Open Access: A Vital Component for Scientific Independence

An editorial in Nature recently lauded India's emergence as a scientific powerhouse, commensurate with its expanding economic might. As evidenced by the Nature Index, which ranks Indian research output third worldwide and quality eleventh, the country's scientific ecosystem is truly remarkable. But the "ease of doing science" that is essential for breakthroughs and creativity depends on strong resources and infrastructure, areas where India still has a long way to go.

University Expansion and Resource Scarcity

• The number of universities in India increased from 760 to 1,113 between 2014 and 2021. Even with this expansion, many colleges continue to lack basic facilities like advanced labs and instrument availability. The absence of access to the literature supporting studies is even more concerning.
  
  
• The innovative I-STEM initiative was launched in order to close this gap. All publicly financed research facilities across the country are indexed by I-STEM and are accessible to researchers according to their needs. The goal of this demand-supply mapping is to make advanced research infrastructure more widely accessible.

The Proposal for One Nation, One Subscription (ONOS)

• In a similar vein, the "One Nation, One Subscription (ONOS)" movement suggests a centralized model of scientific journal subscription that would make the publications available to all institutions that receive public funding. The cost of accessing these commercial journals is high; an estimated ₹1,500 crore is spent annually by Indian institutions on journals and databases.
  
  
• But the wealthiest few institutes are the ones that benefit most from this investment. And the others? In order to deploy ONOS, the Indian government is now in negotiations with the five dominant commercial publishers in the industry.

Is ONOS the Best Course of Action?

• Around 2019, when ONOS was first conceived, a sizable number of academic publications were behind paywalls. But things have changed dramatically since then, with a considerably higher percentage of publications now being made available through Open Access (OA). The percentage of open access papers worldwide climbed from 38% in 2018 to 50% in 2022, according to an examination of publications included in the Web of Science index. This change begs the question of whether it is still necessary or effective to pay for material that is becoming more and more freely available.
• The United States and the European Union are currently pushing hard for open access. The U.S. published an amended Open Access policy in 2023, requiring all research articles financed by the government to be immediately accessible to the public by 2025. Similar to this, significant charitable funding organizations like the Wellcome Trust require open access (OA) for the research they support. It is legitimate to argue that journal subscription costs should go down in light of this trend.

Issues with the Academic Publishing Market's Oligopoly

• Due to the global north's oligopolistic academic publishing market, which is controlled by a small number of strong publishers, it is difficult to negotiate ONOS terms because these publishers can impose strict conditions. Any consideration of alternatives is further stifled by the publishers' well-established reputation and authority.
• The use of public funds in any other government purchase is strictly regulated to guarantee optimal cost-effectiveness and benefit. Why ought the acquisition of scholarly journals to differ in any way? If large amounts of research are already freely available, there is little reason to pay for a single, expensive membership. It's also crucial to remember that ONOS mainly makes it easier for Indian scholars to access journals run by powerful publishing oligarchs; it won't make Indian research accessible to the world at large.

Problems with Digital Archiving

• To make matters more complicated, there is no assurance that access will remain available even for those who pay and subscribe to the journal. The majority of scholarly journals are only accessible online these days. Even though the majority of articles have a digital object identifier (DOI), long-term preservation is not guaranteed by this.
• "Approximately 28% of academic journal articles with DOIs appear entirely unpreserved," according to a recent research. According to this analysis, millions of academic publications run the risk of disappearing from the Internet. For instance, when a chemical journal published by Elsevier and disseminated throughout the world—aside from Japan—was stopped publishing in December 2023, almost 17,000 scientific papers from that magazine vanished.

Heading Towards Autonomy

Prominent publishers with headquarters in the global north, including Wiley and SAGE (U.S.), Taylor Francis (U.K.), Elsevier (Netherlands), Thomson Reuters (Canada), and Springer Nature (Germany). A significant portion of this profit comes from researchers' unpaid labor, which takes the form of editing work and peer evaluations.
In order for India to achieve atmanirbhar (self-reliance), the country must enhance its journal system and do away with the requirement for writers and readers to pay. India could use its technological prowess to lead the global south by developing and disseminating digital public infrastructure that enables high-caliber, reasonably priced scientific publishing.

In summary

Considering how academic publishing is changing, it makes little sense to invest in an all-inclusive subscription model like ONOS. The ONOS concept is no longer as relevant or as cost-effective due to the notable rise in Open Access articles and the push toward OA from key international organizations. The objective of scientific self-reliance will be better served by concentrating on Green Open Access and developing India's own digital infrastructure for scientific publishing.

