For public health as political priority

A systemic reform of the health sector in order to meet the key objectives of equity, efficiency and quality is long overdue. In this, the Central and State governments need to make interventions intelligently, decisively and strategically so that the poor reap the benefits

How does Prime Minister Narendra Modi’s focus on population, health and subjects like public hygiene, the facilitation of toilets and ensuring preventive health through yoga fit in with his party, the Bharatiya Janata Party’s manifesto; one which promises a National Health Assurance (NHA) mission, with its aim of providing cashless hospitalisation in order to reduce out-of-pocket expenses? Why do these concerns seem contradictory? Does pursuing one necessarily hurt the other? These are legitimate questions and concerns. This must be looked at in a global context where there is discussion on Universal Health Coverage (or National Health Assurance) widening inequity in the short and medium term.

In seeking the maximisation of the health and well-being of every individual, the NHA subsumes the essentiality of access to those elements that constitute the foundation of good health — tap water (where conveyance of contamination is reduced by 99 per cent), a toilet and sewerage system, environmental hygiene, nutrition and basic primary care — and in the process, reduce 90 per cent of all morbidities and a substantial proportion of mortality. Evidence of efforts in the United Kingdom to contain tuberculosis by ensuring better housing and nutrition, the successful eradication by India of guinea worm infestation using improved water systems, or eradicating polio through improved sanitation and universal immunisation are some useful reminders of the interconnectivity between disease and environment, and between public health and clinical science.

Addressing inter-State disparities

In India, public health has been severely neglected with about 44 per cent of the population having access to tap water and toilets, 42 per cent of children being malnourished and a majority of people being treated by quacks. Setting right these issues requires an expenditure of an estimated Rs.10.7 lakh crore (recurring and non-recurring) against which the 12th Plan has allocated Rs.3.8 lakh crore. The most challenging of these is in bridging inter-State disparities, with 70 per cent of this investment required by the northern States that have restricted fiscal space, three quarters of the disease burden (preventable with effective primary health care) and weak implementation capacity, making inadequate funding not the only constraint. For example, in Bihar, 2.5 per cent of its rural population has access to tap water, 23 per cent of its people to toilets and a battered primary care system. Should such a State then invest in providing these basic services or in buying expensive care from private hospitals through insurance? What are the moral and ethical imperatives that must guide State action?

The Andhra Pradesh experience

In this regard, a review of the impact of the Rajiv Aarogyasri Health Insurance Scheme (RAS) in former Andhra Pradesh is illustrative of how the State consciously chose to abandon primary care for universal coverage of a select set of tertiary and secondary care conditions.

In 2007, RAS, a State sponsored health insurance scheme (covering 85 per cent of the population, with sum assured of Rs.1.5 per family for cashless treatment in 486 hospitals involving 938 procedures) was launched to provide risk protection against catastrophic illnesses that “have the potential to wipe out a lifetime savings of poor families.” The justification was that there was effective demand for treatment for non-communicable and chronic diseases, low investment in public hospitals and a burgeoning private sector, unaffordable to most.

RAS was perceived to be a popular programme. But there is a thin line between perception and reality. Several commentators have critiqued it as having boosted the revenue streams of private corporate hospitals without necessarily reducing health expenditures or improving health outcomes.

 Scaling-up the National Rural Health Mission’s efforts to revive the primary health-care system would be far cheaper and more sustainable than buying care from private hospitals. 

While there are no systematic evaluations to assess the impact of RAS, a recently conducted household survey in Andhra Pradesh by Access International covering 8,623 households offers interesting insights. While it showed an overall reduction in out-of-pocket expenditure and increased hospitalisation, it had limited impact in reducing impoverishment or indebtedness among the two lowest quintile groups. For example, while per capita expenditures for inpatient treatment nearly trebled from Rs.391 in 2004 to Rs.1,083 (2012) for the poorest quintile, it was down to Rs.1,174 from Rs.1,819 for the fourth quintile group. Likewise, while the proportion of those incurring catastrophic expenditures more than doubled from 1.1 per cent to 2.8 per cent and 1.2 per cent to 3.4 per cent for the two lowest quintiles, the richer quintiles faced reductions. Such wide disparities are attributed to the concentration of half the accredited hospitals in seven districts (towns) resulting in an inequitable distribution of and gross deficiencies in the supply side, making access difficult and unaffordable for those residing in backward districts.

