Stepping out of the shadow

It is rare that a single bilateral invitation conveys as much as Prime Minister Modi’s invitation to U.S. President Obama to be the chief guest at the Republic Day parade does. To begin with, the invitation corrects an anomaly, that has meant that America is the only world power never to have had a dignitary grace the occasion that Russian and Soviet leaders, as well as leaders of France, the U.K., Japan and China have, over 64 years. Secondly, the invitation signals that the India-U.S. relationship is now stepping out of the shadows on all aspects of bilateral relations: economic, political and military. In the past 23 years since India opened up its economy, trade with the U.S. has grown by 1000 per cent, and according to figures given by the Defence Minister in Parliament this August, the U.S. is now India’s biggest defence supplier. Add to this the deep people-to-people ties, built mainly by the more than three million Indian-Americans in the U.S., and thousands of students who graduate from American universities, and the visit will be what one diplomat described as an “open and honest acknowledgement of the relationship’s reality”.

Thirdly, the invitation, and its acceptance by the White House, signifies a much larger move on the world stage, a “coming out” of India and the U.S. with the ties they now share. For the past few months, Mr. Modi’s travels and public speeches have indicated a primacy to the United States that previous governments had stopped shy of giving. Some of the hesitation was owed to an unspoken suspicion of the U.S. felt in India’s establishment. It was this feeling of mistrust that guided much of the criticism of Mr. Manmohan Singh’s tenure during negotiations over the India-U.S. civilian nuclear deal, and spills over into issues of WTO and agricultural subsidies, as well as intellectual property rights. The concerns are also influenced by historical relations: the U.S.’s support to Pakistan during the Bangladesh war, its support of the Mujahideen and then the Taliban to defeat the Soviet Union in the Afghanistan war, and its refusal to take a position during the Kargil war. It would seem both levels of concerns are now in the past, and put aside by the Modi government as it embarks on a new course of relations with the U.S., including engagements with its strategic allies in the region, Japan and Australia. It may be in reaction to these developments that two other significant moves have been seen in India’s neighbourhood — the recent reachout by China to Sri Lanka, the Maldives and Afghanistan, and by Russia to Pakistan with a new defence cooperation agreement. Even as India now prepares to celebrate its shared values with the U.S., the larger meaning of President Obama’s forthcoming visit has clearly not gone unnoticed.

Diagnosis in ‘Digital India’

he diagnosis of the first patient with Ebola in the U.S. was initially missed in an emergency room late night on September 25. Thomas Duncan, a Liberian national visiting Dallas, Texas, complained of flu-like symptoms and fever, but after lab work and CT scans, was given antibiotics and discharged with presumed sinusitis. The opportunity to diagnose Ebola correctly was missed. But there are several lessons to be learnt, many of which are relevant for ‘Digital India’.

Duncan informed a nurse about his travel history from West Africa. She documented this in the electronic health record (EHR). However, this did not set alarm bells ringing despite Ebola awareness preparation preceding this event. And then the hospital fumbled on its explanation, first blaming the nurse saying she did not tell the doctors about the travel history and then blaming a glitch in the EHR saying that because the nurse’s workflow (where the travel history was recorded) was not aligned with the doctor’s workflow, the doctor did not have access to the nurse’s notes. The next day it backtracked saying the EHR system worked just fine. At a U.S. Congressional hearing three weeks later, the hospital finally admitted misdiagnosis. This was from a hospital that was personally chosen by none less than former U.S. President George Bush for a cardiac stent procedure last year.

Missing critical information

Digitisation is aimed at improving health care delivery, quality and safety, and also facilitating the measurement of quality and safety metrics. While there was no computer glitch, the timeline released by the hospital suggested that the doctor spent more time with the computer than with the patient. Doctors in the U.S. now routinely use templates and pick-lists to help them navigate the complexities of medical documentation, billing and quality reporting requirements. But complex human-computer interactions in busy and chaotic clinical settings can also lead doctors to miss critical information. Humans become more reliant on technology and less likely to communicate face-to-face. In this case, the nurse ideally should have let the doctor know verbally about the travel history. Large amounts of data in the EHR can lead one to miss critical “signal” information versus the “noise.” We do know that basic clinical interactions with patients often suffer when attention is diverted to the computer so much.

