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Archives for : Millennium Development Goals

MDG Report 2014: India among worst performers in poverty reduction, maternal death and sanitation

Author(s): Moushumi Sharma 
Date:Jul 9, 2014

Report shows good progress in areas like poverty alleviation and access to clean water and controlling diseases like TB, Malaria

imageSome MDG targets, such as increasing access to sanitation and reducing child and maternal mortality are unlikely to be met before the deadline

The United Nations (UN) released this week the Millennium Development Goals (MDG) Report, 2014. The report, launched by UN secretary-general Ban Ki-moon, says that many of the development goals have been met or are within reach by 2015.

The report is the latest finding to assess the regional progress towards the eight developmental goals that the UN targets to achieve by 2015, including eradication of extreme poverty and hunger, achieving universal primary education, promoting gender equality and women empowerment, reducing child mortality, improving maternal health, combating HIV/AIDS, malaria and other diseases, ensuring environmental sustainability and developing a global partnership for development.

Progress slow but target possible
Ban Ki-moon has lauded the progress so far, saying that many global MDG targets have already been met. The report states that extreme poverty in the world has reduced by half; over 2.3 million people gained access to clean drinking water between 1990 and 2012; gender disparities in school enrollment in developing nations have been eliminated to a large extent; and political participation of women has increased. The report maintains that if the current trend of progress continues, the world might surpass MDG targets on malaria, tuberculosis and access to HIV treatment. An estimated 3.3 million deaths from malaria could be averted between 2000 and 2012 due to substantial expansion of malaria intervention programmes, while intensive efforts to fight tuberculosis have saved an estimated 22 million lives worldwide since 1995.

But it is too soon to celebrate. According to the report, some MDG targets, such as reducing child and maternal mortality and increasing access to sanitation, are unlikely to be met before the deadline.

India’s dismal performance
India’s progress has been below the mark on the parameters of poverty, child and maternal mortality and access to improved sanitation. In 2010, one-third of the world’s 1.2 billion extremely poor (32.9 per cent) lived in India alone. The poverty figures for the same year for Nigeria and Bangladesh, two countries less developed than India, were 8.9 per cent and 5.3 per cent respectively.

A recent study by an international non-profit ranked India 137th among 178 countries when it comes to maternal and child health, categorising the country among the worst performers (Read: India among worst performers in maternal and child health). The UN report states that India had the highest number of under-five deaths in the world in 2012, with 1.4 million children in the country dying before age five. This is shameful when one takes into account notable reductions in the under-five mortality rate since 1990 and particularly since 2000 in low-income countries such as Bangladesh, Ethiopia, Malawi, Nepal, Niger, Rwanda, Uganda and the United Republic of Tanzania.

While the global maternal mortality ratio (MMR) dropped by 45 per cent between 1990 and 2013, India still accounts for 17 per cent of maternal deaths. India’s MMR target for 2015 is to bring down maternal mortality to less than 109 deaths per 100,000 live births. But only three states—Kerala, Tamil Nadu and Maharashtra—have so far been successful in reaching this target (Read: India nowhere near millennium goal for maternal mortality.

The UN report further states that MMR in developing regions—230 maternal deaths per 100,000 live births in 2013—was 14 times higher than that of developed regions, which recorded only 16 maternal deaths per 100,000 live births in the same year. It maintains that the best possible way of reducing neonatal mortality is through greater investment in maternal care during the first 24 hours after birth.

Scourge of open defecation
Between 1990 and 2012, two billion people worldwide gained access to improved sanitation, but a billion people still defecate in the open. A vast majority of the world’s population—82 per cent—resorting to open defecation live in middle-income, populous countries like India and Nigeria.

Official data on open defecation in India will put any country to shame. The country has the world’s largest population that defecates in the open. (Read: Mission possible. According to data released by the National Sample Survey Office in December 2013, 59.4 per cent of the rural population resorted to open defecation. 2011 Census figures put the number of rural houses without toilets at 113 million.

To make matters worse for the country’s reputation, a recent study conducted by the Research Institute for Compassionate Economics, Uttar Pradesh, claims that in 40 per cent of rural households in Bihar, Madhya Pradesh, Uttar Pradesh, Haryana and Rajasthan, which have a functional toilet, at least one member chose to defecate in the open. At least 30 per cent of the world’s population, which defecates in the open, live in these five states alone (Read: Despite having toilets at home, many in rural India choose to defecate in open.

Hope for the future
Presenting the report, Ban Ki-moon said that the world is “at a historic juncture, with several milestones before us”. He underscored that the report makes clear “the MDGs have helped unite, inspire and transform…and the combined action of governments, the international community, civil society and the private sector can make a difference”. “Our efforts to achieve the MDGs are critical to building a solid foundation for development beyond 2015. At the same time, we must aim for a strong successor framework to attend to unfinished business and address areas not covered by the eight MDGs,” the UN chief said.

Read mor where- http://www.downtoearth.org.in/content/mdg-report-2014-india-among-worst-performers-poverty-reduction-maternal-death-and-sanitation

 

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#India – Rape accused Kurien heads for global meet on women #WTFnews #Vaw

Undeterred by Oppn boycott back at home, Rajya Sabha deputy chairman will be the lead speaker at the mega event

dna correspondent @dna

New Delhi: Rajya Sabha deputy chairman PJ Kurien, who is battling rape charges, would represent India at a global conference to discuss issues related to women and their empowerment. The conference is being attended by 60 parliamentarians from world over.
After Congress refused to dismiss Kurien last February, after the resurfacing of the Suryanelli sex scandal case which has rocked Kerala off and on since 1996, opposition parties in Rajya Sabha have decided not to allow him to preside when the House discusses issues related to women.
The case relates to abduction and serial rape of a 16-year-old schoolgirl of Suryanelli in Kerala by 42 men over 41 days in January-February 1996.
Undeterred by the charges and opposition boycott back home, Kurien will deliver the inaugural address at the 3rd Global Women Deliver conference at Kuala Lumpur, capital of Malaysia.
The event will be attended by the prime minister of Malaysia Datuk Seri Najib Razak among other dignitaries.
The three-day conference from May 28 is touted as the largest global event of the decade to focus on the health and empowerment of women.
Women Deliver is a global advocacy organisation bringing together voices from around the world to call for action to improve the health and well-being of girls and women.
Besides, the European Parliamentary Forum on Population and Development in cooperation with its sister parliamentary networks in Africa, Asia and America will organise a parliamentarians forum during the conference.
The three-day event will also review the progress of Millennium Development Goals, whose deadline of 2015 is fast approaching.

 

 

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NAC Working Group on Universal Health Coverage Final Recommendations

09th May, 2013
The National Advisory Council had constituted a Working Group of its Members on “Universal Health Coverage”. The Working Group looked into the issue to propose measures to ensure quality health coverages to all the citizens which are equitable, affordable and unviersal.
02. The Working Group has had several rounds of consultations with the concerned central Ministries, senior officers of the State Governments, Civil Society and Experts. Based on the consultations, the Working Group has come up with the set of draft recommendations in this regard.
03. The draft recommendations of the Working Group are now placed in public domain for comments.
 
 
Comments may be sent to the Convener of the Working Group of NAC by 25th May, 2013 by email at [email protected] 

 

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World Health Statistics 2013 show narrowing healthgap

 


World Health Organization – May 2013

Available online at: http://bit.ly/12uJNUs

“….15 May 2013 – The world has made dramatic progress in improving health in the poorest countries and narrowing the gaps between countries with the best and worst health status in the past two decades, according to the World Health Statistics 2013. “Intensive efforts to achieve the Millennium Development Goals have clearly improved health for people all over the world,” says Dr Margaret Chan, Director-General of WHO.


World Health Statistics 2013 contains WHO’s annual compilation of health-related data for its 194 Member States, and includes a summary of the progress made towards achieving the health-related Millennium Development Goals (MDGs) and associated targets.

This year, it also includes highlight summaries on current trends in official development assistance (ODA) for health.