Impact on poor

Second, 49 per cent of reimbursement was for cardiac, cancer and kidney failure (38 per cent of patients or 0.5 per cent of population), while the two bottom quintiles suffered impoverishment, premature mortality and disability due to lower respiratory infections, diarrhoeal diseases, tuberculosis (TB), ischemic heart diseases and malaria — conditions eminently preventable and treatable with effective primary care.

Besides, partaking RAS benefits implies forced hospitalisation for outpatient care, increasing the risk of hospital acquired infections and higher indirect expenditures that the poor cannot bear.

Third, the primary health-care system that the earlier Telugu Desam Party government had accorded high priority to has all but collapsed. Among 19 major States, Andhra Pradesh incurred the lowest expenditure of Central grants (National Rural Health Mission and disease control programmes) as proportional to its total health spending during 2011; 16 per cent against 31 and 28 percentages by Maharashtra and Karnataka respectively and the only State to slash its primary care budgets from 53 per cent to 46 per cent and allocate just 9 per cent for secondary care down from 12 per cent during 2007-12. In comparison, RAS was provided 23 per cent of the health budget for less than 1 per cent of the population (not necessarily poor) or 11.3 per cent of total hospitalisation. In the absence of cost containment measures and generous pricing, costs are likely to escalate further, impinging on the fiscal space of the two new States of Telangana and Andhra Pradesh. RAS reimbursement rates, say for hysterectomy, laparoscopy, appendectomy or coronary bypass are higher when compared to other schemes in the country. Prices set through negotiations with private hospitals by committees without professionals — like chartered accountants, health economists or systematic unit costing methodologies — can only be arbitrary. Further, package rates provide scope for gaming the system. In the absence of standards to measure quality and regulations to control provider behaviour and fraud, perverse incentives are created, as reflected in unnecessary diagnostics, procedures and surgeries.

RAS was a bold initiative to address the problem of impoverishment that has been partially addressed. Contrary to Tamil Nadu, which witnessed a 10 per cent shift in institutional deliveries from private to public sector, the increase in Andhra Pradesh is in the private sector, resulting in huge borrowings. Access to social determinants and the substantial load of preventable diseases like diarrhoea, TB, sexually transmitted diseases and HIV, are bouncing back due to policy neglect and mismanagement and continue to be issues requiring attention.

Policy corrections

The Andhra Pradesh story shows that lessons need to be learnt in order to reboot health policy along a more sustainable path. Scaling-up the NRHM’s efforts to revive the primary health-care system; incentivising lifestyle changes; universalising access to social determinants; revamping and embedding the primary care system within the community; increasing investments in public sector hospitals, along with improving incentive structures, employing requisite staff and upgrading infrastructure would be far cheaper and more sustainable than buying care from private hospitals for services that are available in the public hospitals at a third of the price. Private care must supplement, not substitute public care. Finally, in order to ensure patient well-being and value for money, standard treatment protocols and guidelines need to be developed; costing of procedures undertaken, monitoring systems for quality such as rates of survival, hospital acquired infections and readmissions developed and regulations enforced alongside establishment of grievance redress systems, with fair compensation and penalties against malpractice.

A systemic reform of the health sector in order to achieve the three principal objectives of equity, efficiency and quality is long overdue. This will require skilful political management and stakeholder negotiations. Governments at the national and State levels need to give up rhetoric and knee-jerk responses as substitutes for real action. Instead, they need to make interventions intelligently, decisively and strategically to ensure that solving one problem does not give rise to another. They also need to stay focussed on doing the simple things right in the first instance so that disparities reduce and the poor reap the benefits in real terms.

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Farming in a fragmented landscape

Average size of landholding has shrunk to 0.80 hectares during 2010-11

Land available for farming in Tamil Nadu is going down year by year. There seems no end to fragmentation.

