Editorials, Opinions & Explained2 Items

Core TopicImportantConcise

OpinionsGS II · GS III · GS IV

01Overtreatment & Overmedication in Indian Health Care02CSR at ₹40,000 Crore — From Spending to Impact

OpinionsSigned op-eds · GS Papers II, III & IV

01

When Medicine Does Too Much: Overtreatment, Overmedication and the Case for Clinical Restraint

Core TopicOpinionGS-II · Health — Health Systems, Regulation of Medical PracticePrelims + MainsThe Hindu · Op-Ed · Chandrakant Lahariya

The author argues that India's health system exhibits a dual pathology — overtreatment of those who can pay coexisting with undertreatment of those who cannot — and that the next phase of medical progress lies as much in knowing when not to intervene as in expanding what can be done.

◈ Conceptual Foundations

The critique of excess medicine has a long intellectual lineage. Ivan Illich's Medical Nemesis (1975) introduced the idea of iatrogenesis — harm caused by medical care itself — and warned against the medicalisation of ordinary life.

• Overdiagnosis: detection of a condition that would never have caused symptoms or death; it converts healthy people into patients without improving outcomes.
• Overtreatment: interventions whose likely harms or costs exceed their benefits for a given patient.
• Polypharmacy: concurrent use of, conventionally, five or more medicines; risk rises with age because of altered drug metabolism and multiple chronic conditions.
• Deprescribing: the planned, supervised reduction or withdrawal of medicines whose risks now outweigh benefits. Tools include the Beers Criteria (American Geriatrics Society) and STOPP/START criteria.
• Information asymmetry: Kenneth Arrow (1963) showed that patients cannot judge the necessity of care, giving providers scope for supplier-induced demand.

The Cascade of Care

The article's central insight is that overtreatment is rarely a single wrong decision. It is typically a sequence, each step individually defensible, that ends in permanent medication or a procedure the patient may never have needed.

Figure 1 — How a routine test can escalate into lifelong treatment

Without a gatekeeper or a review date, the chain rarely reversesRoutine testor check-upIncidentalabnormalityFurther testsand scansNew diagnosis(a ‘label’)Prescriptionor procedureLifelongmedicationEach step adds cost, anxiety and a fresh risk of iatrogenic harm

The remedy is not fewer tests as such, but decision points — a family physician, a review date, a structured medication review — at which the cascade can be stopped.

Five Drivers Identified by the Author

• Indiscriminate testing: bundled health-check packages generate false positives and incidental findings; the capacity to test has outpaced clinical judgment on whom to test.
• Fragmented care: patients bypass generalists for specialists and super-specialists, each optimising one organ system; nobody reconciles the whole prescription.
• Marketisation: tests, procedures, supplements and devices are sold as products; the fee-for-service model rewards volume over restraint, and patients often equate a "complete" consultation with a long prescription.
• Patient expectations: under uncertainty, reassurance and watchful waiting appear as inaction, while a scan or pill appears decisive — and crowded clinics leave little time to explain.
• Defensive medicine: fear of a missed diagnosis — and of litigation — makes one more test look like the safer choice, though every test carries its own downstream risk.

The Evidence Cited

~49%Older adults with polypharmacy (meta-analysis, 2021)

~1 in 3Older adults on 5+ medicines (study, 2025)

28.8%Cases with potentially inappropriate medicines

The author is careful to note that multiple medicines are not proof of overtreatment; the figures instead establish why periodic medication review must become routine, particularly as India ages. The India Ageing Report 2023 (UNFPA) projects the elderly share of the population to exceed 20% by 2050.

Corroborating Evidence — The Caesarean Example

Caesarean delivery is a widely studied marker of provider-driven intervention. NFHS-5 (2019–21) data show a pronounced gap between public and private facilities, well above the level that WHO (2015) found to be associated with lower maternal and newborn mortality at population level (around 10%).

Figure 2 — Births by caesarean section, India, NFHS-5 (2019–21), %

Public facilitiesAll birthsPrivate facilities14.3%21.5%47.4%WHO reference ≈ 10%01020304050

Nearly one in two births in private facilities is by caesarean section — more than three times the public-facility rate — consistent with the incentive effects the author describes. Source: NFHS-5; WHO Statement on Caesarean Section Rates (2015).