Progress on the health – Available in 3 languages English French Spanish

DOWNLOAD THE REPORT IN ENGLISH, BY SECTION

 

Table of contents and introduction

Part I. Health-related Millennium Development Goals

Part II. Highlighted topics

Part III. Global health indicators

Annex 1: Regional and income groupings


THE INDICATOR COMPENDIUM

World Health Statistics 2013 – Indicator compendium

 

 

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Apply Now- India Youth Fund #mustshare

 

What is the India Youth Fund Window? The India Youth Fund Window is a joint program between UN-Habitat and Narotam Sekhsaria Foundation to support urban youth in India with the aim of advancing the achievement of youth empowerment, the Millennium Development Goals, and the Habitat Agenda. The India Youth Fund Window is a specific funding mechanism under the UN-Habitat Urban Youth Fund for Indian youth financed by the Narotam Sekhsaria Foundation.

 

Who can apply for grant? Youth-led groups based in India where majority (50% and above) of the management and board are aged between 15 and 32 years may apply for the India Youth Fund Window. The youth group has to be registered for at least one year before the application deadline (15th April). Projects must be implemented within an urban area as defined by the Census of India.

 

How do I know whether the place I am planning to do my project is a city or town? For the India Youth Fund Window, an urban area is defined as:

  • All places with a municipality, corporation, cantonment board or notified town area committee etc.

All other places which satisfy the following criteria:

  • Minimum population of 5000;
  • At least 75% of male working population engaged in non-agricultural pursuits; and
  • A density of population of at least 400 persons per sq km (1000 per sq mile).

 

You may also want to use Google or other search engines to check the population of your city or town. The information may also be available with your local administration.

 

What are eligible organizations? Organizations must have been legally registered for at least one year. They must be non-profit, non-government (NGOs or CBOs) and youth-led. They must have a valid bank account. They must involve girls and young women at all levels of decision-making.

 

What is an NGO? A Non-governmental Organization (NGO) is a legally constituted organization that operates independently from any government. The term is usually applied only to organizations that pursue some wider social aim.

 

What is a CBO? Community organizations (sometimes known as community-based organizations) are civil society non-profits that operate within a single local community. Like other nonprofits they are often run on a voluntary basis and are self-funding.

 

What organizations are not eligible? Organizations that carry out religious evangelization and organizations affiliated with political parties are not eligible. Organizations where the majority of staff and board members are not aged between 15-32 years are not eligible.

 

What projects are supported? Youth-led Development involves young people actively creating a better future for themselves and their communities, usually based at the grassroots level and are largely carried out by youth volunteers. Initiatives address a broad range of community needs such as health, employment, access to affordable housing, secure land tenure, safer cities and participation in decision-making. The objective of the project is also to develop valuable skills of management, teamwork etc among young people and boost their ability to acquire jobs and participate actively in society.

 

Is it compulsory for my organization to involve girls and young women? Yes! The Urban Youth Fund aims for gender equality and applicant organizations should therefore engage both female and male youth equally in the implementation of the project and among the beneficiaries. Organizations that do not involve girls and young women are not eligible.

 

What is the amount of the grants? Youth-led projects may receive grants of up to INR 8 Lacs.

 

How much does it cost to apply? Nothing! The India Youth Fund Window will not require you to pay any fee during the entire process of your application.

 

Can I apply for more than one project? No! Organizations can submit only one application for each annual deadline. Organizations may however, apply for the Fund the following year if not successful. Organizations that apply for more than one project will be disqualified.

 

When and where will the results be announced? The results will be announced on the Urban Youth Fund website: www.unhabitat.org/youthfund and the Narotam Sekhsaria Foundation website:www.nsfoundation.co.in on before 15th October (within six months of the application deadline). Successful applicants will be individually notified by e-mail.

 

How do I apply for a Fund grant? The application form is available online at http://unhabitatyouthfund.org. To access it, you have to first register on the front page, and then download the application guidelines and application form.

 

 

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Violence Against Women Persists in #Bangladesh #VAW

By Naimul HaqReprint |       |  Print | Send by email |En español
Violence against women is on the rise in Bangladesh. Credit: Naimul Haq/IPSViolence against women is on the rise in Bangladesh. Credit: Naimul Haq/IPS

DHAKA, Oct 17 2012 (IPS) – Bangladesh, often cited as a model of progress in achieving the United Nations Millennium Development Goals (MDGs), appears to be sliding backwards when it comes to dealing with violence against women (VAW).

Police statistics and assessments by non-government organisations (NGOs) working to establish women’s rights show that there is in an increasing trend in VAW.

According to police records, while there were 2,981 cases of dowry-related violence in 2004, the figure has already hit 4,563 in the first nine months of 2012. Also, where there were 2,901 rape cases recorded in 2004, the figure for the current year, up to August, stands at 2,868.

Farida Akhtar, an internationally known rights activist, told IPS that the disturbing aspect of this rising trend in VAW is that it is “taking on different deceptive forms that go beyond the statistics.”

“When women are better aware of their rights through education, and want to assert them, they suffer violence,” said Akhtar, a founder of the NGO, ‘UBINIG’, acronym for ‘Policy Research for Development Alternatives’ in the Bangla language.

With school enrolment at 95 percent, Bangladesh is well on track to achieving the MDGs that deal with gender parity in education by 2015. But gender equity and women’s empowerment are another matter.

Akhtar said there is evidence that Bangladeshi women are now facing more mental torture than before. “Unfortunately, mental torture cannot be quantified and often goes unreported. But, the fact that suicide is the biggest cause of female deaths in this country is telling.”

Women’s rights leaders say that atrocities go unreported because of fear of harassment by religious or political leaders and, of the cases that are registered, a large number end up being dismissed as false allegations.

Police data show that 109,621 complaints of various forms of VAW were lodged during the 2010-2012 (up to August) period.  Of these, 18,484 complaints were taken into cognizance, but only 6,875 cases were deemed ‘genuine’ and fit for further proceedings.

Mohammad Munirul Islam, additional inspector-general of police responsible for dealing with crimes related to VAW at the police headquarters, told IPS, “On many occasions our investigations showed that the law was used to harass the accused. It does seem that not all complaints are genuine.”

Afroza Parvin, executive director of Nari Unnayan Shakti, a women’s rights NGO, told IPS, “Due to better awareness female victims have learnt to raise their voices, but stop short of seeking police help. During our 20 years of experience on VAW we have found that police often do not cooperate with victims and favour the accused.”

Leading women’s movement activist Shireen Huq says that the main difficulty is that of “establishing a prima facie case for lack of eye witnesses, evidence, etc., with the result that the accused are easily acquitted and cases are recorded as false.”

Huq, who is also a founder member of Naripokkho, a local NGO, told IPS that “no matter what the offence or what the form of violence, police and lawyers find it convenient to file the complaint under ‘torture for dowry’, and since this is a non-bailable offence we often hear of the elderly parents of the accused being arrested.”

Failure to fulfill dowry demands is a major cause for VAW in Bangladesh. On average 5,000 complaints of dowry are recorded annually. In 2010, police reported 5,331 cases of dowry, which jumped to 7,079 in 2011.

Despites the debates, official statistics show that VAW continues unabated and many complaints are dismissed without justice. Data from Bangladesh National Women Lawyers’ Association (BNWLA) show that of the 420 recorded rape cases in 2011, only 286 reached the prosecution stage.

Salma Ali, executive director of BNWLA, told IPS that one of the difficulties in establishing the rights of women is the fact that Bangladeshi society is strongly patriarchal. “This means that women suffer discrimination in respect of matrimonial rights, guardianship of children and  inheritance – often through religious injunctions or directives,” the prominent lawyer said.

Hameeda Hossain, chairperson of Ain-o-Shalish Kendra, a leading women’s rights  organisation, told IPS that if  “women are still suffering socially, culturally and politically” it is due to “social acceptance of women’s subordination, discriminatory laws and poor law enforcement.”

“Crimes against women within the family are often ignored, and the women  silenced,” Hossain said. “There is social tolerance of domestic violence and limited intervention.”

To its credit the Bangladesh government has taken a number of legal steps to  improve the situation of women, starting with the Suppression of Violence against Women and Children Act in 2000. In 2009 the National Human Rights Act was passed followed by the Domestic Violence Act in 2010.

Bangladesh is also signatory to international conventions designed to protect women and their rights. Yet, very little is being done on the ground to ensure a secure and safe environment for them, rights activists say.

