User And Public Involvement In Health Services A Literature Review: Fill & Download for Free

1. IntroductionUniversal healthcare (UHC), sometimes referred to as universal health coverage, universal coverage or universal care, usually refers to a healthcare system, which provides healthcare and financial protection to all citizens of a particular country. It is organised around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection, improved access to health services, and improved health outcomes [1]. The World Health Organization (WHO) defines a universal health system as one where ‘all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’. In Ireland, the definition used in current policy for the introduction of UHC does not mention the issue of affordability but instead places the emphasis on access based on clinical need [2]. This is contrary to a key underlying tenet of UHC which is risk protection. Health payments are a heavy financial burden for millions around the world. Financial risk protection is concerned with safeguarding people against the financial hardship associated with paying for health services. The concept of financial risk protection, or conversely the absence of a risk of financial hardship, has been the focus of interest to economists and researchers for many years, and measuring the ability of a health system to protect people against the financial hardship associated with paying for health services has become an important issue for research and analysis across countries at all income levels [3]. It is unclear why health policy in Ireland has chosen to adopt a definition of UHC which is silent on the issue of affordability.The WHO has advocated UHC as the best means of improving global health. However, achieving UHC is not without challenges: from defining the goal of UHC to identifying the most appropriate methods to achieve it. The idea of UHC can be seen in the 1948 WHO Constitution [4] of which Ireland is a signatory. The concept of UHC was first introduced in Ireland through the 1948 Health Act [5]. UHC is also embedded in the 1978 Alma-Ata declaration that contains a number of important principles in relation to health. It specifies that all people regardless of race, religion, political belief, economic or social condition be entitled to enjoy the highest attainable standard of health as a fundamental right. In 2005 [6], 2011 [7] and 2013 [1] UHC has become the focus of various WHO campaigns as the importance and benefits of universal coverage become ever more apparent.Over recent years funding for the health service in Ireland has declined, amidst the most severe economic crisis since the 1930s, while the demands for care and patient expectations have increased [8], [9]. The health system managed ‘to do more with less’ from 2008 to 2012, achieved mostly by transferring the cost of care onto people and by significant resource cuts [10]. This is evident in reduced home care hours, increased wait-times, expensive agency staffing and accentuated inequities of access for patients within the health system. Alongside this there was a growing discourse in society to have a health system that is accountable, effective, efficient and capable of responding to the emerging and on-going needs of the public. This has been illustrated through debates on UHC internationally [11] and in Ireland [2].The structure of the Irish healthcare system has a number of unusual features [12] and is commonly referred to as a ‘two-tiered’ system. ‘Two-tier’ refers to the fact that people who can pay privately or have private health insurance (PHI) can get a diagnosis quicker and can secure faster hospital treatment, even in public hospitals, because they can afford the monthly premiums [13]. About 46% of the population have PHI [14]. Those who cannot afford PHI must often face long waiting lists for acute care [10], for example longer waiting times for minor operations and diagnostics such as CT scans [15]. About two fifths of the population have medical cards under the General Medical Services (GMS) scheme, which are means tested and mostly allocated on the basis of income. These cards enable people on low or no income to access general practice (GP) and hospital care without charge and medicines at a low cost. Healthcare financing relies predominantly on general taxation, which accounted for an estimated 69 per cent of total financing in 2015, with out-of –pocket payments by individuals and PHI contributing an estimated 13 per cent each [16]. Ireland is unusual amongst its European neighbours in not having universal access to primary care [17]. A recent analysis conducted by the European Observatory on Health Systems and Policies found that the highest formal payments in any primary care system exist in Ireland, where patients without a medical card (e.g. when income rises above a specified threshold) pay between €45 and €65 for each GP visit, with no reimbursement [17]. According to recent OECD data on 34 countries, Ireland is in the bottom third for both out-of-pocket expenditure and also unmet medical needs particularly in relation to medical examinations [18], whereby people indicated that they need medical treatment in the previous 12 months but did not receive it [18]. Cross sectional analysis of health seeking behaviour within primary care in Ireland revealed that those who had to pay out-of-pocket payments to see a GP were more likely to put off going to the doctor than those with a GMS card [19]. Similarly analysis on the impact of the introduction of copayments on prescriptions reported a reduction in medication adherence [20]. An antidote to this inequitable two-tiered system is UHC. Possible options for the implementation of UHC, including funding and restructuring as well as dealing with possible positive and negative outcomes are outlined in the Slaintecare report [2]. Details of the complicated nature of the Irish health system are explained in a recent analyses [21].In more recent years Ireland has recommitted its intention to introduce UHC by looking to change the underlying funding model to an insurance based system – universal health insurance (UHI). The 2011-16 Programme for Government states, “under this system there will be no discrimination between patients on the grounds of income or insurance status” [22]. In the final days of the previous Government, UHI became seriously delayed and abandoned in the run up to the 2016 General Election, with the Minister for Health indicating on foot of the publication of costings for UHI that the multi-payer model of private competing insurance companies is not viable stating it was ‘not acceptable, either now or any time in the future’[23]. More recently the Government has formed a cross-party committee, the primary role of which is to ‘establish a universal single tier service where patients are treated on the basis of health need rather than on ability to pay’ [24]. This committee, called the Oireachtas Committee on the Future of Healthcare, published its report entitled Slaintecare in May 2017 outlining a ten year plan for the introduction of UHC in Ireland [2].The issue around universalisation has therefore been an ongoing background debate for decades and periodically comes to the fore when the standing Government seeks to institute reforms. Despite these commitments by Ireland at international and national level, the two-tiered system still exists. This begs the question as to why?The legitimacy and sustainability of any major policy decision increasingly depends on how well it reflects the underlying values of the public. Experts and stakeholders provide essential technical input but their role is distinct from that of the citizen and cannot replace it. It is increasingly understood that citizens should be a stakeholder in framing health policy decisions [25] and it is recognised that citizens’ values should define the boundaries of action in healthcare in any democracy[26], [27], [28], [29]. This is particularly the case for UHC as patients and the public have been identified as key enablers for the implementation of any universal programme [30]. According to the OECD the general public bring new ideas and experiences to the decision-making process; encourage policy makers to think more carefully about the objectives of health services and to be more open and explicit about the choices being made [31].The call for public participation also suggests a shift in political philosophy about who has the democratic right to make healthcare decisions. The WHO have also used the language of rights when arguing that: ‘The people have the right and duty to participate individually and collectively in the planning and implementation of their health care’ [32]. Members of the general public want to be involved in decision-making at the national level [33] and they overwhelmingly want their preferences to inform priority-setting decisions in healthcare [34].Public input into healthcare decision-making, at least in theory, is clearly advocated in Ireland. The importance of patient involvement has been acknowledged in numerous policy documents such as ‘A Vision for Change: Report of the expert group on mental health policy’ [35], ‘The National Health Strategy: Quality and fairness – a health system for you’[36], the Madden Report [37] and most recently in ‘Healthy Ireland – A Framework for Improved Health and Wellbeing 2013–2025 [38], as well as in numerous Health Service Executive (HSE) national service plans [39], [40], [41]. In Ireland researcher-administered questionnaires with 738 patients and family members attending outpatient services reported that 86.2% were supportive of greater patient participation in national level healthcare design, delivery and policy [42].The key prevailing issue relating to the Irish health system is how to end the inequitable two-tiered health system that exists. There has been one formal assessment of the general public’s views and opinions on universalisation in Ireland, however, this study included a convenience sample of patients attending for treatment in a primary care setting[43]. Beyond the media headlines little is actually known about the general public’s views on universal healthcare. We sought to identify what demographic factors and opinions influence the support of the general public for the introduction of universal healthcare (UHC) in Ireland.2. Materials and methods2.1. DesignA cross-sectional survey on the views and opinions of the general public on the introduction of UHC in Ireland.2.2. SamplingA sample of 972 participants were recruited. This provided a 3% margin of error with a 95% confidence level and total population of 4,757,976 based on the 2016 National Census [44].Random sampling was employed with random digit dialling of 85% mobile numbers and 15% landline numbers. This ensured listed and non-listed numbers have the same probability of being contacted. To ensure a representative sample soft quotas for age, gender, location, and social class were monitored. The data was weighted at analysis stage. Weightings were based on data from the 2011 Census and the Joint National Listenership Research (JNLR). The JNLR includes a sample of over 16,000 respondents aged over 15 conducted annually over 50 weeks of the year [45]. This was used alongside Census data to keep weightings as up to date as possible.2.3. ProceduresData collection took place over a two-week period in December 2016. A market research company who specialise in healthcare research were contracted to conduct questionnaires over the phone as part of an omnibus poll. The research team provided the data collectors with definitions for all key terms used in the questionnaire and meetings took place to ensure in depth understanding of the topic and questionnaire. All data collectors were provided with a full day of training, a briefing on the project and 10–15% of interviewer calls were monitored for quality control.The questionnaire was anonymous and researcher-administered over the phone. Consent was implied in completing the questionnaire.Ethical approval was provided by the School of Medicine Level 1 Research Ethics Committee in Trinity College Dublin (reference 20160208).2.4. MeasuresThe questionnaire was developed based on a literature review with standardised questions employed where possible. For example, Question 3b, ‘The government should prioritise spending on healthcare rather than reducing taxes’, was based on work by the Think-tank for Action on Social Change (TASC) which asked about investing in public services in general [46]. A definition of UHC based on the WHO definition was read out to participants after question one (‘I feel well informed about universal healthcare’) was answered. The definition provided was ‘“Universal Healthcare” is that all people have access to the health services they need (prevention, promotion, treatment, rehabilitation and palliative care) free at the point of access.’ (See Supplementary File A: Questionnaire). Further explanation was provided as required throughout the questionnaire after question one was answered. The questionnaire was piloted with 384 members of the general public in two locations in Dublin, Ireland with contrasting levels of deprivation in a face-to-face researcher-administered format. The pilot data was not included in the current paper as the data were collected through different mediums (telephone versus face-to-face) and also a convenience sample was utilised in the pilot.2.4.1. DemographicsParticipants were asked about their age, gender, where in the country they live (location) and level of education. Self reported health, level of healthcare cover, social class and knowledge of UHC were also recorded.Self-reported health (SRH)SRH was assessed by the answer to a single item ‘How is your health in general?’