Rushing In Where Angels Fear To Tread

News reports stated that an eleven years old girl from Simdega district in Jharkhand died apparently because her family could not get their food grain entitlement as their ration card was not Aadhaar-linked. I say “apparently” because, in this post-truth age, one never knows how to separate fact and fiction in media reports. There will also be the usual controversy over whether health or nutrition factors were primarily responsible for her mortality, with all commentators blissfully unaware of the close linkages between the two. But, knowing how things work in India that is Bharat, I am certain that the failure to link their Aadhaar numbers to their ration cards must have cost many families access to subsidised food grains. This view is bolstered by reports that seem to confirm that the ration card of the family in question was not linked to the Aadhaar card.

I am not going into the merits of Aadhaar linkage to beneficiary schemes, on which enough heat and sound has been generated without any light. But I am concerned about the haste in rushing in to implement policy measures without adequate backup systems. This has a lot to do with the current obsession in governments to show results immediately. In the Jharkhand case, time could have been taken to ensure that most of the population had obtained Aadhaar cards and efforts could have been made over some months to ensure Aadhaar linkage with ration cards. But the childish enthusiasm of the political and administrative executive of Jharkhand to score brownie points with the higher-ups in Delhi probably led to their claiming that they had managed almost full linkage of ration cards with Aadhaar numbers.

The same issue bedevils MGNREGA payments in Jharkhand as well, with documented evidence that the system of online bank account transfers has resulted in inordinate delays in wage payments. If you think such poorly planned policies have troubled only the really poor, think again. Major financial decisions taken over the past year have played havoc with large segments of society, not because of lack of intrinsic merit, but because of the desire to impress the public that this is a “government that works”.

Demonetisation was intended to be the sledgehammer that would eliminate black money, check counterfeit currency and improve tax compliance through reliance on digital transactions. A year down the road, even after all the travails borne by the long-suffering public, it is evident that the black money scourge refuses to die, the introduction of more and more currency notes in different denominations will be a boon to counterfeiters and that tax compliance will become a reality only when simplified tax structures are in place and when sound legal systems exist to penalise defaulters quickly and effectively. Which begs the question of whether demonetisation could not have been handled in a more graduated fashion, with new currency notes going into circulation before the withdrawal of old currency notes.

The same thought haunts one when observing the hasty digitisation of the GST. Considering that it took thirteen years for this baby to be born, the infancy phase could have been handled better. The “tryst with destiny” has certainly altered the destiny of small retailers and merchants, many of whom find the process of filing returns excessively cumbersome. In its fourth month of implementation, technical glitches still thwart the filing of returns: GSTR1 filing for July has just been completed, with filings for subsequent months pushed to November. Despite the promises of the Union Finance Minister to process refunds expeditiously, CAs are of the view that refunds could take six months or more, affecting cash flows of businesses. Gradual phasing in of GST online systems with continuation of the service tax regime for some more months would probably have ensured less transitional pain.

Ramming Aadhaar compliance down the throats of income tax payers and bank account holders will, I suspect, unleash another Pandora’s Box in the months to come. Again, I am not questioning the rationale but the speed of expected compliance, consequences be damned. Filing income tax returns for FY 2016-17 required all those not having Aadhaar cards as of April 2017 to get them by July 2017. Pensioners and the elderly were particularly inconvenienced. Linking Aadhaar numbers to bank accounts has its own technical problems. Most banks have no robust online mechanism to enable the account holder to verify that her bank account is indeed Aadhaar-linked. Come February 2018, citizens may well be faced with the nightmare (actually, it should be called daymare) of their accounts being frozen, leading them to beg on the streets. The insistence on linking mobile numbers to Aadhaar numbers, apparently mandated by the Supreme Court, is yet another nuisance around the corner.

Make haste slowly” is a salutary motto for good governance. This tendency of the civil service is viewed unfavourably by professional politicians, obsessed with the five-year election itch: why, even an ex-bureaucrat like Arvind Kejriwal has commented unfavourably on IAS officers sitting on files. Many of us were roasted by Ministers and Chief Ministers when we insisted on listing on file the pros and cons of any decision, probably a reason for at least some of us being overlooked for prize postings. Pointing out all the possible implications of a decision ensures at least that, if Plan A goes wrong, Plans B and C can be put into operation. It is the current fashion to run down the 1991 economic reforms as being rather halting and piecemeal. As one who was in Delhi at that stage, I am happy that even those reforms that did take place at that time went through, given the attachment of establishment politicians to “crony socialism” and the hostility of an established elite to the whittling down of its gravy train.

The rush to push through major decisions has, no doubt, been influenced by the relatively narrow window before the 2019 general elections. If the favourable results take time to mature, the government may well have to reap the whirlwind of short-term resentment. In the present climate of harking back to our glorious past, I take the liberty of recounting the story of Bhasmasura. Blessed by Siva with the boon of turning whatever he touched to ashes, Bhasmasura sought to test the boon on his benefactor. It took the wiles of the damsel Mohini to persuade Bhasmasura (in the hope of acquiring her) to place his hand on his own head and be turned to ashes. Governments would do well to heed this parable. Chasing the electorate (Siva) to test its powers, the government (Bhasmasura) is finally enticed by Mohini (the election process) to destroy its continuance in power through unwise, ill thought out steps. Yet again I resort, ad nauseam ad infinitum, to my favourite quote:

Those who do not remember the past are condemned to repeat it.

This article was originally published on Indus Dictum, a site where thought leaders from diverse fields, spanning business and technology to politics and modern law, contribute unique insights and experiences. You can access the article here.