 

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Evidence, Consensus and Policy: curious case of changes proposed in India’s public health policy

English: National Rural Health Mission of India

English: National Rural Health Mission of India (Photo credit: Wikipedia)

SEPTEMBER 27, 2012

Guest post by KAVERI GILL, at  kafila.org

The world of development is as prone to fashions as any other. In recent times, ‘evidence-based policy’ has become the new gold standard, following hot on the heels of participation and ownership of policy processes and outcomes by academics, activists and civil society groups. This applies within nation states, especially of the global South. India today epitomises such objective and bottom-up democratic largesse in favour of the ‘aam admi’- for largesse it is, make no mistake – with a near constant refrain of the avowed aim of ‘inclusive growth’. And yet, does it really?

Or is politically correct discourse and seemingly open decision-making processes in the social sector sphere merely dangerous fig leaves for seismic and opaque shifts in policy, which have very little to do with evidence and even less to do with broad-based consensus? Rather, they are an outcome of fixed ex-ante views – which may be termed as a distinct partiality to the Chicago School of Economics – about the path to a fictitious endpoint of a mainstream development paradigm, which itself is faith-based. It is not justified by theory or a heterodox reading of the empirical experiences of presently developed countries, let alone latecomer developing nations which are, for various exogenous and endogenous reasons, likely to have different trajectories altogether. I refer here to the hackneyed line about faster growth being pursued as a necessary, if not sufficient, condition for eventual trickle down, no matter that the ‘dur khaima’ of an equitable society is never arrived at!

In his address to the nation last Friday, the Hon. Prime Minister mentioned ‘the common man’ twice in the opening lines, as a straw man in whose name and interests all ‘difficult’ second-stage reforms are being undertaken. On p.1 of the Planning Commission of India’s Approach Paper to the XIIth Plan [1], it is argued that high growth during the XIth Plan was seen as instrumental to achieving two ends: to create income and employment opportunities for better living standards for the majority, and to generate resources in order to finance social sector programmes, aimed at “enabling inclusiveness”. It goes on to define the latter: “…inclusiveness is a multidimensional concept. Inclusive growth should result in lower incidence of poverty, broad-based and significant improvement in health outcomes…” (ibid., p.2). A wish list of the Left liberal’s ideal social contract follows, in the Rawlsian sense of justice, and quite far from Nozick’s Libertarian minimal nightwatchmen role of the state. The discourse could not be better.

But let us unpack the ‘inclusive growth’ jargon – with particular reference to public health care – as an illustrative exercise of evidence, and its selective and biased use to derive unwarranted policy prescriptions in the social sector sphere in recent times. Quickly, to recap a refresher undergraduate course in economics, health care is not a routine commodity, rather more of a public good [2], exhibiting externalities and marked information asymmetries of moral hazard and adverse selection. In layman’s terms, because of these and other characteristics, the state remains heavily involved in this sector even in advanced countries, through public financing, and provision or regulation or both, for the market is bound to fail. When returns to large investments accrue over the time horizon of many generations – and admittedly many governments – then it is only a progressive state that has the gumption to invest in such sectors.

Judging by its expansive discourse and promises, one could be forgiven for thinking this is precisely what the present government in India means to do. For structurally, the ‘demographic dividend’ advantage of a relatively young population, that it  also constantly waxes eloquent about, can only be realised if we have achieved decent health (and education) outcomes for the majority. It is the briefest window of time which, given the present dire state of malnutrition amongst children, and the fact that India is far from attaining any of the numerous health-related goals of the MDGs [3], lead many to suggest it is closed off already. Even discounting this view as needlessly grim, the Approach Paper to the XIIth plan itself concedes that health outcome indicators, such as infant mortality rates and maternal mortality rates, are weaker than they should be at this level of development (cf. Footnote 1).  So what does it propose to actually do, in its Health Chapter of the Approach Paper to the XIIth Plan [4]?

India has averaged 8% p.a. GDP growth rates over the XIth Plan period. And yet, its public spending on (core) health – combined Centre and State, plan and non-plan– has hovered around an abysmal 1-1.2% of GDP [5], one of the lowest in the world [6]. Where the XIth Plan still ostensibly aimed to increase this (core) amount to 2-3% by the end of plan period, the Approach Paper to the XIIth Plan settles for an avowed increase to only 1.58% by the end of the plan period. Why should this be the case, given that higher growth rates for the country are justified time and again as being necessary for fiscal room to spend more on social sector programmes?

And how is this possible, given the government has recently vocalised a desire to move towards universal health care for all, in which connection the Planning Commission of India constituted a High Level Expert Group (HLEG) of respected academics and practitioners, to deliberate and come up with the best way forward [7]. The logistical ‘how’ is threefold in the Health Chapter (August draft).

First, the Centre expects individual States to contribute increasingly to the funding of public health, which over the XIth Plan was roughly in the ratio of 1:2. The previous sharing formula for Centrally Sponsored Schemes, such as the National Rural Health Mission (NRHM), was largely in the form of a self-regulated MOU, which States progressively lived up to over the course of a plan period, depending on their fiscal capacities and levels of development. Such contributions would now be mandatory, in that a large part of the Central funding is conditional on higher investments by States.

The proposed new formula to determine the quantum of the flexible ‘incentive fund’ to each State still takes into account its health lag versus that of the national average. In so doing, it gives some weight to its developmental and poverty levels. But linking this amount to its own contribution, and to “agreed parameters of performance and reform in previous year’s sector wide MOU with the MoHFW” (p. 32, Health Chapter (August draft)) – whatever the latter refers to – penalises the worse off States, which are most likely to be cash-strapped and  have less room for manoeuvre for additional fiscal spend. In a federal system, States are in any case reluctant to own Centrally Sponsored Schemes, such as NRHM, because they are conceived of elsewhere and the political credit for them accrues to the government in power at the Centre.

In recognition of externality and equity issues in the provision of basic health care services at the national level, HLEG recommends “a substantial proportion of financing of these services can and should come from the Central government, even though such services have to be provided at sub-national levels” (p.11, HLEG 2011). Yes, States should not use Central contributions as a substitute for their own spending, as many have done so in the recent past, rather to complement it. But this peculiar form of forced ‘incentivisation’ coming out of a misplaced desire to straighten negotiation between Centres and States on the distribution of funding is likely to result in a poverty trap for poorer and less well governed States, and their hapless populations.

More confounding, given the evidence, is the proposal to follow the ‘managed-care’ model of health care provision, the beacon for it being the USA model. The latter is universally derided for being highly inequitable in provision, extremely expensive, and leading to relatively poor health outcomes, compared to other advanced countries. This despite the fact that the private sector is regulated to a far higher degree in that country and patients have recourse to expensive law suits in case of transgressions in delivery by them. What this model would mean in India is that large corporate networks would compete with public health institutions for public funds, to deliver packages of services (most outpatient care and hospital services) at cost to patients. If they cannot compete, as hitherto poorly funded and supported public sector health institutions are unlikely to be able to do so, they do not survive the Darwinian game. The public sector’s role in delivery of health care will be restricted to a minimal essential package, made up of basic child and reproductive care, as well as prevention and promotion roles. In short, the spectre of the private sector is to be unleashed on the public health delivery system.

Strong critiques of the proposed structural ‘privatisation by stealth’, including indisputable international evidence to show how such managed care models work over time to reduce choice in the range of (free) services on offer, and quality of care, have emerged from committed researchers and practitioners working in the public health sphere, so I will not repeat what they have said far better [8]. Indeed, the Health Chapter (August draft) itself admits the following: “…the system creates strong incentives for whoever is managing the network to minimise total cost… there is limited patient choice, and as such the quality of medical care provided has to be carefully regulated” (p.29, ibid.). I would like to focus instead, in conjecturing what could be the objective intellectual motivations for such a shift in policy, and in so doing, make some observations about public sector performance, quality, regulation and finally, rights and justice, in the Indian social sector context, and health care sphere in particular.

Is the shift driven by an argument about poor public sector performance in delivery in health care? If a researcher is objective and without ideological bias, they cannot deny that it has been lacking, which reflects in the dismal health outcomes in the country (noted previously), as well as the flight of those who can and who cannot afford it from the public delivery systems in health (and education). At 67%, the proportion or private out-of-pocket spending on health is sky high, and research has established that health expenses is one of the primary reasons for pushing households below the poverty line. But how can we best read this voting with one’s feet – or in this case – wallet?