. There were five response categories: ‘very good, “good”, ‘fair’, ‘bad’, and ‘very bad’. This question has become a standard measure for SRH and due to its format can be compared with Irish and international data [47]. For analysis this variable was collapsed into ‘good self-rating of health’ including ‘very good’ and ‘good’ and ‘poor self-rating of health’ consisting of ‘fair’, ‘bad’ and ‘very bad’.2.4.2. Level of healthcare coverWhether the participant was eligible for the GMS scheme, had private health insurance or neither. Due to small numbers for analysis PHI and neither were collapsed together.2.4.3. Social classThe social grading classification system from The British National Readership Survey (NRS) has been well established and used since the 1960s and was employed in this study [48]. This was determined based on a series of questions about the chief income earner of the household in which the participant resides. This included questions on their employment status, type of employer, occupation, role and qualifications. Social class was divided into 5 categories; AB upper/middle class, C1 lower middle class, C2 skilled working class, DE other working class and F farmers.2.4.4. Knowledge of UHCParticipants were asked to indicate how much they agreed with the following statement on a 5-point scale from ‘strongly agree’ to ‘strongly disagree’. ‘I feel well informed about universal healthcare’. Participants were asked to answer this question before being provided with the definition of UHC. Categories were collapsed down to ‘agree’ (which included ‘strongly agree’ and ‘agree’) and ‘ disagree/neither’ (which included ‘neither’, ‘disagree’ and ‘strongly disagree’). The collapse of the answer categories was determined by those participants who indicated that they did not definitely ‘agree’ or ‘strongly agree’.2.4.5. Opinions and views on UHCParticipants were asked to indicate how much they agreed with the following statements on a 5-point scale from ‘strongly agree’ to ‘strongly disagree’. ‘Having the health service as a public system is important’, ‘The government should prioritise spending on healthcare rather than reducing taxes’, ‘I want healthcare free at the point of access’, ‘People who can pay for healthcare should pay’, ‘I am prepared to pay higher taxes for healthcare free at the point of access’. During analysis categories were collapsed down to ‘agree’ (which included ‘strongly agree’ and ‘agree’) and ‘ disagree/neither’ (which included ‘neither’, ‘disagree’ and ‘strongly disagree’). The collapse of the answer categories was determined by those participants who indicated that they did not definitely ‘agree’ or ‘strongly agree’.2.5. AnalysesA weighted logistic regression model was employed to assess the odds of participants who did not support the introduction of UHC in Ireland versus the odds of participants who did support the introduction of UHC in Ireland, taking demographic factors and opinions into account.Contingency tables were examined to ensure adequate sample size for each parameter. The final logistic regression model was selected based on the lowest Akaike’s information criterion (AIC). Interactions were checked for and none found. Tolerance and generalised variance inflation factors (GVIF) for independent variables were assessed to determine the presence of multicollinearity. All values were within acceptable limits with tolerance values lower than 1 [49] and GVIF values less than 2 [50].Results are displayed in terms of odds ratios (OR) and 95% confidence intervals (CI). ORs range from 0 to infinity with 1.0 meaning no difference in odds and ORs greater than 1.0 meaning that the ratio of those who support the introduction of UHC versus those who do not support the introduction of UHC in the selected group is greater than the reference group. If the 95% CI for OR crosses 1 this indicates that there is no evidence to suggest that there is any difference between the reference and selected group when comparing those who do and do not support the introduction of UHC in Ireland.Analysis was conducted using statistical software SPSS Version 22.3. Results3.1. Response rateA total of 1102 people were invited to complete the questionnaire on UHC after random digit dialling and eligibility checks. From this 972 participants completed the questionnaire providing a response rate of 88.2% as illustrated in Fig. 1: Flowchart of participants.Download high-res image (434KB)Download full-size imageFig. 1. Flowchart of Participants.3.2. Descriptive analysesA demographic description of the sample is provided in Table 1 (non-weighted) and Table 2 (weighted). These are broken down by support for the introduction of UHC in Ireland. An overview of opinions relating to UHC in Ireland are also illustrated.Table 1. Non-weighted demographic description broken down by agreement with UHC.CovariateAgreeDisagreeNeitherTotal84687.0%656.7%616.3%972100.0%Age18–249110.823.1711.510010.325–4428033.12030.82744.332733.645–6430636.22436.92134.435136.165+16920.01929.269.819420.0Missing––––––––GenderMale45954.34467.73659.053955.5Female38745.72132.32541.043344.5Missing––––––––ProvinceDublin24328.71624.61219.727127.9Rest of Leinster22927.11929.21931.126727.5Munster23327.51726.21829.526827.6Connaght/Ulster14116.71320.01219.716617.1Missing––––––––EducationSecondary level or lowera39246.83250.01626.244044.7Third levelb44553.23250.04573.852254.3Missing––––––101.0GMS StatuscGMSd21225.11116.9711.523023.7Private health insurance46655.14467.74472.155457.0Neither16819.91015.41016.418819.3Missing––––––––Social ClassUpper middle class13816.31015.42032.816817.3Lower middle class23227.42132.31829.527127.9Skilled working class13816.3710.8813.115315.7Other working class29635.02436.91016.433034.0Farmers425.034.658.2505.1Missing––––––––Having the health service as a public system is importantAgree80595.24975.45386.990793.3Disagree/Neither414.81624.6813.1656.7Missing––––––––The government should prioritise spending on healthcare rather than reduce taxesAgree73186.42944.63760.779782.0Disagree/Neither11513.63655.42439.317518.0Missing––––––––I want healthcare free at the point of accessAgree73086.33146.22947.578981.2Disagree/Neither11613.73553.83252.518318.8Missing––––––––People who can pay for healthcare should payAgree56767.01523.14268.965967.8Disagree/Neither27933.05076.91931.131332.2Missing––––––––I am prepared to pay higher taxes for healthcare free at the point of accessAgree56666.91929.22642.661162.9Disagree/Neither28033.14670.83557.436137.1Missing––––––––I feel well informed about UHCAgree42149.82335.41118.045546.8Disagree/neither42550.24264.65082.051753.2Missing––––––––Self-reported healthPoor16920.01624.669.819119.7Good67780.04975.45590.278180.3Missing––––––––– = Not applicable.aSecondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.bThird level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.cParticipants could select more than one method of health cover. A total of 74 (7.6%) participants indicated having private health insurance as well as some form of a GMS card. These participants were included within the GMS category.dThe state provides a general medical services (GMS) card primarily based on income but also for other criteria such as age and other government schemes (HSE, 2015). This provides free at the point of contact access to healthcare services.Table 2. Weighted demographic description broken down by agreement with UHC.CovariateAgreeDisagreeNeitherTotal84887.5%616.3%606.2%969100.0%Age969100.018–249711.423.3711.710610.925–4432938.82236.13050.038139.345–6427232.12032.81830.031032.065+15017.71727.858.317217.8Missing––––––––Gender969100.0Male40647.93861.33355.047749.2Female44152.12438.72745.049250.8Missing––––––––Province969100.0Dublin25129.61727.41322.028129.0Rest of Leinster22726.81625.81728.826026.9Munster22927.11625.81627.226127.0Connaght/Ulster14016.51321.01322.016617.0Missing10.1Education969100.0Secondary level or lowera38646.03151.71626.743344.6Third levelb45354.02948.34473.352654.2Missing101.2GMS Statusc969100.0GMSd22426.41219.7811.924425.1Private health insurance44452.33963.94067.852354.0Neither18021.31016.41220.320220.9MissingSocial Class969100.0Upper middle class10212.0711.51525.912412.8Lower middle class23227.42032.81931.727128.0Skilled working class17720.9914.81016.719620.3Other working class28633.82236.11016.731832.8Farmers505.934.9610.0596.0Missing10.1Having the health service as a public system is important970100.0Agree80795.34775.85488.590893.6Disagree/Neither404.71524.2711.5626.4Missing––––––––The government should prioritise spending on healthcare rather than reduce taxes969100.0Agree73086.22947.53660.079582.0Disagree/Neither11713.83252.52440.017317.9Missing10.1I want healthcare free at the point of access969100.0Agree73887.13150.82948.379882.4Disagree/Neither10912.93049.23151.717017.5Missing10.1People who can pay for healthcare should pay970100.0Agree55965.94674.24066.764566.5Disagree/Neither28934.11625.82033.332533.5Missing––––––––I am prepared to pay higher taxes for healthcare free at the point of access970100.0Agree56066.12032.32744.360762.6Disagree/Neither28733.94267.73455.736337.4Missing––––––––I fell well informed about UHC969100Agree40748.12134.41118.043945.3Disagree/Neither44051.94065.65082.053054.7Missing––––––––Self-reported health970100.0Poor16919.91524.2610.019019.6Good67980.14775.85490.078080.4Missing––––––––– = Not applicable.aSecondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.bThird level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.cParticipants could select more than one method of health cover. A total of 65 (6.7%) participants indicated having private health insurance as well as some form of a GMS card. These participants were included within the GMS category.dThe state provides a general medical services (GMS) card primarily based on income but also for other criteria such as age and other government schemes (HSE, 2015). This provides free at the point of contact access to healthcare services.Examination of Table 1 (non-weighted) shows that females account for 44.5% (n = 433) of the sample, 33.6% (n = 327) were aged between 25 and 44, 54.3% (n = 522) had a third level qualification and 57.0% (n = 554) of participants had PHI.The introduction of UHC in Ireland was supported by 87.0% (n = 846) of participants. The majority of participants also supported the Government prioritising spending on healthcare rather than reducing taxes (82.0%; n = 797), healthcare free at the point of access (81.2%; n = 789) and that having the health system as a public service is important (93.3%; n = 907).3.3. Regression analysesThe final logistic regression model as determined by the AIC is presented in Table 3 with crude and adjusted ORs for participants who support the introduction of UHC in Ireland compared with those who do not support the introduction of UHC in Ireland (‘disagree’ or ‘neither’). The model was statistically significant and fit the data well [x2[20] = 159.712, p < 0.001; Hosmer and Lemeshow, p > 0.05]. This was the most parsimonious model with the lowest AIC.Table 3. Factors Associated With Agreeing With the Introduction of UHC in Ireland (n = 962; 99.0%).Independent variablesCrude OR95% CIAdjusted ORa95% CIAge18–24BaseBase25–440.69(0.31,1.54)0.64(0.24, 1.67)45–641.10(0.64, 1.89)0.88(0.41, 1.87)65+0.98(0.55, 1.72)0.84(0.31, 1.74)GenderMaleBaseBaseFemale1.52(1.03, 2.24)e1.10(0.70, 1.74)ProvinceDublin1.32(0.76, 2.31)2.16(1.13, 4.11)eRest of Leinster0.84(0.49, 1.43)0.78(0.42, 1.46)Munster1.05(0.62, 1.76)1.14(0.62, 2.10)Connaght/UlsterBaseBaseEducationSecondary level or lowerbBaseBaseThird levelc0.73(0.49, 1.08)0.90(0.54, 1.48)GMS StatusGMSdBaseBasePrivate health insurance/Neither0.54(0.32, 0.89)0.53(0.28, 0.99)*Social ClassUpper middle classBaseBaseLower middle class1.16(0.50, 2.72)1.57(0.59, 4.20)Skilled working class0.91(0.41, 2.01)1.52(0.62, 3.74)Other working class0.61(0.26, 1.43)1.09(0.41, 2.84)Farmers0.61(0.27, 1.35)1.18(0.46, 3.01)Having the health service as a public system is importantAgree4.31(2.45, 7.57)e1.65(0.81, 3.34)Disagree/NeitherBaseBaseThe government should prioritise spending on healthcare rather than reduce taxesAgree5.35(3.56, 8.04)e3.43(2.12, 5.57)eDisagree/NeitherBaseBaseI want healthcare free at the point of accessAgree6.80(4.52,10.23)e4.72(2.95, 7.54)eDisagree/NeitherBaseBasePeople who can pay for healthcare should payAgree0.82(0.54, 1.24)0.72(0.44, 1.19)Disagree/NeitherBaseBaseI am prepared to pay higher taxes for healthcare free at the point of accessAgree3.15(2.13, 4.67)e1.91(1.21, 3.03)eDisagree/NeitherBaseBaseI feel well informed about UHCAgree2.62(1.71, 4.02)e2.13(1.32, 3.44)eDisagree/NeitherBaseBaseSelf-reported healthPoorBaseBaseGood0.85(0.51, 1.40)1.21(0.68, 2.17)aLogistic regression- adjusting for other factors included in the model.bSecondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.cThird level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.dThe state provides a general medical services (GMS) card to households on low income. This provides free at the point of contact access to healthcare services.eStatistically significant.Statistically significant factors associated with support for UHC included location, GMS status and attitudinal related factors (e.g., ‘The government should prioritise spending on healthcare rather than reduce taxes’, ‘I want healthcare free at the point of access’, ‘I am prepared to pay higher taxes for healthcare free at the point of access’ and ‘I feel well informed about UHC’).Adjusting for the effects of other factors, the odds of participants living in Dublin agreeing with the introduction of UHC were greater than those living in Connacht or Ulster (OR 2.16, 95% CI (1.13, 4.11)). The odds for those who do not have a GMS card agreeing with the introduction of UHC were lower than the odds of those who have a GMS card (OR 0.53, 95% CI (0.29, 0.99)). The odds for those who agreed that the Government should prioritise spending on healthcare rather than reducing taxes were greater than the odds of those who indicated ‘disagree’ or ‘neither’ (OR 3.43, 95% CI (2.12, 5.57)). The odds of participants who agreed that they wanted healthcare free at the point of access were greater than the odds of those who did not want healthcare free at the point of access (OR 4.72, 95% CI (2.95, 7.54)). The odds of those prepared to pay higher taxes for healthcare free at the point of access were greater than the odds of those who were not prepared to pay higher taxes for healthcare free at the point of access (OR 1.91, 95% CI (1.21, 3.03)). The odds of those who felt well informed about UHC agreeing with the introduction of UHC were greater than the odds of those who did not feel well informed about UHC (OR 2.13, 95% CI (1.32, 3.44)).4. DiscussionGeneral public support for the introduction of UHC is influenced by demographic factors and related attitudinal factors. The introduction of UHC in Ireland was supported by 87.0% (n = 846) of participants. Of those that supported the introduction of UHC, this was influenced by factors including location, GMS status, opinions on the government prioritising spending on healthcare, healthcare being free at the point of access, taxes being increased to provide care free at the point of access and feeling informed about UHC.Differences in context and reform proposals generate differences in the interests of stakeholders and their positioning on reform making it difficult to make cross-national comparisons [30]. However, in the absence of general population information on this topic it would appear that the high level of support for UHC reported in this study is reflective of support for UHC demonstrated internationally. Web-based surveys with 2241 medical students revealed that 86.8% were supportive of UHC in Ontario and 51.1% in California [51]. A similar sentiment was reported from postal surveys with 1675 physicians in the United States with 89% agreeing that all Americans should receive needed medical care regardless of ability to pay [52].When asked if Government should prioritise spending on healthcare rather than reducing income taxes 82.0% (n = 797) of participants agreed with this statement. The 2015 Behaviour and Attitudes Survey asked a similar question but focused on public services in general rather than just health services. A total of 69% of participants agreed with focusing on spending on public services [46]. This is lower than the support for prioritising spending on healthcare perhaps illustrating the importance placed on healthcare and the support for improving services in this area. This is of importance for health policy leaders and makers, particularly in Ireland, as recent examples of protest and demonstrations from the public have been proven to be