficult autumn and winter months,” said Kyriakides.  “We must never forget the backbone of health systems which is a health workforce.”

The European Commission’s Nathalie Berger, who is Director for Support to Member States’ Reforms, said that 17 member states were being supported to reduce their dependence on Russian fossil fuels and identify and develop renewable energy sources. 

Getting through winter

Daniels Pavluts, Minister for Health in Latvia

Government ministers from Austria and Latvia were simply and immediately focused on regional co-operation to survive the winter without gas from Russia.

Latvian Health Miniser Daniels Pavluts, outlined his two priorities: to help Ukraine win the war and second, to get through the winter. 

Latvia, Estonia and Lithuania have been “among the leading countries providing bilateral help to Ukraine”, said Pavluts, adding that his country had provided treatment and rehabilitation for Ukrainian soldiers and other victims of hostilities, and taken in about 40,000 refugees. 

“We have shared borders with Belarus and Russia and we can easily imagine ourselves being in the place of Ukraine. It is our duty to help Ukraine win this war,” said Pavluts.

Latvian health officials were travelling to Ukraine, to learn “how they operate in these conditions of war” and also how to prepare for nuclear threats, he added.

Breaking dependence on fossil fuels

Leonore Gewessler, Austria’s Minister for Climate Action, Environment and Energy,

Leonore Gewessler, Austria’s Minister for Climate Action, Environment, Energy, Mobility, Innovation and Technology, said that the multiple crises had made government officials break out of their silos.

“You have a minister of health on this panel who speaks as much about war and foreign policy as health. And you now a minister of climate action and energy who speaks as much on social effects of climate policy and health effects of the climate crisis,” said Gewessler.

She was particularly challenged by “the war in Ukraine, and its effects it has both in Ukraine and on Europe’s insecurity of energy supply and the social aspects of the price hikes that we see”.

She was also trying to help people affected by the climate crisis, including “young people who are becoming increasingly anxious about a very existential threat to their well-being”.

“The root of the problem is our dependency on fossil fuels, especially our dependency on Russian fossil fuels,” she added.

In the short-term, “I will need every kilowatt hour that I can get to make sure that I can heat homes as Vladimir Putin does  now uses gas supply as a weapon”, she said.

“In the long term, the only solution is to go renewable and as independent as we can to produce as much of our energy ourselves as much as we can. And this means from every way ,we get rid of our dependency on fossil fuels – solar panel by solar panel, by heat pumps, windmill to windmill.”

Medtronics’ Betteh Life project in Sierra Leone

Infectious diseases like HIV, tuberculosis and malaria have long been the biggest public health challenges in low- and middle-income countries (LMICs) but over the past decade, non-communicable diseases (NCDs) have risen at an alarming rate.

While every country faces a growing NCD burden, low- and middle-income countries are seeing the fastest increase. This epidemiological shift is largely due to increases in exposure to risk factors – urbanization, tobacco, alcohol, ultra-processed food, air pollution and a lack of physical activity – and is exacerbated by more fragile health systems.

Getting NCDs under control in LMICs requires new approaches to securing funds, through innovative partnerships that can creatively leverage resources and technology for efficient and effective service delivery.

‘Betteh Lyfe’ in Sierra Leone

In Africa, the Betteh Lyfe programme – a collaboration between Medtronic LABS, the Christian Health Association of Sierra Leone, and Sanofi Global Health – was launched in Sierra Leone this year. 

Medtronic LABS supports end-to-end care with their digital health platform, SPICE, and their team on the ground. It begins with community health workers who carry out screening for diabetes and hypertension close to people’s homes – even those living in remote areas – and referral to health facilities to begin a treatment programme.

Follow-up and monitoring are community-based or via tele-counselling, making it easier for patients to adhere to treatment. This also generates real-time data that is valuable for clinical, programmatic and policy decision-making. Private sector funding helped to catalyse the programme while collaboration with the existing faith-based network made it possible to build connections with remote and marginalized communities to bring NCD diagnosis and care to their doorsteps.

The total number of people living with diabetes in Africa is predicted to more than double to 55 million by 2045. Hypertension, cardiovascular diseases, cancers and mental health disorders are all on similarly steep upward trajectories.

Today, 74% of all deaths are due to NCDs – with the heaviest and fastest rising burden in LMICs – and yet only 1-2% of global health funding supports NCD care. This number has stagnated since NCDs made it onto the global health agenda two decades ago.

