Can India Achieve the SDG Goal on Ensuring Health and Well-being?

Sustainable Development Goals_E_Final sizes

This article was published in The Dialogue on 30/07/2017 Original Article can be accessed at http://www.thedialogue.co/can-india-achieve-sdg-goal-ensuring-health-well/

Between July 10th-19th, country representatives from all over the globe congregated in New York for the High Level Political Forum Meeting of the Sustainable Development Goals (SDGs) to report on their respective progress towards the Goals, and renew their commitments to the same. The SDGs which were announced in 2016, have created new opportunities around development practice and policies, both in the non-profit sector as well as in policy making in India. In keeping with this commitment, India too participated in this voluntary review and presented the efforts that the government has made. A report[1]on how the Government of India has addressed specific Goals (Goal 1 – Poverty, Goal 2 – Hunger, Goal 3 – Health, Goal 5 – Gender Equality, Goal 9 – Industry, Goal 14 – Life below water and Goal 17 – Global Partnerships) was prepared by the NITI Aayog. The report ‘ Voluntary National Review (VNR) Report on the Implementation of Sustainable Development Goals’ describes the Government of India’s efforts to align its policies with the new global agenda. The VNR report states that India has made significant strides in improving various health indicators. It cites the increase in institutional deliveries, decline in Infant Mortality Rate and Under-5 Mortality Rate and improvement in vaccination coverage for children between 2005-06 and 2015-16, to substantiate these claims. It also describes other efforts such as the development of a composite index to monitor and incentivise improvements in health service delivery and ways in which information technology is being applied in the health sector.

In keeping with its commitment to the SDG agenda, the government has passed several policies and schemes in alignment with the SDG health targets, which have been detailed out in the GoI’s report.The National Health Policy 2017for example addresses several of the Goal 3 targets including communicable and non-communicable diseases, health workforce and universal health coverage. Since the commencement of the SDGs, the government has also passed legislation specifically around Mental Health (Mental Health Care Act, 2017), Disabilities (Rights of Persons with Disabilities Act 2017), HIV /AIDS (Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome Prevention and Control Bill, 2017) and maternity benefits (Maternity Benefits Amendment Act 2017). In March 2017, the Ministry of Statistics Planning and Implementation (MOSPI) also evolved national indicators for the SDGs, in accordance with the global indicators.

Despite the passage of these legislations and policies, and the claims of the government in its report, we would like to highlight some fundamental concerns related to the functioning of the health system and implementation of policies and programmes, as well as the adequacy and reliability of set indicators to monitor progress towards SDG Goal 3.

Financial commitments: Currently, health financing in India is characterised by over dependence on household out-of-pocket payments (OOPs) and consequent lack of financial protection. It is worth noting that annually 55 million people in India are pushed into poverty just to cover health expenses (2011).[2]Global experiences suggest that India’s quest for universal health coverage (UHC) cannot be realised unless public spending is expanded significantly, at least to the level of comparable developing countries. For instance, every other BRICS country government spends more than three percent of GDP on health, while India is hovering around 1.15%.[3]Unfortunately, neither global nor national SDG indicators talk about increasing public spending on health to a certain desirable level. The National Health Policy 2017envisages an increase in spending to 2.5% of the GDP by 2025, which is far too little and too delayed.Meanwhile, contrary to the stated commitment in the NHP, the Union government has been consistently cutting back on the health budget; what has been allocated for 2017-18 is even lesser than the expenditure for the year 2011-12, when adjusted for inflation.[4]

Health system strengthening: As of 2015, Rural Health Statistics (2014-15) indicate that there is still a shortfall in the required number of Sub-Centres, Primary Health Centres and Community Health Centres, despite the investments in NRHM over more than a decade. Similarly, there is a shortfall of human resources, particularly specialists in rural areas. These deficiencies have seriously hampered improvement of health outcomes. For instance, even though the proportion of childbirths occurring in health facilities has increased dramatically over the past 10 years, this has not led to expected improvements in maternal mortality because health facilities have been unable to provide quality services, particularly emergency care. Similarly, the diagnosis and treatment of communicable andnon-communicable diseases, and ensuring psychosocial health and well-being, requires well-equipped, comprehensive and appropriate care at all levels of the health system, which is grossly inadequate today. If these gaps are not addressed, a mere improvement in existing indicators will be meaningless. The National Health Policy 2017 does call for strengthening of primary care in the form of developing “health and wellness centres”, but the poor financial outlays for health seem inconsistent with this ambitious vision.