Advertisements
Posted in government, health & nutrition, political economy, public affairs | Tagged , , , | Leave a comment

The Strong Man Cometh

(*: Man refers in this article to the species homo sapiens and has no gender connotations)

Après nous le déluge(Madame de Pompadour)

Surely the Second Coming is at hand.(The Second Coming: William Butler Yeats)

“If God did not exist, it would be necessary to invent him.(Voltaire)

The apocryphal quote attributed to the mistress of Louis XV of France sums up the attitude of sections of the population to the demise (and the removal from the earth) of a strong, autocratic personality from their midst. One saw it in Uzbekistan, where one despot was replaced by another; why, even in a state like Tamil Nadu, which is part of the noisy, fractious democracy that is India, it was difficult for people to come to terms with Amma’s Anno Domini. The Pandava Yudhishthira was spot on in his reply to the Yaksha’s question “Day after day countless people die. Yet the living wish to live forever. What can be a greater wonder?” This futile desire of the masses to immortalise their icons is reflected in the conviction of those worshipped that they are destined to live, if not forever, at least into the distant future. This is possibly one of the reasons why there is no attempt at succession planning, though the fear of a far more competent successor may well weigh on the mind as well. Be that as it may, what is more worrisome is that more and more societies, especially those with a tradition of liberal democracy, are turning towards perceived “supermen” and “superwomen” to tackle the vexing problems of the twenty first century.

It is not as though there have been no dominant ruling personalities in history – just think of Henry VIII, Ivan the Terrible, Catherine the Great and Napoleon. What distinguished the despots of the twentieth century from their predecessors was the access to technology that enabled them to so totally dominate the minds and actions of their subjects. Stalin, Hitler and Mao, and an assortment of lower-scale tyrants, could impose their will on every citizen, using the reach of communication technology to create an atmosphere of unpredictable terror and herding together citizens into camps and communes (for reeducation, ethnic cleansing and indoctrination) in numbers never contemplated in earlier centuries. Superior weapons, instruments of terror and ideology-brainwashed bureaucracies eliminated millions in the name of future utopias. The inevitable end of the controlling autocrats led to the unravelling of their tyrannical systems. But Tiananmen Square and the fall of the Berlin Wall have not quite led to the expected explosion of democracy. In fact, China continues to combine a liberalised economy with a highly restrictive political system and Russia, after flirting with democracy for a few years, is headed for a one-man, one-party dictatorship for the foreseeable future. Authoritarian regimes are thriving in many countries in Asia, and Africa and Latin America swing between democracy and absolute rule.

What, however, gives greatest cause for concern is the growing tendency for citizens of liberal democracies to readily jettison the basic tenets of democracy – pluralism, tolerance, free expression – in a world where they perceive themselves as insecure, in the economic, political and social senses. It started with the Brexit vote in the United Kingdom, led to the political earthquake of last year in the USA and is now spreading slowly but surely across Italy, France, Holland and Germany (although the citizens of France have thwarted it for the time being). A figure from the right end of the political spectrum is emerging in every democracy who promises heaven on earth to his leaderless flock. So what traits characterise such men (and women) and which environments provide the best soil for their growth and entrenchment in a society? I can think of six such elements:

Megalothymia

Megalothymia is defined by Francis Fukuyama (The End of History and the Last Man) as “the desire to be recognised as superior to other people”. This desire for recognition typically aims at dominating others and bending them to one’s will. Mostly observed in the political class, but equally recognisable in corporate chieftains, top bureaucrats and orchestra conductors, this trait manifests itself in the conviction of the megalothymic person that he has a unique mission to fulfil during his tenure on earth. Fukuyama argues that even a person like Socrates stressed the need for a class of courageous and public-spirited guardians who would sacrifice their material desires and comforts for the common good. But Socrates was also clear that the megalothymic tendency needed to be curbed if the political order was to be preserved. Liberal modern democracies attempt this discipline through the existence of countervailing centres of political power and the second, third and fourth estates (the legislature, judiciary and press respectively) and what could be termed the fifth estate (viz. civil society).

Social engineering:

The unique mission of the megalothymic leader has, since the early twentieth century, taken the form of engaging with the transformation of the very structure of society. Communism and National Socialism represented ideologies that had their own visions of the future course history should take. Forced collectivisation and gulags in the Soviet Union, the solution of the Jewish question in Nazi Germany and its wartime acquisitions and the Great Leap Forward and Cultural Revolution in Communist China were efforts to direct societies in specific directions envisioned by the Great Leader, with the terrible consequences being borne by millions of people in the half century from 1925 onwards. Recent actions or intentions, like extra-judicial executions in the Philippines, demonetization in India, promoting the Islamic way of life in Turkey and the proposals of the new President of the USA to reduce immigration and restrict individual choice in personal matters like abortion and same sex marriage also bear the imprint of social engineering imposed from above.

Infallibility:

In the effort to impose his vision on society, the Leader has, always, to be steadfast in the certainty of his convictions. George Orwell’s “Big Brother” is always right. No opposition or dissent is tolerated, with likely competitors being dealt with through purges (Bukharin), assassination (Trotsky) or reeducation (Deng Xiao Ping). We can observe this trend in political life in India, both in national and state-level parties, where heresy (opposition to the Leader) is punished by banishment from the party and political exile. Democracies have this cardinal virtue: as the philosopher Karl Popper put it, governments can be replaced in a bloodless way, acting as a salutary check on the hubris and vaingloriousness of potential autocrats.

Authoritarian predisposition:

The megalothymic personality is quite likely to display authoritarian tendencies. What encourages this trait in him is the display of an authoritarian predisposition in the population he rules over. Karen Stenner (The Authoritarian Dynamic) has pointed out that, in times of perceived normative threats, this authoritarian disposition is activated and leads to support for the authoritarian who promises a return to a secure, glorious past. Support of the majority of the population is not required; it is enough if a vocal, aggressive section of the population backs the autocrat, with the rest of the population either too divided or disinterested in offering any meaningful opposition. The minority then employs extra-constitutional, vigilante methods to terrify the general population through its unpredictable responses, as Hitler’s Storm Troopers did in the early years of his rise to power.