This case is a perfect prototype for one of the biggest vulnerabilities of medicine — misdiagnosis. In the U.S. alone, 1 in 20 adults are estimated to be misdiagnosed annually in outpatient settings. The numbers are likely to be higher in India. Errors in diagnosis of several common diseases have been well described. Many of these diseases are common in India, including infections, cancers and cardiovascular conditions. Both problems in clinical judgment such as failing to gather or synthesise history, a physical exam or test data appropriately, as well as healthcare system flaws such as a lack of record or data availability, problems with communication or coordinating care, and insufficient access to specialists, can all contribute to misdiagnosis.

Reducing misdiagnosis in the future ‘Digital India’ will remain a challenge without a national body or movement to coordinate patient safety initiatives related to misdiagnosis and strengthening the overall health system. Amid antiquated manual record-keeping systems, there is limited access to diagnostic testing resources and a severe paucity of qualified primary-care providers and specialists. Layering technology on top of these problems won’t produce better patient outcomes unless we address the underlying fundamental problems related to workflow and processes.

Indian medical training traditionally lays greater emphasis on basic clinical examination and history-taking skills, but this might change with digitisation. To maintain physician skill levels, we must use technology to create a learning system where we learn from our mistakes. For example, a general lack of insight into their own diagnosis errors and overconfidence is common among physicians. Currently, there is an absence of effective feedback mechanisms on diagnosis-related performance from hospitals, colleagues or patients. We don’t have a culture of transparency and learning to reduce misdiagnosis, an area in which even U.S. hospitals lag behind. Technology can make things more transparent as long we are prepared to handle this transparency.

The path forward

So what else is needed in the path forward to reduce misdiagnosis in ‘Digital India’? As measurement is the first step to improvement, we must raise awareness of this problem and support health systems research to measure and understand misdiagnosis. We could leverage technology to enable better measurement if we build a culture of transparency and learning. This groundwork could help develop effective strategies to address doctors’ thinking and behaviours as well as address health system flaws, some of which we already know. We could prioritise high-risk areas that can be improved with relatively minor investments, including strengthening primary and emergency care systems. We will need a lot more than 4.1 per cent of GDP to be spent on health care to do that.

The vision of ‘Digital India’ by the current government is inspiring but in a resource-starved setting, setting up a robust and reliable health information technology can be challenging. Policy agenda should first focus on developing and implementing safe and reliable information technology that works all the time. Second, India must develop the workforce and clinical practices required to use this technology correctly and completely. Other countries offer several examples of successes and failures in health IT; we must learn from them rather than reinvent the wheel. Finally, India must leverage technology to improve safety of the health-care system, rather than allowing it to become a distraction, as it happened in Dallas. Multi-disciplinary teamwork is needed with health-care professionals foregoing turf battles and agreeing to work along with experts from policy, IT and patient safety. With a new government working on a new national health policy and a health innovation fund, it must recognise the role low-cost health IT innovations could play in improving diagnostic accuracy, including many that would be useful for rural India.

Misdiagnosis is likely to be one of the bigger health-care safety challenges facing India and solutions are not simple or obvious. While resource-rich nations are still evaluating how to reduce misdiagnosis, we need to start the conversation here and prepare doctors and the health-care policymakers of tomorrow. As we have learnt, even a single misdiagnosis — such as the one in Dallas — can have widespread public health consequences.

GST may subsume all entry taxes

In a move that is likely to draw opposition from some states, the Centre is going to propose subsuming in the proposed goods & services tax (GST) all types of entry tax, including the one for local bodies, when it tables the Constitution Amendment Bill in Parliament. The Bill also seeks to subsume petroleum products in GST but keep alcohol out of it.

The Constitution Amendment Bill tabled in the 15th Lok Sabha by the United Progressive Alliance government had proposed to subsume in GST only the general entry tax - those on import of goods in a state - while keeping entry tax in lieu of octroi (Etiloo, levied by municipal bodies on goods entering a local area) outside its purview.