Medtronic LAB has helped to check people for hypertension in Sierra Leone.

 Kenya’s public-private partnership

Aside from funding, the response on the ground will need to adapt to the evolving epidemiology. It requires ‘all-of-society’ partnerships, that bring together the private sector, public sector, civil society, donors, and most importantly patients themselves in designing and delivering solutions.

Such partnerships are essential if we are to overcome numerous barriers to better health in LMICs, like inadequate funding, hard-to-reach services, poor adherence to treatment, and insufficient data to make informed health policy decisions. We’ve seen their effectiveness proven on the ground.

A similar approach has been employed in Kenya for the last three years in a landmark public-private partnership with Medtronic LABS, the Ministry of Health, the County Government of Makueni, PATH, Novo Nordisk and Kenya Defeat Diabetes Association. 

This multi-sectoral model has focused on public health system strengthening. So far, it has screened 114,000 people, enrolled over 21,000 patients in Makueni County alone, and will extend to all 47 counties in Kenya by 2026. 

Its ethos is based on both reaching and retaining patients. Like the Betteh Lyfe program, community health workers visit people in remote areas for education, screening, follow-up, and blood pressure and blood glucose monitoring while physicians track the readings remotely through the digital health platform. Patients are kept engaged with health services as they do not have to travel prohibitively long distances to access care and begin to see improved outcomes within a year.

Digitizing the health information system

The program has also digitized the national diabetes and hypertension health information system from data collection all the way to aggregation into District Health Information Software (DHIS2), ensuring consistent availability of data for decision-making. As part of the commitment to work within and sustainably transform health systems for scale, the full ownership of the model, including the digital health component is being transitioned to the Ministry of Health.         

These examples highlight how a robust multi-sectoral partnership framework can improve access to essential NCD services, ensure optimal and efficient use of scarce resources and leverage the expertise, capacity and experience of the different partners to mount a more coordinated NCD response. 

Programme leadership from national and sub-national governments and aligning strategies around government priorities whilst engaging faith-based networks and other community groups can ensure sustainable, bespoke and person-centered chronic care.

Rwanda’s Universal Health Coverage

Rwanda is a good example of this approach. Its government has taken a strong lead in the enactment of Universal Health Coverage (UHC), which integrates NCD prevention and care whilst constructively engaging partners, civil society and the community.

Here, 91% of the population is covered by health insurance, primarily the Rwanda Community Based Health Insurance (CBHI) which covers 90% of all health costs at all levels of care. This kind of financial protection, plus ambitious community screening and education programmes, helped increase the use of health services from 30.7% in 2003 to 85% in 2008.

These programmes offer many translatable lessons for other countries looking to improve their health systems through multi-sectoral partnerships: the importance of government leadership, working with community organizations, leveraging community health workers to deliver NCD care, and the role of digital innovations to reach remote or marginalized populations. 

Building experience and evidence from bold partnerships like these will be an important contribution to supporting LMICs as they make gains towards reducing the health and economic burden of NCDs.

 

Alison Cox

 

 

Alison Cox is the Policy and Advocacy Director of the NCD Alliance.

 

 

Megha Kumar

 

 

Megha Kumar is Head of Global Partnerships at Medtronic LABS.

 

 

Anne Stake

 

 

Anne Stake is Chief Strategy & Product Officer at Medtronic LABS

 

Image Credits: Medtronics.

Aam Admi Party leaders Bhagwant Mann (centre), the Punjab chief minister, and Arvind Kejrwal (left), chief minister of Delhi.

NEW DELHI – When India’s Aam Admi Party (AAP) won elections in the northern state of Punjab in March, decisively wresting power away from the Indian National Congress (INC) and defeating the nationalist Bharatiya Janata Party, clean air advocates and activists were optimistic that the burning of crop stubble by Punjab farmers – the biggest contributor to Delhi’s recurring autumn and winter air pollution spikes – would finally be tackled and a real solution found.

There were two primary reasons for this optimism. First, of all Indian political parties, the AAP, which came into power in Delhi in 2013, was one of the earliest to acknowledge the health harm of air pollution and speak out most openly about the need to reduce this environmental toxin.

It even experimented with implementing an odd-even road-sharing plan for vehicles in the high pollution season in early 2016. Even though this scheme failed to deliver – some research showed pollution actually increased during this period – the AAP succeeded in raising awareness about air pollution and making it a mainstream issue.