effective. For example, public outcry against the removal of the GMS card for those over the age of 70, and the attempted removal of GMS cards to very sick children resulted in a rolling back of these policies during the economic recession.Higher socioeconomic status was the principal determining factor for the willingness of members of the general public to support participating in national health insurance in a cross sectional study in St Vincent and the Grenadines [53]. An examination of individual level dynamics in healthcare attitudes toward UHC between 2008 and 2010 in the United States revealed that respondents did not take a position towards UHC reflective of their income [54]. Similarly in the current study social class was not a significant factor influencing support for the introduction of UHC.The current two-tier system has been shown to be ineffective for all groups, GMS and private, with GMS patients facing long waiting times and private patients high insurance premiums and out of pocket payments for both groups [55]. Despite the system not working for any group GMS status influenced participants’ opinions on the introduction of UHC with those with GMS cards slightly more likely to support the introduction of UHC. This is to be expected as those who have PHI nor neither PHI nor a GMS card could be the ones who experience the most change from the introduction of UHC, and may anticipate that not all change will be positive. For example, the creation of a single tier service may mean that those currently with PHI could experience longer waiting times for hospital treatment under UHC than they currently do, but lower out of pocket payments for primary care services.The current research had a number of strengths and limitations. This is a nationally representative sample with 972 participants (response rate of 88%) providing the views and opinions of the general public on UHC at a time when one of the question marks over the implementation of a plan for healthcare in Ireland centres around public opinion. The questionnaire included questions that have been previously used and extensive piloting was conducted. Data collectors were trained and the data collection process was monitored for quality. However, the sample was not weighted in terms of GMS status with the proportion of GMS holders accounting for 23.7% (n = 230) of the sample versus 36% of the general population. Focusing on level of education 54.3% (n = 522) of the sample had a third level education or higher. This is comparison to 34% of the general population aged between 15 and 64 [56]. Additionally, caution must be taken when interpreting results as the number of respondents who selected the ‘disagree’ or ‘neither’ category for the introduction of UHC was substantially lower that the number of respondents whom agreed with the introduction of UHC.5. ConclusionThis paper is relevant and timely for policy leaders both in Ireland and internationally. In Ireland the Slaintecare Report [2] has been published outlining a ten year plan for the introduction of UHC in Ireland and implementation remaining the key question now. Internationally, these findings are of interest as countries with UHC, such as the United Kingdom, are facing difficulties maintaining health services in the public realm with ongoing debate on the privatisation of the NHS [57] and other countries, such as the United States, are debating universal elements for their healthcare system. The current study provides a template that can be used to explore public opinions of UHC in other countries. There is a high level of support for the introduction of UHC in Ireland, which is influenced by demographic, and related attitudinal factors. Patients and the general public have been acknowledged as having a key role to play in all areas of healthcare. This research provides timely information from a representative sample for the ongoing debate on the future of healthcare in Ireland. Future research should explore what people want to obtain from the introduction of UHC and what they are willing to contribute to ensure that the voice of patients and the public is heard at all stages of developments. It would be interesting for this to be explored from a number of different stakeholder groups such as clinicians.

Last Week Revision strategyTwo days for Essay:Prepare quotes, facts and intro and conclusion on below topics. You can also do mind mapping of below topics.Read here my essay strategy:What should be our strategy for the essay paper in the IAS (UPSC) exam?Very Important Topics1. $5 trillion in five years: Can we do it?2. Is Bretton Woods still relevant today?3. Politics without principle is a disaster.4. What India needs: Population control or population development?5. With Big Data comes Big responsibility6. Destiny of the nation is shaped by its citizens7. Is water crisis in India a manmade crisis?8. Means or Ends: what is more important?9. Is Gandhian philosophy relevant today10. Rapid Urbanization : Problems and prospects11. Can Zero Budget Natural farming ensure food security?12. Is privatization panacea for ailing Public Sector?13. Can UBI be a panacea for poverty?14. Rising inequality in India: An anomaly or an outcome of economic reforms?15. Industry 4.0: Is India ready?16. Without the rule of law there can be no democracy.17. Is India’s water Crisis a Man Crisis?18. Is Artificial intelligence boon or curse?19. Can State Funding ensure free and fair elections?20. India’s Population: Demographic dividend or demographic Disaster?21. Development and tribal welfare must be synchronous.22. Extreme is the new normal: Climate Change23. “Is development possible without making compromises on our environment?”24. Inequality is not just a moral issue—it is a macroeconomic issue.25. Is de globalization underway?Less Important Topics:26. The ignorance of one voter in a democracy impairs security of all.27. If you don’t vote you lose the right to complain.28. If voting made the difference they won’t us do it29. Politics, Business and Bureaucracy – a fatal triangle30. E-vehicle : Is it the right time to make a transition31. Malnutrition : A silent epidemic32. Suicide: A silent emergency33. Live simply so that others can simply liveGS Strategy:Answer writing Strategy:What should I do to improve if I only scored a total of 328 marks out 1000 in GS 1,2,3,4 and an overall score of 718 out of 1750 in the UPSC Civil Services 2018 Mains?Important Topics GS1:Culture:1. Mughal painting2. Indian school of philosophy with special focus on Vedanta (advaita, DaVita, Vishist Advaita) and Yoga.3. Ancient Indian Sruti literature4. Aryan invasion theory.5. Trace the evolution of Hindustani and Carnatic style of music in India6. Guptas as Golden Age in Ancient Indian History7. Mughal chroniclesModern India:1. Contribution of Jawaharlal Lal Nehru in pre and post-Independence India2. GoI Act 19193. Subhas Chandra Bose and his Azad Hind Fauj4. Jallianwala Bagh5. Ishwar Chandra Vidya Sagar6. contributions of Indians living abroad in India’s freedom struggle movement, especially during WW1World History:1. French revolution2. Treaty of Versailles of 1919 had sown the seeds for the Second World War3. Colonialization and decolonialisation : China and Hong Kong4. Cold war5. Communism6. Nationalism: Compare and contrast the policy of Bismarck with that of Count Cavour.Post-Independence:1. The language problem2. Unification of post partition India and the princely states under one administration.3. The 1969 bank nationalization4. Assam AccordSociety:1. Secularization of caste in India2. Social exclusion3. New social movement4. Sexual Harassment of women (prevention, prohibition ad redressal) Act and Crimes against Women5. Female labour force participation in India has fallen to 26%.6. Indian family – changing structure and norms7. Pre-conception and Pre-natal Diagnostic techniques Act and intentional sex selection- sex rati8. Discuss the linkage between the poor sanitation and Malnourishment9. POSCO and child sex abuse10. Optimum population and population explosion11. Anti-Trafficking Bill12. Tribal land alienation13. Drug menace in society14. Malnourishment problem15. HIV (Prevention and Control) Act 201716. Multi-dimensional poverty17. Disability and Sugamya Bharat Abhiyan18. Migrant workers and one nation one ration19. Sec 377 and transgender20. What are PVTGs? Discuss their geographical location along with characteristics and vulnerabilities. List few schemes for PVTGs.21. UNCCD’s land degradation neutrality (LDN) and land degradation in India22. Globalizations and tribal23. Globalizations and labour24. Rapid urbanization and environment degradation25. Counter urbanization26. Secularism and Communalism27. Does regionalism a threat to the unity and integrity of IndiaGeography1. Why earthquake and kinds of waves ?2. Tsunami2. Marine biodiversity and Depp ocean mining and deep sea fishing3. Biodiversity hot spots4. Indian monsoon and extreme climate events5. Polar vortex6. Forest fire in India?7. Hindu Kush Himalayan assessment report8. Gacial lakes outburst floods9. Heat wave10. Rare earth minerals significance and distribution around the world.11. Formation and distribution of coal deposits in India12. Two time zones in India.13. How tropical cyclones are formed and what phenomenon strengthens them? Explain how cyclone Tilti and Fani are different from the early ones?14. Identify the significance of jute industry? Explain the factors responsible for jute industry?15. Discuss the factors influencing the locations of automobile manufacturing Clusters in India.16. Port led development17. Bangalore as IT CITY locational factors18. Despite a ban, rat hole mining remains a prevalent practice for coal mining in India, why?19. Discuss the geographical factors responsible for the growth of Iron and steel industry in India?GS 2: Important Topics• Government of India Act, 1919• Due process of law• The 44th amendment• Fundamental duties enlargement and enforcement• Directive Principles• 102nd constitutional amendment Act and 103rd Constitutional Amendment Act. Does this violate the basic structure doctrine?• Assam Accord? Citizen Amendment Bill, 2016• 124A of IPC violate the freedom of expression given in article 19• Mob lynching and rule of law• Right to religious freedom• Section 499 of IPC• Article 32• Concurrent list• Madras High court has held that the elected government of Union Territory generally assumes supremacy over the lieutenant government.• Indian fiscal federalism suffers from vertical and horizontal imbalances- Role of NITI Ayog• Office of the governor and Article 356• 15th Finance commission• Finance of ULBs- municipal bonds• Cooperative federalism is an important tool in healing many evils like inter-state and intra-state inequalities• CBI credibility• Panchayat Extension to Scheduled Areas Act, 1996• Gram panchayat development plans• Inter-state River Water Dispute (Amendment) Bill, 2019 helps in overcoming the challenges.• Cooperative federalism and Zonal councils in this regard.• Demand for smaller states will lead to balkanization of Indian states. In your opinion, can more number of smaller sates bring in effective governance at state level? Discuss• judicial legislation in India• interstate council• Decline in performance of Indian Parliament• Parliamentary committees are like mini Parliament. Discuss how they increase the efficiency and expertise of the Parliament.• Department related standing committees necessary?• Cabinet Committees• Parliamentary privileges codification• office of profit• Compare and contrast the vote on account and interim budget• Rajya Sabha relevance• Anti-defection Law has achieved its desired purpose and role of speaker.• Opposition Party and leader• Need of Legislative Councils• 5th and 6th schedules tribal area administration• Legalizing lobbying• State funding of elections• Rapid criminalization of politics, SC judgment and Regulation of political parties?• Feminization of Indian politics• FPTP system to PR system• Delimitation.• MCC• electoral bonds• Increasing role of PMO vs cabinet secretariat?• Judicial reforms and vacancy• Pressure groups role and limitation• India had a piecemeal approach to transport planning with multiplicity of agencies .How far can a unified ministry.• Election Commission Appointments• Tor of 15th Finance commission• National Green Tribunal• Tribunalization of justice• Lokpal can be an effective anti-corruption body• National Human Rights Commission commemorates its 25th anniversary• centrally sponsored schemesNGOs vs state and National policy on voluntary sector, 2007• Self Help Group and Deen Dayal Antyodaya Yojana• Manual scavenging Act• Transgender being the third genders according to the landmark Supreme Court judgment in NALSA vs. Union of India• Forest Rights Act, 2006• Extensive amendments to Forest Act 1927• The consumer protection bill, 2019 is a major step forward in consumer empowerment. Discuss• RTI (Amendment) Bill is RTI elimination bill and Official Secrets Act• E-Gov• NCD Challenge in India• Ayushman Bharat scheme and how far it would address these limitations?• draft NEP• Bihar Primary health crisis.• What do you understand by family law/personal law? Do they come under laws mentioned in Article 13 of Indian Constitution Lateral entryImportant Topics GS 3:• Middle income trap? How can India avert this?• Employment elasticity? Examine the causes of decline in employment elasticity• domestic demand falling• Private investments• India's tax-GDP ratio is still abysmally low and widening tax base• Restrictive labor laws• MSMEs significance• India’s demographic transition• The nationalization of banks and bank merger , NPA• Under-employment• Share of manufacturing in India’s GDP is low.• Demographics especially age structure of the population and economic growth• Black economy• 1991 reform and inequality• Domestic demand driven economy to export driven economy• Green GDP• Is GDP a satisfactory• capital account convertibility and risk• Twin balance sheet problem• Double farmers’ income by 2022and Agriculture Export Policy, 2018. In this context, discuss the key recommendations of the agriculture export policy.• Farm loan waiver.• Agri distress and structural Imbalance in agriculture• Agriculture census shows trends of slide in farm size and rise in woman land owners• Ease of doing business• The vision of $5trillion economy• Missing middle• Farmer security and Farm security• Agriculture and Inclusive growth• Inclusive growth and increasing economic inequality.• Financial inclusion is a prerequisite to inclusive growth.• Economic Survey 2019 and Budget 2019 role of private investment is a key driver of the growth.• Is there a need to revisit the FRBM act FRBM Review Committee headed by NK Singh• Outcome based budgeting• Cropping pattern? Discuss the factors affecting the cropping pattern in India.• Crop diversification for doubling farmer’s income.• Agricultural marketing problems and APMC , ENAM• Precision agriculture• National Agro-forestry policy 2014• GM crops• Price deficiency payment• Challenges of Public Distribution System• Potential of FPOs• Technology missions in agriculture• Non-farm employment in the rural areas• Global warming and its impact on crop productivity.• Model Contract Farming Act, 2018.