Cross-country data on health expenditures show that a higher level of government spending on health is frequently associated with lower levels of reliance of a country’s health system on private out-of-pocket expenditures [9]. So if the quest is eliciting better performance, isn’t the answer to strengthen the public health care system after decades of below-minimal (forget-optimal) spending by the government on this sector? To completely emasculate and demolish it, on the logic that the private sector will force it to perform better or die out, reeks of rather strong ideological proclivities (of the Chicago School of Economics variety).

Is the idea that frontline providers in the public health care system, be they doctors or paramedical staff, are completely unaccountable and therefore, need the stick of private sector discipline to get in line? Again, any open-minded researcher and practitioner would be foolish to dispute widespread doctor absenteeism in public health care centres, especially in rural India, the system’s de facto privatisation through corrupt medical functionaries diverting patients to their ‘private clinics’ in the same compound, charging a fee for consultation and medicines etc. Indeed, I myself found that to be the case in 2008-09, when working on an evaluation of NRHM, as an independent researcher for the Planning Commission of India [10])!

But in the public health system’s defense, what do we expect from a huge cadre of contract and not regular employees, such as are currently employed in NRHM.  I refer here to doctors and paramedics, not even the accredited social health activists (ASHAs), itself a large cadre of underpaid and overworked ‘voluntary’ women workers, on whom the system exploitatively and cheaply depends [11]. The next question to ask is whether private sector employees would be more accountable? Specialist and super-specialist services in public health centres in rural Bihar are already contracted out to the private sector, and their employees behave as badly, if not worse, than their public sector counterparts. We come to the vexed question of asymmetrical geographical power and monetary incentives in a fully corporatised medical sector, because of course highly well-paid doctors in urban centres have to perform, in terms of showing up and working long hours, to the tune of profit-maximising payroll masters (and broke patients!)

If the idea behind this shift in policy really is to guarantee good performance and high quality in public delivery, a far better idea is to tie powerful people to the public health system in the country, and ensure they have a stake in its doing well, as we have all read and absorbed Hirschman’s classic 1970 treatise on ‘Exit, Voice and Loyalty’. A good beginning would be to somehow link CGHS benefits for all public sector employees – from the most junior to the most senior, as they are all relatively powerful in their own tiers and domains – to the public health care system alone. It will be remarkable how quickly we see an improvement in performance and quality of provision, were such a move undertaken. Additionally, legislation ought to be passed that the private costs of health care, as well as foreign costs of health care, for government and political functionaries, is not underwritten by the Government of India. This will countervail, to a significant extent, the argument that there is no fiscal room for additional social sector spending in these recessionary times, since the amount saved will add to the ability to do so (cross-subsidisation of sorts, always a decent redistribution tool).

Further, is the government willing and able to rein in and regulate the private sector in general? For as the Health Chapter (August draft) itself acknowledges, any kind of privatisation in the provision of health care, such as the managed-care model, has to be carefully and heavily regulated by the government. So far, it is unable to stem empanelled doctors and hospitals from gaming the system and performing unnecessary hysterectomies, in rural and small-town India, the costs of which are reclaimed through the Rashtriya Swasthya Bima Yojana insurance scheme (which we will come to shortly). In subaltern India, it will also find it hard to enforce necessary emergency caesareans be performed, in a managed-care model whose financial imperative act to cut free services over time, especially those of a more expensive nature. Moral hazard and adverse selection are going to be rife in this system, as is the complexity of information and understanding needed sidestep them. Such information asymmetry problems are known to be much worse for poorer and illiterate women, and other subordinate groups, so it will be the government’s duty to safeguard their rights if it is the one foisting this market on them.

What about the argument that the public delivery of health care is irrevocably interwoven with large-scale corruption, such as recently publicised about NRHM in Uttar Pradesh, and therefore, what is the harm in trying the private sector alternative? First, this is not universally true across states of India, as anyone with a passing knowledge of Tamil Nadu and other well performing states’ social sector programmes will counteract. Second, a sophisticated understanding of corruption as also including unilateral power to behave with impunity, especially in today’s India, suggest the  private sector will be allowed to get away with ‘corruption’ on an equally, if not larger, scale than the public sector. In Delhi itself, the post-Imperial capital, the government is unwilling or unable to ensure that powerful private hospitals, who have obtained government land on the condition that they admit a certain percentage of patients from economically weaker sections (EWS), actually do so. It is also turning a blind eye to the hidden but increasing private medical trials industry that is mushrooming in the country.

Privatisation of an entire system is not something that can be easily – or at all – rolled back, in our Age of Capitalism. How hard it is to stuff the genie back in the bottle, in the face of greedy corporates and powerful lobby groups, is something the NHS is set to find out soon in the United Kingdom, just as numerous Presidents of the USA did when trying to reform its deeply flawed system, and ironically, as Obama has fought hard to do in recent times. So before this massive step is taken, let us think very carefully as a nation, especially as our levels of development and health achievements are far worse than that of these countries.

Finally, if privatisation and PPPs are something the government needs for faster growth, as signals to attract FDI and keep the stock market bullish, why not fully privatise numerous other sectors, such as large-scale infrastructure, construction, airlines operations etc.? Let these be riven with ‘efficient corruption’, in the Shleifer and Vishny sense, or not, in which case they can keep rooking on cost, quality and timing, with need for repeat delivery at short intervals etc. (it will keep the aggregate demand high, in any event!) Let the opportunity to earn supra-normal profits, via monopolies and even natural monopolies, be with the private sector alone (not even PPPs). For they matter – relatively – little to the social contract of the state, with its citizens, other than cutting the government’s revenues in earnings.  If something has to be ceded from the public sector portfolio in the India of 2012, to keep it on the conveyor belt of growth, let it be these areas. In lieu, ring fence public spending and the public provision of basic needs, such as health care (and education), for not only are these instrumentally important to achieve ‘inclusive growth’, if we really mean to, but they are constitutively important, to ensure the majority of citizens in a democracy have capabilities to lead a flourishing life.

The less said about the third ‘how’ of financing universal health care, via insurance, in the Health Chapter (August Draft), the better. International evidence is overwhelmingly of the view that this is not possible, and numerous early academic and evaluation studies of the Rashtriya Swasthya Bima Yojana (RSBY) insurance scheme show its many flaws. These are acknowledged by the Planning Commission: “They [HLEG] have also noted the problems with reliance on a market oriented, “fee for service model”, based on insurance in which the premium is paid by the government. This creates incentives for unnecessary curative care and a consequent spiraling of costs (p. 29, Health Chapter (August draft)). And still, it proposes to expand it across the entire BPL population of the country, to numerous other unorganised sector worker groups and so on.

If all these suggestions and the associated policy push are not coming from theory or empirical evidence, then where are they coming from? Unless one were party to inner policy formulation deliberations, it is hard to say. The Health Chapter (August draft) places the full onus on the origin of the managed-care model recommendations with the HLEG. The HLEG 2011 does suggest a networked system at the district level, leaving itself wittingly or unwittingly open to such misinterpretation, as activists feared. If news reportage is correct, there is an on-going debate and disagreement between the Ministry of Health and Family Welfare, and the Planning Commission of India, on the proposed changes. As an outsider, it is again hard to keep track of the exact nature of the differences, and how they are being negotiated, day by day. Therefore, the broader political economy ‘how’, of the eventual form of the Health Chapter (August Draft) in the final approved Approach Paper to the XIIth Plan, is still an open-ended one.

As Buchanan and Tullock (1962) famously noted, government and the bureaucracy is not a monolithic, uniform black-box of an actor, and is rather made up of individuals, their idiosyncracies, their failures, their incentives, their propensities to act in certain ways. So we are yet to see where the chips eventually fall on the policy front, as regards proposed changes to the public health care system. But I will appeal to the higher selves of those determining the final version of the Health Chapter, in the Approach Paper to the XIIth Plan, whomsoever they be, to rather act to strengthen its many good ideas, some drawn from bright  people working within the government and others from HLEG 2011, on the expansion of regional AIIMS-like institutions across the country, medical education in the public sector, the provision of free essential generic medicines, the regulation of private sector quacks through accreditation and so on. This is your and our moment, this country’s moment, if it really aspires to being just, fair and ‘inclusive’.