Access to essential medicines:Although India is one of the leading manufacturer of pharmaceuticals in the world, it is estimated that over 65 percent of its population does not have access to essential medicines[5]. In this scenario, the fact that the National Health Policy 2017 has reinforced the idea of free medicines and diagnostics for all in Public Health facilities, is a good development. However, this is achievable if central Government funding is available instead of this being left entirely to the states. Another positive development has been price control of essential medicines which is being done through the Drug Price Control Order 2013. However, this covers only 15% of the total domestic market of more than Rs. 1 lakh crores.[6]Meanwhile, theNITI Aayog has advocated restricting price control and delinking it from the list of essential drugs, whereas the need of the hour is to extend the coverage of price control to more essential and life-saving drugs.[7]The NITI Aayog has also recommended disinvestment of government owned pharma companies, a move that will rob the Government of a vital tool to promote affordable access to medicines.[8]

Reining in the Private Health Care Sector:India’s large and unregulated private sector continues to operate without proper strictures, but policy developments indicate an unwillingness to take effective measures in this regard. Even as the Clinical Establishments Act remains unimplemented, the National Health Policy 2017 talks of “strategic purchasing”, which indicates a push towards privatisation. The Government of India’s VNR report states “Towards achieving universal health coverage, a health insurance cover of INR 100,000 (USD 1,563) is being extended to all poor families” – even though evidence suggests that the impact on financial protection has been minimal if not detrimental. Irregularities in the private sector which are evident in publicly funded insurance schemes such as the Rasthriya SwasthyaBimaYojana show that, there is an urgent need for regulation.[9]Attainment of targets such as the elimination of communicable diseases requiresthe private sector to comply with treatment guidelines and reporting requirements.In 2012, India started the web-based reporting system –Nikshay for implementing a policy of mandatory TB notification. Yet, despite the progress made, India still needs to track one million missing cases of TB annually, especially in the private sector. With growing threats of infectious diseases, it is imperative that private providers comply with reporting requirements.

Sabka Saath, Sabka Vikas:The SDGs recognize that gross inequities exist within and between countries, and have therefore emphasized the principle of “leaving no one behind”. In a large, unequal and diverse country such as India, this takes on even greater significance. The Government of India’s VNR report too states that the slogan of “Sabka Saath, Sabka Vikas” underpins its development efforts. However, nowhere in the report are inequalities examined, or analyzed. For instance, the report cites the reduction in Infant and Under-5 Mortality Rates over the past decade but fails to mention that child mortality rates among scheduled castes and scheduled tribes are higher than other groups.[10]“Leaving no one behind” implies reaching out to neglected populations using different strategies to address their unique concerns. For instance, even though there is a rise in institutional child births (which the GoI report mentions as one of the achievements of the last decade), one in four deliveries in rural areas still occur at home, and these have been systematically neglected. Disrespectful treatment of women, especially those from marginalized communities, during childbirth has been reported from various parts of the country, but is not acknowledged as a problem.

Despite overwhelming evidence of disparities in indicators, the GoI has not published recent disaggregated data on these. In fact, three rounds of the Annual Health Survey, conducted in high-focus states with the expressed purpose of contributing to meaningful tracking of progress towards MDGs, have not published any kind of disaggregated data. The same mistake is being made with the SDGs; none of the indicators, across targets are disaggregated and this will render it impossible to track progress of marginalized communities towards the goal.

Reporting, Transparency and AccountabilityTracking progress towards the SDG targets will require a robust and reliable monitoring system, as well as a strong accountability mechanism, both of which are currently lacking. Several of the indicators proposed by MOSPI are premised on the assumption that reliable data will be available; however existing discrepancies in data belie this assumption. For instance, according to the Global Burden of Disease Study report, India had 196,000 new cases of HIV infection in 2015 whereas the report by NACO states that there were 86,000 new cases of HIV in the same year. Establishing accurate and robust data systems is only a critical first step. Ultimately, it is the manner in which the data is used to determine problems, identify risks, develop strategies, set targets, allocate resources and fix accountability that will matter. A lack of transparency and will to seriously implement such accountability measures, has been a significant barrier, as demonstrated in case of maternal health, where although monitoring and accountability mechanisms like Maternal Death Reviewsexist, they are opaque and have yet not been fully operationalized.In addition to accountability within the system, social accountability and monitoring by community actors should also be ensured.

 Conclusion

Despite the claims in Government of India’s VNR report, unless fundamental concerns around the organizing, financing and delivery of health care services are addressed, these efforts will remain as token measures. A fund starved, poorly equipped, non-transparent and unaccountable health system cannot be expected to fulfil the ambitious targets that the SDGs have set. Learning from the experience of the MDGs, it is therefore critical that these long standing concerns be addressed with urgency.