But it was the second reason that gave activists cause for optimism this season. For years, the AAP has loudly, aggressively and publicly blamed the INC for the winter pollution peaks in Delhi and northern India, saying that the Congress-ruled Punjab government has been  unable to control fires set by farmers to prepare their fields for winter sowing. 

Satellite image of northern India on 26 October 2020 shows the Delhi region with “very poor” to “severe” air quality, largely as a result of of crop burning in Punjab, whose capital is Chandigarh.

Now that the AAP had taken control of Punjab with a sweeping majority, the party had all the power to stop farm fires – whose toxic drifts southward towards Delhi in early and mid-winter, setting off choking pollution crises in the city for more than a decade.

But the AAP’s proposal that the central government, the Punjab state government and the Delhi state government jointly pay farmers a cash incentive of Rs 2500 per acre – not to burn crop residue appears to have already fallen through. The party has been unable to explain why – although it’s likley attributable to the deep political rivalries that exist between the centre-left AAP, now controlling Punjab state and Prime Minister Narendra Modi’s Hindu nationalist Bharatiya Janata Party (BJP), which controls the government today.

Specific questions sent by Health Policy Watch to AAP leaders and spokespersons, including chairperson of the Delhi Assembly’s environment committee and legislative assembly member Atishi Marlena, were either ignored or given generic responses. 

One AAP spokesperson referred us back to a YouTube video of a speech made by the Punjab Chief Minister, Bhagwant Mann, in which Mann said that the state government has asked the central government for help in paying farmers the no-burn cash incentive. 

Punjab chief minister claims central government nixed farmer incentives

Mann said the proposal calls for the central government to cover Rs 1500 of the cost of the no-burn incenteive, while the Punjab and Delhi state governments would each add Rs 500 per acre – in light of the huge health impacts the stubble burning has downwind – including in New Delhi, India’s capital city, and the greater Delhi metropolitan area, India’s second largest.  

“The central government has rejected our proposal,” Mann said, speaking in the video in Punjabi. “But doesn’t matter, even if the central government doesn’t help us, we will go ahead with our contributions and also ask every one of our officers to spread awareness (about the harms from burning) and inform farmers that they should not light fires,” he added. 

However, subsequently, Punjab Agriculture minister Kuldeep Singh Dhaliwal said the plan to give cash incentives to farmers not to burn crop stubble had been shelved in its entirety. “How can we pay when the centre is not giving?” the minister asked.

Meanwhile, Mann said the Punjab government would also deploy 105,000 crop residue management machines in to grind the crop waste  – another much touted alternative to waste burning. But it remained unclear if the Punjab government intended to buy the machines or merely encourage farmers to buy them via subsidies – and what timelines were being planned. 

And he said that the government would also incentivize farmers to make wider use of an innovative new chemical composting technique, known as the Pusa decomposer, an indigenous catalyst that converts rice stalks to valuable manure, and has been successfully tested by the Delhi State government over the past two years in its own non-basmati rice-growing farmlands.  However, the stalks still take several weeks to decompose and it remains to be seen if farmers will perceive the value of the compost thus created as worth the wait. 

Early start of toxic air?

Pollution in Delhi peaks in late autumn when drifting emissions from crop burning exacerbate the usual urban household, traffic and industrial sources

With the harvest season beginning imminently, however, it is already getting late to take pre-emptive action – with some Punjabi farmers already beginning to set their fields on fire.

Like every monsoon season, August and September have seen the cleanest air, and the lowest Air Quality Index (AQI) numbers, in north India in 2022, with rains clearing smoke and fine particulates that are the most hazardous to health, and would otherwise drift hundreds of kilometers towards Delhi. 

On Friday 16 September, for instance, the AQI in Delhi was 44, putting it squarely in the “good” category (AQI under 50), due to a long period of light rain – the first “good” air day since 18 October 2021, which was the only good air day in 2021. 

There were only five good air days in 2020, mainly because of the lockdown. But there wasn’t a single good air day in 2015, 2016 and 2018.

This post-monsoon air is clean because it has been washed by rains – no political party or smog tower can claim credit for this although that hasn’t stopped politicians from trying. 

But as those who track air pollution know that this is the calm before the storm.  It is a narrow window of time after which, rice paddy straw burning during the dry season that follows begins to push PM2.5 readings up to dangerous levels – made even more hazardous by fireworks from the Hindu Diwali festival, to be celebrated this year on 24 October.  

