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The Hindu Editorial Analysis | PDF Download

Date: 07 February 2019

 

Checks and balance

  • Seeking a count of 50% of VVPAT slips is too much; the focus should be on ending glitches
  • In a significant and welcome change from their earlier demand for a return to paper ballots, representatives of a large section of the mainstream Opposition parties met the Election Commission (ECI) to demand changes to the Voter Verifiable Paper Audit Trail counting process during the general elections. Returning to paper ballots will be regressive. The Electronic Voting Machine process, despite the plethora of grievances about its functioning from the Opposition parties, is a major improvement over paper-based voting. There has been no evidence of EVM-tampering as claimed by some parties, and administrative and technical safeguards instituted by the ECI and EVM manufacturers have held steady since the introduction of the EVM. Despite this, the ECI had fast-tracked the implementation of the VVPAT, an adjunct to the EVM that allows for a paper trail for voting and later verification of the electronically registered mandate in the ballot unit of the EVM. VVPATs are now deployed in all Assembly and parliamentary elections with EVMs. This implementation has not been without some misgivings. The Opposition’s demand for a count of 50% of the VVPAT slips, as opposed to the current system of counting VVPAT slips in one randomly selected booth of each constituency, is aimed at ensuring that EVMs have not been tampered with.
  • ECI safeguards are robust enough to prevent this, but VVPAT recounts could eliminate any remaining doubt about possible “insider fraud” by errant officials or manufacturers.
  • While the demand to count half of all the slips is an over-reaction, as a scientifically and randomly chosen sample of booths is a reasonable enough verification for the process, there remains the question whether counting one booth per constituency is a statistically significant sample to rule out errors.
  • A more robust sampling technique that factors in the average size of the electorate in any constituency for each State and voter turnout, involving the counting of more than a single booth in some States, may be a better method. The ECI’s response that it is waiting for a report on this from the Indian Statistical Institute should be encouraging.
  • The other issue with the VVPAT is more significant: machine glitches. During the parliamentary byelections in Uttar Pradesh and Bihar, and Assembly elections in Karnataka in 2018, VVPAT glitches resulted in machine replacement rates rising to 20% and 4%, respectively. Glitches in the VVPAT machines were largely due to spooling issues in the print unit, which was sensitive to extreme weather. Some hardwarerelated changes were introduced, which improved its functioning in the recent elections in five States. Machine replacement rates due to VVPAT failures came down to 1.89% for Chhattisgarh. Deployment of improved machines should help curb glitches in the Lok Sabha elections.

 We need a leap in healthcare spending

  •  India needs to focus on long-term investment, not only episodes of care
  • The Central and State governments have introduced several innovations in the healthcare sector in recent times, in line with India’s relentless pursuit of reforms.
  • However, while the government’s goal is to increase public health spending to 2.5% of GDP, health spending is only 1.15-1.5% of GDP. To reach its target, the government should increase funding for health by 20-25% every year for the next five years or more.
  • While the Interim Budget is responsive to the needs of farmers and the middle class, it does not adequately respond to the needs of the health sector.
  • The total allocation to healthcare is ₹61,398 crore. While this is an increase of ₹7,000 crore from the previous Budget, there is no net increase since the total amount is 2.2% of the Budget, the same as the previous Budget.
  • The increase roughly equates the ₹6,400 crore allocated for implementation of the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY).

Per capita spending on health

  • According to the National Health Profile of 2018, public per capita expenditure on health increased from ₹621 in 2009-10 to ₹1,112 in 2015-16. These are the latest official numbers available, although in 2018 the amount may have risen to about ₹1,500. This amounts to about $20, or about $100 when adjusted for purchasing power parity. Despite the doubling of per capita expenditure on health over six years, the figure is still abysmal.
  • To understand why, let’s compare this with other countries. The U.S. spends $10,224 per capita on healthcare per year (2017 data). A comparison between two large democracies is telling: the U.S.’s health expenditure is 18% of GDP, while India’s is still under 1.5%.
  • In Budget terms, of the U.S. Federal Budget of $4.4 trillion, spending on Medicare and Medicaid amount to $1.04 trillion, which is 23.5% of the Budget. Federal Budget spending per capita on health in the U.S. is therefore $3,150 ($1.04 trillion/ 330 million, the population).
  • In India, allocation for healthcare is merely 2.2% of the Budget. Per capita spending on health in the Budget in India is ₹458 (₹61,398 crore/ 134 crore, which is the population). (Medicare and Medicaid come under ‘mandatory spending’ along with social security.) Adjusting for purchasing power parity, this is about $30 — one-hundredth of the U.S.
  • Admittedly, this runaway healthcare cost in the U.S. is not to be emulated, since comparable developed countries spend half as much per capita as the U.S. Yet, the $4,000-$5,000 per capita spending in other OECD countries is not comparable with India’s dismal per capita health expenditure. The rate of growth in U.S. expenditure has slowed in the last decade, in line with other comparable nations.
  • The ₹6,400 crore allocation to Ayushman Bharat-PMJAY in the Interim Budget will help reduce out-of-pocket expenditure on health, which is at a massive 67%. This notwithstanding, per capita Budget expenditure on health in India is among the lowest in the world. This requires immediate attention.