[1]https://sustainabledevelopment.un.org/content/documents/15836India.pdf

[2]http://www.thehindubusinessline.com/specials/pulse/the-bitter-bill-of-healthcare/article8824855.ece

[3] National Health System Resource Centre. (2016). National Health Accounts Estimates for India (2013-14). New Delhi: Ministry of Health and Family Welfare, Government of India.

[4]https://scroll.in/pulse/828471/in-budget-2017-arun-jaitley-gave-flailing-public-health-programmes-little-hope

[5]http://www.searo.who.int/publications/journals/seajph/issues/seajphv3n3p289.pdf?ua=1

[6]Pharmatrac, May 2017, Industry Highlights

[7]https://thewire.in/131449/niti-aayog-modi-affordable-medicines/

[8]http://www.indiainfoline.com/article/news-top-story/niti-aayog-recomends-psus-niti-aayog-recommends-12-psus-to-be-put-on-block-117032300272_1.html

[9]https://hcs.pitt.edu/ojs/index.php/hcs/article/view/61

[10]http://unicef.in/CkEditor/ck_Uploaded_Images/img_1364.pdf

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Over Population: Facts and Myths

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This article was published in The Dialogue on 16/07/2017 Original Article can be accessed at http://www.thedialogue.co/population-facts-myths/

The World Population Day is celebrated every year on the 11th of July as a result of a UN Resolution in 1990 seeking to enhance awareness of population issues, including their relations to the environment and development.

In India the World Population Day has more often than not been an occasion to highlight the ‘over-population’ in the country with a focus on the total number of people living in India and that this number is ‘too much’. This year this focus on overpopulation has been reinforced by a new group of concerned citizens called TAXAB or the Taxpayers Association of Bharat who are calling for a new population control law under the hashtag #Bharat4PopulationLaw. The overall logic of this campaign is two-fold – the first part argues that as tax-payers of India we should be concerned about the misuse of our taxes by the system towards the development of Bharat. The second part explains the nature of the misuse which manifests as lack of good roads, joblessness, increasing poverty, lack of good food, clean air etc. And this lack of good infrastructure and facilities as well as pollution is due to increasing population – primarily among the BPL. In quick strokes it creates a division between the tax-payer who is being short-changed by the poor who are growing in numbers, and secondly it attributes all the ills of the country to growing population, though it first argues that there is mismanagement by the system. The problems in the country are there for all to experience, and urban overcrowding is a phenomenon nearly all taxpayers are facing daily – so the logic is bound to be extremely attractive. However this entire argument is based on myths.

The population growth rate in India is not growing but instead has been slowing for the last few decades. From a high of 2.3 percent per year in the 1970’s and 80’s it is now down to 1.2% per year. At the level of the family the Total Fertility Rate or number of children a woman has in her life has reduced from 5 in the 1970’s to 2.2 in 2015-16. The total wanted fertility is below 2 but women do not receive the contraceptive services that they want. The population growth rate is a function of birth, death and migration. In India, the birth rates are still a little high, but not because women are having more babies but because the number of young couples in India is higher than ever before. And this large number of young couples even when they have fewer babies each, the total adds up. This will come down as the babies born in the heydays of population growth and their children become older. In other words there is not much we can do to reduce their reproductive rate other than provide them with spacing methods.

Now understand the various problems that have been attributed to population growth. India was a poor country in 1947 when India became independent, now it is no longer a poor country. By expert estimates the GDP growth between 1951 and 2011 was over 20 times and food grain output grew by over 4 times while population grew by a little over 3 times in the same period. Clearly the total amount of food or income available per head has grown but poverty seem to be all around us. The TAXAB campaign has highlighted the bad state of roads and infrastructure as a result of overpopulation, highlighting the poor state of infrastructure in cities. This overcrowding of Indian cities is not a result of overpopulation but migration from villages to cities. This migration is often as a result of rural distress, and lack of employment opportunities which is highlighted by the continuing news of farmer suicides from across the country. The TAXAB campaign also makes reference to pollution in the name of ‘shudh’ and ‘ashudh’ food, water and air. Pollution in India is undeniable, but is overpopulation the cause behind it as the #Bharat4PopulationLaw seems to imply? Pollution is most often contributed by the burning of fossil fuels, either for transportation or for factories or for generating electricity which then powers our air conditioners, or factories. We need to understand that the poor, who are a much larger proportion of the population, require very little fossil fuel generated energy. Their requirements for water too are very little. Research shows that the richer countries and the rich in countries like ours consume 20 – 30 times more energy in their whole lifetimes than the poor. Here if the population of people is to be seen as a problem, it is the fewer rich who pose much more problems for the absolute consumption of resources as well as the contribution to pollution.