States had argued, after introduction of GST, they should be empowered to collect entry tax for distribution to local bodies, instead of local bodies collecting those, to avoid harassment of traders at check posts. At present, Etiloo is collected by the state administration in most states and devolved to local bodies. In the case of Maharashtra, though, it is levied by local bodies. The Centre has decided to completely do away with the tax, regardless of whether it is levied by the state concerned or a local body.

"Any kind of entry tax will restrict free flow of goods and services and defeat the purpose of making India a common market. It is a cause for protracted litigation," said a finance ministry official asking not to be identified.

At about Rs 50,000 crore, entry taxes account for 14 per cent of states' total tax collection of about Rs 3,50,000 crore. According to experts, most entry taxes are in the nature if Etiloo and account for the bulk of this revenue.

 

 

 

The rate of entry tax varies from state to state. West Bengal, for example, levies a flat rate of one per cent but the tax paid does not qualify for a set-off against value-added tax. Bihar levies it on 35 goods at rates between two per cent and 16 per cent; petroleum products and alcohol at the highest rates. Uttar Pradesh follows a similar pattern. The rate in Madhya Pradesh is five-six per cent on most items. Select goods are taxed at only one per cent and, in such cases, a set-off is not allowed. The average rate in Maharashtra is five per cent.

If Etiloo is subsumed in GST, Maharashtra will incur the biggest loss, of over Rs 16,000 crore. The state had opposed the proposed move, which was supported by West Bengal, Odisha, Tamil Nadu, Kerala, and Uttar Pradesh. However, with the Bharatiya Janata Party part of the state government now, there might not be much resistance from Maharashtra.

According to sources in state governments, Karnataka, which might lose about Rs 8,000 crore if Etiloo is not retained, has supported the proposal. So have Gujarat and Bihar, because if Etiloo is kept outside the ambit of GST, it would not be possible for taxpayers to claim the credit for payment of entry tax in their returns.

"We are in favour of doing away with the entry tax. It puts a huge compliance burden on taxpayers and increases administrative costs for the state machinery," said a state government official who did not wish to be named.

The flip side of removing entry tax is that the compensation to be paid to states for any possible losses on account of switching to GST will increase; or, the revenue-neutral rate (RNR) that has already been estimated to be very high (at 27 per cent) by a sub-committee of Centre and state government officials, will further go up.

"If all entry taxes, including those levied by states in lieu of octroi, are included in GST, it will be difficult to give a uniform benefit across states. The RNR calculation will be difficult," said EY tax partner Bipin Sapra.

Article 301 of the Constitution precludes states from taxing inter-state transactions. This is meant to prevent barriers to inter-state trade. Article 304 allows a state to impose tax on goods imported from other states in line with the tax imposed on similar goods produced in that state, to avoid any discrimination between the two.

"The continuation of entry tax outside GST would perpetuate such complexities and litigation and impose barriers to trade," industry body CII had told Parliament's standing committee on finance.

Before taking the Bill to Parliament, the Centre is likely to discuss the draft Constitution Amendment Bill with the empowered committee of state finance ministers, at their meeting, likely in the first week of December.

While the Centre will also seek to subsume petroleum products in GST, it has agreed to keep alcohol, another major revenue for states, constitutionally out of GST.

"At a meeting with the 14th Finance Commission in July, the empowered committee had conveyed that most issues had been settled, except entry tax, compensation, petroleum and tax on inter-state movement of goods," added the state government official.

The Centre is not willing to concede on states' demand to provide for GST compensation in the Constitution, but it is working on a legal mechanism to address their concerns. The 14th Finance Commission will suggest the compensation mechanism for states in its report, likely to be given to the government next month.

"If they ensure compensation through a legal mechanism, we will support the Bill. But the Centre's suggestion to keep petroleum products under GST and make it zero-rated might not work," the official said.

Once a broad understanding is reached with states, the finance ministry will table the Bill in the Lok Sabha before the end of the winter session on December 23. The government is trying to meet the April 2016 deadline for introduction of GST.