AMRUT Scheme: Modernizing India's Urban Infrastructure Despite Obstacles

India's urban landscape is changing quickly as a greater share of the country's population lives in cities. As of right now, 36% of Indians reside in cities, and by 2047, that percentage is expected to rise to 50%. According to World Bank estimates, over the next 15 years, an astounding $840 billion will be needed to address the needs for basic urban infrastructure. The NDA-1 administration introduced the Atal Mission for Rejuvenation and Urban Transformation (AMRUT) program in June 2015 to address these expanding urban concerns. The goal of this project is to address important problems with urban infrastructure, specifically with pollution control, sewage, and water supply. The goal of AMRUT 2.0, which debuted on October 1, 2021, is now to improve sewage systems and make cities more water-secure.

Goals and Purpose of the AMRUT Program

The AMRUT programme was created to tackle particular issues related to urban infrastructure. Making sure that every home has access to a tap with a dependable water supply and a sewerage connection is one of its main goals. Additionally, by creating green areas like parks and promoting public transportation and non-motorized transportation options, the program seeks to improve the aesthetic and environmental value of cities while also lowering pollution.

500 cities and towns with a population of more than 100,000 are the focus of the mission; all of these have informed the relevant municipalities. AMRUT required ₹50,000 crore in total funding throughout the first phase, which ran from FY 2015–16 to FY 2019–20. The objective of AMRUT 2.0 is to expand upon these advantages by establishing 'water secure' cities and supplying all statutory town dwellings with functional water tap connections. 500 cities are to have 100% sewage management, one of the phase's lofty goals. AMRUT 2.0 would cost ₹2,99,000 crore in total; the states and cities will fund the remaining amount, with the federal government providing ₹76,760 crore over the course of five years.

Allocation and Utilization of Funds

According to the AMRUT dashboard, as of May 19, 2024, ₹83,357 crore have been paid out for several plan projects. 37,49,467 sewerage connections and 58,66,237 tap connections have been made possible thanks to this assistance. The mission has also constructed 2,411 parks and installed 62,78,571 LED lights as part of its attempts to lower energy usage and improve urban infrastructure.

Actualities and Contemporary Urban Difficulties

Even with the AMRUT scheme's advancements, there are still big problems. India is still facing serious problems with water, sanitation, and hygiene. An estimated 200,000 people die each year as a result of poor infrastructure related to water and sanitation. India has a very high illness burden due to contaminated water and inadequate sanitation; this hasn't changed much since 2016, when it was reported to be 40 times worse than in China.

Furthermore, a sizable portion of wastewater is left untreated, which accelerates the development of illnesses. Just 40% of the 150 monitored reservoirs in the nation, which are essential for agricultural, drinking water, and hydroelectric generation, were filled to capacity recently. With 21 large cities at risk of running out of groundwater, this problem of water scarcity is very serious. According to an NITI Aayog estimate, by 2030, 40% of Indians may not have access to clean drinking water. At the moment, 67.3% of urban dwellings are not connected to a sewer system, and 31% of households lack piped water. In metropolitan areas, the average daily water supply per person is 69.25 liters, far less than the necessary 135 liters.

The state of the air in AMRUT cities and other major cities keeps getting worse. Air pollution is still a serious problem, despite the National Clean Air Programme's 2019 start. This emphasizes the necessity for more extensive measures beyond AMRUT 2.0's water and sewage focus.

Limitations of the AMRUT Program

The AMRUT plan has been rendered less successful due to a number of fundamental problems. The plan's project-oriented methodology, which lacks a comprehensive vision for urban development, is one of the main problems. Furthermore, the cities themselves played a little role in the scheme's design. Elected city officials had little say in it; instead, bureaucratic procedures and commercial interests were the main drivers.

This discrepancy is further illustrated by the AMRUT governance structure. The Secretary of the Ministry of Housing and Urban Affairs (MOHUA) presides over the apex committee at the central level; elected representatives are not present. Similarly, the powerful state committee, which excludes local representation in defiance of the 74th Constitutional Amendment, is led by the Chief Secretary and comprises consultants and professionals from the business sector.

Furthermore, the scheme's approach to water management frequently ignores the unique temperature and rainfall patterns of various regions, in addition to the infrastructure already in place for combined sewers. This has led to inefficiencies, such as the need for waste to travel a greater distance to reach sewage treatment plants, which are situated distant from residential areas. Large private companies and real estate developers have also distorted urban planning, which has resulted in insufficient stormwater drainage systems, the elimination of natural water bodies, and disturbed stormwater flows.

Advice

The AMRUT program has to embrace more holistic, people-centered strategies and nature-based solutions to address these deficiencies. Important first steps toward accomplishing this goal include giving local entities more authority and incorporating elected officials in the planning and execution phases. The current infrastructure and the local climate should be taken into account when designing urban areas in order to build more sustainable and effective systems.

Furthermore, in order to guarantee the long-term viability of urban development efforts, a change from a project-oriented to a holistic strategy is required. This entails tackling more general problems like air quality and sustainable transportation in addition to enhancing the water and sewage systems. The AMRUT initiative aims to develop more resilient and habitable cities for India's rapidly expanding urban population by increasing the role of local governments and encouraging greater community participation.