The Policy and Legal Landscape

• Constitutional frame: public health is a State subject (Entry 6, List II); Article 47 places a duty on the State to improve public health; the Supreme Court has read a right to health into Article 21 (Paschim Banga Khet Mazdoor Samity, 1996).
• Primary care as gatekeeper: the Alma-Ata Declaration (1978) and Astana Declaration (2018) place primary care at the centre of health systems; the National Health Policy 2017 sought to allocate two-thirds or more of public health resources to primary care.
• Ayushman Bharat (2018): Ayushman Arogya Mandirs provide the first-contact layer; AB-PMJAY provides hospitalisation cover of ₹5 lakh per family per year, extended in 2024 to all citizens aged 70 and above.
• Standard treatment guidelines: the Clinical Establishments (Registration and Regulation) Act, 2010 empowers prescription of standard treatment guidelines, but adoption across States remains partial.
• Medical liability: Indian Medical Association v. V.P. Shantha (1995) brought medical services under consumer protection law; Jacob Mathew v. State of Punjab (2005) set a high threshold of "gross negligence" for criminal liability — both shape the incentives behind defensive medicine.
• Antimicrobial misuse: the National Action Plan on AMR (2017) recognises irrational antibiotic prescription as a form of overmedication with population-level consequences.

The Insurance Paradox — Moral Hazard

Insurance protects households from catastrophic expenditure, yet it can alter behaviour. Ex-ante moral hazard weakens incentives for prevention, since illness is financially cushioned; ex-post moral hazard raises utilisation once illness occurs, because the insurer, not the patient, bears the marginal cost.

• Under package-based reimbursement, providers may favour procedures that are well remunerated over conservative management.
• The author's ethical point is sharp: a third party bears the cost, but the patient's body bears the risk; paying premiums creates no reason to "recover" value through surgery.

Remedies Proposed — and an Assessment

• Restore the family physician as the first point of contact, with specialist referral through a defined pathway — the gatekeeper model of the UK's NHS and several European systems.
• Review and stop dates on prescriptions, and structured medication reviews for older adults and anyone on five or more medicines.
• Indian low-value care lists developed by professional societies and the ICMR, modelled on the Choosing Wisely campaign (begun in the US in 2012; about 80 societies issued nearly 700 recommendations by 2023), embedded in training and accreditation (e.g., NABH).
• Four patient questions — Why do I need this? What if I wait? What are the benefits and risks? What are the alternatives? — to support shared decision-making.
• Payment reform towards outcomes, continuity and clinical reasoning, for instance capitation or bundled payments, rather than volume.

The proposals are well grounded, but three constraints deserve attention. India's primary-care workforce is thin, especially in cities where specialists dominate. Most care is delivered in a loosely regulated private sector.

And any campaign against "low-value care" must avoid deepening undertreatment among the poor, for whom the problem is too little care, not too much.

✎ Mains Practice Question

“In India, overtreatment coexists with undertreatment.” Examine the structural drivers of overmedicalisation in the Indian health system and suggest measures to align clinical incentives with patient welfare. 15 marks · 250 words

02

A Decade of Mandatory CSR: Moving the Measure from Rupees Spent to Outcomes Achieved

Core TopicOpinionGS-III · Economy — Mobilisation of Resources, Inclusive Growth; GS-IV · Corporate GovernancePrelims + MainsThe Indian Express · Op-Ed · Purvi Mehta

India's mandatory Corporate Social Responsibility (CSR) regime has mobilised about ₹2.6 lakh crore in a decade and ₹40,794 crore in 2024–25 alone; the author contends that the policy question must now shift from how much is spent to what that spending achieves.

◈ Static Anchor — The Legal Framework

India became the first country to make CSR spending a statutory obligation, through Section 135 of the Companies Act, 2013, effective 1 April 2014. Eligible activities are listed in Schedule VII of the Act.

• Applicability: a company with net worth ≥ ₹500 crore, turnover ≥ ₹1,000 crore or net profit ≥ ₹5 crore in the preceding financial year.
• Obligation: spend at least 2% of average net profits of the three immediately preceding financial years.
• Governance: a board-level CSR Committee is required where the obligation exceeds ₹50 lakh; implementing agencies must register with the MCA (Form CSR-1).
• Unspent funds (2019 and 2021 amendments): amounts for ongoing projects go to an Unspent CSR Account and must be used within three years; other unspent sums go to a Schedule VII fund within six months.
• Enforcement: non-compliance was decriminalised in 2020 and now attracts monetary penalties.
• Impact assessment: under the CSR Rules, 2021, companies with average obligations of ₹10 crore or more must commission independent impact assessments for projects of ₹1 crore or more.
• Tax treatment: CSR expenditure is not deductible as a business expense under income-tax law, reflecting its character as an obligation, not a cost of earning income.

