A stitch in time, saves nine….

As promised, my last post on the topic is here - 

The total expenditure that the government has budgeted for the Financial Year 2018-19 is Rs. 24,42,213 crore and the allocation for health is Rs. 54,600 crore. The budget for National Health Mission has been reduced from 30,801.56 crore to Rs. 30,129.61 crore. 

The allocation for the Department of Health Research for 2018-19 was raised to Rs 1,800.00 crore from the last budget's allocation of Rs 1,500.00 crore, an increase of Rs 300 crore. Under the flexible pool for non-communicable diseases, injury and trauma, an allocation of Rs 1,004.67 crore has been made. Rs 1,200 crore have been committed to construct 1.5 lakh health and wellness centres, that will increase the accessibility of the health systems and will bring health closer to the homes of people. Rs. 2000 crore have been channeled through RSBY to National Health Protection Scheme and an additional Rs 600 crore to provide nutritional support to all tuberculosis patients at the rate of Rs 500 per 10-month cycle till the duration of the treatment.

As the structure is in the country, most of the allocations made for Health in the budget go to NHM followed by Department of Health and Family Welfare, National AIDS control Society, Department of AYUSH and then Department of Health Research. If we look at the break up of allocations in the budget vis-à-vis the actual expenditure made for 2015-16, the figures look like this –

Budget Allocations	Budgeted Amount – 2015-16 (Rs. Crores)	Actual Expenditure 2015-16 (Rs. Crores)	Budgeted Amount 2016-17
National Health Mission	18295	18295	19000
Department of Health and Family welfare	6254	7504	9100
National AIDS Control Society	1008	900	1050
Department of Ayush	600	657	750
Department of Health Research	1397	1615	1700

One of the biggest challenges about increasing health expenditures in India has been a low ratio of budgeted to actual expenditure. Departments and schemes are not able to exhaust funds allocated to them. To be able to achieve SDG goals, health expenditure in India is to be increased, and there is a lot of international pressure also regarding that. Before the budget, we were thus at a situation where government departments were not able to spend funds allocated to them, in simple understanding, while they knew where to spend the money because the money was allocated under various schemes, they did not have the willingness to do that. India’s continuous dismal performance on healthcare, with low government healthcare spending and high disease burden, results in extremely sad outcomes. According to World Bank data, 62.4% of total health expenditure in the country was out of pocket (OOP) as of 2014, compared to a global average of a little over 18%.

Rather than going into the details of this grave situation where there is huge out of pocket expenditure made by people in India, and government departments not being able to spend the money allocated to them and finding out reasons for that, a simple solution to increase expenditure in health care was thought about. Allocate the money to the private sector, give it right in the hands of the people, there would be a better performance on expenditure. It has been assumed that resultantly the health indicators devised on SGD Goal -3, index would improve, and the nation will become a healthier nation. An increase of 1% in the special ‘health’ cess that the tax payer has been paying has been increased to achieve that.

The government has estimated the premium for NHPS at Rs 1,000-1,200 per family per year for a cover of up to Rs 500,000 for a family, for 10,000 crore families. That works out to be an annual increased expenditure of about Rs. 100,000,000 crores. The Union government said it would provide 60 per cent funds, and the state governments were expected to pool in the remaining 40 per cent.

There were some other possible solutions to the problem, but they were tougher solutions. But before we look at the solutions, let us try and look at the possible problems with the implementation of the NHPS in the coming year.

The finance minister said he will be able to meet the funding requirement through the 1 percent increase in education and health cess on income tax, which was imposed to garner an additional Rs 11,000 crore, and the newly re-imposed long term capital gains tax, which is expected to bring another Rs 20,000 crore to the government’s coffers. The government estimates the premium outgo to cost anywhere between Rs 11,000-12,000 crore. However, the allocation made in the budget was just Rs 2,000 crore, which seemed a paltry sum for a scheme of this size as of now.