Exclusivist ideology

The regime of the strong man requires the development of an insular approach, with the ‘other’ identified as the source of threat. Policies are tweaked to restrict the freedoms available to specific groups, related to association, livelihood, movement and expression. Media outlets are encouraged to spread an atmosphere of fear and insecurity. The results are already visible in the world’s two largest democracies, where vigilante groups and individuals are dispensing “street justice” to the victims of their ire, innocent citizens who are merely going about their daily lives.

Institutional capture

Institutional capture begins with the electoral process. Adverse domestic economic conditions, an insecure external environment, joblessness, inflation and (increasingly in many countries) a harkening back to past glories, religious dogma and perceived historical injustices bring electoral majorities to the strong man. With the legislature under control, other institutions are subtly subverted. The media, which is already overwhelmingly under business control, is slowly moulded to conform to the vision of the strong man and to hail the utopia he is bringing about. Packing the senior judiciary with persons whose ideological stances mirror those of the ruling dispensation enables dilution of the one check on executive power. The civil service is kept in line through side-lining independent professionals and promoting those committed to the ruling ideology. Above all, the control over pedagogic content is ensured through staffing educational institutions with loyal apparatchiks and rewriting history to mould the minds of the coming generation to accept a worldview vastly different from that of their preceding generation.

The emergence of the strong man in society after society comes at a time when liberal democracies are coming under increasing threat. Those who have benefited economically and socially from the efforts of past governments readily run down the achievements of these previous governments and place the blame for all ills on the inertia and corruption of the past. With a largely technocratic approach to life, and discounting the liberalism and pluralism that have been the fundamental bedrocks of prosperity, the citizens of the “Brave New World” yearn for certainty and security, forgetting that it is they who have the power to make or unmake their future. In this environment of disenchantment and hopelessness steps in the strong man fulfilling the dire prediction of Yeats “And what rough beast, its hour come round at last, slouches towards Bethlehem to be born?”

 

 

 

 

 

Posted in political economy, public affairs | Tagged , , , , , | Leave a comment

The commercialisation of nutrition – Maharashtra comes full circle

The flip-flops in India’s child nutrition policies are nowhere better exemplified than in the recent decision of the Maharashtra government to issue a tender for the supply of fortified ready-to-cook pre-mixes for feeding children, aged three to six years, in rural anganwadis.

Maharashtra has, for many years now, outsourced the supply of take home rations (THR) for mothers and children below the age of three years to so-called Mahila Sansthas that in turn have subcontracted this work to private manufacturers in the state and outside.

With the tendering for ready to cook pre-mixes, Maharashtra is turning the clock back on the important Supreme Court (SC) decision of 2004 that mandated state governments to serve hot cooked meals prepared by women self-help groups, or similar locally based women’s organisations, to children attending anganwadis.

What does this imply for the ICDS* supplementary nutrition programme and what are its likely ramifications?

Quality of food supply is the first and most important concern.
It is difficult to take at face value the tender stipulations that quality checks will be carried out by the supplier organisation at in-house laboratories. Nor can one take comfort from the provision for quality checks at independent laboratories ordered by the ICDS Commissioner. Public laboratories in India are notorious for delays in furnishing reports, enabling defaulters to get away.

The 2012 report of the SC Right to Food Commissioners to the SC highlighted the poor quality of THR supplies in Maharashtra. However, despite complaints about poor THR quality, no action has ever been taken in the past against politically powerful suppliers, either in Maharashtra or other states. In any case, public laboratories in India are notorious for delays in furnishing reports, enabling defaulters to get away.

There is also the issue of whether pre-mixes supplied to children will be as nutritious as hot cooked meals, apart from the question of palatability. Even adults who use pre-mixes to quickly rustle up upmaor sheera at home will testify that the pre-mixes’ taste is nowhere close to that of items prepared from fresh natural ingredients.

With a provision of only INR 6 per child per day, there is also the very real apprehension that the suppliers will be tempted to compromise on quality to maintain their profit margins.

Quantities of pre-mixes supplied to anganwadis, and used for meal preparation, will be the next issue.
At one time, probably about four decades ago, states such as Maharashtra and Gujarat set the standard for efficient, responsive administration. Unfortunately, these states too have degenerated in administrative efficiency and probity to the levels of their counterparts in northern and eastern India. The travesty that represents ICDS nutrition supplies in Uttar Pradesh has been well documented.

When the then Minister for Women & Child Development, Government of India pushed for commercial supply of food items in the ICDS in 2008, it did not meet with the approval of the Cabinet Committee on Economic Affairs (because it would open the doors to large-scale corruption).

The apprehensions of poor programme delivery are amplified by the top-down approach adopted in this tendering system. There is no mention anywhere in the tender document of social accountability through monitoring of supplies and service delivery by village level institutions like the gram panchayats, their health and nutrition committees and mothers’ groups, let alone their involvement in the process of meal preparation.

As one who was involved with the ICDS in Maharashtra through the first decade of this millennium, I can vouchsafe for the beneficial multiplier effects of involving local bodies from the Zilla Parishad to the Gram Panchayat, as well as local communities, in the management of child nutrition. In the present scenario, the pre-mix will be distributed from the project to the anganwadi, with no check on whether the right quantities are reaching the anganwadi.

Stipulations within the tender raise questions around corruption and the concentration of production among a handful of large players.
What is disturbing about the tender are the numerous conditions which straight away disqualify smaller groups from participating in the supply of nutrition to children. Although the tender document specifies that only women self-help groups, Mahila Mandals, Mahila Sansthas and village communities are eligible to bid, the requirements to be fulfilled by the successful bidder rule out the possibility of the tender being awarded to any small group.