PM2.5 is the microscopic particulate matter that bypasses human defences to settle deep into the lungs. It is absorbed by the bloodstream and carried to every organ in the human body, fueling inflammation and a host of cardiovascular and respiratory diseases, among others.

Often these can spike more than 250 times above the World Health Organization (WHO) limit of five micrograms per cubic metre on the day after Diwali. 

With the monsoon receding early, leaving a rainfall deficit of 35% in Delhi according to the India Meteorological Department, wind speeds dropping and some early signs of crop stubble burning, toxic air may make an early entry this year. 

Farmers already burning fields

There is a very brief turn-around between the autumn rice harvest and the time when farmers need to sow wheat, making rice stalk burning attractive to farmers.

According to the Punjab Remote Sensing Center, farmers have already begun lighting their fields. Last Tuesday the AQI immediately rose to 182, the highest since 25 June, when it was 230. 

Farm fires usually begin in Punjab’s Majha region and progress towards the Malwa region. Unless there is some miracle, Delhi and north India’s Gangetic plain are in for another toxic winter, as governments flounder without focus or specific plans to reduce the burning of agricultural waste, 

North India’s unique geography, topography and meteorology make controlling stubble burning critical to curbing air pollution. The geography of the Indo-Gangetic plain – with the great Himalayan range in the north acting as a physical barrier, preventing dirty air from dissipating quickly – traps pollution generated in the region for long periods. 

As the monsoons recede and the air becomes cooler and drier over the winter months, wind speeds also reduce. Seasonal temperature inversions  – when lighter, warmer air rises and traps cooler, denser air – further confines pollution to the ground level, keeping atmospheric particulate concentration high. 

Air pollution in this region is bad year round – but during autumn and winter, these geographical and meteorological misfortunes combine with stubble-burning to create the perfect storm, turning India’s northern plains into one gigantic bowl of pollution that its residents are forced to breathe for months on end.

Health costs of stubble burning

Analysis of the proportions of a) people exposed and b) land area covered by air pollution at various levels, based on data extracted by Washington University, St. Louis USA.

Stubble-burning is one of the major contributors to air pollution in South Asia. But the problem is particularly acute in north India due to the unique mix of crop cultivation patterns, the timing of harvests, and weather. In India’s Punjab and neighboring states, farmers burn their fields to quickly clear them of straw in the short window of time that they have between the end of rice-harvesting and the wheat-sowing period. These fires are so large that they can be seen from space.

Until September, densely populated urban areas like Delhi experience mixed winds, including the moisture-laden easterlies and south-easterlies. But by early October, the winds change direction, blowing in from the northwest so if paddy fields are on fire at this time, smoke from the fires move directly towards the urban areas – and the 46 million people living in the greater Delhi region who inhale the smoke with every breath they take.  

According to some estimates, farmers reportedly produce almost 50 million tonnes of straw a year in the northern states of Haryana, Punjab, Rajasthan and Uttar Pradesh, burning about four-fifths of the waste. Punjab alone produces 20 million tonnes of paddy residue.

Another, more conservative estimate of the International Wheat and Maize Improvement Center holds that farmers in North India burn around 23 million tonnes of straw from their rice harvests.  But this is still huge; if the stalks were packed into 38-cm-high bales, and piled on top of each other, they would reach the moon.  

The air pollution cost due to stubble burning is estimated at $30 billion annually in terms of health and economic disruptions such as flight and train delays and car crashes, according to National Institute of Public Finance and Policy.

Rural as well as urban populations experience the negative health impacts. An October 2021 study on the respiratory effects of crop stubble burning in the Patiala district of Punjab, undertaken by the Energy Resources Institute, found respiratory complaints and reduced lung function across all age groups – with the most reduced lung function in the lowest age groups whose developing bodies may be stunted by pollution for life. 

Exposure to stubble burning increased a person’s risk of lung cancer by 36%, the study also found, with more adverse health effects among women as compared to men.  

Stubble burning also harms soil fertility, destroying many nutrients. One report estimated the losses as follows: nitrogen (5.5kg), phosphorous (2.3 kg), potassium (25 kg) and sulphur (1.2 kg). The heat also kills beneficial bacteria and fungi, according to the report.

Alternative uses for stubble

For nearly a decade, Indian agricultural experts and air quality advocates have tried to promote alternative crop management practices including not only the incorporation of rice stubble into the soil through mechanical tilling or composting, but also other creative uses for the thick rigid stalks as inputs to: pulp and paper production; biofuel; soil-enriching biochar, or for production of cement and bricks.