To remind public sector naysayers, within and outside the government, health care is not a normal commodity in many respects (neither is education). Both are linked to fundamental needs and aspirations of the people, what it means to be human, in essence, and as a social animal, a community. A catastrophic illness in the poorest family will compel them to spend all their money, even money they do not have, on the slim chance of survival for one of its members. The desperation of the poor to better their situation and become upwardly mobile – though that is semantically a misleading gradient, too opulent at that standard of living – is what compels families to enroll their children in schools, as they are doing in droves at present in India, against every socio-economic odd and every geographical constraint of vast distances between remote hamlets and providers. Such aspiration is only going to grow in our country today, because of what the media and every single sensory source in our Age of Information Overload is consciously projecting as our country’s shining future.

If the judiciary is increasingly recognising and legislating on rights in the social sector sphere, surely the government ignores them at its own peril in a democracy? And if it is going to do so, let us forget all this humbug about faster growth being pursued to better the lot of ‘the common man’. Let us openly acknowledge that evidence-base and ownership by academics, activist and civil society groups matters not a whit to eventual policy formulation. Let us not attempt to co-opt all dissenting voices, by soliciting their views in endless committees and platforms, while proceeding exactly or even worse than before (such as a supposed desire to move towards universal health care, disguising all sorts of sins of omission and commission), for it is more cynical an act than never having consulted them at all. And let us be prepared politically for the consequences of systematically and knowingly ruling out the possibility of the majority ever being able to participate in a democracy’s so-called ‘success story’, of growth alone. Pursued for its own sake, it is to be a private celebration for an exclusive few.

(Kaveri Gill is an independent academic and researcher based in Delhi. The views expressed in this piece are the author’s own and are independent of any professional institutional affiliation she holds, past or present).


[2] So is education, especially elementary education.

[3] On the primary education side, too, there has been an increase in enrollment and fall in drop-out rates in recent years, but grave questions remain about the actual learning levels and quality of education.

[4] I allude in this piece to an August draft of the proposed Health Chapter of the Approach Paper to the XIIth Plan, which is at present being finalised by the Planning Commission of India. It shall forthwith be referred to as the Health Chapter (August draft). Since there are many drafts and it is a work in progress, figures may differ slightly in citations of different versions by various authors.

[5] These figures vary by source, but the range remains as stated. Public spending increases marginally, if spending on co-determinants of health, such as water, sanitation etcetera, is included.

[6] At 19%, public spending on health as a percentage of total health expenditure is also lower in India (WHO 2007 & 2008) than all South Asian countries, except Pakistan (Sri Lanka: 46.2%; Bangladesh: 29.1%; Nepal: 28.1%; Pakistan: 17.5%), let alone China (38.8%) and Brazil (44.1%). Interestingly, Europe (Germany: 76.9%; France: 79.9%; UK: 87.1%) – with its tradition of welfare states – far outshines the USA (45.1%) in this respect.

[7] It produced, “High Level Expert Group Report on Universal Health Coverage for India” (November 2011), forthwith referred to as HLEG 2011.

[8] Inter alia, “Dangerous Drift in Health Policy – Jan Swasthya Abhiyan Action Alert” (August-September 2012) maybe be accessed at: http://www.scribd.com/doc/103888531/Jan-Swasthya-Abhiyan-Action-Alert; “Setting up Universal Health Care Pvt. Ltd.”, Rakhal Gaitonde and Abhay Shukla, op-ed in The Hindu, 13 September 2012).

[9] Much also “depends upon the specific way the additional public spending is pooled and spent. Prepayment from compulsory sources (i.e. some form of taxation) and the pooling of these revenues for the purpose of purchasing healthcare services on behalf of the entire population is the cornerstone of the proposed universal healthcare…[it] is essential for ensuring that the system is able to redistribute resources and thus services to those in greatest need…both theory and evidence [shows] that no country that can be said to have attained universal coverage relies predominantly on voluntary funding sources (p. 9, HLEG 2011).

[10] “A Primary Evaluation of Service Delivery under the National Rural Health Mission (NRHM): Findings from a Study in Andhra Pradesh, Uttar Pradesh, Bihar and Rajasthan”, Gill 2009, Working Paper 1/2009 – PEO, Planning Commission of India.

[11] This trend for contractual employment to do the same job, in the public and private sector in India (the distribution of regular to contractual workers in Maruti Suzuki’s factory in Manesar is a good example of the latter), can also be traced to the many labour market perils of unfettered globalisation and capitalism.

Related posts

Evidence, Consensus and Policy: curious case of changes proposed in India’s public health policy

English: National Rural Health Mission of India

English: National Rural Health Mission of India (Photo credit: Wikipedia)

SEPTEMBER 27, 2012

Guest post by KAVERI GILL, at  kafila.org

The world of development is as prone to fashions as any other. In recent times, ‘evidence-based policy’ has become the new gold standard, following hot on the heels of participation and ownership of policy processes and outcomes by academics, activists and civil society groups. This applies within nation states, especially of the global South. India today epitomises such objective and bottom-up democratic largesse in favour of the ‘aam admi’- for largesse it is, make no mistake – with a near constant refrain of the avowed aim of ‘inclusive growth’. And yet, does it really?

Or is politically correct discourse and seemingly open decision-making processes in the social sector sphere merely dangerous fig leaves for seismic and opaque shifts in policy, which have very little to do with evidence and even less to do with broad-based consensus? Rather, they are an outcome of fixed ex-ante views – which may be termed as a distinct partiality to the Chicago School of Economics – about the path to a fictitious endpoint of a mainstream development paradigm, which itself is faith-based. It is not justified by theory or a heterodox reading of the empirical experiences of presently developed countries, let alone latecomer developing nations which are, for various exogenous and endogenous reasons, likely to have different trajectories altogether. I refer here to the hackneyed line about faster growth being pursued as a necessary, if not sufficient, condition for eventual trickle down, no matter that the ‘dur khaima’ of an equitable society is never arrived at!

In his address to the nation last Friday, the Hon. Prime Minister mentioned ‘the common man’ twice in the opening lines, as a straw man in whose name and interests all ‘difficult’ second-stage reforms are being undertaken. On p.1 of the Planning Commission of India’s Approach Paper to the XIIth Plan [1], it is argued that high growth during the XIth Plan was seen as instrumental to achieving two ends: to create income and employment opportunities for better living standards for the majority, and to generate resources in order to finance social sector programmes, aimed at “enabling inclusiveness”. It goes on to define the latter: “…inclusiveness is a multidimensional concept. Inclusive growth should result in lower incidence of poverty, broad-based and significant improvement in health outcomes…” (ibid., p.2). A wish list of the Left liberal’s ideal social contract follows, in the Rawlsian sense of justice, and quite far from Nozick’s Libertarian minimal nightwatchmen role of the state. The discourse could not be better.

But let us unpack the ‘inclusive growth’ jargon – with particular reference to public health care – as an illustrative exercise of evidence, and its selective and biased use to derive unwarranted policy prescriptions in the social sector sphere in recent times. Quickly, to recap a refresher undergraduate course in economics, health care is not a routine commodity, rather more of a public good [2], exhibiting externalities and marked information asymmetries of moral hazard and adverse selection. In layman’s terms, because of these and other characteristics, the state remains heavily involved in this sector even in advanced countries, through public financing, and provision or regulation or both, for the market is bound to fail. When returns to large investments accrue over the time horizon of many generations – and admittedly many governments – then it is only a progressive state that has the gumption to invest in such sectors.

Judging by its expansive discourse and promises, one could be forgiven for thinking this is precisely what the present government in India means to do. For structurally, the ‘demographic dividend’ advantage of a relatively young population, that it  also constantly waxes eloquent about, can only be realised if we have achieved decent health (and education) outcomes for the majority. It is the briefest window of time which, given the present dire state of malnutrition amongst children, and the fact that India is far from attaining any of the numerous health-related goals of the MDGs [3], lead many to suggest it is closed off already. Even discounting this view as needlessly grim, the Approach Paper to the XIIth plan itself concedes that health outcome indicators, such as infant mortality rates and maternal mortality rates, are weaker than they should be at this level of development (cf. Footnote 1).  So what does it propose to actually do, in its Health Chapter of the Approach Paper to the XIIth Plan [4]?

India has averaged 8% p.a. GDP growth rates over the XIth Plan period. And yet, its public spending on (core) health – combined Centre and State, plan and non-plan– has hovered around an abysmal 1-1.2% of GDP [5], one of the lowest in the world [6]. Where the XIth Plan still ostensibly aimed to increase this (core) amount to 2-3% by the end of plan period, the Approach Paper to the XIIth Plan settles for an avowed increase to only 1.58% by the end of the plan period. Why should this be the case, given that higher growth rates for the country are justified time and again as being necessary for fiscal room to spend more on social sector programmes?