Merit-based civil service will boost growth’

Investment bank Goldman Sachs has estimated that civil service reforms that include a bureaucracy that is merit-based rather than seniority-based, could add nearly a percentage point annually to India’s per capita growth, which stood at 3.4 per cent last year.

The report reiterates recommendations from the Administrative Reforms Commission (ARC) such as reduction in the age for entry and the number of attempts allowed for civil service aspirants, and encouraging lateral entry of technocrats from the private sector. “We estimate that if India were to pursue civil service reforms and reach the Asian average on government effectiveness, it could add 0.9 percentage points annually to per capita GDP... Institutional quality is a crucial driver of economic performance.”

It will take India a decade to reach the Asian average on government effectiveness, it estimates.

To achieve this, the report said: “As previous reform commissions have argued, the structure of the civil service, which is largely unchanged since Independence, might benefit from a greater focus on merit rather than seniority for promotions and incentives for good performance.”

The report suggests two reviews – after the seventh year and the 15th year of service – to determine if the civil servant should continue in service following the second evaluation.

It will take India a decade to reach Asian average on govt. effectiveness: Goldman Sachs report

Saarc without a backbone

Despite his commitment to greater regional cooperation, Prime Minister Narendra Modi will have his work cut out for him at the Saarc summit in Kathmandu. Saarc declarations have made considerable progress on a range of issues, from trade and connectivity to ecology. But these declarations only serve to highlight that Saarc has near zero credibility. Can Modi convert a traditionally bureaucratic exercise, at the margins of our political imagination, into an ambitious political gambit with more meaningful outcomes?

There is some hope. The normative discourse on greater connectivity in the region has shifted. There are many projects already on the ground, ranging from grid connectivity with Bangladesh to power agreements with Nepal. These are very modest beginnings. Only in a culture that sets the bar as low as South Asia can these be regarded as progress. They are a far cry from the need to think of South Asia as shared ecological space, a connected energy market, a free-trade area, a zone of freer movement of people, a unified transport area, and more ambitiously, a zone of free, self-confident democracies. Contrary to our traditional fears, greater regional cooperation strengthens individual nations in Saarc rather than weakening them.

Saarc was always hostage to the India-Pakistan relationship: India always feared it being used as a forum for bilateral one-upmanship by our neighbours. This fear has diminished considerably. That is because some of India’s bilaterals have improved, making it harder for all countries to gang up, as it were. There is also the view that regional cooperation can proceed at a different pace with different countries. And finally, at this point, the momentum of India-Pakistan relations has very little to do with India’s actions. Pakistan needs to sort out what kind of national and regional player it wants to become: Indian conduct is, both for the Pakistani military and its Western supporters, largely an alibi for not facing up to its internal problems. Its human costs are high. But the only thing India can do is signal powerfully that there is a new regional imagination taking shape. This imagination has a lot of potential, and Pakistan can join the party if it wants to. The Pakistan factor is more reason to strengthen Saarc, not weaken it.

But there are serious obstacles. Regional institutions seldom overcome the pathologies of the bureaucracies of individual states. The importance of the credibility gap cannot be overestimated. Saarc would initiate a healthy precedent if, instead of making a lot of new pronouncements for the future, it began with an honest report card on how much delivery has fallen short of declarations. You can judge how serious an organisation is not by the scale of its promises, but whether it has an effective monitoring mechanism for implementation. The already agreed to Saarc roadmap for a transition from the Safta to a customs union would warm anyone’s heart; the pace of implementation would drive anyone to despair. Even projects that have got off the ground, like the Saarc University, invite more scepticism than admiration. And Saarc institutions are pathetic both in capacity and in prestige.

India has to shoulder some of the blame. It is a tall order to expect India to do well in the region what it does only in fits and starts at home: build top-class infrastructure. But whether we like it or not, infrastructure is the most potent tool of security, connectivity and diplomacy. India is not even off the starting block on this. We have rejected many infrastructure projects offered to us. Our execution does not command respect. It is also an open question whether the scale of financially viable projects is enough to add up to an infrastructure revolution in the region that has real political bite. But infrastructure is the backbone of regional cooperation. Right now, Saarc is a project without a backbone. The truth is that unless India shows exemplary execution capabilities in this area, the esteem it commands will be limited. And much of our neighbours’ interest in us will depend on how well our economy does in the next decade.