There are onerous conditions regarding the high annual turnover needed to qualify, the need for a functional and operative licensed manufacturing unit and an in-house testing facility to test the quality of the premix. The three Mahila Sansthas that were awarded the THR contract had leased facilities for THR production from private agro-companies; ownership and operational control of the Sansthas as well as the companies were vested in the same family.

With the present tender also permitting the participation of Mahila Sansthas, there is ample scope for the same stratagem being employed to circumvent the SC rulings on contractors and private suppliers.

From an equity viewpoint too, the concentration of production in a few organisations denies economic benefits to a very large number of rural women’s groups, which earn their daily bread through the preparation of meals for children.

Ultimately, the issue boils down to whether government programme funds of about INR 2,500 crores should be channelled to a few organisations with, if previous experience is any guide, links to private producers.

Other states are adopting more equitable and empowering solutions
The move of Maharashtra to premix supplies comes at a time when other states are innovatively experimenting with public systems to improve nutrition supplies to mothers and children.

Karnataka has introduced eggs and milk in the daily diet for 3-6 years children, Orissa is promoting the cultivation of local millets and Chhattisgarh has improved its public distribution system to ensure regular food grain supplies to families.

As the foregoing discussion brings out, this policy serves neither the ends of efficiency (given the scope for possible quality and quantity aberrations), nor those of equity (concentration of supply in a few hands) or empowerment (with no role for participation of local governments and communities). Whether such a policy behoves a land that is the karmabhumi of Shahu Maharaj, Jyotiba Phule and Babasaheb Ambedkar is the question that ought to concern us today.

*ICDS (Integrated Child Development Services) is the largest programme in the world devoted to the care of pregnant and nursing mothers and children under six years of age.

This article was originally published on India Development Review (IDR), the country’s first independent online media platform for leaders in the development community. You can access the article here 

Posted in government, health & nutrition, political economy, public policy | Tagged , , , | 1 Comment

What trips street-level bureaucracy?

“There’s many a slip ‘twixt the cup and the lip.”  Nowhere is this proverb truer than in the government machinery of India that is tasked with the staggering responsibility of delivering various crucial services to the 1.3 billion inhabitants of this country.

Whether it is the police guaranteeing the security of the common citizen, the doctor attending to patients at the public health facility or the teacher imparting basic education to children in schools in remote areas, it is glaringly evident that citizens of India are being seriously short-changed in availing public services that are their inalienable right.

We in India, especially the middle class, are quick to blame the street-level bureaucracy (SLB) for faulty implementation of what we consider to be impeccably-designed policies.

Where does the truth really lie? An examination of the functioning of SLBs, covering anganwadi workers and their immediate supervisors in the Integrated Child Development Services (ICDS)*, reveals some home truths on where things are going wrong.

I. Policy vs implementation

The first unpleasant truth is that programmes as packaged in statutes and administrative regulations are not quite what the SLB implements on the ground. There are quite a few reasons for this:

Focus on a limited set of activities
While the ICDS manual prescribes several duties for the anganwadi worker, the ICDS machinery focuses only on supplementary nutrition provision to mothers and children. It excludes activities such as monitoring the growth of children, counselling of caregivers on health and nutrition, and early childhood education.

Food supply is the only concern of the officials of ICDS directorates and the departments at the state level. As a result, the anganwadi worker is considered to have done her duty if she has distributed take home rations (THR) to mothers and children aged under three, and handled cooked meals for children in the 3-6 age group.

Emphasis on paperwork versus outcomes
The anganwadi worker is also required to complete a huge load of paperwork on the supply of food and on the nutrition status of children, to be sent to her superiors every month. If these duties are completed and reports sent to the state and central governments regularly, there is no accountability for outcomes. For example, the nutrition status of children—as revealed by their height and weight measurements, which are critical for determining and addressing stunting and wasting in children below five years—is never addressed in a systematic manner.

II. Leakage in programme implementation

The second shocking fact lies in the subversion of the supplementary nutrition programme by the contractor-politician-bureaucrat nexus. An average Indian state has around 75 lakh children aged below six. With a provision of supplementary nutrition at a rate of INR 6 per day to each child, the annual bill works out to approximately INR 1,350 crore. This huge budget lends itself to manipulation by vested interests.

A recent LANSA study documents the systematic siphoning of public money in Uttar Pradesh through this programme. While a few packets of the THR (daliya) are distributed to families, the bulk of the supplies are sold as cattle feed, giving additional illegal income to the anganwadi worker. Silence is bought through the complicity of all those who are part of the supply chain.

The situation is not much better in respect of hot, cooked meals, where the proceeds of funds received (even if irregularly) are distributed among all stakeholders, including the anganwadi worker and the ICDS supervisor, with very little reaching children in the form of improved nutrition.

III. Socio-cultural barriers

Traditional social prejudices and behavioural patterns also adversely impact the messages being understood and acted upon. Two examples come to mind. Promoting early breastfeeding within an hour of birth has been recommended for a variety of reasons. However, social practices have often militated against this, with the belief that the child must be fed specific fluids before breastfeeding is initiated.

In the area of sanitation, proper hygiene practices and the absence of open defecation are known to promote the healthy growth of children. A recent study by Diane Coffey and Dean Spears has attributed the failure in restricting open defecation in India to social and cultural forces unique to the country. These are centred around religious practices of purity and pollution and the consequent reluctance to locate toilets in proximity to the house.

While these instances reflect the demand factor impacting the efficacy of public services, there are also supply aspects that affect client response to public services.

IV. Inadequate infrastructure

Irregularly functioning Primary Health Centres, which are often closed when the citizen has spent time and money to make her way there, act as a disincentive to use public health facilities. The problem is compounded when the health provider behaves indifferently, and/or demands illegal payments. Such experiences discourage citizens from using the facility and force many to shift to private doctors, sometimes of very dubious quality.

What is being done to address this?