• E-technological intervention for farmers?• Discuss the scope and prospects of food processing in India. Also examine the challenges faced by the sector.• It has often been suggested that an essential element of “Make in India” has to be “Bake in India”, i.e. a renewed focus on value addition and on processed agricultural products. Comment• land reforms of India• How far LPG reforms introduced in 1991 succeeded in fulfilling the original goal of liberalization? Do you think the economic reforms are the main causes of increasing inequality in India? What are its impacts? How can this be corrected?• What is Industry 4.0? Do you think that India is prepared for this?• dedicated freight corridor-• Infrastructure deficit is the biggest hurdle in achieving $5 trillion economy. In this context, discuss the budget proposal to build a robust infrastructure.• What is strategic oil reserves• What do you understand by energy poverty• Only Solar farming• Private investments need to be encouraged in infrastructure through renewed public private partnership (PPP) mechanism on the lines suggested by the Kelkar Committee.• What is Artificial Intelligence? How artificial intelligence can transform the Indian economy and provide for inclusive growth? Discuss in the light of Niti Aayog's National Strategy for Artificial Intelligence.• Internet of Things IoT and Big Data• India’s policy on Data localization and its implications.• Net Neutrality.• Block chain• Gene editing? What is the role of Crisper-Cas9• DNA Technology (use and Application) Regulation Bill, 2019 would augment the justice delivery system of the countr• What is Personalized Medicine? How Genome India Project• Food fortification• Antibiotic resistance, superbugs.• gravitational waves• ISRO space industry and Vikram Sarabhai contribution• Mission Shakti. Does• Why the world is in a second race to the moon? What is the importance of India launching Chandrayaan-2 mission to moon?• Electric vehicles• India’s new drone regulations• Generic medicine and pharma industry• Plant Varieties and Farmers’ Rights Act, 2001• India's rank in Global Innovation Index.• National Supercomputing Mission (NSM)• Water crisis• Biofuel Policy• The coastal regulation zone notification 2018• Rat hole mining• Illegal mining has ravaged the Aravallis• Space private players• E Wastes• Large hydropower reservoirs• Extreme climate events• Circular Economy?• zero draft EIA notification, 2019• solar geoengineering• Biofuel policy 2018.• climate change on Ocean• National Clean Air Programme and Green Mobility• water crisis• GM technology• . Modernization and indigenization for the armed forces.• Digital currency security• Money laundering• Coastal Security• Smart fencing on borders• India nuclear doctrine• Mission Shakti• Indian Army's "Cold Start" doctrine• How organized crime in India is reinforcing Terrorism• NIA (Amendment) bill and UAPA bILL• Police reforms• Central Armed forces• State and non-state actorsGS 4: Topics:• Altruism• Surrogacy ethics• Medical Ethics• Sports ethics• Political campaign Ethics• Climate justice• Citizen Charter• Work Culture• Citizen charter• Probity• Courage of conviction• Civil service activism• Neutrality• Intellectual Integrity• Organ donation• Prejudice and stereotype• Mob violence –psychology• Abortion ethical dilemma• Price gouging• Sacrifice• Honor killing• Social audit• CSR• Corporate governance• Trusteeship• Auditors ethics• Politics and principles• Consumerism• Challenges of corruption• Leadership ethics• Altruistic surrogacy:• What do you understand by altruism? Does true altruism• How is compassion related to altruism?• What is ethical egoism?• What are ethical and legal issues in surrogacy?• Altruistic surrogacy and Women agency?• What are medical ethics?• Women hysterectomies:Doctors sans ethics: How medical malpractice has made hysterectomies a big business in MarathwadaWhy many women in Maharashtra’s Beed district have no wombs• What do you understand by medical malpractice?• What are reproductive rights?Fire: A young man saved life in Ahmadabad fire incident.This man saved two girls from deadly Surat coaching centre fire. Internet calls him a hero• What do you understand by self-sacrifice and courage? Why courage is called mother of all virtues?Caste discriminationNegative attitude and prejudice.Defections: Politics without principle is a disaster. Politics Without Ethics | Youth Ki AwaazWhat are the ethical issues involved in gene editing?Ethics in voting: Explain the below quote and their relevance in present context.• If you don’t vote you lose the right to complain. Somewhere inside all of us is the power to change the world.• The ballot is stronger than bulletAbortionDiscuss the moral, legal and religious issues regarding abortion.Prejudice and stereotypes• What are prejudices? Explain with examples.• How do we develop prejudices? How it leads to discriminatory behavior? How can we get rid of it?Ethics in disasters• Disasters are not administrative challenge they create moral problems also. Discuss• What is price gouging? What are the ethical issues involved in it?• Should businesses lower prices of their services during disaster?Sports ethics• What role ethics plays in sports?• Why ethics is important in sports?• What are the ethical issues involved in allowing use of performance enhancing drugs in sports?Social accountability: RTI, SOCIAL AUDIRSensitivityPrivate and Public Ethics• Is it sufficient to practice ethics in public life?Important Facts for mains 2019ResourcesWater:World’s 9th largest freshwater reservesTotal water resource: 1869 BCMReplenishable groundwater: 433 BCMAnnual per capita water availability 1951 20195177 1720 Cubic MeterWorld Bank Report: Ganga River Basin water shortage: 39%Asian Development forecast: By 2030, water deficit of 50%Niti Ayog Report: 600 mn will face water shortageStanding Committee on water resources: Waterbodies, wetlands are getting encroachedGroundwater: 85% used only for irrigation (221 BCM out of 243BCM).80% of rural people still don't have access to piped water supply.India has only 4% of the world’s renewable water resources but about 18% of the world’s population.NITI Ayog “Composite water management Index”- The report warns that twenty-one cities, including Delhi, Bengaluru, Chennai, and Hyderabad will run out of groundwater by 2020, affecting 100 million people. If the present situation continues, there will be a 6 percent loss to the country’s GDP by 2050.Of 91 major reservoirs in the country, 11 have zero percent storage. Further, almost two-thirds of the country's reservoirs have below normal levels, a report by the Central Water Commission’s report.As per a 2018 study by NABARD and Indian Council for Research on International Economic Relations, shifting a major chunk of the rice production to India’s central and eastern states like Chhattisgarh and Jharkhand, while encouraging wheat cultivation through sustainable irrigation in the rice-growing regions of Punjab and Haryana, could help India prevent an impending water crisis by 2030.As per the Central Water Commission, 85.3 percent of the total water consumed in India was for agriculture in 2000, and the figure is likely to decrease to 83.3 percent by 2025.Rice and wheat, two of India’s most important food crops, are the most water-intensive. Producing a kilogram of rice requires an average of 2,800 liters of water, while a kilogram of wheat requires 1,654 liters of water, as per a recent report by WaterAid IndiaGroundwater makes up 40 percent of the country’s water supply. The erratic monsoon and successive droughts have led to excessive depletion of groundwater, which resulted in the decline of groundwater by 61 percent between 2007 and 2017. A 2018 report by Water Aid has already put India at the top of a list of countries with the worst access to clean water close to homesUtilization of water: Agriculture>Domestic>Industrial>Commercial consumptionAcc. to The Energy and Resources Institute states, quoting the Central Public Health and Environmental Engineering Organization, that the average water supply in urban local bodies of the country is 69.25 litres per capita per day (LPCD) against the service level benchmark of 135 LPCD.On an average, 85 liters of water goes waste for every 100 liters utilized.According to information furnished by the Centre, while urban areas of the country generate 61,948 MLD of sewage on a daily basis, the installed capacity of sewage treatment plants (STPs) is just 23,277 MLD. This means that only 37.5% of sewage generated can be treated.As per the Agriculture Census 2010-11, there are 138.35 million farm-holdings in India, of which 92.8 million are marginal (<1 ha) and 24.8 million are small (1-2 ha). Even though small and marginal farmers account for more than 85% of total farm holdings, their share in operational area is only 41.2%. About 1.5-2 million new marginal and small farmers are added every year due to law of inheritance.The International Seabed Authority (ISA), an autonomous international organization established under the 1982 United Nations Convention on the Law of the Sea, allots the ‘area’ for deep-sea mining. India was the first country to receive the status of a ‘Pioneer Investor ‘ in 1987 and was given an area of about 1.5 lakh sq km in the Central Indian Ocean Basin (CIOB) for nodule exploration. In 2002, India signed a contract with the ISA and after complete resource analysis of the seabed 50% was surrendered and the country retained an area of 75,000 sq km.According to a release from the Ministry of Earth Sciences, the estimated polymetallic nodule resource potential in this area is 380 million tonnes (MT), containing 4.7 MT of nickel, 4.29 MT of copper, 0.55 MT of cobalt and 92.59 MT of manganeseClose to 80% of the electricity generated is from coal and gas. Yet another 50,000MW of coal-fired power plants are being set up under the National Electricity Plan. More than 20% of all the electricity generated goes into “transmission and distribution losses"Due to inadequate and irregular last-mile supply, close to 15 million tonnes of diesel is used by local generators to produce 80 billion KWh of electricity. Close to $2 billion worth of battery storage capacity is imported every year. And most independent power plants operate at 12-15% below their declared capacity as they over-invoice plant costs.Official estimates indicate that around 3, 00,000 farmers have committed suicide over the past 30 years.The single largest factor about India’s water is that 90% of it is consumed in farming. 80 per cent of this irrigation is for water-guzzling crops — rice, wheat and sugarcaneFood Security:·Global Food Security Index (Economist Intelligence Unit) india’s rank - 76/113Resource Mobilisation:Tax collection for 2018-19 fell by,Direct Tax: 74,774crIndirect tax: 93,198Gross tax revenue- GDP 2018-19= 11.9% 2019-20=11.7Direct Tax:GDP will fall from 6.4 to 6.3Indirect Tax:GDP will fall from 5.5 to 5.3Disinvestment target :1 lac croreGovernment interest payment for past borrowings forms the largest component of revenue expenditureCapital expenditure is projected to grow at a rate slower than the projected rate of GDP growth.Investments of Rs 100 lakh crore would be needed cumulatively over the next 5 years to boost infrastructure.The digital payment market, with 800 million mobile users in the country of which more than 430 million have internet access, is estimated to grow to over $ 1 tn by 2025.Pre 1980’s era- GDP growth rate was about 3-3.5% and the population growth rate was 2%.World bank in its Global Economic Prospects, has projected weakening of global trade in 2019. It is projected to grow at 2.6% this year.Requirement will rise to 2.3-2.7 million digitally-skilled professionals during 2023: NasscomIIP dips to 3.1% in May owing to slow down.Index of Industrial Production (IIP) measures the quantum of changes in the industrial production in an economy and captures the general level of industrial activity in the country.Index of Industrial Production is compiled and published every month by the Central Statistics Office (CSO) of the Ministry of Statistics and Programme ImplementationBlockchain technology is considered revolutionary for its ability to enable the secure movement of assets, without intermediaries, with its economic impact projected to exceed $3 trillion in the next decade. Blockchain is now the fastest-growing skill set demanded on job sites, with job growth rates at 2,000-6,000% and salaries for blockchain developers 50-100% higher than regular developer jobs.Blue Revolution:Blue Revolution 1.0: 1987-1997Blue revolution 2.0: 2016 onwardsIndia is second in the world in aquaculture production @ 4.7mn tnChina no.1 @ 60mn tnEEZ= 2MN km squareIndia exported fish worth 2017-18Energy:India is one of the world’s largest producers and consumers in 2 and 3 wheelers.Under National Biofuel Policy, 2018- 20% ethanol blending by 2030 10% ethanol blending by 2022One of the key requirements for a $ 5 tn economy is an investment of about Rs 5 lakh crore in the power transmission sector over the next few years, in order to cater to the 1.8 lakh crore units of electricity that India is likely to consume by 2025.·Share of green power increased from 6 %( 2014-15) to 10 %( 2018-19).Acc. to Oil Minister, India will continue to rely on petrol and diesel for running automobiles, and needs to expand its oil refining capacity by 80%.About ⅕ th of the world’s oil passes through the Strait of Hormuz.Even with the growth of renewable energy, coal has been projected to be the backbone of electricity sector until 2030 and beyond.India has created 80,000 MW of renewable energy and set a target of achieving 1,75,000 MW by 2022, reduced energy intensity by 21%.Global Innovation Index 2019 : Rank 52Boost demand for vehicles as 1 mnIndia and China will surpass the U.S. as the World’s Centers of Tech Innovation by 2035, according to Bloomberg New Economy Global Survey.India has just 4% of the world’s renewable energy but have 18% of the world's population.·The advantages of transporting water over water include the fact that one Horsepower of energy can move 150 kg on road, 500 kg on rail and 4,000 kg on water. Similarly, one liter of fuel can move 24 tonnes per km on road, 85 tones on rail and 105 tones on inland water transport.·China is way ahead of India in its expansion. Over the 2014-17 period, China’s addition to its renewable energy capacity (207.2 GW) was nearly six times India’s (33.3 GW). Over the same period, China increased its installed capacity in solar energy by 105.5 GW, while India increased its capacity by only 14.3 GW — a mere one-seventh of the former. Advanced economies like the U.S. and Japan installed almost twice the amount of solar capacity over this period compared to India.·India’s annual coal demand rose by 9.1% to nearly one billion tones during the year ending March 2019. Coal features among the top five imports of India, with total imports rising from 166.9 million tons in 2013-14 to 235.24 million tons in 2018-19.