▤ The Numbers (as reported for 2024–25)

• Total CSR spend: ₹40,794 crore by about 29,500 companies across roughly 72,000 projects.
• Cumulative mobilisation since 2014: about ₹2.6 lakh crore.
• Top four destinations: Maharashtra ₹8,631 crore, Gujarat ₹4,549 crore, Karnataka ₹3,395 crore, Delhi ₹2,753 crore — together about ₹19,300 crore, or roughly 47% of the total.
• Average project size: about ₹57 lakh (₹40,794 crore ÷ 72,000) — an indicator of fragmentation.

Figure 3 — Where CSR money went, 2024–25 (₹ crore)

MaharashtraGujaratKarnatakaDelhiAll others*8,6314,5493,3952,75321,466*All other States/UTs and multi-State (‘PAN India’) projects; total minus the four named.

Four relatively developed States and UTs absorb close to half of all CSR spending, while the remaining 30-odd States and UTs and multi-State projects share the rest.

The Author's Diagnosis

The argument is not that CSR money is wasted — much of it supports education, health and livelihoods — but that the sum of tens of thousands of discrete projects is unknown. Two structural weaknesses follow.

• Geographic skew: spending follows corporate location (registered offices and plants) rather than development deficit. Section 135 itself asks companies to give preference to the local area of operations, which partly institutionalises this skew.
• Fragmentation: many small, short-cycle projects produce outputs — beneficiaries counted, assets built — without systemic change in a district's health or learning outcomes.

From Inputs to Impact — The Results Chain

Figure 4 — Where CSR accountability sits today, and where it needs to move

Current reporting focusWhere accountability should moveInputsActivitiesOutputsOutcomesImpact₹ spentprojects runpeople reachedlearning, healthdistrict systemsMeasured by the 2% compliance testNeeds common indicators, pooled fundsand longer project horizons

The 2% rule audits the first link of the chain; the reforms proposed aim to make the last two links the test of success.

Three Reforms Proposed

• Outcome accountability: pair the existing spend-based compliance with standardised outcome indicators, so results are comparable across companies and sectors.
• Aggregation: use the law's existing provision for collaboration to pool funds around common themes and geographies — ten firms jointly committing ₹100 crore to one results framework can shift a district system in a way ten scattered ₹10-crore projects cannot.
• Core competence: deploy knowledge, networks and managerial capacity, not only money — an agri-business supporting farmer productivity and value chains is likely to achieve more than it would in an unrelated sector.

Analytical Perspectives

• Theoretical frame: the third reform echoes Porter and Kramer's "Creating Shared Value" (2011), which argues that firms create most social value where it intersects with their business, in contrast to Milton Friedman's (1970) view that business's sole social responsibility is profit within the rules.
• Indian roots: Gandhi's idea of trusteeship — wealth held in trust for society — is often cited as the ethical antecedent of Indian corporate philanthropy.
• Aligning with public priorities: the Aspirational Districts Programme (2018, 112 districts) and Aspirational Blocks Programme (2023, 500 blocks) offer ready geographies and indicator frameworks for directing pooled CSR.
• Outcome-based instruments: SEBI's Social Stock Exchange framework (2022) and development impact bonds such as the Utkrisht DIB (maternal health, Rajasthan) pay against verified results — models CSR could adopt.

The Critical View

• A quasi-tax? Critics argue that a mandated, non-deductible spend functions as an earmarked levy on profits, while leaving allocation to firms that may lack development expertise.
• Directing spending has limits: steering CSR towards specific districts could dilute corporate discretion, the very feature that distinguishes CSR from taxation.
• Measurement cost: rigorous impact evaluation is expensive; demanding it of small projects may consume a large share of their budgets — hence the current ₹10-crore / ₹1-crore thresholds.
• Supplement, not substitute: at about ₹41,000 crore a year, CSR is significant but small beside public spending on the social sector; the author rightly frames it as a supplement to public expenditure.

✎ Mains Practice Question

A decade after India made Corporate Social Responsibility mandatory, the debate has shifted from how much is spent to what is achieved. Critically evaluate the CSR framework under the Companies Act, 2013, and suggest reforms to improve its developmental impact. 15 marks · 250 words