India’s policy mandarins are frustrated by this lack of success at translating significant budgetary allocations and governmental effort into improved outcomes in different social sectors. They are, thus, increasingly seduced by direct cash transfers to clients and privatisation of health, education and corrective services.

However, this approach still begs the question: are citizens guaranteed access to improved services? There will still be need for regulatory agencies that monitor how private agencies function, including the quality and pricing of their services. Poor governance in direct management of public service delivery systems can easily transfer to equally poor oversight of private providers.

Take the case of the Universal Basic Income (UBI), which has caught the fancy of academics and policymakers in India. Apart from the vital issue of who will be entitled to UBI, and its fiscal implications, the question of fair and equal access to services critical to human health and development is still a moot point.

Is there a solution?

The few short-lived successes in child nutrition programmes in certain states have been the result of inspiring bureaucratic leadership, backed by political commitment. Unfortunately, results show only as long as the bureaucratic champion is around.

But long-term success in reducing key indicators of malnutrition, such as stunting and wasting, require sustained efforts to put in place functional systems that can operate irrespective of personalities and governments. These include:

  1. Evidence-based, nutrition-specific and nutrition-sensitive interventions, backed by committed government budgets and active participation of different government departments and agencies.
  2. Health and nutrition protocols that are scrupulously followed, with rigorous monitoring of child nutrition outcomes to ensure accountability.
  3. Empowering local governments and frontline workers and supervisors with financial and administrative authority to deliver meaningful outcomes.

Above all, the political and bureaucratic leadership in the various states must provide a conducive and supportive environment for the effective functioning of SLBs, something that has been sorely lacking till now.

*ICDS is the largest programme in the world devoted to the care of pregnant and nursing mothers and children under 6 years of age.

This article was originally published on India Development Review (IDR), the country’s first independent online media platform for leaders in the development community. You can access the article here

Posted in government, health & nutrition, political economy, public policy | Tagged , , | Leave a comment

Himalayan Blunders in Healthcare – Gorakhpur and Beyond

This article was originally published on Indus Dictum, a site where thought leaders from diverse fields, spanning business and technology to politics and modern law, contribute unique insights and experiences. You can access the article at https://indusdictum.com/2017/08/17/himalayan-blunders-in-healthcare-gorakhpur-and-beyond/

In a country which is seemingly inured to bad news, the news of the deaths of a large number of children, infants and adults in a major hospital in Gorakhpur, Uttar Pradesh (UP) was like an atom bomb being dropped. Predictably, the blame game started immediately, with every opposition party and every media hack trying to pin the blame on someone, preferably the head honcho of the state. The previous Chief Minister was loudest in his criticism, forgetting that he had presided over the destinies of the state (and its health systems) till just a few months ago. In this atmosphere of cynicism and one upmanship, we are in danger of losing sight of the disease and focusing merely on the symptoms.

Let us start with some visuals, which convey the bald facts about the state of amenities in the Paediatric and Neonatal Intensive Care Units (PICU and NICU) of the hospital in question, the Baba Raghav Das (B.R.D.) Medical College and Hospital, the major tertiary health facility in the city of Gorakhpur, the bastion of the present Chief Minister of UP. These are reproduced from a tweet from Rahul Verma (@rahulverma08) based on the replies to a Right To Information (RTI) query of 2011.


image 1 principal BRD Medical college RTI.png

Reply from the office of the Principal, B.R.D. Medical College, to an RTI application.


The RTI reply of early 2012 gives telling evidence about the lack of facilities in the hospital (in particular, the non-functioning of critical life-saving equipment because of poor maintenance) and the significant staff shortages in both medical and nursing staff. Although this is a slightly dated reply, there is little reason to suppose that matters have greatly improved in 2017, given the disclosure that lack of oxygen supply to children and neonates could possibly have been a prime cause of the large number of deaths.


image 2 staffin shortage.png

Staffing shortages in medical and nursing personnel (Jan 2012)


The reply, which is signed by the Head of the Department of Paediatrics of the hospital, shows that 50% of the qualified medical posts are unmanned and 40% of the nursing posts are not filled in. Even more disheartening is the state of affairs in respect of critical equipment in the ICUs. The incubators, pulse oximeters and infant ventilators are not working, while 16% of the cardiorespiratory monitors are non-functional.

Only a detailed enquiry will (hopefully) establish the truth of the allegation that one of the primary causes for the deaths was, apart from encephalitis, the shortage of oxygen supply in the paediatric and neonatal wards. I am not too sanguine about the truth in this regard coming out given the conflicting statements from politicians, doctors and bureaucrats on when payments were released to the oxygen supplier and on whether oxygen shortage was in fact responsible for the deaths.


status of equipment and machinery.jpg

Status of equipment and machinery in PICU and NICU.


But the issue goes far deeper than that of lack of oxygen supply alone. It is a pointer to the systemic rot in UP’s public institutions and in its systems of governance, a malaise that can be seen across institutional structures in different Indian states. Nowhere is this better exemplified than in the condition of India’s health systems.

UP’s public health care systems do not reach many of its citizens, especially the most vulnerable. This is partly due to the low percentage of public expenditure on health systems, as reflected in a 33% to 40% shortfall of over 31,000 health sub-centres, over 5000 primary health centres and 1300 community health centres in the state (as reported in the Financial Express). On top of this is the abysmal functioning of even such public health care institutions as do exist at the primary and secondary levels and the resultant lack of confidence of the public in these facilities. With primary and secondary public healthcare services not adequately available in Gorakhpur and its neighbouring districts, Sant Kabir NagarSiddharth NagarMaharajganjKushinagar and Deoria, the public is forced to come to a tertiary care facility even for ailments that can be treated at lower levels. A large hospital that already suffers from shortage of funds and skilled manpower, poor management, and corruption, is thereby further overburdened. The National Family Health Survey of 2015 (NFHS-4) data reveals the poor quality of health services that mothers and children receive. While 5% to 10% of mothers receive full antenatal care, medical check-up of neonates in the first two days after birth ranges from 9% to 25%. About 66% of children in the 12-23 month age group are fully immunised in Gorakhpur and Deoria districts, with the percentage falling to just over 40% in the other four districts.