·A report published by the Centre for Financial Accountability in June 2018 showed that out of a total lending of ₹83,680 crore for 72 energy projects, 12 coal-fired power plants with a combined capacity of 17 GW obtained loans of ₹60,767 crore. The 60 renewable energy projects, with a combined capacity of 4.5 GW, were able to mobilize only ₹22,913 crore·According to BP Energy Outlook 2019, coal’s share in India’s primary energy consumption will decline from 56% in 2017 to 48% in 2040. But that is still nearly half of the total energy mix and way ahead of any other source of energy. Oil’s share, the second largest, will decline from 29% to 23%, and the contribution of renewables will rise fivefold to 16%. Even the NITI Aayog, which replaced the Planning Commission, in a 2017 report estimated the share of coal in the energy mix in 2040 to be at least 44%.Science and technology:Chandrayaan-1- Launched by PSLV -C11. Detected signs of water molecules.·Chandrayaan-2- Orbiter, Lander(Vikram) and a rover(Pragyan). GSLV Mk III. 3 stage(solid, liquid, cryogenic). 2 Vikas engine. Science and Technology.·The establishment of Indian Space Research Organisation (ISRO) in 1969 heralded the Indian space programme. As the sixth-largest space agency celebrates its golden jubilee, India has slowly and steadily emerged as a pre-eminent space power with 102 spacecraft missions, the largest fleet of civilian satellites in the Asia-Pacific region, a successful inter-planetary Mars Orbiter Mission and a world record of launching 104 satellites from a single rocket.·The establishment of Indian Space Research Organization (ISRO) in 1969 heralded the Indian space programme. As the sixth-largest space agency celebrates its golden jubilee, India has slowly and steadily emerged as a pre-eminent space power with 102 spacecraft missions, the largest fleet of civilian satellites in the Asia-Pacific region, a successful inter-planetary Mars Orbiter Mission and a world record of launching 104 satellites from a single rocketEducation:·Acc. to RTI query, scientists from SC and ST are grossly underrepresented in scientific institutions funded by Dept. of Biotechnology.·UGC has issued list of 23 fake universities and 14 of them also appear on the 2005-2006 list of fake universities by UGC·Water: India has 4% of the world's renewable water and 18% of the population.Health:Health: SDG AIM END AIDS BY 2030AIDS: consumed 20 mn lives22 mn under ART1.7mn new infections every year and 1mn deathsPreventing mother to child transmission of HIV by 2020By 2024- 80% less new HIV infection.The second edition of NITI Aayog’s Health Index was recently released in its report titled ‘Healthy States, Progressive India: Report on Rank of States and UTs’.What does the trend imply?Some States and Union Territories are doing better on health and well-being even with a lower economic output.In contrast, others are not improving upon high standards, and some are actually slipping in their performance.In the assessment during 2017-18, a few large States showed less encouraging progress.This reflects the low priority their governments have accorded to health and human development since the first edition of the ranking for 2015-16.The disparities are very evident in the rankings, with the populous and politically important Uttar Pradesh being in the bottom of the list.A World Health Assembly Resolution passed in May is hoping to catalyse domestic and external investments to help reach the global targets. These include ensuring at least 60% of all healthcare facilities have basic WASH services by 2022; at least 80% have the same by 2025; and 100% of all facilities provide basic WASH services by 2030.As a joint report published earlier this year by the World Health Organization and the UN Children’s Fund (UNICEF) outlines, WASH services in many facilities across the world are missing or substandard. According to data from 2016, an estimated 896 million people globally had no water service at their healthcare facility. More than 1.5 billion had no sanitation service. One in every six healthcare facilities was estimated to have no hygiene service .Despite decades of effort, India still has less than one doctor for every 1,000 people, the World Health Organization’s minimum ratio for a country’s healthcare adequacy.On an average, a government doctor attends to 11,082 people, more than 10 times than what the WHO recommends. The shortage of government doctors does not augur well for India where 70 per cent of health care expenses are met by out-of-pocket expenditureIn Bihar, one government doctor serves 28,391 people. Uttar Pradesh is ranked second with 19,962 patients per doctor, which is followed by Jharkhand (18,518), Madhya Pradesh (16,996), Chhattisgarh (15,916) and Karnataka (13,556).Delhi is better in terms of doctor-population ratio (1:2203), but it is still twice the ratio recommended by WHO. The states and UTs that are closest to meeting the WHO standards are Arunachal Pradesh, Puducherry, Manipur and Sikkim.As of March 31, 2017, the country had a shortfall of 10,112 female health workers at primary health centres, 11,712 female health assistants, 15,592 male health assistants and more than 6,1000 female health workers and auxiliary nurse midwifes at sub-centres.In fact, primary health centres across the country are in want of at least 3,000 doctors with 1,974 such centres operating without a single doctor. In community health centres, there is a shortfall of close to 5,000 surgeonsThere are reportedly 462 medical colleges that churn out 56,748 doctors every year. Similarly, 3,123 institutions across the country prepare 125,764 nurses each year. However, with India’s population increasing by about 26 million each year, the increase in number of medical staff is too little.States, which are the worst performers in the entrance test for admission to MBBS courses, have the highest number of registered doctors. Maharashtra and Tamil Nadu had the lowest pass percentage in entrance test and yet they top the list of registered doctors—153,513 and 126,399, respectively. Rajasthan, the best-performing state in entrance test, has less than half the number of registered doctors.If the entire country wants to achieve 1:1,000 ratio, it will need 2.07 million more doctors by 2030, according to a study published in the Indian Journal of Public Health, in September last year. With the government sparing just 1.3 per cent of the GDP for public healthcare, as opposed to the global average of 6 per cent, shortage of government doctors means people will continue to incur heavy medical expenditure in private health care system.The study titled 'The Health Workforce in India', published in June 2016 by WHO, also revealed that in urban parts of India, only 58.4% of doctors have a medical qualification. The figure is really poor in rural areas with only 18.8% qualified doctorsAs per the WHO World Health Statistics 2015, India ranked 187 out of 194 countries for its public healthcare services with the public sector spending only 1.16% on health as a percentage of the GDP.Non Communicable Diseases- disease pattern in India in general and particularly in rural India has undergone a significant shift over the last 15 years. An early inkling of this change was evident in a 2001-2003 government of India report on the causes of death in the country. The report revealed that the deaths in rural India due to communicable diseases (41%) were almost matched by those due to NCDs (40%)A follow-up study on the causes of death in rural India for the years 2010-13 showed that NCDs accounted for 47% of all deaths while communicable, maternal, peri-natal and nutritional conditions together accounted for 30%High blood pressure, the biggest risk factor for death worldwide, now affects one in five adults in rural India, while diabetes affects about one in 20 adultsA recent report released by the India State-Level Disease Burden Initiative shows that three of the top five leading causes of DALYs lost in India were NCDs: coronary artery disease, chronic lung diseases and stroke.It is estimated that India is likely to lose $4.58 trillion before 2030 due to NCDs.NCDs in rural India are affecting a relatively younger population—about a decade younger—compared to that in the developed countries. This is likely to be due to malnutrition early in life, which paradoxically increases the risk of NCDs and an unhealthy lifestyle in early adulthood.The government-run healthcare system in rural India largely focuses on maternal and child health and infection. For instance, of the total health budget of Rs47,343 crore in 2017-18, only Rs955 crore was allotted to the NCD programme.India has a doctor-population ratio of 1:1,655; the World Health Organisation standard is 1:1,000. Moreover, there is a considerable skew in the distribution of doctors, with the urban to rural doctor density ratio being 3.8:1.Diabetes has increased in every Indian state between 1990 and 2016, even among the poor, rising from 26 million in 1990 to 65 million in 2016. This number is projected to double by 2030. A major contributor to this epidemic is the displacement of whole foods in our diets by energy dense and nutrient-poor, ultra-processed food products.Self-styled doctors without formal training provide up to 75 per cent of primary care visits. Moreover, at present, 57.3 per cent of personnel practicing allopathic medicine do not have a medical qualification.Population:·As the National Family Health Survey-4 (2015-16) notes, women in the lowest wealth quintile have an average of 1.6 more children than women in the highest wealth quintile, translating to a total fertility rate of 3.2 children versus 1.5 children moving from the wealthiest to the poorest.·Similarly, the number of children per woman declines with a woman’s level of schooling. Women with no schooling have an average 3.1 children, compared with 1.7 children for women with 12 or more years of schooling.·This reveals the depth of the connections between health, education and inequality, with those having little access to health and education being caught in a cycle of poverty, leading to more and more children, and the burden that state control on number of children could impose on the weakest.·As the latest Economic Survey points out, States with high population growth are also the ones with the lowest per capita availability of hospital beds.·Today, as many as 23 States and Union Territories, including all the States in the south region, already have fertility below the replacement level of 2.1 children per woman·The Economic Survey 2018-19 notes that India is set to witness a “sharp slowdown in population growth in the next two decades”. The fact is that by the 2030s, some States will start transitioning to an ageing society as part of a well-studied process of “demographic transition”·A study by the UN Population Fund titled Demographic Dividend in India projects that by 2060, India’s population is expected to touch 166 crore. Most of this increase will translate into a larger working population of people aged between 15 and 59 years. Eighty percent of India’s total population growth during the period 2001-’31 will get translated into an increase in the working age population. By the mid-2040s, this sub-group will consist of more than a billion people·For the first time in Indian history, the population increase during 2001-2011 has been greater in urban areas than in rural areas. Nearly one-third of India’s population, 377 million people, lives in urban areas. The level of urbanization is higher in the south-western Indian states at an advanced demographic stage, accounting for 45% of the population of India’s urban population.Demographic Dividend:·For the first time since independence, India’s working age population — those aged between 15-64 years — will outnumber its dependents, that is, children aged 14 and below as well as people aged 65 and above·This demographic dividend is expected to last for the next 37 years, till 2055 — and is expected to spur India’s economic growth, as well as per capita income.·In Japan, for instance, which was among the first major economies to experience rapid growth because of changing population structure, the demographic dividend phase started in 1964 and ended in 2004. It was seen that in the first 10 years of this phase, it recorded a double digit GDP growth in five of those years, above 8% in two of those years and a little less than 6% in one year. Only two of these 10 years saw growth below 5%.·In Singapore, the dividend years started in 1979 and in the next 10 years, there were only two years when its economy grew at less than 7%. The island country saw double digit growth in four of these 10 years. South Korea entered this phase in 1987 and in the next 10 years, there were only two years when its growth rate fell below 7%.·The dividend years started in 1979 in Hong Kong and it witnessed less than 8% growth rate in only two of the next ten years.·According to the UNFPA — which cites the example of Latin American countries that, despite a demographic dividend, saw only a two-fold increase in their GDP in the late 20th century whereas the Asian countries in the same period saw a seven-fold increase.·Much of what India is able to achieve through its working population increase, says the UNFPA, will depend on whether India is able to provide good health, quality education and decent employment to its entire population.·India’s dependency ratio has declined from 68.4 %( 1950) to 49.8 %( 2018). Total Fertility rate declined from 5.9(1950) to 2.2(2018).India’s working-age population is now increasing because of rapidly declining birth and death rates.In their study, Atri Mukherjee, Priyanka Bajaj and Sarthak Gulati examine how changes in India’s population have influenced macroeconomic outcomes between 1975 and 2017. They find that while overall population growth is associated with lower economic growth, an increase in the working-age population is associated with higher growth.India’s age dependency ratio, the ratio of dependents (children and the elderly) to the working-age population (14- to 65-year-olds), is expected to only start rising in 2040, as per UN estimates.India’s labour force participation rate is declining, especially among rural youth (15- to 29-year-olds) and women.Agriculture:Acc. to FAO, insufficient investment in the agriculture sector in most developing countries over the past 30 years has resulted in low productivity and stagnant production.In India, with a steadily decreasing share of 14.4% in Gross Value Added since 2015-16, the sector’s contribution to a $ 5 tn economy would be around $1 tn- assuming a positive annual growth rate.An early experience of BRIC nations has shown that a 1% growth in agriculture is at least 2-3 .times more effective in reducing poverty than similar growth in non-agricultural sector.Public Investment in agricultural research and development in terms of percentage share in agriculture GVA stands at 0.37%, which is fairly low in comparison to between 3% and 5% in developed countries.·Acc. to Deputy Governor, RBI disinvestment in PSEs would alleviate crowding out effects of government borrowings in the country. Currently, the share of capital expenditure is meagre 14%.