Earlier we have seen that RSBY (Rashtriya Swashya Beema Yojna), aimed to cover Below Poverty Line (BPL) households, funding private insurance for inpatient coverage of Rs30,000 for five members per household, has been riddled with problems. Research reports have shown that the scheme had failed in both its primary objectives. It had misfired in targeting, covering only 12.7% of households among the poorest quintile at the national level. And while the scheme increased the number of admissions, it failed to significantly impact OOP expenditure or reduce health-related poverty for the former.

Why the outcome has been poor? At both the central and state levels, governments have lacked the capacity to regulate RSBY effectively. RSBY provides, Insurers find it more profitable to insure households less than five members, which is mandated or issue the registration cards halfway through the year. Effective targeting has also not been a priority. Doctors and hospitals, recommend unnecessary procedures to claim reimbursements.

Healthcare lies at a confluence of inelastic demand, political sensitivity, economic consequences, and ethical governance that makes the state’s role crucial. Alongside an increase in the quantum of funding, there is a need to improve the policy design and quality of spending to ensure closer alignment with health outcomes. Every rupee spent on health has an opportunity cost in a developing economy, because there are many sectors such as education, infrastructure, which also claim the same resources.

What are the health outcomes we want to achieve? It is not rocket science to figure that out. We want every citizen of India physically and mentally healthy. We want every citizen of India to have access to health and not merely an access to cure. Thus, health outcomes are achieved not just by curative care but by many other factors too. Curative care providers, worldwide, have a strong lobby and great negotiating powers, though.

The other factors that are responsible for health outcomes are, healthy environment, adequate nutrition, gender equality, low stress in society, road safety, absence of extreme poverty conditions, and healthy lifestyle. All these factors fall under preventive care. Hospitals and insurance cover do not cover any of these.

Health expenditure comprises of revenue and capital expenditures. Traditionally, capital expenditure on healthcare is low. It was on an average about 10% of the total health expenditures in the last ten years. Studies have shown that a large part of growing revenue expenditure goes is one head – Salaries.

There are significant infrastructural gaps in India, as far as health care delivery is concerned. There is a normative gap of 3469 community health centers for a population of .1 million, 5887 primary health centers for every 30000 people and 27430 subcenters for every 5000 people. Even if these facilities exist they are not fully equipped. There is a gap in the number of doctors, nurses, paramedics, and frontline health workers required to run this system as well. Because of this gap at the lower levels a referral system cannot be created and thus the burden is shifted to tertiary level hospitals and medical colleges in the district. Capital expenditure needs to increase to fulfill these gaps.

A study done by Somnath Rudra, in Thanjavur district, through a medical-geographical approach to assess the health status in the district reveals that the most prevalent diseases reported are acute diarrhea, worm infection, ear discharge, scabies, dental problem, eye vision defect, night blindness, anemia, leprosy and filaria. Thanjavur is primarily a rural, betel nut growing district. It was found that most of these diseases are because of poor sewage and drainage facilities resulting in stagnation of sewage water and unhygienic living condition. Dental problems are due to betel nut chewing habit, prevalent amongst people. In this district construction of a proper drainage and provision of clean drinking water will solve a large part of the problem. Betel nut chewing habit would require behavior change. Malnutrition is responsible for some other conditions. Lifestyle diseases like diabetes, hypertension, cardio vascular diseases require lifestyle changes. Curative care provided where preventive care is required is a very very costly solution. There is also a zero sum game between preventive and curative care, as both claim the same resources.  

Each district in India is unique in terms of health challenges that it may face. When the problem is specific, a blanket solution cannot be invented for the problem. A more serious effort is to be made to do research on the disease profiling at the districts, possible reasons for the prevalent diseases must be found and documented and then the solutions have to be evolved. Hospitals, doctors and nurses, alone cannot solve the problem.

Public health official cadre at the district level should be created, they should do extensive research and collect data on a continuous basis. Epidemiology is the branch of medicine which deals with the incidence, distribution, and possible control of diseases and other factors relating to health. District epidemiological reports should be prepared on an annual basis and based on that district health interventions should be designed.

Putting too much of money in insurance, considering wide gaps in government infrastructure will transfer committed funds (Rs. 1200 crores in this budget) to private sector every year. Capital Expenditure on health will get a boost in the private sector, but it will also give rise to cost of care, drugs, and diagnostics. Very strict regulations will have to be enforced to make this public private machinery work, otherwise it will give rise to various un-ethical practices. Privatization of a basic service like healthcare, may bring up unique inequities, like those that we have in US, those who can pay will have a better access to health. 