And how is this possible, given the government has recently vocalised a desire to move towards universal health care for all, in which connection the Planning Commission of India constituted a High Level Expert Group (HLEG) of respected academics and practitioners, to deliberate and come up with the best way forward [7]. The logistical ‘how’ is threefold in the Health Chapter (August draft).

First, the Centre expects individual States to contribute increasingly to the funding of public health, which over the XIth Plan was roughly in the ratio of 1:2. The previous sharing formula for Centrally Sponsored Schemes, such as the National Rural Health Mission (NRHM), was largely in the form of a self-regulated MOU, which States progressively lived up to over the course of a plan period, depending on their fiscal capacities and levels of development. Such contributions would now be mandatory, in that a large part of the Central funding is conditional on higher investments by States.

The proposed new formula to determine the quantum of the flexible ‘incentive fund’ to each State still takes into account its health lag versus that of the national average. In so doing, it gives some weight to its developmental and poverty levels. But linking this amount to its own contribution, and to “agreed parameters of performance and reform in previous year’s sector wide MOU with the MoHFW” (p. 32, Health Chapter (August draft)) – whatever the latter refers to – penalises the worse off States, which are most likely to be cash-strapped and  have less room for manoeuvre for additional fiscal spend. In a federal system, States are in any case reluctant to own Centrally Sponsored Schemes, such as NRHM, because they are conceived of elsewhere and the political credit for them accrues to the government in power at the Centre.

In recognition of externality and equity issues in the provision of basic health care services at the national level, HLEG recommends “a substantial proportion of financing of these services can and should come from the Central government, even though such services have to be provided at sub-national levels” (p.11, HLEG 2011). Yes, States should not use Central contributions as a substitute for their own spending, as many have done so in the recent past, rather to complement it. But this peculiar form of forced ‘incentivisation’ coming out of a misplaced desire to straighten negotiation between Centres and States on the distribution of funding is likely to result in a poverty trap for poorer and less well governed States, and their hapless populations.

More confounding, given the evidence, is the proposal to follow the ‘managed-care’ model of health care provision, the beacon for it being the USA model. The latter is universally derided for being highly inequitable in provision, extremely expensive, and leading to relatively poor health outcomes, compared to other advanced countries. This despite the fact that the private sector is regulated to a far higher degree in that country and patients have recourse to expensive law suits in case of transgressions in delivery by them. What this model would mean in India is that large corporate networks would compete with public health institutions for public funds, to deliver packages of services (most outpatient care and hospital services) at cost to patients. If they cannot compete, as hitherto poorly funded and supported public sector health institutions are unlikely to be able to do so, they do not survive the Darwinian game. The public sector’s role in delivery of health care will be restricted to a minimal essential package, made up of basic child and reproductive care, as well as prevention and promotion roles. In short, the spectre of the private sector is to be unleashed on the public health delivery system.

Strong critiques of the proposed structural ‘privatisation by stealth’, including indisputable international evidence to show how such managed care models work over time to reduce choice in the range of (free) services on offer, and quality of care, have emerged from committed researchers and practitioners working in the public health sphere, so I will not repeat what they have said far better [8]. Indeed, the Health Chapter (August draft) itself admits the following: “…the system creates strong incentives for whoever is managing the network to minimise total cost… there is limited patient choice, and as such the quality of medical care provided has to be carefully regulated” (p.29, ibid.). I would like to focus instead, in conjecturing what could be the objective intellectual motivations for such a shift in policy, and in so doing, make some observations about public sector performance, quality, regulation and finally, rights and justice, in the Indian social sector context, and health care sphere in particular.

Is the shift driven by an argument about poor public sector performance in delivery in health care? If a researcher is objective and without ideological bias, they cannot deny that it has been lacking, which reflects in the dismal health outcomes in the country (noted previously), as well as the flight of those who can and who cannot afford it from the public delivery systems in health (and education). At 67%, the proportion or private out-of-pocket spending on health is sky high, and research has established that health expenses is one of the primary reasons for pushing households below the poverty line. But how can we best read this voting with one’s feet – or in this case – wallet?

Cross-country data on health expenditures show that a higher level of government spending on health is frequently associated with lower levels of reliance of a country’s health system on private out-of-pocket expenditures [9]. So if the quest is eliciting better performance, isn’t the answer to strengthen the public health care system after decades of below-minimal (forget-optimal) spending by the government on this sector? To completely emasculate and demolish it, on the logic that the private sector will force it to perform better or die out, reeks of rather strong ideological proclivities (of the Chicago School of Economics variety).

Is the idea that frontline providers in the public health care system, be they doctors or paramedical staff, are completely unaccountable and therefore, need the stick of private sector discipline to get in line? Again, any open-minded researcher and practitioner would be foolish to dispute widespread doctor absenteeism in public health care centres, especially in rural India, the system’s de facto privatisation through corrupt medical functionaries diverting patients to their ‘private clinics’ in the same compound, charging a fee for consultation and medicines etc. Indeed, I myself found that to be the case in 2008-09, when working on an evaluation of NRHM, as an independent researcher for the Planning Commission of India [10])!

But in the public health system’s defense, what do we expect from a huge cadre of contract and not regular employees, such as are currently employed in NRHM.  I refer here to doctors and paramedics, not even the accredited social health activists (ASHAs), itself a large cadre of underpaid and overworked ‘voluntary’ women workers, on whom the system exploitatively and cheaply depends [11]. The next question to ask is whether private sector employees would be more accountable? Specialist and super-specialist services in public health centres in rural Bihar are already contracted out to the private sector, and their employees behave as badly, if not worse, than their public sector counterparts. We come to the vexed question of asymmetrical geographical power and monetary incentives in a fully corporatised medical sector, because of course highly well-paid doctors in urban centres have to perform, in terms of showing up and working long hours, to the tune of profit-maximising payroll masters (and broke patients!)

If the idea behind this shift in policy really is to guarantee good performance and high quality in public delivery, a far better idea is to tie powerful people to the public health system in the country, and ensure they have a stake in its doing well, as we have all read and absorbed Hirschman’s classic 1970 treatise on ‘Exit, Voice and Loyalty’. A good beginning would be to somehow link CGHS benefits for all public sector employees – from the most junior to the most senior, as they are all relatively powerful in their own tiers and domains – to the public health care system alone. It will be remarkable how quickly we see an improvement in performance and quality of provision, were such a move undertaken. Additionally, legislation ought to be passed that the private costs of health care, as well as foreign costs of health care, for government and political functionaries, is not underwritten by the Government of India. This will countervail, to a significant extent, the argument that there is no fiscal room for additional social sector spending in these recessionary times, since the amount saved will add to the ability to do so (cross-subsidisation of sorts, always a decent redistribution tool).

Further, is the government willing and able to rein in and regulate the private sector in general? For as the Health Chapter (August draft) itself acknowledges, any kind of privatisation in the provision of health care, such as the managed-care model, has to be carefully and heavily regulated by the government. So far, it is unable to stem empanelled doctors and hospitals from gaming the system and performing unnecessary hysterectomies, in rural and small-town India, the costs of which are reclaimed through the Rashtriya Swasthya Bima Yojana insurance scheme (which we will come to shortly). In subaltern India, it will also find it hard to enforce necessary emergency caesareans be performed, in a managed-care model whose financial imperative act to cut free services over time, especially those of a more expensive nature. Moral hazard and adverse selection are going to be rife in this system, as is the complexity of information and understanding needed sidestep them. Such information asymmetry problems are known to be much worse for poorer and illiterate women, and other subordinate groups, so it will be the government’s duty to safeguard their rights if it is the one foisting this market on them.

What about the argument that the public delivery of health care is irrevocably interwoven with large-scale corruption, such as recently publicised about NRHM in Uttar Pradesh, and therefore, what is the harm in trying the private sector alternative? First, this is not universally true across states of India, as anyone with a passing knowledge of Tamil Nadu and other well performing states’ social sector programmes will counteract. Second, a sophisticated understanding of corruption as also including unilateral power to behave with impunity, especially in today’s India, suggest the  private sector will be allowed to get away with ‘corruption’ on an equally, if not larger, scale than the public sector. In Delhi itself, the post-Imperial capital, the government is unwilling or unable to ensure that powerful private hospitals, who have obtained government land on the condition that they admit a certain percentage of patients from economically weaker sections (EWS), actually do so. It is also turning a blind eye to the hidden but increasing private medical trials industry that is mushrooming in the country.