·Digital Payment- The number of transactions done through UPI has increased by 180 times since its inception in 2016. However, private players have cut into the government backed BHIM app’s share of the transactions, while card based transactions are still the most preferred online payment method.The Ashok Dalwai Committee clarified real incomes will need to be doubled over seven years (over a base income of 2015-16), which requires a growth rate of 10.4 percent per year in order to realise doubling of farmer’s income by 2022.India is the largest exporter of rice in the world, exporting about 12 to 13 MMT of the cereal per year. If the government raises the MSP of rice, by say 20 per cent, rice exports will drop and stocks with the government will rise to levels far beyond the buffer stock norms.Today, India spends roughly 0.7 per cent of agri-GDP on agri-R&D and extension together. This needs to double in the next five years.India, with a large and diverse agriculture, is among the world’s leading producer of cereals, milk, sugar, fruits and vegetables, spices, eggs and seafood products. Indian agriculture continues to be the backbone of our society and it provides livelihood to nearly 50 per cent of our population. India is supporting 17.84 per cent of world’s population, 15% of livestock population with merely 2.4 per cent of world’s land and 4 per cent water resources.Various studies on fresh fruits and vegetables, fisheries in India have indicated a loss percentage ranging from about 8% to 18% on account of poor post-harvest management, absence of cold chain and processing facilitiesIndia is currently ranked tenth amongst the major exporters globally as per WTO trade data for 2016. India’s share in global exports of agriculture products has increased from 1% a few years ago, to 2.2 % in 2016.Women in agriculture:The UN's Food and Agriculture Organisation estimates that if women had the same access to productive resources as men, they could increase yields on their farms by 20-30%. This could raise total agricultural output in developing countries by up to 4%, which could in turn reduce the number of hungry people in the world by 12–17% - that's 100-150 million people.MobilityThe higher your educational qualifications, the longer your work commute. That, in essence, is the finding reported in a working paper on mobility in one of India’s most congested cities, Bengaluru, by researchers from the Institute for Social and Economic Change (ISEC).Unlike people with higher education qualifications, those in the unorganised sector without degrees work within five km of home.The commute to work required 42.45 minutes for about 10.84 km. This is an increase from around 40 minutes in 2001. Peak hours add on average six minutes to the commute one-way. Over 95% working in government, or in trade and commerce, move in peak time, while in the industrial sector, 66% of workers have peak-hour travel. That figure falls to just 10% for IT and 6% for the informal sector.Also, 41.91% of commuters used public transport, and a quarter used two-wheelers. Over 10% of commuters walked to work, highlighting the need for better pedestrian infrastructure.·Farm Mechanization: Laser guided land leveler can flatten the land in less time than oxen powered scrapper. It increases farmers productivity by 15%.·Agriculture Census 2018: Uttar Pradesh is home to the largest number of people tilling land, followed by Bihar and Maharashtra, according to the 2015-16 Agriculture Census.·India has been allotted a site of 75,000 sq. km. in the Central Indian Ocean Basin (CIOB) by the UN International SeaBed Authority for exploitation of polymetallic nodules (PMN). These are rocks scattered on the seabed containing iron, manganese, nickel and cobalt.·Being able to lay hands on even 10% of that reserve can meet the energy requirement for the next 100 years. It has been estimated that 380 million metric tonnes of polymetallic nodules are available at the bottom of the seas in the Central Indian Ocean.·India’s Exclusive Economic Zone spreads over 2.2 million sq. km. and in the deep sea, lies “unexplored and unutilised”·The Amazon basin, spread across millions of hectares in multiple countries, hosts massive sinks of sequestered carbon, and the forests are a key factor in regulating monsoon systems.·As the custodian of forests in about 5 million sq km of Amazon land. One estimate by the World Bank some years ago noted that 15 million hectares had been abandoned due to degradation. Globally, there is tremendous momentum to save the Amazon forests. Brazil must welcome initiatives such as the billion-dollar Amazon Fund backed by Norway and Germany which has been operating for over a decade, instead of trying to shut them down.·The rainforests harbour rich biodiversity and about 400 known indigenous groups whose presence has prevented commercial interests from overrunning the lands.Zero Based Natural Farming:·Acc. to NSSO 70% of agri household spend more than they earn·50% of farmers are in debt.·In AP and Telangana debtedness is 90%(Avg debt 1lac)·Acc to NITI Aayog , more than 1.6 lakh farmers are practicing the ZBNF in almost 1,000 villages.Banking:The opening of 36 crore bank accounts in Jan Dhan Yojana has linked the poor to our growing economy.Government is in talks with foreign lenders to provide $14.5 bn in credit to millions of small firmsIndia’s 63 million firms in micro, small and medium firm sector are responsible for more than a quarter of the country’s manufacturing and services output. Gross domestic product growth fell to a 5 year low of 5.8% in January-March quarter, well below the 8% plus rates that the government is targeting.Credit availability for SMEs, which also account for about 45% of the country’s exports, has worsened due to a liquidity crisis in the NBFCs sector.A study by RBI Panel said the overall deficit in credit for the MSME sector is estimated at about Rs 20-25 lakh crore.Employment:MGNREGA- Lack of adequate financial allocation, pending liabilities and low wages have dogged the programme over the past 8 years.About 20% of budget allocation in each of the last 5 years is pending wage liabilities from previous years. It was worst in 2016-17 when pending liabilities were 35% out of total allocation of Rs 38,500 crore.MGNREGA wages in many states are about 40% lower than the national minimum wage.Swaraj Abhiyan vs Union of India, 2015- Government should provide more work to the people of drought prone area and timely wages.Public employment in India is only one-tenth of that in Norway, only 15% of that in Brazil and much than a third of that in ChinaAuto Industry:8-10 lac job lossAutomatic Hubs: Gurugram - Manesar belt , Pune , Jamshedpur,PithampurEnvironment:The total surface area of our Earth is 52 billion hectares (Ha), and 31% of this has been forest cover.FAO defines forest as a land area of at least 0.5 hectare, covered by at least 10% tree cover without any agricultural activity or human settlementSwiss and French ecologists have found out that there is potential climate change mitigation through global tree restoration by adding 0.9 bn hectares. More than 50% of this restoration potential can be found in 6 countriesIndia has 21.54% tree cover and between 2015 and 2018, we have added 6,778 sq kmPhilippines Success story- Making mandatory for each elementary, high school and college student to plant 10 trees before graduatingSection 15 of the Environment Protection Act(for thermal power plants) provides for blanket penalty for contravention of any of the provisions of EPA: up to 5 years of imprisonment and up to Rs 1 lakh fine along with additional daily fines for continuing offences.·As per Bureau of Indian Standards (BIS) norms for upgraded fuels, (IS: 2796 – petrol and IS: 1460 – diesel), sulphur content is reduced to 10 mg/kg max in BS-VI from 50 mg/kg under BS-IV. This key reduction in sulphur makes it possible to equip vehicles with better catalytic converters that capture pollutants.·As per June 2019 sales data released by SIAM, automobile companies sold 16.28% fewer passenger vehicles compared to June 2018. There was a 23.39% drop in the sale of commercial vehicles in the same period. Two-wheeler sales dipped by 11.70%.·India has been emerging as one of the world’s most polluted countries, with particulate matter PM 2.5 levels spiking more than 999 microgram per cubic metre in parts of Delhi last year.·The government also commissioned a study to gauge the economic value of tiger reserves. Based on an analysis of 10 of them, the government claimed that the cumulative benefits — from the carbon and timber conserved, livelihood to those who depend on forests and tourism — were anywhere from ₹4,200 crore to ₹16,000 crore annually.·Nearly 3,000 tigers now reside in India, that's more than 70% of the world's tiger population.·The National Tiger Conservation Authority (NTCA) has asserted in its report, ‘Status of Tigers in India’ 2018, that 83% of the big cats censused were individually photographed using camera traps, 87% were confirmed through a camera trap based capture-recapture technique, and other estimation methods were used to establish the total number.·The less accessible Western Ghats has witnessed a steady increase in numbers from 2006, notably in Karnataka, and Central India has an abundance, but there is a marked drop in Chhattisgarh and Odisha; in Buxa, Dampa, Palamau, which are Tiger Reserves, no trace of animal was found.·Madhya Pradesh saw the highest number at 526, closely followed by Karnataka (524) and Uttarakhand (442).·Chhattisgarh and Mizoram saw a decline in tiger population and all other states saw a “positive” increase, according to a press statement.Studies show that India’s road transport emissions are small in global comparison but increasing exponentially.Global Carbon Project reports that India’s carbon emissions are rising more than 2 times as fast as the global rise in 2018.Globally, the transport sector accounts for a quarter of total emissions, out of which three quarters are from road transport.According to the recent National Family Health Survey(2015-16), nearly 30% of all men are overweight or obese in southwest Delhi. These data correlate with high reliance of car use in Delhi and low demand for walking.India Human Development Survey shows that 10% increase in cycling could lower chronic disease for 0.3 mn people.A recent UN Global Assessment Report estimated India’s economic losses would be 4% of GDP annually if we don’t invest in building natural ecosystems, while a 2018 World Bank Report said that 600 million Indians are moderately to severely affected by changes in temperature and rainfall.Greenpeace air pollution report for 2019 lists as many as seven Indian cities among the 10 worst in the worldAnother report said that 1.2 million deaths in 2017 could be directly attributable to all-round pollutionThe IPCC report warns that clean energy, clean transport and reduction emissions alone will not cut global emissions enough to avoid dangerous warming beyond 2 degrees Celsius. It points out that the global food system is responsible for 21 to 37 per cent of the world’s GHG emissionsAbout a quarter of the Earth’s ice-free land area is subjected to what the report describes as “human-induced degradation”. Rapid agricultural expansion has led to destruction of forests, wetlands and grasslands and other ecosystems. Soil erosion from agricultural fields, the report estimates, is 10 to 100 times higher than the soil formation rate.The Directorate General of Hydrocarbons (DGH) estimates that the commercial production of shale gas would require multiple fracking activities in each well with water requirement of up to nine million liters per fracking activity. As of today, 56 sites across six States have been identified for fracking, and according to the World Resources Institute, all of them fall under ‘water stress’ zones, having limited supply of fresh water.The world is 1° C hotter than preindustrial 1850-1900 levels, with 2015-19 comprising the hottest years on record.As a result of global warming, sea levels could rise by 2.8 ft. by 2100, presenting an existential threat to India’s coastlines.Driving this temperature increase, carbon emissions rose by a record 2.65 parts per million (ppm) a year in 2015-19, reaching 412 ppm today. At this rate, the catastrophic threshold of 450 ppm for reaching the 2° C increase in warming will be breached in just 15 years. By 2050, temperatures in India are projected to increase 1.5-3° C relative to 1981-2010, if little action is taken.The average cost of these two renewable power sources is now in the range of the cost of fossil fuels. Even so, renewable energy still accounts for only 17% of India’s electricity needs, with 80% coming from polluting fossil fuelsAlso, energy-related CO2 is rising because of increased fossil fuel consumption, encouraged by government subsidies for this energy source. Worldwide, these subsidies increased by one-third in 2018, to $400 billion globally.Perversely, coal plant capacity is set to expanding South and Southeast Asia, which together account for half of the world’s planned coal power expansion, with India, Vietnam and Indonesia combined for over 30%. Bangladesh and Pakistan plan to increase coal-based capacity threefold, and the Philippines wants to double capacity.·Marine culture: Agriculture Minister further said that fish production in India is estimated at 11.4 million tones, out of which 68% is registered from inland fisheries sector and the remaining 32% from marine sector. It is expected that the indigenous fish requirement by 2020 would be 15 million tones as against the production of 11.4 million tonnes. This gap of 3.62 million tonnes is expected to be made up by Inland Aquaculture and also through Mari culture.E-Waste:According to the United Nations University’s Global E-waste Monitor, India’s e-waste generation amounted to 2 million tonnes in 2017. Computer and telecom equipment accounted for 82 per cent of the total e-waste generated in India, according to an ASSOCHAM-KPMG study.However, only 0 .036 million tonnes of waste was processed.E-waste generation in India is estimated to increase by 500 per cent by 2020. Approximately 95 per cent of e-waste generated ends up in the informal sector according to reports.As of now, government has 312 registered recycling facilities across 19 states with the capacity to recycle 0.78 million metric tonnes.Infrastructure:Road Transport- More people die in India due to road accident related incidents than anywhere else in the world. With over half a million accidents and over 1.5 lakh fatalities every year — and that’s the official figure; unofficially, fatalities could be 20 per cent higher and accidents 50 per cent higher than what’s captured in the crime records database.India overtook China in 2006 as the country with the world’s deadliest roads. A total of 146,133 people were killed on Indian roads in 2015, an increase of 4.6% from 2014, according to the latest data with the roads ministry. The number of road accidents in India increased 2.5% in 2015 to 501,423 while injuries from road accidents rose 1.4% to 500,279 in 2015.According to NITI Aayog “Transforming Mobility Report”, congestion in the 4 biggest metro causes annual economic losses of over $22 bnElectric Vehicles:In 2018 China accounted for 57% of EV sold globally.By 2023 100% electric 3 wheelersBikes by 2025Science and Technology:It is feared that these multidrug-resistant superbugs may kill as many as 10 million people worldwide by 2050.On Medical Devices- “The fact is after the GST regime, importers have to pay respective customs duty which is around 7.5%-10% in addition to 12% of GST. So in effect, importers are paying more taxes after the GST regime than before.It is true that the input tax credit is applicable against GST component on inputs, but the same is available for locally manufactured goods as well.In total, GST regime does not benefit importers in any way over domestic players. In fact, post-GST import duties on many implantable devices have gone up to 10% due to increase in custom duties.Micro RNAs- These are regulators of gene expression, acting like switches. They decide which protein should be made and how much in a given cell or tissue or an organism. They are tiny, having some 20-22 digits of RNA.