According to the latest report of the Department of Evaluation and Applied Research (DEAR) on the State’s economic appraisal for the period from 2011-12 to 2013-14, the average size of landholding has shrunk from 1.45 hectares during 1970-71 to 0.80 hectares during 2010-11.

The report, quoting the last Agricultural Census (2010-11), says the average size of landholding in the State is even lower than the national average, which is 1.16 hectares.

The report states that a combination of factors, such as increasing industrialisation, growing urbanisation and real estate and infrastructure development, has diverted farmland to non-farm use, reducing the area under cultivation.

Marginal and small farmers owning up to two hectares account for 92 per cent of the total number of landholdings. The medium (2-10 hectares) and big (over 10 hectares) farmers possess 8 per cent.

As for area, the share of small and marginal farmers is 61 per cent, whereas the medium and big farmers own 39 per cent. While a marginal farmer holds, on an average, 0.37 hectare, a big farmer owns 20.59 hectares.

The silver lining is that there has been no corresponding fall in grain production. The technological advances and better water management have helped the farmers achieve a fairly reasonable rate of yield: around three tonnes per hectare.

The production was 101.5 lakh tonnes during 2011-12 and 110.65 lakh tonnes during 2013-14. “There is still scope for improvement,” an official says.

In the past 40 years, the share of agriculture in the Gross State Domestic Product (GSDP) has dropped drastically, from 34.79 per cent to 8.81 per cent. Yet, the farm sector remains the biggest employer, accounting for 45 per cent of employment.

The secondary and tertiary sectors, which now contribute 30.5 and 60.6 per cent to the GSDP, employ 27 per cent of the workforce each.

The report has recommended that the marginal and small farmers be motivated to form farmers’ groups so that they get all technical inputs in time and to ensure judicious use of scarce resources.

Device-led distraction

Do not let your mobile phones, tablets or laptops take control of your life.

In the past few weeks, I’ve come across more than one article discussing the presence of mobile devices in the classroom. Some teachers have very clear rules about switching off mobile phones in the classroom, and some do not allow devices of any kind to be used when a lecture is in progress. But there are also quite a few teachers who have a more open attitude to device use in class, as long as it is not disruptive to the group as a whole.

The disturbance

Clay Shirky, who teaches the theory and practice of social media at New York University, talks about how he recently decided to impose a complete ban on laptops and other devices in his classroom. He found that the level of distraction from the use of laptops, tablets and mobile phones was becoming difficult to control. He notes that the quality of engagement and conversation in the class become much higher once the phones and tablets were put away. It was, in his words, “as if someone had let fresh air into the room.” He further describes the challenges faced by the teacher who is competing against an entire machinery — hardware and software — that is “designed to distract” because “attention is the substance that makes the whole consumer Internet go”.

Losing concentration

The distraction-by-device factor may be somewhat possible to control inside a classroom, where the teacher’s orders rule, but what about other places — in our hostel rooms, at our study tables and in discussion groups at the canteen? How do we draw ourselves away from those flickering screens, the beeping mobiles, the pings on our tablets and the status updates on open Facebook and Instagram feeds? Most of us keep our browsers open while we are working on documents or reading a soft copy of a document. We open the laptop in complete earnestness, planning to finish an assignment, and before we know it, we’ve allowed our fingers to click here and there, scrolling down a dozen screens in pursuit of a momentary interest and a whole hour has just vanished! (Confession: I found myself going off to check various open windows no less than five times between the start and end of this paragraph!)

It takes a lot of discipline to put our devices away when we are by ourselves — or even when we are with others. And then, it takes even more discipline to stay on one screen when we’re immersed in our computers. It may begin with a valid reason — that you need to check something periodically for your assignment. But then it turns into a search without purpose, where you flit from site to site for no reason other than idle curiosity.

The lurking danger

The most dangerous aspect of all this is that we do not even realise we are being distracted. When there is noise or physical discomfort, we find ways to deal with it so that we can continue our work. But when the distraction comes from inside our heads, it’s much, much harder to control. It takes us a while to even recognise it as distraction, as taking us away from something. Sometimes, it seems as if being distracted has become the normal state. It’s common to find people checking their messages or answering their phones right in the middle of a conversation. When we are working on our computers too, we routinely “multitask” across several open windows.