Politicians in the region tend to be risk averse. In private, their normative and intellectual commitments are all for greater cooperation. In public, they face three obstacles. In some of the smaller countries, they fear being outflanked by their rivals, who are all too ready to use an anti-India card. Our neighbours are not alarmed by trade deficits with China, but the slightest spectre of a trade deficit with India is a political issue. These fears are exaggerated. But they have palpable effects.

Much of the discourse of regional cooperation is couched in very abstract terms and speaks of aggregate benefits to the countries involved. But aggregate benefits are seldom strong enough to override the opposition of entrenched interest groups which fear immediate distributive consequences. Moreover, the local communities where projects are going to be sited are often given little stake in them. Quite the contrary: they often fear that they will be used merely as way stations to seemingly lofty goals, without benefits flowing to them. None of these are insurmountable obstacles. But the form of local political advocacy needed to get projects off the ground still does not exist to a sufficient degree.

Finally, the domestic political cycles for many of our neighbours have to be taken into account. Nepal still has a political stalemate of sorts. Bangladesh is doing well, but the window of opportunity before the legitimacy crisis for the current government enlarges is small. Sri Lanka now has a cussedness about regional cooperation, largely buttressed by the view that China can sustain it. And it is unclear what compromises the new government in Afghanistan will make and what this entails for India. But the lesson is this: whenever there is a small window of opportunity, it is important to make maximum use of it, to deliver and execute projects that can endure the surface movements of politics. For example, coming good on all our commitments to Bangladesh is of such vital importance because if this moment is not used, the consequences will be serious.

Modi has a political opportunity. He can put an unprecedented political imprimatur on a usually moribund summit. It is a chance to boldly sketch what a new regional imagination, one that is vibrant and meaningful yet reassuring to all our neighbours, would look like. In many ways, this project is far more consequential, even for the future of secularism in the region, than we usually recognise. But he will also have to work hard to overcome the scepticism that big dreams usually incite in South Asia.

Objects of state control

The tragedy of several women dying after undergoing sterilisation operations in the Bilaspur district of Chhattisgarh has once again thrown up uncomfortable questions around India’s population programme. Although the cases are being investigated and the exact cause of the deaths has not been ascertained, the incident brings to light the abysmal conditions in which women are compelled to accept government-provided contraception.
India is a signatory to an agreement at the International Conference on Population and Development (ICPD) in 1994 that called for a reproductive health and rights approach rather than a “population control” approach, with greater attention to male responsibility and the special needs of adolescents and youth. In keeping with the ICPD, India changed its family planning programme in 1996 to a target-free approach and emphasised the assessment of community needs for reproductive and child health services in 1997-98.

Despite these tall promises, however, in practice, India continued to punish citizens who had more than the approved number of children by denying them the right to contest elections to local bodies in some states, the right to obtain maternity benefits, scholarships and educational benefits that all children should have equal claim to. The government of India continued to promote and provide sterilisation as the preferred mode of contraception. This is a surgical procedure to be performed by qualified doctors, but doctors in the under-resourced public sector are in woefully short supply. Yet, contraceptive users are not using other methods that can be provided by nurses and even frontline workers, such as condoms, oral pills and so forth. The shortage of doctors leads to large numbers of women being operated upon within a short time in “camps” that are often organised in non-hospital settings in peripheral areas.

The sub-standard conditions under which female sterilisation was performed in camps was studied in 2002 by Healthwatch Uttar Pradesh, and a writ petition was filed in the Supreme Court (Ramakant Rai and Healthwatch UP vs Union of India). The court issued orders to the government in 2005, based on which quality standards were reviewed, quality assurance committees mandated in each district and insurance coverage set up for female sterilisation acceptors by 2006. Each woman who came for sterilisation was meant to sign a consent form read out to her if she was not literate, and informed about the insurance coverage in case of adverse effects. All sterilisation acceptors are entitled to a certificate in case they need to claim compensation.