In India, we do not have a universal health coverage and thus we do not have a model either, we must construct one. That gives us a unique opportunity too. We can learn from the rest of the world, from the fallacies of different models, make use of technological developments, and leapfrog to a better and more sustainable health care delivery system.

Even before we construct enough infrastructure, we have an ability to develop a robust HEALTH MIS, a data base that contains health related information of all the citizens of the country based on a unique identity number and district epidemiological reports. Tamil Nadu has made efforts in that direction. With the help of this kind of data, we develop specific customized solutions based on preventive care along with curative care. We can then make use of technological innovations like telemedicine, gene mapping, largescale diagnostic labs etc. to leapfrog to a more vibrant health care delivery system. A large population is to be served, but it also gives opportunity in terms of scale economies, as per person cost of technology is bare minimum.

The nation should have publicly operated, not for profit health insurance model for all the citizens in the country. (FM announced that the three government general insurance companies will be merged and later as part of disinvestment initiative be listed on stock exchange) Health insurance should be kept in public domain and a new company for health insurance should be created, in the public domain. This company can create various insurance products, for different kinds of payers. Scale economies will generate low cost products, let people bear the cost of insurance largely. Poor and marginalized population should also pay a part of the premium. For profit insurance models, the one that we have in US, generally gives rise to middlemen and agency costs. It increases, drugs, diagnostics and treatment costs. Distributing freebies in a developing economy, merely increases fiscal deficit and crowds out private investment resulting in slow economic growth. It doesn’t help the poor either, because it pushes them back to the subsistence sector. At least a part of the premium should be paid by the poor family too. We need to create capacities to pay rather than distributing freebies.

The last initiative would be improving the management of hospitals. Government Hospitals are very poorly managed, and the reason often cited is the over crowdedness of the hospitals. Military hospitals in India are equally loaded, a doctor sitting in OPD, in a military hospital usually entertains, the same number of patients, OTs, wards and other services are also equally demanded for. The difference is in the management. Military hospitals are managed efficiently, SOPs are followed, and monitoring and regulation is very strict. The same can be done for government hospitals too.

To conclude, my health financing solution would be -

• Government should increase capital expenditure and create infrastructure from the tax payer’s funds.
• Government should increase its expenditure in preventive and promotive methods, as curative care would tackle just one part of the problem and preventive care solution are much more sustainable and cost effective.
• Health Insurance should be publicly provided and should be made a not for profit sector.
• Privatization of healthcare is not desirable. Private investment has a greater capital cost.
• Cost effective free drugs and diagnostic models be developed.
• Management of government hospitals should be improved. We should get back to the good old days of government hospitals.
• Make judicious use of technology to leapfrog to advanced care models. First step should be to have a robust MIS.
• Let the citizens pay their taxes and enjoy an equitable, universal basic health for all.

Public spending in any sector, should be outcome oriented. Every rupee spent has a greater accountability because it is a tax payer’s money. We are extremely happy to hear an announcement of an increased expenditure of Rs. 50000 crores in healthcare. We are also happy that like everywhere else, health should become an election agenda. We should argue and debate thus – on wherewithal’s, and whereto’s.

A Stitch in Time Saves Nine………………………. Medically too. 😊

Theoretical underpinnings of a blanket insurance policy for all. Wherewithal's?

The Finance Minister gave a commitment to spend 50000 crore on healthcare in the budget. Government Health spending in India has always been one of the lowest in the world at 1.1% of GDP. A commitment towards increasing this health spending first was reflected in the Health Policy 2017 document and later in the Budget 2018. An increase in public expenditure on health is imminent because of two reasons – One, that lakhs of people every year are pushed back to poverty because of huge out of pocket health spending. Studies have shown that they fall into a debt trap, sell their assets, to seek health and thus from a welfare state perspective, it is essential for state to make public expenditure, so that an affordable access to health services is ensured to all. That is also termed as ‘Universal Health Coverage’. Two, for a developing country, human capital is the most critical link to growth, and thus health is something that needs utmost attention as a developing country needs a healthy work force. The basic aim of health care is to keep people healthy, treating the sick at affordable prices and protecting households against catastrophic expenditures and resultant financial ruin due to medical bills.

