Sunday August 25, 2019

How govt can provide better healthcare system to more than 125 crore people in India

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With a population of more than 125 crore, contemporary India yearns for another opportunity to become a global leader. Looking at our credentials of democracy, diversity and tolerance, many look upon us as the future of the world. But the rural-urban divide and non-inclusive, lopsided development remain a matter of concern. While Silicon Valley in USA thrives upon the innovative minds of Indians, back home, the country has no credible research and development (R&D) and innovations to boast about. Similarly, Indians constitute 5% of the doctor workforce in USA (and 20% of its International Medical Graduates). Indian health workers are also the pillars of medical services in the Middle East. In contrast, in India we continue to struggle with health challenges. With a massive population load and gross national income per capita of $3,900, India spends just 4.1% of its national budget on health. It has one doctor for 1700 citizens (WHO says the optimal number should be 1:1000). Cuba has 6.7 and America has 1.5 doctors for their 1000 population. With its gross national income per capita of $54,000, USA spends about 18% of its budget on health. However, this is not to say that everything is in perfect shape in USA. In fact, many experts feel that the American health system is ‘broken’ due to its inability to provide health care to millions of uninsured people.

With this background, let us study the basic health care delivery models that are prevalent in the world.

The most prevalent service model is ‘Out of Pocket’. In India, we may not have any problem in understanding this concept: You are responsible for footing the fee and bills to the doctor and/or hospital. Well, many will say, the government does provide free universal health care to all its citizens. That is true. India claims (unlike USA, as we shall see below) that anyone can visit a government healthcare facility and avail treatment literally free of cost. However, in actuality, the government health facilities are dilapidated, over-crowded and dysfunctional thanks to poor work ethics, chronic absenteeism and corruption, thereby limiting the access for a large chunk of population.

Contrast this with Britain’s National Health System (called the Beveridge Model). Here, the government provides health care through its government doctors, clinics and hospitals. The private medical sector is negligible. Everyone is eligible to choose a General Practitioner (GP) who is your primary doctor and avail medical care free of cost (the care is free at the point of use).The government will pay your bills. In communist Cuba, hailed by many as the successful model for a developing world, the same system is seen in extreme form: the whole health care system – be it clinic or a pharmacy- is owned by the government. No doctor is allowed to have a private practice.

Canada also provides a universal health care to its citizens, but in a different way. The government provides every citizen a health insurance (National Health Insurance model). The patient can choose to go to a private clinic or a government doctor or facility.

Germany has a slightly different system. The government mandates a health insurance for everyone, and that is provided by the employer. The employee also contributes a part of that. But the whole system is created not to make profit and must cover everyone, even if unemployed.

The above models are typical examples of what we call Socialised Medicine, where the government pitches in to provide subsidies through taxation. In other words, these are public-funded health care programs.

When it comes to USA, the concept of universal health care becomes fuzzy. According to the Institute of Medicine, USA is an exception among the developed countries that does not provide a universal health care. Here the government hardly runs any health care centres (except a few county hospitals administered by county governments. One famous example is Cook County hospital in Chicago). For a majority of people, health care benefits come through their jobs. In other words, your employer will buy you a private health insurance. You also pay a portion of that premium per month, though. The companies that issue health insurance are called Health Maintenance Organisations (H.M.Os) and they are for profit. But if you become unemployed or operate your own business, you have to buy your own private health insurance. However, for army men, the government provides health care through government–owned and operated facilities (Department of Veteran Affairs). For senior citizens (more than 65 years of age), the government runs a Medicare insurance scheme and thus bears the costs of their medical bills (Canadian system).

Thus it is obvious that India has a mixed system where the government pledges to provide health care, but is unable to meet the demand. The private health sector is robust, but the poor and needy may not be able to use the services for want of money. How do we strengthen the health care system in India, then? We need to increase access to affordable and quality health care for everyone. India needs to increase its budget share on health, particularly preventive and primary health care. In addition, we must produce more doctors and para-medical forces. Instead of running the health facilities itself, the government will do well to broaden health insurance to its citizens and put good regulations in place so that through the private sector, it can provide much needed health care to its citizens.

A MK

The author is a a practicing Neonatologist in Chicago. This op-ed is an exclusive article in his series Musings from Chicago. You can reach out to him at e-mail ID: pedia333@gmail.com and on Twitter @drMunishRaizada.

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India Needs to Define Special Placement of Function of Intelligence in Interest of National Security

The Pulwama attack on a CRPF convoy, in February last, by a suicide bomber of Jaish-e-Mohammad, was a case more of inadequate response

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India, Intelligence, National Security
Terrorists would always have a lead in springing up surprises -- it has to be appreciated, therefore, that the agencies using both human and technical means have produced information to preempt them in most cases. Pixabay

It is a matter of deep satisfaction for the people of India that our Intelligence agencies moulded in a non-political work ethos and practising the dictum of ‘working with urgency even when there was no emergency’ enabled the first Modi regime to successfully deal with the threats to national security — particularly in Kashmir where they helped the security forces to pursue Intelligence-based operations that guaranteed minimal collateral damage in counter-terror work. Terrorists would always have a lead in springing up surprises — it has to be appreciated, therefore, that the agencies using both human and technical means have produced information to preempt them in most cases.