Privatisation of an entire system is not something that can be easily – or at all – rolled back, in our Age of Capitalism. How hard it is to stuff the genie back in the bottle, in the face of greedy corporates and powerful lobby groups, is something the NHS is set to find out soon in the United Kingdom, just as numerous Presidents of the USA did when trying to reform its deeply flawed system, and ironically, as Obama has fought hard to do in recent times. So before this massive step is taken, let us think very carefully as a nation, especially as our levels of development and health achievements are far worse than that of these countries.

Finally, if privatisation and PPPs are something the government needs for faster growth, as signals to attract FDI and keep the stock market bullish, why not fully privatise numerous other sectors, such as large-scale infrastructure, construction, airlines operations etc.? Let these be riven with ‘efficient corruption’, in the Shleifer and Vishny sense, or not, in which case they can keep rooking on cost, quality and timing, with need for repeat delivery at short intervals etc. (it will keep the aggregate demand high, in any event!) Let the opportunity to earn supra-normal profits, via monopolies and even natural monopolies, be with the private sector alone (not even PPPs). For they matter – relatively – little to the social contract of the state, with its citizens, other than cutting the government’s revenues in earnings.  If something has to be ceded from the public sector portfolio in the India of 2012, to keep it on the conveyor belt of growth, let it be these areas. In lieu, ring fence public spending and the public provision of basic needs, such as health care (and education), for not only are these instrumentally important to achieve ‘inclusive growth’, if we really mean to, but they are constitutively important, to ensure the majority of citizens in a democracy have capabilities to lead a flourishing life.

The less said about the third ‘how’ of financing universal health care, via insurance, in the Health Chapter (August Draft), the better. International evidence is overwhelmingly of the view that this is not possible, and numerous early academic and evaluation studies of the Rashtriya Swasthya Bima Yojana (RSBY) insurance scheme show its many flaws. These are acknowledged by the Planning Commission: “They [HLEG] have also noted the problems with reliance on a market oriented, “fee for service model”, based on insurance in which the premium is paid by the government. This creates incentives for unnecessary curative care and a consequent spiraling of costs (p. 29, Health Chapter (August draft)). And still, it proposes to expand it across the entire BPL population of the country, to numerous other unorganised sector worker groups and so on.

If all these suggestions and the associated policy push are not coming from theory or empirical evidence, then where are they coming from? Unless one were party to inner policy formulation deliberations, it is hard to say. The Health Chapter (August draft) places the full onus on the origin of the managed-care model recommendations with the HLEG. The HLEG 2011 does suggest a networked system at the district level, leaving itself wittingly or unwittingly open to such misinterpretation, as activists feared. If news reportage is correct, there is an on-going debate and disagreement between the Ministry of Health and Family Welfare, and the Planning Commission of India, on the proposed changes. As an outsider, it is again hard to keep track of the exact nature of the differences, and how they are being negotiated, day by day. Therefore, the broader political economy ‘how’, of the eventual form of the Health Chapter (August Draft) in the final approved Approach Paper to the XIIth Plan, is still an open-ended one.

As Buchanan and Tullock (1962) famously noted, government and the bureaucracy is not a monolithic, uniform black-box of an actor, and is rather made up of individuals, their idiosyncracies, their failures, their incentives, their propensities to act in certain ways. So we are yet to see where the chips eventually fall on the policy front, as regards proposed changes to the public health care system. But I will appeal to the higher selves of those determining the final version of the Health Chapter, in the Approach Paper to the XIIth Plan, whomsoever they be, to rather act to strengthen its many good ideas, some drawn from bright  people working within the government and others from HLEG 2011, on the expansion of regional AIIMS-like institutions across the country, medical education in the public sector, the provision of free essential generic medicines, the regulation of private sector quacks through accreditation and so on. This is your and our moment, this country’s moment, if it really aspires to being just, fair and ‘inclusive’.

To remind public sector naysayers, within and outside the government, health care is not a normal commodity in many respects (neither is education). Both are linked to fundamental needs and aspirations of the people, what it means to be human, in essence, and as a social animal, a community. A catastrophic illness in the poorest family will compel them to spend all their money, even money they do not have, on the slim chance of survival for one of its members. The desperation of the poor to better their situation and become upwardly mobile – though that is semantically a misleading gradient, too opulent at that standard of living – is what compels families to enroll their children in schools, as they are doing in droves at present in India, against every socio-economic odd and every geographical constraint of vast distances between remote hamlets and providers. Such aspiration is only going to grow in our country today, because of what the media and every single sensory source in our Age of Information Overload is consciously projecting as our country’s shining future.

If the judiciary is increasingly recognising and legislating on rights in the social sector sphere, surely the government ignores them at its own peril in a democracy? And if it is going to do so, let us forget all this humbug about faster growth being pursued to better the lot of ‘the common man’. Let us openly acknowledge that evidence-base and ownership by academics, activist and civil society groups matters not a whit to eventual policy formulation. Let us not attempt to co-opt all dissenting voices, by soliciting their views in endless committees and platforms, while proceeding exactly or even worse than before (such as a supposed desire to move towards universal health care, disguising all sorts of sins of omission and commission), for it is more cynical an act than never having consulted them at all. And let us be prepared politically for the consequences of systematically and knowingly ruling out the possibility of the majority ever being able to participate in a democracy’s so-called ‘success story’, of growth alone. Pursued for its own sake, it is to be a private celebration for an exclusive few.

(Kaveri Gill is an independent academic and researcher based in Delhi. The views expressed in this piece are the author’s own and are independent of any professional institutional affiliation she holds, past or present).


[2] So is education, especially elementary education.

[3] On the primary education side, too, there has been an increase in enrollment and fall in drop-out rates in recent years, but grave questions remain about the actual learning levels and quality of education.

[4] I allude in this piece to an August draft of the proposed Health Chapter of the Approach Paper to the XIIth Plan, which is at present being finalised by the Planning Commission of India. It shall forthwith be referred to as the Health Chapter (August draft). Since there are many drafts and it is a work in progress, figures may differ slightly in citations of different versions by various authors.

[5] These figures vary by source, but the range remains as stated. Public spending increases marginally, if spending on co-determinants of health, such as water, sanitation etcetera, is included.

[6] At 19%, public spending on health as a percentage of total health expenditure is also lower in India (WHO 2007 & 2008) than all South Asian countries, except Pakistan (Sri Lanka: 46.2%; Bangladesh: 29.1%; Nepal: 28.1%; Pakistan: 17.5%), let alone China (38.8%) and Brazil (44.1%). Interestingly, Europe (Germany: 76.9%; France: 79.9%; UK: 87.1%) – with its tradition of welfare states – far outshines the USA (45.1%) in this respect.

[7] It produced, “High Level Expert Group Report on Universal Health Coverage for India” (November 2011), forthwith referred to as HLEG 2011.

[8] Inter alia, “Dangerous Drift in Health Policy – Jan Swasthya Abhiyan Action Alert” (August-September 2012) maybe be accessed at: http://www.scribd.com/doc/103888531/Jan-Swasthya-Abhiyan-Action-Alert; “Setting up Universal Health Care Pvt. Ltd.”, Rakhal Gaitonde and Abhay Shukla, op-ed in The Hindu, 13 September 2012).

[9] Much also “depends upon the specific way the additional public spending is pooled and spent. Prepayment from compulsory sources (i.e. some form of taxation) and the pooling of these revenues for the purpose of purchasing healthcare services on behalf of the entire population is the cornerstone of the proposed universal healthcare…[it] is essential for ensuring that the system is able to redistribute resources and thus services to those in greatest need…both theory and evidence [shows] that no country that can be said to have attained universal coverage relies predominantly on voluntary funding sources (p. 9, HLEG 2011).

[10] “A Primary Evaluation of Service Delivery under the National Rural Health Mission (NRHM): Findings from a Study in Andhra Pradesh, Uttar Pradesh, Bihar and Rajasthan”, Gill 2009, Working Paper 1/2009 – PEO, Planning Commission of India.