Not surprisingly, then, rates of child undernutrition, morbidity and mortality, as well as maternal mortality rates (MMR), are high in this region. Mortality rates of under-5 children vary from 76 to 116 per 1000 live births and of infants (0-1 year) from 62 to 87 per 1000 live births, with 80% of the infant mortality rate being accounted for in the first 28 days after birth. Stunting and underweight rates in under-5 children exceed 40% and 32%, with well over 10% of children falling in the wasting category. MMR in the Basti and Gorakhpur mandals, where these districts are located are 304 and 302 respectively per 100,000 live births (all mortality figures are taken from the Annual Health Survey 2012-13 of Uttar Pradesh, conducted by the Census Commissioner of India and undernutrition figures from the NFHS-4 data). All these figures are distressingly high and place many of UP’s districts in the same league as war-torn states of Africa in health and nutrition indicators.


gorakhpur tragedy hospital doctors watermark.png


The underlying morbidity and mortality proneness of the population in this region, especially its children, is exacerbated by the surrounding external environment. In their recently published book, Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste, Diane Coffey and Dean Spears have highlighted the contribution of the practice of open defecation to high stunting rates in children. Open defecation has persisted despite the Swachh Bharat Abhiyan, because of the notions of pollution associated with latrines in the house and the reluctance to empty the pit latrines. The Japanese Encephalitis (JE) virus, to which a large number of the present deaths are attributed, is spread by the Culex mosquito breeding in the swampy paddy fields which are a feature of eastern UP. With traditional immunisation rates themselves being low in this region, it should be self-evident that the two doses of the JE virus immunisation are also not covering a significant portion of children. Insanitary conditions coupled with poor immunisation rates and failure to reach health care early to affected persons – especially children – constitute a lethal combination that contributes significantly to high mortality rates.

This deadly cocktail of factors is aggravated by the endemic corruption in the health and nutrition sectors in UP. The scam in the National Rural Health Mission in UP has been facilitated by politicians and highly placed bureaucrats, including some from my former service, the IAS. Fictitious purchases of medicines for which payments were made were facilitated by doctors and officers of the health department in collusion with suppliers. This disease is by no means confined to UP: nearly every state in India is prone to this syndrome, given the centralisation of purchase powers in the state secretariats. In fact, the purchase of medicines is mostly made keeping in mind the interests of politically-linked powerful suppliers, with no analysis of the disease and illness pattern in different areas of the state, which would enable a scientific assessment of the type and quantum of medical supplies required. States are loath to adopt the pattern of Tamil Nadu, which set up the Tamil Nadu Medical Services Corporation over two decades ago to streamline the procedure for procurement, storage and distribution of essential drugs and medicines to government medical institutions throughout the state. UP has a similar scam operating in the ICDS sector, which is meant to provide wholesome take home rations to mothers and under-3 children, and hot cooked meals to children in the 3-6 year age bracket. A recent LANSA study details the systematic misappropriation of huge sums from the ICDS budget for lining the pockets of the politician-bureaucrat-contractor nexus.

Once again, in the ritual breast-beating that is going on in the media, there is the real danger that we will revert to the “business as usual” approach after a short hiatus. The Harvard economist, Lant Pritchett, characterised India as a “flailing state”, not quite failed like many of its Asian and African confrères but where accountability is extremely weak and where there is little control of the head over the limbs of the state. Even this is a very charitable interpretation given that, in the Indian context, the limbs behave just as the head dictates. What I wish to highlight is the need to focus on systemic processes and institutions rather than personalities and political formations. As the preceding paragraphs seek to establish, a combination of factors – man-made and natural – have contributed to the ongoing crisis in India’s health systems. Rather than looking for temporary scapegoats, the need for an overhaul of the system is overdue (one possible solution is outlined by the Foundation for Democratic Reforms). The acid test for the new government in Uttar Pradesh has arrived, whether it will tread the same beaten track of its predecessors or chart a new path to governance and the arrival of achhe din in UP. Else, we will be left to exclaim “Even you, Brutus?”

Posted in health & nutrition, political economy, public affairs, public policy | Tagged , , , , , , | 1 Comment

The Indian Political League

This article was originally published on Indus Dictum, a site where thought leaders from diverse fields, spanning business and technology to politics and modern law, contribute unique insights and experiences. You can access the article at https://indusdictum.com/2017/08/10/the-indian-political-league/

The match went down to the wire… ultimately, the winner was decided by the third umpire. No, I am not referring to a close finish in a cricket T20 match, but to the results of the Rajya Sabha polls in Gujarat. Like its acronymic twin, the Indian Premier League (IPL), the Indian Political League (IPoL) is today’s greatest spectator sport for the ten months of the year that the cricket IPL is not in operation. Indians have an abiding interest in these two spectator sports: cricket and politics. Spectator, because most have never played the game and because both circuses (like the Roman ones) provide titillation on an almost continuous basis, given the ubiquity of cricketing and political contests in the subcontinent.

I thought we Bharatvasis had had more than our fill of political spills and thrills after the Yadav father-son battle in Uttar Pradesh, the coronation of a religious head as Chief Minister in the same UP, the internecine struggle for power in Tamil Nadu after Amma’s departure and the “about-turn” change of government in Bihar. I was wrong: we are now in a perpetual silly season, where political shenanigans in different states dominate the public consciousness, titillated by the blow-by-blow descriptions given on a round-the-clock basis by screeching reps of the electronic media. As Gujarat has shown, we need our daily dose of Bollywood-style drama, replete with Bengaluru resorts, income tax raids and exciting polling processes coupled with hysterical scenes outside the Election Commission in New Delhi.