Let us try and understand the different types of Healthcare Management Models are available in the world –

The first is the ‘Beveridge Model’, given by William Beveridge, who designed British Health System. Under this model, healthcare is provided to all the citizens by government and is financed through taxes. Most of the hospitals are owned by the government and a large part of the healthcare work force be it doctors, nurses or paramedics, work for the government. There are also private doctors, but they collect their fee from the government, when they provide their services. Government is a sole buyer of the service in Britain, can control what doctors can do and charge, and thus per capita health system cost is maintained at a minimum. In Britain, you never get a doctor bill. That is the reason Princess Kate delivers her baby in the same hospital as other common people and avails the same services. Britain, Spain, Norway, Sweden, Finland, New Zealand and Cuba have adopted this model. Cuba’s model is the purest Beveridge as it is the model of complete government control.

The second Model is the ‘Bismarck Model’. It was invented by Chancellor Otto Van Bismarck, during the process of unification of Germany in the 19^th Century. This model covers everyone in the country under a health insurance plan, where the insurer does not make a profit. Thus, it is a model based on ‘not for profit’ insurance. The insurers are called ‘sickness funds’, financed jointly by employers and employees. Germany has about 240 different funds, and this is a multi-payer model. Tight regulation gives government much of the cost control. Apart from Germany, Japan, Belgium, Netherlands, France and Switzerland follow this model.

The third model is the ‘National Health Insurance Model’. It has elements of both Beveridge and Bismarck. It uses private sector providers that come under a government run insurance program. Every citizen must pay for this insurance program, and every citizen is covered under it. There is no financial motive to deny claims, and no profit, thus it is a cheap and administratively simple model. National Health Insurance Plan, controls costs by getting the sole power of supplying patients to hospitals on one hand, and on the other, attain immense negotiating powers to keep medicine and diagnostic costs from pharma companies and diagnostic service providers to the minimum. Canada, Taiwan and South Korea have adopted this model successfully. The joke is that Canadian drug costs are so low that American stores forge and buy pills from them north of the border.

The fourth model is the ‘Out of Pocket Expenditure’ model, where state does not provide much assistance and medical bills are largely paid out of pocket by the people. In this kind of a system the rich get medical care and the poor get sick and die in the absence of it. This kind of model is prevalent in Africa, India, Rural China and South America.

As far as United States is concerned they have a hybrid model. They have separate systems for separate classes of people. Their Health Insurance Model is a for profit health insurance model. For the veterans, it is Beveridge, for the workforce it is Bismarck, and for the 15% of people with no health insurance, it is out of pocket. Americans, it is said, have messed up their healthcare system. In Baltimore, just 100 yards away from Johns Hopkins Hospital, which is perhaps one of the best hospitals in the world, I saw a sick person lying on the street.

The coinage of the term ‘Modi care’ comes from ‘Obama Care’. I will make a comparison between the two when I have understood ‘Modi Care’ better.

For now, it looks like a hurried exercise to develop a hybrid model. We have free diagnostics and drug distribution schemes, running in some states in India. We have RSBY, and other schemes which are insurance schemes for the poor. We have government hospitals and dispensaries, providing healthcare at low cost and we have corporate hospitals and private clinics, that charge exorbitant amount of money for providing healthcare. We still have a majority of the population paying out of pocket for healthcare.

What are the wherewithal’s of Modicare? Many health economists in the country have said that it is a very difficult fiscal arithmetic to make. Meryll Lynch, has made a calculation that Modicare will cost the government a minimum of $20 billion.

Wait for my next post.

A highly promising Budget.................... !!