The Pulwama attack on a CRPF convoy, in February last, by a suicide bomber of Jaish-e-Mohammad, was a case more of inadequate response than Intelligence failure. In security, failure of ‘action’ not of ‘information’ does happen often enough to remind us of the need to improve coordinated responses to Intelligence alerts and to never be dismissive about information. No Intelligence is ‘non-actionable’ as it should rightly be presumed to be the tip of the iceberg warranting all possible preventive measures, howsoever tedious these might seem to be for the action takers.

Most of the serious threats to national security have external and internal dimensions and the Multi Agency Centres at Delhi and in the state capitals with years of functioning now, make sure that the available actionable information is passed on to the concerned functionaries without delay and that further lines of pursuit to dig out more intelligence were specified as an ongoing task. Our Inteligence agencies — inheriting a British tradition — exercise the sovereign power of identifying the emerging threats to national security and initiating the effort to ‘cover’ them to ensure a constant flow of information on them without waiting for a clearance from the political executive. They have to keep the latter fully informed at the same time. This is what enables the agencies to go on without change of pace even when a new government assumes charge at the Centre after a General Election.

The system in India has upheld the position that national security was above politics and this principle was in play for most times since India became a democratic republic in 1950 — except for spells when the Intelligence chief of the day himself fell short of the highest levels of objectivity and independence. The natural changes brought about by the country’s democratic process enabled me to serve as Director Intelligence Bureau with three Prime Ministers of different political backgrounds — Congress, BJP and the United Front. Since the institution of National Security Advisor did not exist then, that function was also built into the DIB’s working in my time. I can say with emphasis that all the three valued IB’s information on national security even when they chose to run their politics in their own ways – by and large without involving Intelligence agencies in their political agenda.

India, Intelligence, National Security
It is a matter of deep satisfaction for the people of India that our Intelligence agencies moulded in a non-political work ethos and practising the dictum of ‘working with urgency even when there was no emergency’ enabled the first Modi regime to successfully deal with the threats. Pixabay

Because of the ever enlarging threat scenario, Intelligence agencies were in need of more manpower, funds and logistical support. As a historical legacy Intelligence Bureau was manned and led by officers of IPS — this made for the agency’s close cooperation with and a much-needed mentoring role in regard to the state police organisations. The Bureau was regarded as a Central Police Organisation for cadre management but was not otherwise bracketed with the investigation outfits or the para military organisations of the government. Intelligence agencies have a bulk of operators directly recruited from amongst the best through a rigorous examination and thoroughly trained in the trade craft.

The IPS officers leading them are on a turf of anonymity, covert operations and delicate information gathering — entirely different from the sphere of visible legal action handled by men in uniform including investigators. The Intelligence set-up, therefore, ought to have its own performance and promotion parameters. This is what gave Director IB the status and pay grade as the most senior police officer in the country in keeping with his function as the Chairman of the DGPs Conference even when IPS officers with longer years of service headed the state police or other police organisations at the Centre.

Intelligence agencies in Indian conditions handle only ‘information’ accessed through trade craft techniques and the responsibility of taking ‘action’ against a suspect in a legally empowered way would fall on the state police or a central investigation body like the NIA. The Intelligence agencies act as the eyes and ears of the sovereign power ruling the democratic state and could be scanning any other functionary — high or low — in the national interest under the express authorisation of the highest political executive exercising that power. Since Intelligence agency does not dictate ‘action’ or ‘policy’ it cannot be blamed for any legally untenable response of the police. The Centre needs to define the special placement of the function of Intelligence in the interest of national security.

The internal security situation in the country and the developing threat scenario around the world justify a quantum jump being made in the manpower and resources provided to the Intelligence set-up in general and Intelligence Bureau — the mother agency for counter intelligence work — in particular. IB watches every nook and corner of the country where terror agents and other anti-national elements might be harbouring taking advantage of the free society offered by Indian democracy. Kashmir, typically, illustrated the challenge to national security created by the paucity of ‘Intelligence from below’. Now that the J& K has been fully integrated with the rest of the country the Centre must raise enough trained professionals of the state to cover every Panchayat circle and town from the angle of counter terror watch. Failure to quickly identify the local masterminds behind the organised stone pelting was a major reason why the J&K government could not effectively handle the civic disturbances occurring in Srinagar and elsewhere in recent months. The collusion of the Valley parties ruling the state with the pro-Pak Hurriyat was the principal reason why the state administration remained infested with separatists and failed to work for the development and uplift of the average Kashmiri.

Also Read- Pakistan’s Imran Khan Government Bans Creation of New Posts, Purchase of All Vehicles

A hard-pressed organisation like IB should have no ‘vacancies’ caused by procedural delays arising out of the issue of equivalence of batch positions of IPS officers serving elsewhere. An officer is inducted and kept in IB purely on a special evaluation of merit and suitability and a faster career graph for him or her during the stay with the agency should be a part of the deal. IB, in any case, was expected to be ahead of the state cadres in matters of promotion. National security is the joint preserve of the Centre and the states. Cadre management complexities should not, therefore, be allowed to come in the way of central Intelligence agencies getting the best of the available manpower at any point of time. The new global terror targeting the Indian subcontinent adds urgency to this requirement. (IANS)