The overall logic of the #Bharat4PopulationLaw campaign seems to imply that the taxpayers need to be worried because not much has happened through their taxes in the last seventy years. And this is where the campaign organisers have been completely misled. While overcrowding is a fact, it does not indicate a failure of contraceptive related practices among the people. Overall contraceptive usage rates have increased from 13% in the 1970’s to over 56% now. Infant mortality rate, or number of children who die before reaching the age of one year has reduced from over 130 per 1000 children to 41 now. Overall life expectancy has also increased from less than 40 years at the time of independence to over 64 years now. More people are living, less people are dying, fewer children are being born but more people are crowding to cities where there is inadequate infrastructure, few job opportunities and we see more poor people in our streets.

A population control law is not the solution to the problems that have been indicated by TAXAB. A population control law as we have seen in China will lead to further decline in the number of girls in the country, a problem that our society is already facing. It will lead to reducing opportunities for the poor, and marginalized, including the dalits, as such laws deny benefits to those with more children. Data shows the poor have more children, but not because they want it, but because they don’t receive the appropriate services. Women bear the disproportionate burden of population control laws, as they bear children and can be faced with repeated abortions or even desertion as men take desperate measures to keep their family size small and qualify for positions for which they can become disqualified.

Yes we need changes in policies and the way they are implemented to address the issues that TAXAB has highlighted but the approach is misplaced. . The problem lies not in the population related policies but in economic policies which have not focused adequately on health or education or economic opportunities for the poor. Yes tax-payers need to rise up and make demands from our government to increase the investment of healthcare so that not only the poor but we all are healthier and more capable, without become penurious due to healthcare costs. We need to make demands to increase the quality of standards of the government schools so that children educated there are more empowered, and we are all confident enough to send our children to these schools rather than the very expensive private schools that are coming up every day. Our family planning programme needs to be reoriented towards the needs of younger couples through increased availability of spacing methods. Men need to involved in discussions around family planning. And last but not the least we need to ensure all young people have adequate knowledge and information about their bodies, and reproductive health which enables them to take decisions that will enable them to live healthy and productive lives.

Campaign Seeks Men and Boys to be Partners of Gender Justice

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This article was published in The Dialogue on 18/04/2017 Original Article can be accessed at http://www.thedialogue.co/campaign-seeks-men-boys-partners-gender-justice/

Thousands of passengers who travelled by Delhi Metro from 27th March to 10th April witnessed banners with motivational slogans and standees depicting statement and pictures of famous activists encouraging men and boys to reflect the attitude of being masculine and understand the impact of their thought on the lives of women and girls. Students were also seen distributing brochures and mobile stickers and interacting with visitors curious to know about the campaign rolled out across ten metro stations. Interaction, banner, standees, canopies and volunteer engagement with metro travelers were all part of the collaborative effort of the Delhi Metro Rail Corporation and National Campaign EK Saath led by Forum to Engage Men, India Alliance for Gender Justice and One Billion Rising in across ten states in India to encourage men for achieving gender.

Through this collaborative initiative, the metro authorities intended to create a safe environment for women while commuting and Ek Saath desired to have a pool of men interested to change social norms rendering women into subordination. The mutual effort resulted in the form of commitment and pledge of over hundreds of men desired to be referred as advocates of equality to be more equitable for gender equality. Delhi metro as part of its commitment has been active to ensure the safety of women while commuting. This time metro authorities adopted men engage approach for making metro safer for women passengers by focusing on changing mindset of men folk in addition to setting up of cameras and imposing fine to deter men and boys from travelling in women’s coach. The idea resulted in a form of launching promotional event of Ek Saath campaign. The main objective of the campaign is to promote men and boys active partnership to change gender discriminatory social norms in the family and community. In this collaborative effort for encouraging men, of thousands of people who travelled by metro throughout period of the campaign, over two thousand men and boys showed their interest to be a part of Ek Saath campaign for changing themselves and their fellows for achieving equality and working for gender justice.

The promotional and interactive engagement gained by volunteerism thought of students of Shivaji College of Delhi University. The personal experiences of students mostly of boys already claim themselves as advocates of equality in the national capital thought of metro stations for encouraging men to challenge gender discriminatory social norms and making safe space for women. Experiences perceived after the informal interaction with metro visitors, self-motivated students realized that there is a lack of sensitization among metro visitors. They have inequitable attitudes towards women who happen to be their fellow travellers.