By focusing on several different things at the same time, we fail to give our full attention — and, therefore, our best — to the main task at hand. While multitasking may be useful and even necessary at times, it is not something that is desirable when we are doing a task that requires concentration. Reading class notes, listening to a lecture, writing a paper, taking part in discussions that lead us to understand challenging concepts — these are activities that demand our full attention and intellectual engagement.

Finding focus

Distraction is hard enough to fight even without our electronic devices. All of us know how difficult it is to keep our minds on something that we are not very interested in, or that we are forced to do (like listening to lectures!). But maybe this natural inclination to let our minds wander is being fuelled by the presence of these digital devices that pull our attention away from the here and now? This is a distraction we can work to fight, if we become conscious of it. Once we are aware of it, we need to ask ourselves some simple questions: What is it that we need to be focusing on right now? Why do we need to check our messages every few minutes? What will we really gain by staying online during the time we are working on something?

The answers to these questions are (usually) surprisingly simple.

I’d suggest that even if you have a teacher who does not ban laptops, tablets and phones from class, you do it yourself. And when you’re alone, working on that assignment that refuses to get done, try finishing your reading, gathering your notes together, and then consciously shutting down all windows but one — the one you actually need to be working on!

Childhood, peace and development

The Nobel Peace prize for 2014 has been awarded to two South Asian activists in the field of child rights, Malala Yousafzai and Kailash Satyarthi. The first is a thoughtful and fearless teenager who, despite deadly opposition, lit a path to learning and liberation for girls in Pakistan. The second is a 60-year old campaigner from India who has worked to liberate children from the shackles of compulsory labour and bondage. In choosing them, the Nobel Committee may appear to have chosen unusually. Malala is, at 17, the youngest Nobel Peace Prize winner ever, and Mr. Satyarthi a relatively unknown name outside the region and his field of work. However, the Committee’s choice has been hailed as both bold and necessary. It has sought to underscore a crucial but widely disregarded prerequisite for development and peace in our times, namely, the responsibility of nations to provide the means of formal education, leisure, safety, and care for all children. As this year’s citation says, “It is a prerequisite for peaceful global development that the rights of children and young people be respected. In conflict-ridden areas in particular, the violation of children leads to the continuation of violence from generation to generation.” Growing up in the Swat Valley of Pakistan under the brute rule of religious bigots opposed to education for girls, Malala grasped the link between school education — and particularly education for girls — and larger social change early in life. How an outspoken child fought a public campaign for the right to education, surviving even an attempt on her life, is well known. She continues to lead the battle for girls’ education from her current location in Birmingham in the United Kingdom.

Mr. Satyarthi, a founder of Bachpan Bachao Andolan (Save Childhood Campaign), has led the rescue of over 78,500 children from bondage. He gave shape to the Global March Against Child Labour, a coalition of national campaign groups. He too sees education as the key instrument for the liberation of children from poverty, exploitation and neglect. In his pioneering work on child labour and school education in India, the late political scientist Myron Weiner wrote: “Modern states regard education as a legal duty, not merely a right: parents are required to send their children to school, children are required to attend school, and the state is obliged to enforce compulsory education ... This is not the view held in India. Primary education is not compulsory, nor is child labour illegal.” The Nobel Peace Prize this year recognises the crucial links among child rights, labour, and school education and, in doing so, recognises one of the most fundamental prerequisites of a better tomorrow for millions of children everywhere.

Six labour schemes launched in 'Make in India'