Budget 2018 had brought forth rather unusual pre-budget questions in the curious intellectual minds of the country. In the absence of a scenario of estimating policy fallouts largely from indirect tax levies, for the first time the focus shifted to direct tax levies, and a prospective, policy implication of corporate tax levies or income tax levies.  The whole debate about low GDP to investment ratio, ease of doing business, cost of doing business going up by 2-3 % versus infrastructure development, farm sector reforms, job creation with the help of increased government spending, poverty eradication, health and education, the rich becoming richer, and the poor remaining poor because of economic reform; was to be continued in the context of budgetary announcements. Winter slowly walking out of the door, and the Sun shining more brightly over the country, made for an adequate budget season, and a perfect setting for a Nehru Jacket Clad Finance Minister’s budget speech.

It was going to be a reformist, or a populist budget was a no brainer at all. Thus, for those of us who claim to be economists, the more interesting part was going to be allocations. We had full confidence that the Finance Minister would be able to do the necessary jugulary of numbers and will balance tax receipts with new populist allocations, while at the same time keep a check on fiscal deficit. Which sectors will receive allocations in the wake of an imminent populist budget, was what we were looking for in the budget speech.

This was a budget focused on farm sector and healthcare, as it turned out to be.

The budget allocations to health sector, in the form of National Health Protection Scheme, providing a health insurance cover of ₹5 lakh per family and termed as ‘biggest scheme of health assurance’, in the world, to address the current healthcare needs, and establishment of tertiary care hospitals and medical colleges, to fulfill the future healthcare needs; is indeed more than welcome. Out of pocket expenditures on healthcare will be financed by National Health Protection Scheme. It does bring in the ease of living. The implementation plan of this scheme would be soon out partly, in the budget fine-print, and later in the announcements made by the ministry. However, it looks like the scheme at present is likely to benefit private sector more than the government sector in health care. Unoccupied beds in private hospitals and nursing homes will come under the affordability of larger population, as government hospitals are already crowded and overburdened as a result of this scheme. The government is then, putting an increased expenditure on healthcare amounting to 50000 crores and transferring a large part of it to the private sector in the short run. An increased 1% increase in the health cess is what the common taxpayer must pay for that. The devil is in the detail. Empanelment of private hospitals under this scheme, and the coverage would be a critical implementation question. What caught my eye was a Fortis Hospital stock going down on the stock market, while Apollo Hospitals going significantly up.

Nevertheless, the out of pocket expenditure (OoPE) on health by households is as high as 62% which adversely affects the poorer sections and widens inequalities. As per National Health Accounts 2014-15, the government healthcare providers accounted for around 23% of the Current Health Expenditure while the share of private hospitals and clinics was higher at 31%. Expenditure on diagnostics (including medicines and diagnostic tests) by households was about 10% of the total OoPE during 2013-14.

Earlier, in the economic survey, there was a mention of National Nutrition Mission, with a target to reduce malnutrition and low birth weight by 2% each year. The government has budgeted ₹9,046 crore for the mission for a period of three years. All the states and districts will be covered in a phased manner; to begin with the worst affected 315 districts will be targeted this financial year. The core idea behind the mission is to converge all the existing programs on a single platform. Farm sector reforms will increase disposable income in the rural areas and is likely to bring up consumption. Rise in minimum support price for Kharif crop by 1.5 times, should bring up farm incomes. However, a robust implementation plan which is to be prepared by NITI Aayog, would be very critical to realize effects.

We have been arguing for long about increasing allocations to preventive care, and step towards allocations made to nutrition is welcome. If we look at the nutritional deficiencies of people in the country, we find that about 80% of the population in India is low on vitamin and protein intake. Indian diet is largely carbohydrate rich diet. Advent of commodity exchanges, and futures trading in farm produce on these exchanges, increased the price of pulses and cereals. Much of agricultural sector inflation is artificial in nature, because of artificial ways of creating demand. In that kind of a system the middle-men benefit rather than the farmer. In a nutrition starved country, the demand-supply mechanism of price determination in the agriculture sector should not let the prices rise. We just hope that NITI Aayog considers this simple logic before determining the implementation plan for the MSP.