·The establishment of Indian Space Research Organisation (ISRO) in 1969 heralded the Indian space programme. As the sixth-largest space agency celebrates its golden jubilee, India has slowly and steadily emerged as a pre-eminent space power with 102 spacecraft missions, the largest fleet of civilian satellites in the Asia-Pacific region, a successful inter-planetary Mars Orbiter Mission and a world record of launching 104 satellites from a single rocketSecurity:“30,000 to 40,000” militants — trained in Afghanistan and Kashmir — are still operating in Pakistan, Mr. Khan(PM of Pakistan) has admitted.Western countries such as U.S, U.K, Canada, Australia, Germany advise their citizens against travelling to Kashmir valley. Against 13 lakh tourists who travelled to Kashmir in 2016, the first 6 months of 2019 recorded just 3.54 lakh.Migration:·Top out migration states: UP,Bihar , Rajasthan,MP,Karnataka·Top in migration states: Maharashtra, delhi, up , gujarat,Haryana.5.43 cr roughly population of Myanmar was the interstate migrant at the time of census 2011.More migrants in Maharashtra ( 91l) than Delhi ( 63l)and Rajasthan(26l). Gujrat( 39l), UP( 41L)21% of interstate migrant go to Maharashtra.22% of job seeker migrants prefer MaharashtraReasons for migration:23% for employment31% for marriage3% for education1% for business40% for familyGender perspective:o47 % Men migrate for employmento4% Women migrate for employmentoHalf of women interstate migrant state marriage as the mains reason.Innovation:·Global Innovation Index : India’s rank 52nd·Israel in top 10.·It invest 7% of GDP in education.·It invest 4% in R&D.Organized Crime:·In 2016, in its reply to a Lok Sabha question, the Union Health Ministry noted that there is a huge gap between the demand and supply of human organs for transplant even though the precise numbers of premature deaths due to heart, liver, lung and pancreas failures have not been compiled.·The Ministry noted that against the demand of 2 lakh kidneys, only 6,000 were available. Similarly, against the demand of 30,000 livers only 1,500 were available, and against the demand of 50,000 hearts merely 15 were available across the country.·According to the Multi Organ Harvesting Aid Network Foundation (Mohan Foundation), a Chennai-based NGO working on organ donation, only about 3% of the demand is met.·“In India, [the] deceased organ donation programme is largely restricted to big institutions and the private sector which makes it less accessible for all. The deceased donation rate in 2013 was 0.26/million population and this went up to 0.36/million population in 2014.Innovation:·Global Innovation Index : India’s rank 52nd·Israel in top 10.·It invest 7% of GDP in education.·It invest 4% in R&DEconomyThe latest International Monetary Fund (IMF)-World Economic Outlook update in July 2019 has confirmed a growing belief that global growth has decelerated and dark clouds seem to be looming in the near term. Specifically, the IMF has downgraded global growth multiple times since October 2018 and now projects it to be 3.2% compared to 3.6% in 2018.The government’s fiscal deficit touched ₹4.32 lakh crore for the June quarter, which is 61.4% of the Budget Estimate for 2019-20 fiscal.In absolute terms, the fiscal deficit, or the gap between expenditure and revenue, was ₹4.32 lakh crore at June-end, as per the data released by the Controller General of Accounts (CGA).The government aims to restrict the fiscal deficit to 3.4% of the GDP (gross domestic product) in the current fiscal, the same as last financial year.India dropped two places in GDP rankings in 2018 compared to2017. With a slump in consumption, and new investments reducing to a trickle, the government’s aim of making India a $5 trillion economy 2024 seems far fetched.Drop in position : In 2017, the size of the Indian economy stood at $2.65 trillion, the fifth largest. In 2018, India’s economy in $ terms grew by 3.01% to $2.73 trillion. But in the same period, the U.K. and France grew by 6.8% and 7..3% respectively, pushing India to the seventh place in the World Bank’s GDP rankings in 2018.Investment Woes : Investments in new projects nosedived to a 15 year low in the quarter ending June 2019. The drop in value of new projects was driven by a dip in both private and government investments.Consumption drops : Three of the four major indicators of the consumer economy recorded negative growth rates in the first half of 2019.Downward revision : The IMF, Asian Development Bank and CRISIL brought down their projections for India for FY20. While both IMF and ADB have projected that India will grow at 7% or more, CRISIL has estimated that the GDP will grow by 6.9%India will now need to attract private capital amounting to 3%-4% of GDP for the ‘Great March’ that Prime Minister Narendra Modi has flagged off to $5 trillion GDPBanking: After nationalisation of banks in 1969, the share of institutional sources in the outstanding debt of rural households increased from just 16.9% (1962) to 64%(1992).The share of bank deposits to GDP rose from 13% in 1969 to 38% in 1991. The gross savings rate rose from 12.8% in 1969 to 21.7% in 1990. The share of advances to GDP rose from 10% in 1969 to 25% in 1991. The gross investment rate rose from 13.9% in 1969 to 24.1% in 1990.After economic reforms of 1991, more than 900 rural bank branches closed down across the country. The rate of growth of agricultural credit fell sharply from around 7% per annum in the 1980s to about 2% per annum in the 1990s.Between 1991 and 2002, the share of institutional sources in the total outstanding debt of rural households fell from 64% to 57.1%RBI new branch authorisation policy in 2005- the number of rural bank branches rose from 30,646 in 2005, to 33,967 in 2011 and 48,536 in 2015. The annual growth rate of real agricultural credit rose from about 2% in the 1990s to about 18% between 2001 and 2015.Between 2010 and 2016, the key responsibility of opening no-frills accounts for the unbanked poor fell upon public banks. Data show that more than 90% of the new no-frills accounts were opened in public banks·A revenue deficit of Central govt. Is relatively recent, having been virtually non existent till the 1980s. After that a rampant populism has taken over all political parties, reflected in revenue deficit accounting for over ⅔ rd of the fiscal deficit.·World Economy: IMF forecast for the world is 3.2%Disaster ManagementAccording to the World Health Organization (WHO), 30-40 per cent of the victims of catastrophic natural disasters suffer from major mental distress and require counselling.CybersecurityInternet Shut down·During 2012-017, says Icrier, 16,315 hours of Internet shutdown cost India’s economy around $3 billion, the 12,600 hours of mobile Internet shutdown about $2.37 billion, and the 3,700 hours of mobile and fixed-line Internet shutdowns nearly $678.4 million.··India is the 5th largest producer of solar energy and 6 th largest producer of renewable energy.·China ranks 1st in terms of renewable energy production according to International Renewable Energy Agency·A study by the Centre for Science and Environment, New Delhi, shows that Indian coal-fired thermal power plants are considered the most inefficient and polluting in the world. More than 75% of these plants don’t comply with governmental regulations.IMPORTANT TOPICS FOR MAINS-2019:Employment:The Periodic Labour Force Survey (PLFS) of the National Sample Survey Office (NSSO) released on Friday showed the unemployment rate in the country in FY18 was at 5.3% in rural India and 7.8% in urban India, resulting in overall unemployment rate of 6.1%.Middle income trap:The per-capita income at current prices during 2018-19 is estimated to have attained a level of ₹1,26,406 ( ₹10,533.83 monthly) as compared to the estimated for the year 2017-18 of₹1,14,958 ( ₹9,579.83 a month), showing a rise of 10%," according to the annual national income and GDP 2018-19 data released by the Ministry of Statistics and Programme Implementation (MoSPI).Export policy:India’s revenue from exports of merchandise over the last four fiscal years was $310 billion, $262 billion, $275 billion and $302 billion, respectively. Thus over the four years from April 2014 till March 2018, the total growth was zero, or, rather, a tad negative. Even the ratio of exports to gross domestic product (GDP), at 11.6%, is at a 14-year low.In 2014, the trade policy announced by the Union commerce minister envisaged total exports worth $900 billion by 2020. That looks almost impossible, unless exports grow by 40% per annum from now onEmployment elasticity:The old link between growth and jobs is now much weaker than before. In the 1990s, the employment elasticity in India was nearly 0.4. This number measures how much a given rise in growth impacts jobs. At 0.4, a one per cent rise in GDP growth gives us a 0.4% rise in employment; 5% growth gives jobs a 2% boost.Now, this elasticity is down to 0.2 or lower. This means, for every percentage rise in growth, we get only a 0.2% impact on employment. Put another way, we need a minimum of 10% GDP growth to give us the kind of jobs kick we used to get in the 1990s.The gap between jobs created and jobs sought will be just over 1.5 million annually.Tax-GDP Ratio :The tax-GDP ratio is expected to cross 12% in FY19, a new high in over a decade, but lower than emerging market peers.Tax-to-GDP ratio for India has inched up slightly in recent years, but remains well below the world average. It is 10.6% , 11.6% , 12.1% in the years 2016, 2018, 2019 respectively.MSME :MSME has played a prominent role in the development of the country in terms of creating employment opportunities-MSME has employed more than 50 million people, scaling manufacturing capabilities, curtailing regional disparities, balancing the distribution of wealth, and contributing to the GDP-MSME sector forms 8% of GDP.MSME sector has cut jobs in the last seven yearsDemographic transition:India’s working-age population is now increasing because of rapidly declining birth and death ratesIndia’s age dependency ratio, the ratio of dependents (children and the elderly) to the working-age population (14- to 65-year-olds), is expected to only start rising in 2040, as per UN estimatesDemographic Dividend:For the first time since independence, India’s working age population — those aged between 15-64 years — will outnumber its dependents, that is, children aged 14 and below as well as people aged 65 and above.India’s dependency ratio has declined from 68.4 %( 1950) to 49.8 %( 2018). Total Fertility rate declined from 5.9(1950) to 2.2(2018).Black Money:Various studies and estimates have pegged black money circulation india anywhere between 7 per cent and 120 per cent of the country’s GDP in 2009-10 and 2010-11.Green GDP:Damage to the environment is put at Rs 34,0000 crores per year and it reduces the GDP by 9.5 percent annually.If water scarcity persists, it can lead to an alarming loss of six percent in the GDP by year 2050.Non Performing Asset:In recent years, the gross NPAs of banks have increased from 2.3% of total loans in 2008 to 4.3% in 2015 .Care Ratings says 17 banks have bad loan ratio above 10%. Gross NPAs of a set of 36 banks increased from ₹6.71 lakh crore in March 2017 to a peak of ₹9.66 lakh crore in March 2018 and subsequently moderated to ₹8.70 lakh crore in March 2019 before increasing to ₹8.97 lakh crore in June 2019.Agriculture export policy :India’s share in global exports of agriculture products has increased from 1% a few years ago, to 2.2 % in 2016.In 2018, India accrued a $14.6 billion trade surplus of agricultural, fishery, and forestry goods. Leadingexports consisted of Basmati rice, carabeef/meat of bovine animals, frozen shrimp and prawns, cotton, and refined sugar.Farm loan waiver:Agricultural NPAs were on a continuous decline between 2001 and 2008. Second, there is no evidence to argue that the 2008 waiver led to a rise in default rates among farmers.The rise of agricultural NPAs, from 2% to 5%, is no evidence for indiscipline in farmer repayment behaviour. One, NPAs in agriculture remained stable at around 4 to 5% between 2011 and 2015. This was despite the fact that agricultural growth averaged just 1.5% between 2011 and 2015.Agriculture census:Small and marginal farmers with less than two hectares of land account for 86.2% of all farmers in India, but own just 47.3% of the crop area, according to provisional numbers from the 10th agriculture census 2015-16.Inequality and Inclusive growth :About 50% of wealth in India in owned by just 100 people which is due to unequal distribution of wealth.Agriculture has a share of 17% in the GDP but employs about half the total labour force while the micro, small and medium enterprises (MSME) have a share of 32% in the gross value added (GVA) and have an important place in providing an “above the poverty line” lifestyle to the people (GoI 2018).Financial Inclusion:600 million deposit accounts were opened between fiscals 2013 and 2016, or twice the number between 2010 and 2013. Nearly a third of this was on account of Jan Dhan.for fiscal 2016 (the latest period for which data is available) show financial inclusion has improved significantly in India, with the all-India score rising to 58.0 in fiscal 2016, compared with 50.1 in fiscal 2013.Private investment:Investment in private sector projects fell similarly (83% compared to the previous quarter and 89% compared to last year).The stalling rate of private sector projects, which has hovered above 20% since the September 2017 quarter, reached an all-time high of 26.1% in the June 2019 quarter.Livestock Population:About 20.5 million people depend upon livestock for their livelihood. Livestock contributed 16% to the income of small farm households.The value of output from livestock was about 31.11% of the value of the output from total agriculture and allied sector.Food security in India :The country is home to 270 million hungry people, the highest in the world. India stands 97th in Oxfam’s Food Availability Index, and 103rd in the 2018 Global Hunger Index. In 2015-16, food grains accounted for 79 per cent of the imported agricultural produce; the figure was 76% the following year.Large-scale import of wheat in 2016 is often attributed to drought years. But there has been large-scale import of edible oil and pulses as well in the past two decades.Energy Poverty:India has just 4% of the world’s renewable energy but have 18% of the world's population.Agricultural technology:Farm Mechanization: Laser guided land leveler can flatten the land in less time than oxen powered scrapper. It increases farmers productivity by 15%.Food processing :According to the ministry of food processing industries annual report, the sector employs 12.8% of the workforce in the organised sector (factories registered under Factories Act, 1948), and 13.7% of the workforce in the unorganised sector. Despite being one of the largest producers of agricultural and food products in the world, India ranks fairly low in the global food processing value chains.Food processing is also important from the point of reducing food waste. In fact, the United Nations estimates that 40% of production is wasted. Similarly, the NITI Aayog cited a study that estimated annual post-harvest losses of close to Rs 90,000 crore.Renewable energy and energy security :Even with the growth of renewable energy, coal has been projected to be the backbone of electricity sector until 2030 and beyond.India has created 80,000 MW of renewable energy and set a target of achieving 1,75,000 MW by 2022, reduced energy intensity by 21%.India’s annual coal demand rose by 9.1% to nearly one billion tones during the year ending March 2019. Coal features among the top five imports of India, with total imports rising from 166.9 million tons in 2013-14 to 235.24 million tons in 2018-19.Best of luck to all mains candidates!God bless you all