In summary

Even though the AMRUT program has significantly improved urban infrastructure, there is still much to be done. A more integrated, participatory strategy that gives urban inhabitants' needs and voices priority is needed to address the problems and weaknesses of the current system. With these adjustments, AMRUT will be in a better position to support India's cities' sustainable growth and raise the standard of living for all city inhabitants.

India and Managed Care's Promise

One of the main components of India's plan for universal health care (UHC) is currently health insurance. Advances in digital technology are creating opportunities for reforms akin to those in the US but customized to save expenses. A large South Indian healthcare chain has unveiled a model akin to managed care organizations (MCOs) that integrates insurance and medical services. This development raises the question of whether MCOs could successfully increase UHC in India.

Historical Overview of Managed Care Organizations

• MCOs originated in the United States in the 20th century with some basic prepaid healthcare practices. Concerns over health care costs peaked in the 1970s, which provided the biggest push for mainstreaming MCOs in American healthcare.
• The health insurance market was once dominated by highly compensated providers who collaborated closely with insurers. However, during the economic downturn of the 1970s, purchasers found high rates to be increasingly unappealing. Due to this circumstance, the insurance and provisioning activities were combined under one roof, prevention and early management were prioritized, and cost control was strictly enforced in exchange for an enrollee-paid set premium.
• Ever since, MCOs have undergone numerous generations and transformations, deeply influencing the health insurance market. There isn't enough solid data to say that they improved health outcomes or prioritized preventative treatment, but they did contribute to a decrease in expensive hospital stays and related expenses.

India's Health Insurance Evolution

• Notwithstanding the existence of a roughly $26 billion market for outpatient consultations in India, since the introduction of the nation's first public commercial health insurance in the 1980s, the emphasis has been on indemnity insurance and paying for hospital stays. As Thomas (2011) pointed out, there has been little innovation in health insurance and high, frequently unaffordable, operating expenses because it is less important than life and general insurance.

In contrast to the United States

• Tollman et al. first examined the HMO (health maintenance organization, a sort of MCO) experience in developing countries and noted many significant traits: MCOs tended to be concentrated in urban areas, drew wealthy clientele, and prospered in areas where the public sector was faltering or lacked solid socialist foundations. Furthermore, stakeholders needed to contribute significant financial resources, administrative skills, labor, and well-defined, affluent beneficiary bases in order for MCOs to be successful.
• In comparison, India's health insurance system has evolved in a way that hasn't produced many natural incentives for cost containment driven by the consumer. Insurance has mostly targeted the thin, affluent urban group; outpatient procedures have a high degree of informality; and there is a dearth of universally accepted clinical guidelines. Theoretically, unsuccessful operations and excessive rates could spur change, but they haven't resulted in a significant systemic movement in the direction of managed care.

Possibility of MCOs in India

• Major health-care brands with devoted metropolitan patient bases and substantial financial resources to establish networks and invest in infrastructure and administrative capabilities may be the source of a few successful ventures. On the other hand, it seems unlikely that these projects will significantly advance UHC if they are solely driven by private initiative.
• However, there may be benefit to taking a careful and gradual approach to public patronage when investigating managed care options. Given that each person receives three consultations on average annually and since insurance pays for a minuscule portion of outpatient care, there is a great deal of room for cost savings through the early treatments made possible by comprehensive outpatient care coverage. At the moment, health insurers have minimal influence over a patient's pre-hospital travels.

The Report and Recommendations of NITI Aayog

• A research published in 2021 by NITI Aayog supported a subscription-based outpatient care insurance plan that would improve care integration and result in cost reductions. A well-run managed care system can yield significant benefits. Positive spillovers could offer a long-term, viable solution for outpatient care coverage. These include the consolidation of dispersed practices, the simplification of management standards, and the integration of a much-needed preventive care focus in the private sector.
• Incentives were offered under the Ayushman Bharat Mission to encourage the establishment of hospitals in underprivileged areas to provide priority care to Pradhan Mantri Jan Arogya Yojana (PMJAY) beneficiaries. On a limited and experimental basis, similar incentives may be designed for MCOs to insure and serve PMJAY patients in addition to a private, self-paying clientele. This strategy could eventually help raise awareness and broaden the reach of MCOs by being applicable to other public sector social health insurance programs. The need for managed care would rise in tandem with the growth of the self-paying pool.

In summary

Like all complicated systems, UHC is a maze with many facets, and there is never a single correct answer. MCOs can contribute to the larger solution that Indian health care is currently looking for, even though they cannot be expected to be the ideal solution. Managed care companies could play a major role in helping India achieve universal health coverage if they have the right kind of public support and are strategically implemented.