Ashwini Choubey, the national government’s Minister of State for Environment, Forest and Climate Change, told the Parliament in July that Punjab aimed to bring its 20 million tonnes of stubble burning down to zero by 2024 by switching to other crops (reduction of 5.22 million tonnes), in-situ management with composting and mulching in the fields itself (10.70 million) and managing the remainder ex-situ (4.66 million tonnes).

However, a big part of this plan was the farmers’ subsidy to not burn crop waste, with the state governments of Delhi, Punjab and the central government sharing the cost of this subsidy in a 1:1:3 ratio. 

This came to nought with central government declining to share this cost, and later, the AAP itself deciding not to go ahead with this payout.

The subsidy was to be supplemented with a two-pronged system of support for crop waste management alternatives – including use of the Pusa decomposer and mechanical waste shredders. 

Shredding stubble and seeding simultaneously

In terms of mechanical methods, machines with names like the Happy Seeder and the Super Seeder have been marketed as devices that can be attached to conventional mechanized harvesters to shred crop residue while simultaneously seeding the winter wheat crop, eliminating the need for rice stalk burning.

But while the government has widely promoted their use in the last few years, uptake has still been limited.

A substantial increase in diesel fuel prices has proved to be an impediment for farmers’ uptake of the mechanical shredding technologies, as fuel-related costs account for 25% of the total operations costs.  

Farmers also remain wary about the Pusa decomposer – partly due to lack of awareness and partly because the benefits of the compost produced from the rice stalks is not yet perceived as  a benefit that outweighs the cost of the time lost in the process of waiting for the residues to rot – even at an accelerated pace. 

Rice paddies are too water-intensive.

Rice is the wrong crop- above and below ground

The more fundamental crux of the problem is that India is growing the wrong crop, experts say. Rice is water-intensive and  Punjab and Haryana, and to some extent UP and Rajasthan are short on water, including groundwater. But even so, in recent decades farmers have gradually switched over from the cultivation of traditional food crops like pearl millet (bajra), finger millet (ragi), sorghum (jowar), barley, rye and maize to rice, due to the government subsidies made available for the latter. The irony is that the legumes are healthy sources of nutrition, including iron, for local communities in a country harbors one quarter of the world’s cases of anaemia – while much of the rice is now exported.   

The air pollution impacts of the changing crop plantation patterns are evident in a mapping of smoke emitted from different farm regions during the autumn, a Council for Energy, Environment and Water (CEEW) study observes. It found higher emissions of PM2.5 from crop stubble burning in the rice paddy-intensive districts of Punjab’s Ludhiana and Sangrur, as compared to other parts of the state, such as Hoshiarpur and Pathankot, where more traditional plants and legumes remain popular.

Meanwhile, below ground, the rice cultivation had negative impacts on the stability of underground water aquifers, also vital for drinking water.  To remedy that, a Punjab Preservation of Subsoil Water Act in 2009 ordered farmers to delay the start of the rice-planting season from April until June – ensuring that the first summer monsoon rains could adequately recharge groundwater reservoirs before rice cultivation began. This, however, delayed the rice harvest, and that had knock-on effects –  shrinking the window of time farmers had to clear their fields between the rice harvest and wheat planting season.

From that point in time, Delhi’s autumn air pollution emergencies became more and more acute, studies of trends over time show.  

More than two decades later, turning the clock back remains a formidable challenge for the new government of Punjab, critics say now. If the AAP is truly to commit itself to controlling pollution, it will have to take a more integrated approach. 

This means expanding the uptake of non-burn alternatives to crop stubble use, as well as striking at the roots of the problem – literally – by encouraging farmers to shift to more diverse crops, including early-maturing rice varieties such as those now being developed by the Punjab Agricultural University. That would allow farmers to plant and harvest their summer crops earlier, before monsoon rains stop and wind direction and speeds pick up.

But that also means changing the regime of price supports so that farmers can still make a profit if they switch from water-guzzling rice paddies to high-nutrient millet and maize.

Unfortunately, until those systemic issues are addressed, toxic air pollution is likely to darken Delhi’s skies once more this autumn and winter – at least for another year.

Image Credits: @pawanpgupta, Flickr, Zubair Hussain/ Unsplash, urbanemissions.info, Jagamohan Senapati/ Unsplash.