After inviting domestic and foreign firms to make in India, Prime Minister Narendra Modi is set to unveil half a dozen schemes on October 16 that would bring much needed relief to manufacturers from the country’s cumbersome labour laws as well as provide skilled manpower to these factories.
The labour ministry is organising an event titled ‘Shrameva Jayate’ to launch six of its revamped schemes including the universal account number (UAN) for subscribers of the EPFO, on-line compliance system for labour laws, a new labour inspection system, revamped Industrial Training Institutes(ITIs), apprenticeship scheme and health insurance plan for unorganised sector workers.
“The event planned for October 16 is aimed to address the requirements of all — employers as well as workers from the cumbersome labour laws. While we have been working on these schemes for long, they will be formally launched next week,” said a senior labour ministry official.
The event has been titled keeping in mind the Prime Minister’s emphasis on providing empowerment and dignity of labour, said the official, adding that it will be part of the birth celebrations of Pandit Deendayal Upadhyaya.
For employers, the event will unveil a unified web portal to simplify compliance of labour laws where employers can submit a single common return on compliance of 16 Central labour laws. “State labour ministers will also be present at the event and will be invited to provide similar facilities so that all compliance returns can be submitted online providing ease of business,” said the official.
The Prime Minister will also launch a new inspection system that will herald the end of the inspector raj in labour laws, benefitting over 13 lakh units that currently have to file compliance returns and undergo inspections.
Four agencies including the EPFO, the Employees’ State Insurance Corporation, office of the Chief Labour Commissioner and Director General of Mines Safety will be brought under the new system where in compliance reports filed on the web portal by employers would be analysed by a proposed Central Analysis and Intelligence Unit that would pick up establishments for inspection.
“Each inspector will have to submit his report online within three days, making the process transparent and accountable,” said the official, pointing out that at present 18,000 inspectors are deployed and carry out an annual 2 lakh inspections. “The new facilities of online returns and inspections will make our work also more focused,” he said.
Meanwhile, the labour ministry also plans to showcase its revamped ITIs with up-to-date courses, for which it is keen to coordinate with companies for not only placement of students but also setting up such institutes and tailoring training courses to their needs. “Brand ambassadors for the ITIs will be unveiled and some of the students also felicitated,” said a second official.
With the passage of the amendments to the Apprenticeship Act in the Lok Sabha, the Prime Minister will also inaugurate a new scheme for apprentices that will provide training in trades apart from manufacturing. Further, to make the scheme more attractive, stipends will have to meet the minimum wages in each state. The government will compensate employers by chipping in 50 per cent of the stipend amount, the official said.
For workers, the labour ministry will launch the UAN for members of the EPFO will mean that workers will have permanent account numbers despite changing jobs.
It will also announce a revamped Rashtriya Swasthya Bima Yojana with centralised issuance of smart cards, third party audits and a call centre. “These will make the scheme, which has over 3 crore members from the unorganised sector, more transparent,” said another official.
In the second stage, the scheme will be merged with the Indira Gandhi National Old Age Pension Scheme to provide comprehensive health insurance to unorganised sector workers.

Politics 4.0

History teaches us that minorities can sustain unjust equilibriums for many years. But it also teaches us that discrete events create fertile mental possibilities that combine with one big event and change history. I’d like to make the case that the prosecution of former Tamil Nadu Chief Minister J. Jayalalithaa in a disproportionate assets case makes 2014, like 1919, a year that marks the end of a joint venture between a political minorities and their chosen constituencies. In 1919, 62 years after the British empire officially began, Indian life expectancy was 27 years and only 11 per cent of men and 1.1 per cent of women could read. This empire was a joint venture with narcissist maharajas; Rajendra Singh of Patiala told a viceroy’s representative that “he worked hard spending an hour and a half every day on state business and at the end of it he was exhausted”. An extract from Bikaner’s annual budget from that period symbolises royal priorities — prince’s wedding, Rs 8.25 lakh, palace repairs, Rs 4.26 lakh, royal family, Rs 2.24 lakh, public works Rs 0.30 lakh and sanitation Rs 0.05 lakh. The turning point for our freedom struggle was Jallianwala Bagh in 1919. But the run-up was important: Gandhiji returned to India in 1915, the rift between reformists and extremists from the 1906 Surat Congress session healed in 1916, and the Bolsheviks got rid of the tsar in 1917. Historians suggest that Jallianwala Bagh happened because Indian soldiers returning from the First World War, having fought with and killed white people, asked deep questions about racial superiority that made independence mentally possible. Similarly, Jayalalithaa’s prosecution combines with recent events to make a new politics possible.