I researched on Workplace Violence (WPV) in the healthcare sector for my MPH Master thesis at KIT Amsterdam. The issue of healthcare violence has systemic implications, and yet it is described mostly at the level of individuals (employee or client characteristics). Unsurprisingly, this leads to solutions that are themselves narrowly focused on individuals. For instance, many organisations have instituted communication and de-escalation training for health workers. Whereas there is considerable merit to the idea that frontline healthcare workers (including doctors, nurses and others) have better soft skills, there is perhaps also an element of victim-blaming in an approach that puts the onus of de-escalation squarely on survivors.At the other end of the spectrum, there are calls for stricter laws providing for harsher punishments to perpetrators. Many states across India have passed such laws in recent years. It remains unclear though as to how much benefit this will have, given the widespread sentiment that doctors ought to forgive erring patients. Case in point, in the states of Punjab and Haryana, no alleged perpetrator had been punished under newer anti-violence legislation between 2010-2015. The right to safe workplaces for health workers has to be calibrated against Right to Health for the population at large. As such, a security-first approach that does not address the underlying causes of WPV in the Healthcare sector (WPVH), is likely to do more harm than good.The key takeaway for me was that occupational violence is a sign of long-simmering structural defects in the health system. Left unattended, these manifest in a whole range of undesirable interactions between Health Care Providers (HCP - includes doctors, nurses and other ‘frontline’ health workers) and clients (patients/caregivers/visitors). These affect not only the individuals concerned, but are harmful also for the functioning of the health system at large. To address the issue in a meaningful way, it is hence important to identify the root causes of WPVH. And yet, even as we describe each of these in isolation, it is important to recognize that in reality they constitute an inter-connected web of causation.Causes of Healthcare Violence1. Lack of Public Investment in Health: This is more so a problem of the developing world, where government investments in health have simply not kept pace with the growth of population or the changing nature of diseases in society. Inevitably, this causes some persons to go without access to life-saving treatment, be it well-maintained hospitals, HCPs or essential drugs etc. The result is poor quality of care leading to avoidable suffering and death. Even in the developed part of the world, there is a widening mismatch between the expectations of the general public and what the health system is capable of providing (longer wait lines, reduced coverage etc). Perceived neglect and poor quality of care is a major risk factor of WPVH, especially when combined with adverse treatment outcomes.2. Corporatisation of healthcare: Inadequate public provisioning of healthcare services leads to a growing demand for privatised health care. In countries such as India with deep-seated inequities and lacking in Universal Health Coverage, only a small fraction of the population with purchasing power get privileged access to available Human Resources in Health (HRH), to the exclusion of the majority of the population. This trend has accelerated in recent years, as many family-run nursing homes have either shut down or been taken over by corporate groups. Four out of five doctors in India are currently employed by the private sector. Advent of more expensive treatment modalities, combined with unclear pricing in the private sector, rises the risk of catastrophic health expenditure. As such, growing financial insecurity for the salaried classes – that has been documented over much of the world in the past decade – increases risk of aggression and violence towards hospitals and HCPs.3. Principal-Agent relationship and Moral Hazard: In Health Systems where Out of Pocket (OOP) payments at the point of care constitute the default payment mechanism for a majority of the population, doctors are faced with a clear conflict of interest. On the one hand lies their duty towards patients and on the other, serving the financial interests of their employers. Often, their own pay is significantly dependant on the revenues generated at facility-level. Even if an individual doctor does not let such considerations influence their clinical decision-making, the fact that such role strain exists causes patients to lose trust in doctors and the health system at large. This might result in incivility and aggression towards frontline workers, who are the most visible face of the health system.4. Unsustainable healthcare-seeking behaviour: A consequence of the rise of privatised healthcare is bypassing of ‘gatekeeping’ function, traditionally performed by General Practitioners (GP) in the community. Healthcare is an ‘imperfect’ marketplace, characterized by gross asymmetries of information and power between patient and provider. Marketing campaigns that are directed at the end-users distort care seeking behaviour, drawing patients towards tertiary care facilities. It is not uncommon to have subspecialists provide primary care in India, especially in corporate hospitals. Not only does this create artificial bottlenecks for the wider population, but it also leads to higher direct and indirect costs for those seeking such care. These costs are justified to the patient by the promise of excellent quality of care and impeccable treatment outcomes. Whether such promise is implicit or explicit, adverse outcomes are likely to be viewed much more harshly under these circumstances.5. Erosion of trust: There is globally a well-documented trend towards rise of new-age religious and political movements that are sceptical towards the institutional mainstream of society (so-called ‘Establishment’). This has occurred broadly in parallel to rising inequalities in the developed part of the world, where many middle class jobs have either been automated or shifted overseas. Even though globalisation has helped to lift millions out of poverty in poorer countries, the lack of job security and income stability makes for a middle class that is unsure of its own place in the world. Integral to this “doubting ecosystem” are alternative therapies that seeks to dismiss the entire edifice of modern medicine as corrupt and beholden to vested interests. Not only does the government and media fail to curb such disinformation, but they often serve to spread and amplify the same.6. Distortions in training curriculum: Medical training across much of the developing world has come to develop an overly technical focus. Trainees are evaluated on the basis of their ability to accurately diagnose and manage medical emergencies or complex illnesses. Medical specialists (and subspecialists) are almost always in charge of setting the public health agenda. One casualty of this is the devaluation of humanities, management, ethics and law within the medical training curriculum. Needless to say, this causes HCPs to be less than ideally prepared to deal with every-day challenges outside of patient care.7. Reluctance to sanction: The discussion around healthcare violence tends to be centred around extreme incidents (such as the one described by OP “What are some precautions a doctor has to take to not get beaten by an angry mob in the case if a patient dies?”) and/or lead to sudden strikes by HCPs. This speaks to a well-documented reluctance on the part of media, policy makers, police officials, administrators and many HCPs themselves to both underreport incidence as well as understate the severity of WPVH. Such reluctance is understandable, fundamentally rooted as it is in compassion for the sick - a deeply seated value in all civilized societies.8. Inefficiencies in the criminal justice system: The police force in most parts of India are by and large susceptible to political influence, which interferes with their ability to exercise professional judgement when incidents of WPVH are reported. Judicial processes tend to lag, leaving courts with backlog of cases going back many years. Stretched thin by competing demands, police in India incentivise parties to seek out of court settlement. Such inefficiencies in the police and judicial system may increase risk of Workplace Violence in the Healthcare sector.9. Improper framing of the issue: During the NHS strike of 2016, the general public in the U.K. was perceived as by and large sympathetic towards striking doctors. In India there is comparatively less support among the general public for strike action by healthcare professionals. Instead, the dominant narrative in this part of the world is that of broken social contract between the medical profession and the society that invested scarce resources in their training. The courts too have taken a stringent view of striking doctors as impinging on patients’ Constitutionally-guaranteed “Right to Health”. Strikes by doctors and nurses are seen as collective punishment meted on the society for the mistakes of a few. Perpetrators of WPVH are often portrayed as being under extreme and legitimate emotional distress.10. A cultural history of violence: India has a long history of social exclusion and devaluation towards those engaged in providing personal care services, especially of an intimate nature. Nursing comprises activities that involve handling of bodily fluids and secretions, a ritualistically “polluting” activity. The global health workforce is largely female, and in India those employed in the lower rungs of the health system tend to be both female as well as from lower caste status. Caste and Gender constitute two intersecting axes of disenfranchisement, that have continued to persist in India to the present day. As such, WPVH has to be understood in the larger context of Caste and Gender-based violence in India.Consequences of WPVH:LanctÔt and Guay(1) describe 7 categories of consequences of WPV for Health Workers: physical, psychological, emotional, work functioning, relationship with patients/ quality of care, social/ general, and financial. An estimated 5–32% of survivors of workplace violence meet diagnostic criteria for Post-Traumatic Stress Disorder (PTSD). This represents both a danger to service recipients as well as a cost to employers. Survivors report being less able to control anger than before. They feel mistrust and fear of patients in general after the incident – not just those who were violent towards them in the past. Survivors report losing pleasure in interacting with patients, and in one study more than half had changed their behaviour at work as a result of the experience.When physicians experience poor mental health due to severe work-related stress, they are more likely to make mistakes while taking care of patients. Employees who lose trust in management’s ability or willingness to protect them may disengage from work, both physically as well as psychologically. Lack of commitment from health workers towards organizational goals has adverse impact on over-all effectiveness of care provided by a healthcare organisation. Being faced with WPV significantly increases the likelihood that an employee leaves an organisation, if not the profession itself. Survivors are also significantly more likely to take leave of absence. As its disruptive impact on health systems becomes increasingly evident, WPVH is being recognized as a global public health problem.Interventions:With this background, let us rephrase the original question: What can the individual doctor do to better protect his or her self from WPVH?1. Educate themselves on the causes and consequences of WPVH, both for HCPs as well as the wider public. Gain basic understanding of relevant sections of the law.2. Engage with hospital management, members of the media, legal fraternity as well as the general public to frame the problem as one affecting both HCPs and patients.3. Insist on improvements to physical environment and workforce management as appropriate at their health facilities. Resist working under perverse incentive structures.4. Encourage patients to take health insurance. Facilitate shared decision-making with patients and caregivers.5. Support and encourage nurses and other auxiliary staff to share their concerns freely. Post-incident investigations reveal that there is a spiral of adversarial interactions that culminate in major violence. Hospital managers and doctors often turn a blind eye to harassment directed towards those employed in subordinate roles.6. Be willing to prosecute perpetrators to the full extent of the law. Consider handing over to a third party, any negotiations while the case is subjudice.7. Maintain open and adequate documentation and communication at all times, including risk of adverse outcomes. Remember to document the communications as well as to communicate to the patient regarding documentation.8. Develop a culture of teamwork, inviting inputs from professional colleagues. Allow, if not encourage, patients or bystanders to get a second opinion.9. Do not refuse referral or discharge to another hospital. If the discharge is against medical advise, communicate risks appropriately and document the communication.10. Refrain from giving opinions on treatments received at other centers, unless required by law.REFERENCES1. LanctÔt N, Guay S. The aftermath of workplace violence among healthcare workers: A systematic literature review of the consequences. Aggression and Violent Behavior [Internet]. 2014;19(5):492–501. Available from: The aftermath of workplace violence among healthcare workers: A systematic literature review of the consequences