As perceived, men reinforce social norms discriminatory for women together boast their masculinity by sharing anecdotes of their life. India, however, has been progressing on the economic front, gender discriminatory social norms remain unchanged and women continue to have subordinate status compared to men. Because of this conversation usually happen in daily lives, the situation of boys and girls in society is very clear and simple to understand. While the son is given a better share of care and supports this creates a sense of entitlement and privilege. The life circumstance and opportunities of girls in India are different from that of boys, much of it due different social norms and expectations from boys and girls, daughters and sons, women and men. The son is taught to control his wife, take all decisions, to compete and work hard, to succeed, and to win at all costs. The messages are clear: ‘do not to cry like a girl’, ‘do not play with dolls like a sissy, take the gun’, ‘do not come into the kitchen, its women’s work’. The society creates ‘sons’ who not only have an overwhelming sense of self-importance and privilege but have been trained to be strong, tolerate pain, to be angry, to be violent. Silently and efficiently society remains engaged in reproducing patriarchy which results in the form of gender-based violence and discrimination. With a view of changing this kind of thought burgeoning in men of being masculine by way of encouraging them to reverse tasks assigned to them being men, the campaign has been very successful to reach a good number of men and boys in ten states.

This time in Delhi, campaign was launched with Delhi Metro for creating a pool of men and boys travelling in metro to be referred later as Gender Equality Advocates or Samanta Saathi as a change strategy is about men and boys advocating for and acting to advance gender equality. This strategy of change mobilises and encourages men to work together and influence their peers to question and understand gender discriminatory practices and to lead action to accelerate social change.  These men would be encouraged to experiment with shedding their gender privileges and bringing about change in their own lives and relationships and promote these among others. The strategy of identifying these men is approaching them in the community, educational institutions, workplaces or public places by conducting innovatively designed activities and events like film shows, gender equality fairs, discussions, street plays etc. Several interactions, audio and videos were recorded at the metro stations of men and boys who came forward for knowing more about the campaign and working as advocates of equality. The encouraging and motivational statement and pictures of Kamla Bhasin and Rahul Bose and K Onler Kom depicting on standees were placed at stations to encourage men to change their thoughts of masculinity and become partners for gender justice.

Challenge before the National Health Policy: Rebuilding trust between Patients and the Healthcare system

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Image Courtesy: Livemint

This article was published in The Dialogue on 29/03/2017 Original Article can be accessed at http://www.thedialogue.co/challenge-national-health-policy-rebuilding-trust-patients-healthcare-system/

In the months of February and March a couple of incidents took place in hospitals across the country that need close consideration. In Dhule, Maharashtra an Orthopaedic Surgeon Dr Rohan Mhamunkar was beaten up severely by some patients relatives for not attending their patient quickly enough. Then in Mumbai Sion Hospital a junior doctor as beaten up. This was followed by news from Aurangabad that a similar incident had happened. The news about this series of attacks on doctors led the doctors association in Maharashtra to strike calling for safe work environment. The Maharashtra Association of Resident Doctors (MARD) claimed that over 50 such cases had taken place in the last one year. The Bombay High Court did not look favorably at this strike and said that is was a matter of shame “if doctors go on strike like factory men”. It further advised that if, “they want to continue their strike then they should stay 100 feet away from hospitals”. Far away from Dhule in Kolkata anger against private hospitals for charging exorbitant fees spiraled into a patient doctor face off. Dr Suneep Banerjee an intervention cardiologist was sued for negligence by patients’ relatives when a patient on whom he had conducted angioplasty died after amputation for gangrene of the leg. Then in Chittaranjan Medical College Hospital the relatives of a patient beat up the doctors on duty when their patient died during treatment.

In Maharashtra the situation has eased somewhat, but not before doctors in other cities and states started protesting and the Government relented, agreeing to post security guards. In West Bengal, the Government has tried to resolve the public anger against hospitals by enacting the Clinical Establishment (Registration, Regulation and Transparency) Bill, 2017. This bill has further upset the doctors in the state who feel that this puts all their clinical decisions and actions under unwarranted scrutiny and many doctors feel that this will not only open a flood gate of cases against them but also incite violence.

The Medical Council mechanism is dysfunctional with the Indian Medical Council being suspended by the Supreme Court for not fulfilling functions. There are no effective regulations around clinical standards and quality of care.

These incidents draw attention to the fact that the relationship between doctors and hospitals and patients and agencies of the state is tense. Services at both public and private hospitals are being seen with suspicion and the trust that patients and society at large had with respect to doctors has been severely eroded. It is important to understand the reasons behind this severe breakdown in trust regarding one of the most hallowed institutions and professions of society.