[11] This trend for contractual employment to do the same job, in the public and private sector in India (the distribution of regular to contractual workers in Maruti Suzuki’s factory in Manesar is a good example of the latter), can also be traced to the many labour market perils of unfettered globalisation and capitalism.

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Ghana: Of Women, Human Rights and Laws

English: Eleanor Roosevelt and United Nations ...

English: Eleanor Roosevelt and United Nations Universal Declaration of Human Rights in Spanish text. (Photo credit: Wikipedia)

By Mavis Otinkorang, 4 June 2012

Laws are meant to regulate society and protect the human rights of all citizens. The 1992 Fourth Republican Constitution has clear provisions guaranteeing the fundamental human rights of all citizens.

Article 12 of the Constitution guarantees every person in Ghana‘s fundamental rights and freedoms and Article 17 provides protection against discrimination and enjoins the State to take steps to end all forms of discrimination on grounds of gender, race, colour, ethnicity, religion and creed, social and economic status. Article 35 (5) (6) enjoin the State to end all forms of discrimination through law reforms and affirmative action.

In addition to the Constitution, there are both national and international laws which address the issue affecting particular segments of the population. Examples are the Labour Act 2003 (Act 651) and the Children Act 1998 (Act 560) protect the right of workers and children respectively.

Laws, instrument and Convention to improve Women?s Status and Promote Gender Equality

On women, laws have been paased over the years to improve their situation. These include the Intestate Succession Law PNDC Law 111(1985), Customary Marriage and Divorce Registration Law PNDC 112 (1985) and the Labour Act 651 (2003).

Amendments of some criminal laws, now contained in the consolidated Criminal Code, have provisions which protect women from harmful traditional practices such as female genital mutilation. These provisions have also broadened protection against sexual violence. The Children’s Act protects children from early marriage, and Matrimonial Causes Act supports women seeking divorce under both customary and ordinance marriages.

Ghana has also obligations under international human rights instruments such as the UN Chapter of 1945 and Universal Declaration of Human Rights of 1948 and the International Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) of 1979.

Ghana also has obligations under regional instruments such as African Charter on Human and Peoples Right. The state is required to incorporate the provisions of these instruments into national laws.

In addition there are commitments arising from various UN conferences on women. The 1985 Nairobi Forward Looking Strategies (NFLS), the 1995 Beijing Platform for Action (PfA) and the 2000 review on Beijing commitments known as the Beijing + 5 as well as, UN conferences such as the Vienna Human Rights Conference, the International Conference on Population and Development (ICPD) (1994), the Social Summit (1994), and the 2000 Mellennium Development Goals (MDGs) have clear provisions for improving the status of women and promoting gender equality.

Women continue to live with discrimination and biases

In spite of these laws and instruments, women continue to suffer bias and discrimination in Ghana. International Human Rights instruments have not been fully integrated and enforced within national law.

In addition, national laws do not go far enough and fail to address the requirement of a comprehensive review of all laws to ensure the repeal of discriminatory laws. Certain legal instruments such as the Bill on Property Rights are yet to become laws, although years have passed since the 1992 Constitution called for their passage.

As a result, women continue to contend with discrimination and practices in employment, marriage, divorce, and in access to resources such as land, labour, capital and technology.

For example, only a minority of women in formal employment enjoy protection from labour laws. Also, women continue to live with discrimination in relation to their rights and obligations in marriage and the grounds for divorce. Additionally, women, can be divorced under customary laws on grounds of witchcraft, stealing and adultery, while these are not grounds for divorcing a man.

Practices such as polygamy, though lawful under customary and religious laws, are discriminatory, unconstitutional and increase women?s insecurity and vulnerability in marriage life. Several men who are involved in acts of bigamy are not made to account for their actions even though the Criminal Code makes such acts unlawful.

Court decisions show that the law governing the distribution of marital property after divorce does not sufficiently take into account women?s non-monetary contributions to the acquisition of such property.

There are also critical issues of poor implementation of the law due to bias against poor women and men, lack of resources, low capacity, undue delays in court processes, entrenched patriarchal attitudes and systemic gender inequalities. Furthermore, there is limited or no access to legal processes as a result of problems of cost availability of services.

The few women are who are able to access the legal system find themselves dealing with an unduly formal and alienating environment. Very few women and men are fully aware of women?s rights under the law partly because of the poor performance of institutions tasked with legal education.

To ensure that the law becomes an effective instrument for gender justice, Ghanaian women are demanding that, among others that, government initiates a constitutional review process to ensure that all constitutional provisions promote the principle of fundamental human rights, freedoms, economic and social rights for all women and men on an equal basis.

Also, it is being demanded of government to complete the review of the entire body of laws in Ghana to ensure their conformity with the 1992 Constitution and obligations under International and Regional Human Rights Instruments.

While recorgnising the validity of polygamous marriages under customary and religious laws, the government and law enforcement agencies should ensure that the laws against bigamy are properly enforced.

Again, government should put in place policies and programmes which discourage polygamy and encourage monogamy, with the view to abolishing polygamy as a form of marriage in Ghana in the future.

The grounds for divorce under customary laws should be amended to make them uniform for both men and women.

Women?s non-monetary contributions to their household should be recognised and valued through equal distribution of property acquired during marriage and divorce and inheritance proceedings.

The Customary Marriage Registration Law should be reformed to enable either party to register a marriage, if it is established that the other party is obstructing registration without justification in order to protect the right of persons in customary law marriage.

Economically, government should by 2015 complete reforms of the entire social security system to expand its scope and coverage to ensure the meaningful protection for all citizenry. Specifically, women demand that the conception scope of social security be expanded to enable all citizenry of Ghana to enjoy unemployment benefit and pensions as taxpayers. This also implies a fundamental reform of the tax systems to broaden and strengthen the revenues base.

Also, that the coverage of Social Security benefits is expanded to include medical care, sickness insurance, family and maternity benefits and unemployment benefits.

That the Social Security and National Insurance Trust (SSINT) vigorously implements the changes in the current Social Security laws to extend coverage to all citizens irrespective of the nature and place of their work.

Government should by 2008 make and implement an Affirmative Action policy with legal backing to ensure the full integration of women in all spheres of public life.

Additionally, law enforcement institutions should vigorously implement laws passed to protect women?s rights including the prosecution of violations of such laws.

Also government by 2012 should enact and fully implement specifics laws and measures to promote and protect the rights of women and girls in accordance with the provisions of the Convention on the Elimination of All forms of Discrimination against women (CEDAW) and all international and regional instrument regarding women?s rights and take steps to ratify the Optional Protocol to CEDAW to enable women in Ghana to benefit from its provision.

Others are that, the National Commission for Civic Education (NCCE) develops and implements a comprehensive programme to raise awareness about provisions of international, regional and national women?s rights laws and instruments, and inculcate in the general public respect for the rights of women.

Lastly, the Ministry of Education should activate Human Rights education from primary to tertiary levels of education.

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UNESCO: Launch of World Atlas of Gender Equality in Education

To mark International Women’s Day, UNESCO and the UIS have jointly released the World Atlas of Gender Equality in Education, which includes over 120 maps, charts and tables featuring a wide range of sex-disaggregated indicators.

The vivid presentation of information and analysis calls attention to persistent gender disparities and the need for greater focus on girls’ education as a human right.

The atlas illustrates the educational pathways of girls and boys and the changes in gender disparities over time. It hones in on the gender impact of critical factors such as national wealth, geographic location, investment in education, and fields of study.

The data show that:
Although access to education remains a challenge in many countries, girls enrolled in primary school tend to outperform boys. Dropout rates are higher for boys than girls in 63% of countries with data.
Countries with high proportions of girls enrolled in secondary education have more women teaching primary education than men.
Women are the majority of tertiary students in two-thirds of countries with available data. However, men continue to dominate the highest levels of study, accounting for 56% of PhD graduates and 71% of researchers.

The atlas also provides a fresh perspective on the progress countries are making towards gender-related targets set by the international community under Education for All and the Millennium Development Goals.

The print edition of the atlas will be accompanied by an online data mapping tool that enables users to track trends over time, adapt maps and export data. This eAtlas will be regularly updated with the latest available data from the UNESCO Institute for Statistics.

Download full report here

Download the full report or obtain a printed copy

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