 Health and wellness centres

  • Last year, it was announced that nearly 1.5 lakh health and wellness centres would be set up under Ayushman Bharat.
  • The mandate of these centres is preventive health, screening, and community-based management of basic health problems. The mandate should include health education and holistic wellness integrating modern medicine with traditional Indian medicine. Both communicable disease containment as well as non-communicable disease programmes should be included. An estimated ₹250 crore has been allocated for setting up health and wellness centres under the National Urban Health Mission.
  • Under the National Rural Health Mission, ₹1,350 crore has been allocated for the same.
  • The non-communicable diseases programme of the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke has been allocated ₹175 crore, from ₹275 crore.
  • Allocation to the National Tobacco Control Programme and Drug De-addiction Programme is only ₹65 crore, a decrease of ₹2 crore. The allocation for each of the wellness centres is less than ₹1 lakh per year. This is a meagre amount.
  • History shows that where there is long-term commitment and resource allocation, rich return on investment is possible. For instance, AIIMS, New Delhi is the premier health institute in India with a brand value because of resource allocation over decades. AIIMS Delhi alone has been allocated nearly ₹3,600 crore in the Interim Budget, which is a 20% increase from last year. Similar allocation over the long term is needed in priority areas.

Prevention and its link to GDP

  • NITI Aayog has proposed higher taxes on tobacco, alcohol and unhealthy food in order to revamp the public and preventive health system. This has not found its way into the Interim Budget.
  • A focused approach in adding tax on tobacco and alcohol, to fund non-communicable disease prevention strategies at health and wellness centres, should be considered. Cancer screening and prevention are not covered.
  • There is no resource allocation for preventive oncology, diabetes and hypertension. Prevention of chronic kidney disease, which affects 15-17% of the population, is not appropriately addressed. The progressive nature of asymptomatic chronic kidney disease leads to enormous social and economic burden for the community at large, in terms of burgeoning dialysis and transplant costs which will only see an exponential rise in the next decade and will not be sustainable unless we reduce chronic kidney disease incidence and prevalence through screening and prevention.
  • Due to lack of focus in preventive oncology in India, over 70% of cancers are diagnosed in stages III or IV. The reverse is true in developed countries. Consequently, the cure rate is low, the death rate is high, and treatment of advanced cancer costs three-four times more than treatment of early cancer. The standard health insurance policies cover cancer but only part of the treatment cost. As a consequence, either out-of-pocket expenditure goes up or patients drop out of treatment.
  • Increase of GDP alone does not guarantee health, since there is no direct correlation between GDP and health outcomes.
  • However, improvement in health does relate positively to GDP, since a healthy workforce contributes to productivity. We don’t mean to say that funding must be redirected from current allocations to preventive care. The 1,354 packages for various procedures in PMJAY must be linked to quality. For various diseases, allocation should be realigned for disease management over a defined time period, not merely for episodes of care. Further, the health sector must be made a priority area, like defence. Since a major innovation in universal healthcare is being rolled out, it must be matched with a quantum leap in funding. Only if we invest more for the long-term health of the nation will there be a similar rise in GDP.

 At the cost of quality

  •  The decision to provide financial rewards for publication in science journals and patents is fraught with problems
  • On January 30, a little more than four years after the last hike, the Ministry of Science and Technology increased the fellowship stipend for PhD students by nearly 25%. The government says the hike will be reviewed periodically. Since the increase is far less than the 80% hike that research fellows have been demanding for the last six months, they have decided to continue with their protests.
  • The government is also planning to provide “financial and academic incentives to enhance and recognise the performance of research fellows”, for which an InterMinisterial Empowered Committee has been set up. Excerpts of the Committee’s recommendations, tweeted by the Department of Science and Technology on February 2, provide a glimpse of the financial rewards to be given for publication and patents. While the modalities are yet to be worked out, offering financial rewards for publication is a bad idea.