There are four key players in this relationship – the doctors and hospitals are in one corner and the patients are on the opposite corner. Somewhere in between is the state, unsure about its role – arbiter or supporter of one side or the other. To understand this relationship one needs to go back thirty five years. The first round of liberalization gave an impetus to the private medical industry. While India’s healthcare has always been served by a large ‘private sector’, liberalization meant that the unorganized sector of small nursing homes have over time been replaced by large corporate entities. Earlier most of the well-known and ‘star’ specialists would be associated with a government medical college and at the same time have their practice. Over time the government run medical colleges lost these consultants and new consultants were no longer joining the government one’s. Side by side large number private medical colleges emerged all across the country – and admission to these was no longer by merit alone but with large ‘capitation’ fees as well. Now healthcare was no longer a public good but and industry and medical education was no longer for a social purpose but only a means to a lucrative profession.

As India’s health care industry boomed it became attractive to patients from neighbouring countries as well as those in far-off Africa and the medical tourism industry was established. At the same time the Government health care system comprising of sub-divisional hospitals, district hospitals and medical colleges creaked under an ever increasing patient load. Doctors in these hospitals often were double timing – concurrently see patients in their private chamber as well as in the government hospital. A network of associated medial service providers grey up around hospitals – laboratories, X-ray, ultrasound and CT clinics mushroomed around hospitals, providing incentives to doctors to send patients their way. It was not surprising that some prescription audit have shown that patients often had a long list of drugs and tests many of which were not completely necessary.

In the 2000s economic studies of healthcare in the country started revealing a pathetic reality. India had among the lowest public investments in health anywhere in the world. It was not surprising therefore that hospitalization was among the leading causes of impoverishment. While there has been a call for increasing public investment in health the growth of the health budget has been very slow. However healthcare contributes over 5% to the GDP. This means that most of the healthcare cost is borne by the patient. And in India this is direct payment at the point of care, because few Indian’s have health insurance and the nature of health insurance too is not comprehensive. So while the healthcare industry has grown, it has done so through rising medical bills – which go to pay the hospital, the ancillary medical services which are often part of the hospital infrastructure, and of course a new breed of doctors many of whom have been trained privately. Even doctors who have received state sponsored training rarely seek public service as medicine is increasingly seen as a high paying profession, and corporate hospitals are the only place where they can ply their expertise.

Besides high payment, another illness that plagues the Indian healthcare system is a complete lack of accountability. The Medical Council mechanism is dysfunctional with the Indian Medical Council being suspended by the Supreme Court for not fulfilling functions. There are no effective regulations around clinical standards and quality of care. The recently enacted Clinical Establishment Act has been adopted by a small handful of states and even there the rules remain to be framed. Thus a privatized, highly expensive but unregulated health care sector was a disaster waiting to happen.

While these changes have taken place in hospitals, doctors and in public policy making around healthcare, the patient profile in India has also undergone rapid changes. Exposed to the market and new information technology, they are no longer docile. They have more aspirations, but they also face the crippling cost of health care. They expect results as they pay. Patients know doctors take ‘cuts’ and are now impatient. While policy makers have been hesitant to raise the health budget, the politicians current stands against hospitals and doctors in West Bengal and Maharashtra shows their clear empathy with their electorate. They are quick to take action against the erring doctor and hospital without realizing that this is also the result of decades of policy inaction in the health sector.

It is in this reality that the National Health Policy 2017 has been announced. It has very ambitious goals. It promises assured health services for all and to raise the health budget by nearly twice in the next eight years. It promises to strengthen public hospitals and to align the growth of the private sector to public health goals. These are extremely welcome goals. However like all Indian public policies, the proof of the pudding will be in the way it is implemented. Without clearly finding ways to reduce costs of health care, strengthen regulatory and accountability mechanisms and bringing doctors back to serve the people with care and respect, it will be difficult to build trust between the health care system and the public.

 

TAP conundrum

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Image Courtesy: Mint

This article was published in The Dialogue on 24/02/2017 Original Article can be accessed at http://www.thedialogue.co/tap-conundrum/

In the first ten days of February I was in the US where I attended a few events around the theme of Transparency Accountability, Participation and Good Governance. The World Bank has been promoting anti-corruption measures among governments across the world asking them to adopt transparency and accountability as a means of promoting good governance. The Transparency and Accountability field is based on the assumption that if there is greater transparency in the governance process, corrupt practices will become difficult to sustain. According to the website of Transparency and Accountability Initiatives, one of the leading organisations working on this issue globally these measures “enable citizens to have a say about issues that matter to them and a  chance to influence decision-making and hold those making decisions to account.” Transparency and accountability together allow citizens to ask questions and seek answers from their public officials and representatives around the decisions they take. This is expected to reduce corrupt practices and increase effective and efficient governance. Globally there are a number of efforts like the Open Government Partnership, Extractive Industries Transparency Index and the Open Budget Index which are mechanisms to foster such transparency in the governance process.