The IPL is, of course, still in its childhood (nine years and counting) as compared to its hoary grandfather, the IPoL, which has entered its sixty-sixth year of life. The IPoL, in the first fifteen years of life, was somewhat staid in appearance, resembling Indian cricket of that time, when test matches were the only source of entertainment for the masses. Things became far more exciting when legislators started defecting en masse on an almost daily basis after 1967, giving rise to the popular Aaya Ram Gaya Ram phenomenon. Elections also ceased to be once-in-five-year affairs and, with the delinking of Parliament and State Assembly elections, were held year in and year out. Things have become far more exciting in the past four decades, ever since the Congress Party’s dominance in the political hustings was successfully challenged, much in the same way that Bombay’s stranglehold over the Ranji Trophy was loosened by upstarts like Delhi and Karnataka.

But it is the similarities in the IPL and IPoL that command our interest and attention. An examination of these highlight both the features that the two have in common as well as the ways in which, with its infinitely superior financial resources and experience, the IPoL has managed to straddle universes that are outside the reach of a modest IPL.


ipl auction watermark


Everything starts with the auction of players. However, unlike the annual or biennial auctions in the IPL, the IPoL auctions are continuous in nature. These auctions are conducted by the team managements themselves and are held on camera. Unlike the IPL, there is no way to know the cost of each player to the team. In earlier days, especially after anti-defection laws were passed, auctions took place only at specified intervals, when elections or by-elections were due. Nowadays, the trend is towards mass auctions of large portions of a team, rather than individuals. After a match (read election) is over, even an entire competing team can be merged with the existing team (think Goa and Manipur).

What keeps the players in the IPoL engaged continuously are the opportunities given to them to twist the rules of the game to keep adding to the moolah already given to them at auction time. Even before the match starts, there are chances available to seduce the ground staff to prepare a pitch conducive to one’s strengths. These could include freebies distributed recklessly prior to the election or illegally transferred just prior to the start of the match. The players would not be averse to nobbling the on-field umpires as well: to their eternal regret, the umpires (the Election Commission and its paraphernalia) have proved immune to blandishments.

But nothing stops the players of one team from influencing the opposing team members, given that the open auction system is in place. The match can then be suitably fixed, with all the 22 players going through the motions of a keenly contested match. Even measures like shepherding all the players of one team to a hidden sanctuary prior to the match and producing them only at match time are often futile, given the ubiquity of mobile phones. Where phones are confiscated, there is nothing to prevent signals being given on field to compromised players, as was the case in IPL matches (and as was so wonderfully demonstrated during the Gujarat Rajya Sabha elections). The unsuspecting public is generally unaware of the charade, though it does wonder sometimes why its favourite batsmen are throwing their wickets away. The match-fixers — the management, the players and their backers and financiers — are reaping the rewards of the crowd attendance, through revenues from crowd payments (taxes, etc.) as well as from the extra-legal earnings through inflated infrastructure and supply contracts.


ipl stadium watermark


The only flies in the ointment for the players in the IPoL are the oversight authorities in the form of the Election Commission and the courts of the land. The players have a code of omertà between themselves, known more commonly as “honour among thieves”. Knowing that matches can go either way, depending on the quality of manipulation by both parties, the best option is to keep silent on the transgressions of one’s opponents, in the hope (and trust) that the favour will be reciprocated at the opportune moment. When nemesis does catch up in the form of a whistle-blower, an enthusiastic judge or a conscientious civil servant, the indicted players rely on the lumbering judicial system and the loopholes of the law to stay out of prison as long as possible.

This then is the “saam-daam-dand-bheda” approach, attributed to the astute Chanakya, that is the governing philosophy of the IPoL. It starts with friendly advice to opponents to join the current popular dispensation while the going is good. Where moral suasion is insufficient, the lubrication of lucre is added to sweeten the deal, either in the form of upfront payments or deferred gratifications in terms of dabbling in patronage and sharing in the spoils. The unmoving opponent is then subjected to the travails of the legal system, through innuendoes and insinuations leading to registration of cases and protracted litigation that could go on for decades, punctuated possibly by stretches in prison. It helps that most players in the IPoL have a past that renders them vulnerable to such pressures.

The final tool is the “divide and rule” strategy that has been perfected over the centuries by our colonial masters. The IPoL players are masters at winning the support of important segments of the crowd by exploiting differences in language, religion, caste and ethnicity. And so, the game goes on “to the last syllable of recorded time” as lamented by Macbeth. It is apposite that his soliloquy ends with the statement “It is a tale told by an idiot, full of sound and fury, signifying nothing.” His ruminations would find favour with our ancient sages, who saw this life on earth as maya. And yet, we go through the illusive make-believe, the political dramas that characterise our petty lives.

Posted in irony, political economy, public affairs | Tagged , | Leave a comment

WHEN SILENCE IS NOT AN OPTION

(The full version of the open letter of 10 June 2017 can be accessed at the wire.in)

Sixty-five retired officers from different services came together in early June 2017 to pen an open letter to the public expressing their disquiet at the growing aggression in all forms of public discourse, the open expression of intolerance of the ‘other’ as well as the easy categorisation of all dissent as ‘anti-national’. These officers between them represent over two thousand person-years of public service in various capacities in state and central governments as well as overseas. What really motivated them to move from their quiet, retired environs into the public gaze, knowing fully well that there is a substantial constituency that would run down their motivations, vilify their reputations and seek explanations for their questioning society (and, by implication, the governments of the day) for acquiescing in, if not actively promoting, an environment that fosters animosity and hatred for one’s fellow human beings and a dogged desire to enforce conformity of behaviour in social and cultural norms, right down to personal choices in respect of food, relationships and dress?