 Cause for concern

  • Giving rewards based on papers published in journals, and determining the incentive based on whether the paper is published in an international or Indian journal, is fraught with problems. In China, for example, researchers were given about $44,000 in 2016 for a single paper published in prestigious journals such as Nature and Science.
  • The impact factor (a proxy for the relative importance of a journal) of journals was used to calculate the prize money for publication. This led to an unprecedented increase in unethical research practices and frauds committed by Chinese researchers. This could also happen in India, which already has an ignominious record in this area and has no nodal body to address scientific frauds and unethical practices.
  • In India, a one-time financial reward of ₹50,000 and ₹20,000 has been recommended for a paper published in an international and Indian journal, respectively.
  • This is a “hare-brained scheme,” says P. Balaram, former director of the Indian Institute of Science and former editor of Current Science. “Whoever has come up with this is ignorant of the history of scientific publishing. They will destroy research (with this scheme).”
  • It is worth remembering that though the University Grants Commission’s intent to introduce Academic Performance Indicators was good, APIs were largely responsible for the spike in predatory journals published from India. There is little guarantee that the reward system based on publication will not lead to further erosion in the quality of science research in India.
  • In addition, giving greater rewards for publication in international journals makes no sense as international journals are not uniformly superior in quality to Indian ones. While Nature, Science, Cell and The Lancet are prestigious, there are many journals which are of poor quality. Similarly, some Indian journals are better than international ones despite having a low impact factor.
  • “If average or below average papers are submitted to Indian journals, the overall quality of the journals will be low compared with international titles,” says Professor Balaram. By giving 60% lower stipend to students publishing in Indian journals, the government will unwittingly be widening the gap between Indian and international journals, which will be self-destructive in the long run.
  • Also, “Indian science suffers from deep-rooted, structural problems — fellowships get delayed and project funding is not released on time,” says Gautam Menon, a computational biologist at the Institute of Mathematical Sciences, Chennai. He argues that “the government should reward good research with generous funding and fewer constraints.” With hundreds of papers being published each year, it is debatable whether the government will be able to provide incentives given that research labs have reportedly been facing a fund crunch of late.

  Reward for patents

  • The proposal to provide students an incentive of ₹1,00,000 on obtaining a patent (Indian or international) is a bigger recipe for disaster.
  • While obtaining a patent is not difficult, it costs ₹10,000-₹30,000 to file a patent in India. Drafting the patent costs an additional ₹50,000 and there is also an annual renewal fee. Also, not all patents translate into products.
  • The Science Ministry has not learnt from the mistakes of the Council of Scientific and Industrial Research (CSIR). In late 2016, the CSIR instructed its 38 labs to stop indiscriminate filing of Indian and foreign patents. Then CSIR Director-General Girish Sahni had said that a “majority of patents are ‘biodata’ patents” and had been “filed for the sake of filing without any techno-commercial and legal evaluation”. In such a scenario, a financial incentive for patent-filing will only exacerbate the problem.

 A worrying approach

  •  Will Ayushman Bharat hurt the spirit of cooperative federalism?
  • With West Bengal, Telangana, Delhi and Odisha not joining Ayushman Bharat, the question arises whether the scheme is hurting the idea of cooperative federalism. The Seventh Schedule of the Constitution makes States responsible for hospital services. The States have their own schemes to provide financial risk protection to those seeking medical relief. Based on the ongoing centrally sponsored scheme, the Rashtriya Swasthya Bima Yojana, the Central government launched an improved version in 2018 called the National Health Protection Scheme (NHPS) for a sum assured of ₹5 lakh per family per year.
  • The insistence to prefix Ayushman Bharat to existing State names and the despatch of a personalised letter to 7.5 crore families with only the Prime Minister’s photograph were seen as attempts to attribute the entire credit to the current administration, though State governments are equal partners — funding 40% of the scheme, bearing the responsibility of its implementation and covering double the number of beneficiaries.
  • Given that the Central government transfers funds to States through the Finance Commission, Central Sector Schemes and the Centrally Sponsored Schemes, it is expected of the National Health Agency (NHA) to build an institutional architecture, standardize procedures, costs and access all data for effective monitoring.
  • This is important as it is accountable to Parliament and the Comptroller and Auditor General for the proper utilization of allocated funds. But such standardization can stifle innovation and entail costly structures that may not accommodate local conditions, preferences, and cost-effective solutions. Instead, when funds are provided, subject to achieving certain goals, States have scope to innovate, model the design to fit their context, resource base, epidemiological status, level of development, take total ownership and be accountable for outcomes.
  • The NHA’s approach does not appear to be built on consensus. Its model consists of outsourcing the vital functions of pricing services, pre-authorisations, scrutiny of bills, grievance redressal, and fraud detection to private companies and third-party administrators. This may increase administrative costs from the current 6% to 30%, as seen in the Medicare scheme of the U.S.

 Trump and his generals

  •  For all their discord, no one appears to know how to manage chaos at a time of U.S. retreat
  •  Not even U.S. President Donald Trump’s worst enemies would deny that he has fulfilled many election campaign foreign policy promises, including opting out of international agreements on climate change, the Iran nuclear accord and the Trans-Pacific Partnership, the relocation of the U.S. embassy to Jerusalem, and pressurizing allies to pay more for joint defence. A matter for surprise then, is that another Trump campaign pledge, to end the ‘endless wars’ and bring American troops abroad back home, specifically to withdraw U.S. forces from Syria and Afghanistan, is met with denunciation and open or indirect obstruction from both civilian and military circles.