While I hold that transparency are accountability are important values in governance, this neat causal chain has never convinced me. In India the Right to Information law is a very important tool for citizen’s access to public information and was obtained through a tough struggle. It is also under threat under successive political and bureaucratic regimes as they seek to dilute its provisions. Information about government schemes are now routinely ‘published’ either on boards or on websites, and each department has a ‘Public Information Officer’ or PIO who is charged with meeting the responsibilities of disclosure of information. However despite this law and provisions, not many citizens are aware of these and not many seek redress compared to the numbers distressed by official obfuscation and denial of entitlements. Personally I wonder how much corruption has been reduced by these transparency and accountability measures alone.

As a person involved in the field I have held that ‘participation’ the third alphabet in the alphabet soup is extremely important as it defines the levels of awareness and desire for accountability of citizens from the government. The Right to Information act in many ways came about through many public hearings (jansunwai) that were conducted across the country to check on leakage in Panchayat (local government) funds. Today having public hearings is part of the National Rural Employment Guarantee Act (NREGA). However holding such hearings is not common practice or happens notionally in many places places. It is only when the citizens are ‘empowered’ to ask questions through facilitating organisations do these mechanisms work. If there is ‘fear’ among citizens in asking questions from people in positions of power then no amount of laws or schemes are sufficient for the marginalized citizens to ask questions of people in positions of authority who they see as ‘benefactors’ rather than ‘representatives’.

On returning home an interesting Transparency Accountability Partnership conundrum has hit me squarely in the face. A couple of weeks ago Ms Jayalalitha, the charismatic Chief Minister of the State of Tamil Nadu died after a brief illness. The party replaced her with a senior cabinet colleague but sycophants in the party as well as the rank and file of the party desired that her close personal associate be nominated to the Chief Minister’s post. This lady is a member of the party but is not an elected member of the state parliament. Very quickly she was elected head of the party and a tussle for the Chief Ministership ensued, and the party split. In all this process a writ was filed in the Supreme Court of India to activate a dormant case of ‘disproportionate assets’ or corruption against this lady and the late Ms Jayalalitha. In the true democratic spirit this case had kept in abeyance /put in the freezer while Ms Jayalalitha was CM. The Supreme Court was prompt to make its verdict known and upheld charges on corruption against Ms Sasikala, Ms Jayalalitha’s associate and she is now not only in jail, but can’t contest elections for the next ten years.

Till this point the story seems to follow an expected trajectory of the corruption and governance narrative, where the corrupt are being nailed and jailed and removed from governance process. But the story continued. According to recent reports Ms Sasikala continues to rein supreme in the heart of the party and its millions of supporters. So she before going to jail she anointed her choice as Chief Minister of Tamil Nadu. And her choice has been supported by thousands of the party loyalists and millions of supporters across the state.

It is important to note that this is not the story of a poor backward state in India. Tamil Nadu is among the top states in India in terms of its economic and social status. It is one of the best governed states in the country and ranks high in the list of Economic Freedom rankings. Not surprisingly it home to a wide range of industries. Earlier Ms Jayalalitha had a slew of corruption charges against her, but this did not stop her from standing for elections, winning and becoming Chief Minister. Now her associate, who owes her popularity only through her close association with Ms Jayalalitha also receives the citizen’s support and despite going to jail, successfully selects her associate as Chief Minister. Clearly knowledge of corruption in this case does not seem to restrict popular political choice. But the people of Tamil Nadu are known as proactive voters and usually do not repeat the same government twice. Governance in Tamil Nadu can also be said to be strong and efficient. Tamil Nadu is also a leader in digital governance among Indian states, which can buttress a claim to more transparency. So clearly we have a TAP conundrum here where corruption coexists with high levels of popular support within strong and smart governance embedded in a democratic framework. I wonder what the mandarins of the World Bank have to say about a situation like this?