Nutritionists around the world have argued that the food grown locally is the best food to be consumed for health. Before transportation and cold storage facilities, we largely consumed local food. The diversity in food pattern and cuisines in the various regions of the country is a testimonial to that. Modern science contributed to capturing hunger, by helping in creating efficient food supply chains, to make food available in places where there was less production or drought. But it also killed local staple food patterns and gave place to something like ‘junk food’ in our diet. Taking on Nutrition on a mission mode, should also consider doing extensive research on developing staple diet based on local produce, so that food options like Ragi, Millets, Groundnut, sesame, Jawar, Bajra and locally grown fruits and vegetables remain a part of our diet and remain cost effective, because a lesser amount of money is to be spent on supply chain.

A good amount of allocation has been made to infrastructure development for the farm sector. Nutritional diversity, stress on locally grown food should be considered as major factors to make prudent allocations to infrastructure and that would be good for health too. NITI Aayog will arrange for an institutional mechanism for practices of price and demand forecasting. Can NITI Aayog develop such an infrastructure that the prices of pulses and basic cereals reduce in-spite of an increase in MSP? Would that be a difficult balancing act to make? The delivery of the promises made in the budget would be challenging.

Proposed increased expenditures on hospitals and wellness centers in primary and tertiary will definitely create jobs in the healthcare sector, but largely on the clinical side. Public Health Management cadre jobs will perhaps produce far bigger impact on health, in the long run. A zero sum game between preventive and curative expenditure is a fact that has been proven by research. A long term sustainable health system in the country should be based on preventive health, was articulated very well in the Health Policy 2017. The road map to increased expenditures in healthcare should take care of that. Some funds could be allocated to know how many doctors and nurses currently working in the hospitals have a knowledge of public health?

A little bit on other parts of the budget – marginal decrease in corporate tax, offset by an increase in capital gains tax – if it inspires corporates to make investments in productive assets rather than financial assets, will do something to create jobs. Increased investment by government in infrastructure, roads, railways, and housing should not be criticized because if jobs are created by increased government expenditure, so be it. An increase in disposable incomes in the rural areas will give a boost to consumption spending and will resultantly increase the rate of growth, is a good theoretical premise, how it unfolds practically is yet to be seen.

Overall, I wish to congratulate the FM for not going very far from the reforms, even while working with-in the compulsions of having to prepare a populist budget this time. The key to this budget would be implementation efficiency. Promises, should help in infusing confidence, we do not know. However, we let the FM score a few marks on the intention though.

The stock market till now, looks as confusing as most of the people in the country would be.

Don't Waste things, Give ....

The Culture of giving, as I am often told, has not been a part of Indian tradition. However, I find that is a misconstrued opinion. Making an effort to find a historical evidence, to the proposition of an existence of culture of giving; takes us back to mythology, to a folklore of 'daanveer Karna', a king who chose to give away even the parts of his body, when someone asked for it. The folklore celebrated the importance of giving in the Indian culture, and was a reference point for any noteworthy act of giving, done by an individual in the society for centuries. 

Indian state, from ancient times has been federal in nature, the village being its last unit. In a federal system of government, a social security net provided by the central government is more often than not supported by a local social security net, in order to increase its functional efficacy. During the olden days, a unique social security net existed in India. The community took upon itself a responsibility of taking care of the old, the poor, the deceased and the disabled. Basic amenities like food, clothing and shelter were arranged by the community  for the disadvantaged; and it was done under an ethic of sharing food or clothing with those who were disadvantaged. A traditional ethic of not refusing 'do muththi anaj' to anyone who needed it, created a unique social security net, in which the household was the last unit. There is no statistic to prove that no one died of hunger under this system, but there has definitely been an evidence of an existence of a social concern about sharing food as a day to day practice for centuries.

The agrarian economy that existed in India about 200 years ago, had a large part of the capital, invested in agricultural produce, and thus that was the biggest contributor to GDP. Household income comprised of agricultural produce, and in villages it was used to barter the other essential commodities. The village economy thrived on agriculture and thus the social security net was also very effectively constructed around the agricultural produce. 

It was a right based approach to eliminate hunger. Anyone could come and ask for 'do muthi anaj' from a household. It was a tradition not to refuse him. 