The prosecution of a sitting chief minister in a disproportionate assets case is a decision with long shadows. Accountability for corruption at high levels has been difficult because there are often no fingerprints on the murder weapon. This is not a uniquely Indian problem; even American gangster Al Capone could finally only be convicted for income tax fraud. Lately, Indian politicians have dropped the narrative of frugality and left footprints in their assets and lifestyle that are difficult to erase. Many families in Punjab, Jammu and Kashmir, Uttar Pradesh, Jharkhand, Maharashtra, Sikkim, Telangana and other states must be worried. Over the last two decades, politics has been the Indian business with the highest EBITDA (earnings before interest, taxes, depreciation and amortisation) margins and returns on invested capital. It is silly when a former Bangalore ward corporator with no previous job and a low salary declares he has more assets than Nancy Pelosi, who received a substantial salary as former head of the US Democratic Party.

Hopefully, this conviction will also make frugality fashionable in publicagain. It is a myth that political dynasties are sustained because of brand; the primary weapon for most sexually transmitted political positions is treasure. Finding money to fight elections without corruption is complicated but not impossible, and if we dry the swamp, we make it feasible to fight elections on keeping promises. Simplifying things substantially, we have had three phases in Indian politics. Politics 1.0 was the Independence struggle, which created a mass movement along with vibrant inner-party democracy for the Congress. Politics 2.0 began in 1947 and lasted till Indira Gandhi became PM; the idealism of an independent nation glowed brightly, politicians led frugal lives and political legitimacy came from building institutions. Politics 3.0 started in 1968; inner-party democracy vanished in the Congress party, the politics of poverty meant populism, corruption was necessary to sustain your political machinery, frugality became old-fashioned, so ostentatious weddings, houses and cars became common. A series of recent events — the Aam Aadmi Party, corruption investigations in telecom and coal, a massive divergence between real and nominal wages, and agriculture employing 50 per cent of workers but only generating 15 per cent of the GDP — created the churn that crystallised in a 2014 national election that was not won on populism. Combine that outcome with the prosecution of a sitting chief minister for disproportionate assets and the contours of politics 4.0 start emerging; a politics anchored in execution and keeping promises. The 2014 election was lost on positioning the state as the solution to poverty and won on the promise of keeping promises. The results were magnificently described by a British columnist as “the day the British finally left India”. Even the populist Rajasthan state government lost the assembly elections badly. Populism matters but only works if it seems sustainable. As the quip goes, you campaign in poetry but govern in prose. Populism is about governing in poetry and it isn’t working well because voters now understand that free power means no power. Central government priorities are emerging: Make in India, Skill India, Digital India, and Clean India. And the state government in Rajasthan has initiated labour law and school reform, and is building roads. Policy outcomes in the past have been patchy on the ground because governments are organised vertically but these problems are horizontal. This government’s fewer goals, clearer strategies and stronger leadership show promise. Of course, populism, corruption as a source of campaign finance and religious manipulation will not go away as political strategies in the next few elections. But I believe serious religious trouble will be avoided because this government knows that its biggest vulnerability, and its best bet, is most Indian Muslims agreeing with what Naseeruddin Shah says in his wonderful recent biography, And then One Day: “My father did not move to Pakistan because he was not a gambler. As it happened, he was not wrong in his assessment of our future chances in India”. Politicians sabotaging corruption prosecutions and offering populism not only sound like the maharaja of Patiala opposing1929 Congress resolution for Purna Swaraj, but will also be left behind by politicians focusing on execution. Like 1919, 2014 is turning out to be a great year for Indian democracy. - 

World Bank Launches Global Infrastructure Facility (GIF)

The World Bank (WB) has launched the GIF to specifically cater to the infrastructure needs of the emerging economies and developing countries. The GIF will channel money towards bankable infrastructure project in such countries. GIF also places importance on sustainable development. Its key focus will be on climate friendly infrastructureinvestments and projects that will boost trade.

The GIF will collaborate with other international and multilateral agencies which provide loans and financial assistance to countries across the globe. It will also help these agencies with its expertise in financing, supervising and implementing projects. Another areas where GIF could provide assistance it ensuring that all regulatory, environmental and social safeguards are met with while investing in large scale infrastructure projects. GIF will also work with private entities like asset management companies, private equity firms, pensions and insurance funds and commercial banks to tap into multiple sources of funding.