Happy Republic Day

INDIA-FRANCE-REPUBLIC DAY PARADE

An Indian soldier salutes as he rides a Smerch rocket launcher during India’s Republic Day parade in New Delhi on January 26, 2016. Thousands gathered in New Delhi amid tight security January 26 for India’s annual Republic Day parade, a pomp-filled spectacle of military might featuring camels and daredevil stuntwomen, with French President Francois Hollande the chief guest. AFP PHOTO / Roberto SCHMIDT

This article was published in The Dialogue on 27/01/2017 Original Article can be accessed at http://www.thedialogue.co/happy-republic-day/

January 26th provides India an occasion to ‘celebrate’ its national identity and its military might. For citizens republic greetings are an occasion for reaffirming their much valued patriotism. India became an independent nation on the 15th of August of 1947, so that settled the achievement of no longer being a second class colonial subject of the British Empire. But are we conscious about the additional achievement of January 26th, while sending out social media messages, or was it reflex action in our media infused milieu? What does the rumbling of tanks down the Rajpath on January 26th signify- that makes the flag hoisting on this day different from that on the 15th of August? A student of class 6 will probably give the text book answer that India adopted the Constitution on 26th of January, the basic rules of the game of governance which decide public life in India. So while saluting the flag and standing to attention to the national anthem do we reflect whether we have achieved the promises made on 26th of January 1952, both as a state and as citizens?

The preamble promised justice, equality, liberty, dignity for all within a secular democracy in 1952. However even today we are reminded that many among us do not want to give up their upper caste privileges and do not believe in the equal dignity of dalits. Patriarchy rules in almost every family and gender discrimination continues in new forms denying women of physical, economic and sexual autonomy which men take for granted. This denial of equality is more among the social and economic elites. Religious majoritarianism and minority appeasement, both aimed at social polarization and disharmony, receive active encouragement from politicians who swear by the constitutional value of fraternity when they come to power.

Am I happy on this Republic Day? How should I respond to these messages, I wonder. For me this day is a day of reflection. Are we all ‘equal’ citizens of our republic, do we promote equality, non-discrimination, dignity and respect through our own values and behaviours? I am disturbed by what I see.

India has made great progress since our first Republic Day. The GDP has increased from roughly 2.7 lakh crores in 1950-51 to nearly 60 lakh crores now and food grain production has increased from 50 million tonnes to over 250 million tonnes.

Compared with this rapid economic growth, population growth has been relatively low, from about 340 million people to about 1.2 billion and currently our total fertility rate (TFR), or number of children per couple, is 2.3 very close to the goal of 2.1 or the replacement fertility level. Urban TFR is an even lower 1.8 which indicates that our urban population has started collapsing even through rapid urbanization. With such good news it seems that our Constitutional promises are all fulfilled, but a closer look at data brings out a different story. Hunger and poverty are pernicious in our country. We rank 97 out of 118 countries in the global hunger index with 39% of our children below 5 being stunted. While the number of Indian’s continue to rise on the global billionaire’s list we also have nearly 250 million people living on less than USD 1.90 per day, the global poverty line. When we consider the caste wise distribution of poverty ratio of poor increases from 16% for the Other’s Category to over 2.5 times to 37% for the SCcategory. It is not surprising that the Gini Index an economic index on economic equality shows that inequality has risen from 1990 to 2013.

Despite many advances, women in India continue to live as second class citizens. While laws forbid child marriage, nearly half all girls aged 18 are married by that age, and in some states it is as high as two-third. Such girls remain deprived of health and educational benefits. Physical and sexual violence against women is slowly being acknowledged, which is a good thing, but the daily news in the media shows that such news does not affect perpetrators and crimes against women are on rise.

Population based surveys show that nearly 40% of all adult women have faced violence after they became adults, mostly from men at home.

Many fewer girls complete their schooling compared to boys, women receive lesser wages for the work they do, and the glass ceiling exists for the most high achieving women – either in board rooms or in representative assemblies. By law India has reservation for women in the panchayats but the ‘Vidhan Sabha’ or the ‘Lok Sabha’ are considered too important by men to let women in and prove their worth. Misogyny and sexism are common in all platforms that men get together be it the tea time adda, the pub or the Whatsapp group. Nearly all women have had to face harassment either a leer, a taunt or an advance. And this can be in the office, the bus, the streets, any place that is considered a ‘male space’.

But does this disturb us as Indian citizens of the Indian Republic that we all are wishing for. Many of us are disturbed about ‘corruption’, often referring to it as the biggest problem in India. True, corruption is a huge problem in India but the Republic Day promise is not only different but probably much bigger. I was not born in 1952 but I abide by the beautiful promise that ‘We the People of India’ gave ourselves by adopting the Constitution. We all need to contribute to fulfill this promise. Today I strengthen my resolve to achieve the promises of the Republic of India as a citizen.