The opposition within

  • This opposition, marked by some high-level resignations such as Secretary of Defence James Mattis — which have been accorded hero-martyr status by the media — has been provoked by Mr. Trump’s decision to repatriate some 2,000 forces from Syria and around 7,000, which is around half the total number, from Afghanistan. Mr. Trump’s moves are condemned as isolationist and favouring the ‘enemies’ of the U.S., especially Russia and Iran.
  • Regarding Afghanistan, his opposition was not astute enough to perceive that the drawdown was a necessary prelude to direct negotiations with the Taliban. The objectors also imply that Israel is exposed to greater danger, a cause certain to enjoy bi-partisan favour. General Mattis, in his resignation letter, wrote he was leaving “because you have the right to have a Secretary of Defense whose views are better aligned with yours.” It is amazing that it took him two years to detect any mis-alignment.
  • No proposal to draw down the U.S. military presence abroad will be acceptable to Mr. Trump’s critics, because the American military-industrial complex referenced by President Dwight Eisenhower in 1961 still holds the civilian authority in thrall, and since World War l, U.S. foreign policy has been totally militarized. To every international problem, Washington has only two responses: the application of sanctions, and the threat or use of force.
  • Mr. Trump is vilified as isolationist by the mainstream media, evidence that the neo-imperial spirit and god-given right to hold military hegemony is deeply internalized in the entire U.S. establishment.
  • So also is the Francis Fukuyama prediction that “the end point of mankind’s ideological evolution [is the] universalization of Western liberal democracy as the final form of human government.”
  • Insinuations about a sellout foreshadow whatever contact Mr. Trump wishes to make with the only world power that can incinerate the U.S., though every previous U.S. leader held talks with his Russian counterpart to make the world a safer place. This has less to do with Special Counsel Robert Mueller’s interminable inquiry about Russian collusion, and more with the imagining of America’s role in the world.
  • The New York Times writes of a “world order that the U.S. has led for 73 years since the Second World War”, accusing Mr. Trump of reducing that “global footprint needed to keep that order together”. The same theme is dutifully echoed by compliant European allies such as Germany’s Chancellor Angela Merkel, who in July 2018 bewailed that under Mr. Trump the U.S. could not be relied upon to “impose order”. But whose order?
  • Mr. Trump is wrong in asserting that the U.S. destroyed the Islamic State (IS) in Syria, not only because there are some remnants of it left, but because while U.S.-coalition aircraft have dropped ordnance from several thousand feet and killed innumerable civilians in the process, the actual fighting against the IS has been done by Kurds in northeast Syria, and the Assad government, Russians, Iranians and Hezbollah elsewhere. The small U.S. contingent of about 2,000 serves to train and supply the Kurds, constrain the Turks and obstruct progress towards a peace settlement. As elsewhere, the Americans are ready to fight till the last local soldier. Mr. Trump has the support of Congress, media and the military on a tough line on Iran — again, a campaign promise — but in West Asia, Mr. Trump outsources local action to allies such as Saudi Arabia, turning a blind eye to its criminal activities in Yemen and also the murder of journalist Jamal Khashoggi.
  • In the process of demonizing Mr. Trump, accountability, responsibility and civilian oversight are discarded, while people in uniform and in the shadows — the ubiquitous U.S. intelligence services — are raised on lofty pedestals, encouraging dissidence. To no surprise, Mr. Trump’s announcements have resulted in a flurry of alarmist reactions. As demanded by the media and Congress, the U.S. National Aeronautics and Space Administration cancelled meetings with its Russian counterpart, and an end to U.S.-Russia collaboration in space appears probable. The Pentagon now reports that China seeks expansion by “military and non-military means” and military bases in Pakistan, Cambodia, and elsewhere that the American public have never heard of. The Pentagon concludes that China is “developing the capacity to dissuade, deter, and defeat a potential third-party [read, U.S.] intervention in regional conflicts”. With a second summit between Mr. Trump and North Korean Supreme Leader Kim Jong-un in the offing, the media is predictably cautioning against any reduction of U.S. forces in South Korea as a result of any U.S.-North Korean détente, with head of the American Joint Chiefs of Staff, General Joseph Dunford, weighing in to predict that China “probably poses the greatest threat to our nation by about 2025”.

 Last word with Iran

  • The last word rests with Iran, regarded as an enemy by both Mr. Trump and his domestic adversaries. When U.S. Secretary of State Mike Pompeo claimed in January that “when America retreats, chaos often follows”, Iran’s Foreign Minister Mohammad Javad Zarif countered by tweeting, “Whenever and wherever US interferes, chaos, repression, and resentment follow.” No one in the United States is listening.