For there is no doubt that the trolls and Doubting Thomases have crept out of the woodwork to attack the recent effort with renewed vigour. The assaults focus on the usual reasons:

  • Why did these officers not raise their voice in the past to instances of vigilante violence and misuse of authority by the state apparatus?
  • Many of them must be officers beholden to the past regime for favours granted to them or must be disgruntled at not being considered for plum post-retirement sinecures by the present dispensation.
  • Did these officers take questionable decisions in their different assignments while in service?
  • Having ruined the country over seventy years with their maladministration of public affairs, these retired officers now seek to demoralise the present government and place obstacles in the way of its effective functioning.

Answering these four issues may cast light on why persons who hung up their boots years ago have deemed it necessary to listen to their inner voices.

Those who point to the apparent failure of these retired officers to agitate issues in the past forget that these officers (and many of their colleagues) observed the dharma of organisational discipline while in service. Opposing wrong decisions does not require rushing to the press at the first opportunity, though this unfortunate trait has been observed increasingly in recent years. There are several ways of standing up to blatantly wrong political decisions: persuading the politician to change her decision, pointing out one’s inability to implement the decision and, therefore, accepting a transfer. It is not correct to say that retired officers have not expressed their reservations over government actions (and inaction) in the past, be it the 1984 anti-Sikh pogroms, the 1993 Bombay riots or the 2002 Gujarat episode. If retired officers did not come together often to voice a collective protest in the past, it was because events did not follow a predictable pattern at that time. The current hype built up over the dietary habits of a substantial section of the population and the efforts to restrict these, the aggressive responses to perceived threats to the nation and the repeated questioning of the loyalty of significant segments of the population by responsible public figures are a recent phenomenon. Many of the signatories have served in vulnerable areas at times when the nation faced both internal and external challenges. But never in the past was the atmosphere cranked up to such a fever pitch as is the case at present and certainly not at the cost of disrupting what is still a relatively delicate social fabric.

I am not ruling out that, like elsewhere in society, some of my fellow officers cultivate an unhealthily close relationship with political patrons. Speaking for my fellow signatories, I am sure that they are not in the game of repaying favours. Most of us worked under different political dispensations: I, for one, have worked with politicians of all the four major political parties in Maharashtra. While maintaining friendly ties with all, we have kept our distance from developing too cosy a relationship with any one political outfit: call it the survival instinct, if you will. We were aware of, and dismayed by, the aimless drift of the previous regime and the difficulties in working with some of the worthies of that coalition government. It amuses many of us that we are perceived as hankering after the fishes and loaves of office post our retirement. A look at the list of signatories reveals that a significant number of them resigned or prematurely retired from government service to pursue their passions or private avenues of employment. Even those who did occupy positions in the immediate post-retirement period were fully aware of the fact that 65 (that magic number again!) was the upper age limit for gainful employment, unless you were fortunate enough to be destined for governorships, ambassadorships or a political career. In any case, a disgruntled person still harbouring ambitions would be shooting herself in the foot by signing such a letter.

The easiest way to target a person is to cast aspersions on his/her character and integrity, especially in relation to decisions taken while in service. It is always easy to be an ex post facto guru, pointing out the apparent errors committed in the past. What is forgotten are the circumstances at the time the decision was taken, the processes followed in arriving at the decision and the quality and quantum of information available to the decision-maker at the relevant time. The civil servant lays no claim to infallibility: s(he) can only vouch for her/his bona fide actions while arriving at a decision. In any case, the issues presently at stake are of a nature where passing of judgments on the past actions of a signatory are of no relevance.

The final charge against us merits the closest attention and rebuttal. Politicians of all hues find it most convenient to blame civil servants for faulty policies, forgetting their role in contributing to the state of affairs. Unfortunately, the aam janata, stuck as it is between the Scylla of one political party’s rule (in one five-year tenure) and its opposing party’s rule (in the next five years) has no further options and lays the blame at the doors of the civil service. Where has the political class provided the inspiring leadership to motivate and guide the civil service to deliver great results? My seniors of the Nehruvian era and those of us fortunate enough to participate as (minor) actors in the immediate post-1991 period recall the enthusiasm in the civil services in putting together and implementing plans and programmes for economic development and change. There are many dynamic officers who innovate and bring change in their districts and departments. Alas, there is little publicity for these efforts, especially in the rarefied precincts of Lutyens’ Delhi and Dalal Street. The last thing any retired officer would do is to run down the government of the day. S(he) knows the constraints governments work under, especially at the state level, and always hopes and prays for rapid development and improvement in living standards of her/his countrywomen/men.

What has dismayed us is the approach (or rather, the lack of it) to building a social consensus on issues critical to the survival of the common woman/man. India has, unfortunately, never had participatory governance: the trend towards centralisation has been amplified in recent times, whether it be currency demonetisation, regulation of cattle slaughter or ensuring the dignity of women. Matters are not helped when public functionaries routinely ventilate historical grievances and seek to lecture the public on social norms and traditions. An aspirational society with a positive demographic dividend is routinely fed with tales of past glory (with a specific religious bent), rather than developing a scientific, analytical approach to life that can meet the unpredictable challenges of the twenty-first century. Above all, those controlling the levers of power seem to have conveniently forgotten the intricate mosaic of social and economic relationships that are the hallmark of a pluralist society. Imposing uniformity and conformity will stultify society and severely damage entrepreneurial abilities. At a time when fundamentalism and religious obscurantism are gaining a toehold (and more) all over the world, it behoves India, as one of the world’s most ancient, tolerant civilisations, to act as the beacon for guiding the world through increasingly stormy waters. Our open letter is an appeal to our fellow countrywomen/men to realise their oneness with all humanity and promote compassion, love and peace rather than intolerance, hatred and violence.

Posted in government, political economy, public affairs, public policy | Tagged , , | 5 Comments