However, the experience of poor women accepting sterilisation has not changed significantly, as evident from the Bilaspur sterilisation camps. Women continue to be the focus of all drives for small families, although terminal methods for women involve opening the abdomen, and vasectomies performed upon men would be much safer and lead to far less discomfort. The community health volunteers who provide health information have never been trained to speak on vasectomy and are unable to dispel common misconceptions around vasectomy leading to impotence or “weakness” in men. Their kit does not include a supply of condoms for younger couples wanting to delay the first pregnancy or space out their children.

These health workers can easily identify the women tired of not being in control of their reproduction and aspiring for better lives and small families. Since spacing methods are not promoted, women tend to have their pregnancies in quick succession. By the time they have had two or three children, the health department recognises their need for a contraceptive. The only method offered and therefore “preferred” is female sterilisation, euphemistically and erroneously referred to as “family planning”. It is hardly surprising that India has the dubious distinction of almost 98 per cent sterilisations performed upon women. Sterilisation targets continue to exist for female sterilisation, and sub-district health functionaries are often under pressure to meet their targets by March 31. The government of India may choose to deny this, but it is accountable for this discrepancy between policy and practice since population is a Central subject.

The records of the current disaster indicate that 83 women were herded into a camp, not in the sterile conditions of a hospital operation theatre but in an abandoned building once intended to be a private hospital. The sole qualified doctor who hurriedly performed these operations barely spent a few minutes on each woman and used only one laparoscopic instrument, which was obviously not sterilised between operations. These mass surgeries are recognised and publicly rewarded by the state government when any surgeon achieves 50,000 or 1,00,000 sterilisations.

The question is, how can the government at the state and Centre condone this gross violation of a woman’s right to safe contraception as promised 20 years ago at the ICPD? We do not hear about the responsibilities of men being addressed. It is astonishing that vasectomy is not promoted even though it is safer; neither does the state health department engage with men through male functionaries who can dispel the myths around the procedure. It is also a sad truth that the middle classes do not care about this anyway, since they do not use contraceptives offered by the government. The gender injustice of the population programme leaves them untouched.

Women from the poorer classes therefore continue to be objects of state control, a state that prefers to terminate their reproductive capacity as soon as it considers that they have produced enough future citizens, but does not look after their reproductive health before or after. There is an urgent need to build greater accountability for this violation and strengthen the public health sector, so that men and women can access year-round safe contraceptive services.

The writer is convener, National Alliance for Maternal Health and Human Rights.

Government to Start Jal Gram Scheme in Every District Says Uma Bharti

Three Day National Conference Jal Manthan on Issues for Optimal use of Water Resources Concludes

This centre will start Jal Gram (Water Village) scheme next year. Announcing this here today Union Minister for Water Resources, River Development and Ganga Rejuvenation Sushri Uma Bharti said that initially the scheme will be implemented as a pilot project. The Minister was speaking at the concluding session of the three day national conference Jal Mathan on issues for optimal use of water resources. Sushri Bharti said that the village with utmost water scarcity in every district will be indentified as Jal Gram. She said the assistance of other central Government Ministries and voluntary organizations will also be taken in the scheme. The Minister said later the scheme will be implemented in every district of the country. She said her Ministry will celebrate next as water conservation year and during this various programmes will be organized by her Ministry in every district of the country to create awareness about water conservation. Referring to the Ganga conservation programme the Minister said a lot of money was spent in the past in haste which did not give desired result. She said “We will do something solid on this which will have long lasting result.” The Minister assured the participants that her Ministry will seriously consider each and every issue raised during the conference and its suggestions. She said “After two years I will invite all of you here again and explain the steps taken by my Ministry on your suggestions.” The Minister also released a booklet about Ganga Manthan, a national dialogue on Ganga Rejuvenation which was held on 7th July this year in New Delhi. The booklet contains various suggestions and conclusions of deliberation held during the dialogue.