Inequality, in terms of ownership of resources is one of the key challenges of our times. In developed and in developing countries. the poorest half of the population often owns less than 10% of the resources. This could be a dangerous situation, and a big threat to world peace. Population, particularly youth belonging to disadvantaged groups could become an easy fodder of conflict. Another very serious problem that arises from an unequal distribution of resources is the wastage of resources by those who have in abundance, while the same resources could easily be transferred to those who survive in subsistence. 

Modern living leaves us with a lot of resources at home that we tend to waste. Our homes are piled up with, no longer in use gadgets, mobile phones, toys, books, cycles, utensils, food etc. and they could easily be shared with someone who would need them. When we waste these products, we waste the world's resources, increase the landfills, and make our contribution to environmental degradation. 

Isn't it almost criminal to waste resources? 

If we get back to the older system of making a household the last unit in developing a social security net, we will perhaps live in a better society. A peaceful and sustainable world will have to develop its own solutions, more so with people's participation rather than by state intervention. 

We can begin with a small step - Let us not waste the resources, we have. Lets share them.

An impending judgement in Salman Khan's case - A cause for Road Safety in India

We were returning home after an official foreign trip. We landed at Delhi airport early morning and hired a taxi to travel to Jaipur. It was end of January, a peak winter season. I was with a colleague and a few students. We had merely crossed Delhi and it had started raining. Most of our luggage was in a carrier on the top and we realised that there was a need to cover the luggage. The car was stopped. The driver arranged for a polyethelene sheet and he, with the help of two of our students managed to tie it over our luggage. In the process the driver got a little wet. I feared that he might catch a cold. I inquired from him whether the sweater he was wearing had gotten wet. He turned a deaf ear to my question. I asked again, he muttered a disinterested 'haan', I thought, of what I could barely hear. We drove a little further, and took the car in the side lane only to stop in front of a few roadside shops. He got off the car saying that he would return back in a few minutes and disappeared in a by-lane. He did appear again after good fifteen minutes. This time when he took the wheels he removed his sweater too. Concerned, I tried to ask him again if he was not feeling cold?..... if he had something else in the car to cover him up?..... if we could give him a shawl? I was feeling bad for him and a little guilty too. He gave a patient reply that he did not need anything and that he was fine. He asked me not to worry. 

We had had a long international flight and we were all very sleepy. Perhaps in a little drowsy state that I was in,  a thought flashed in my mind and made me sit up in a jiffy. Were we being driven by a drunk driver? I carefully examined his demeanor. We were moving at a reasonable speed. I could not see any signs of rash driving. He was careful did not seem to do a reckless overtake or a hurried lane changing. I decided to keep the thought to myself. But I had lost my sleep to this thought. We reached Jaipur safely. I do not habitually thank almighty for minor day to day events like a safe journey, or a good day. Nonetheless, the journey had been fearful, no doubt about that. A minor detail, I have not mentioned as yet is the fact that there was a photograph of a bespectacled 'Chulbul Pande' stuck on one corner of the front glass in the car. 

One of the fears in life is a fear of being driven by a drunk driver. Or worse, being hit by a drunk driver. 

The Global status report on road safety 2013 estimates that more than 231 000 people are killed in road traffic crashes in India every year. Approximately half of all deaths on the country's roads are among vulnerable road users - motorcyclists, pedestrians and cyclists. While India has less than 3% of the world’s vehicles, it accounts for some 11% of the world’s road deaths. That too, when many such incidents are not documented at all. Road accidents are not only traumatic for victims and their families but also take a huge economic toll on the country.    They cost an estimated 3% of GDP each year. Road accident victims are mostly the poorest of the poor, thus it is also a matter of social equity. It is estimated that 17-18 percent of these fatalities occur in urban areas.

Salman Khan may be let go off Scott Free by the court, in his 2002 case. Or may be he gets a maximum imprisonment of five years. The court will give its verdict. It has been a long time and what I gather from the newspapers and from the TV channels, the family members of the victims in that famous car accident case are not much bothered whether a punishment is given to the superstar or not. A time lapse has made them less bothered, and life's struggle over a period of 13 years have forced them to move on from a family tragedy of a sudden death of a family member. 

Many road accidents in India remain undocumented because the driver would fly away from the site, a blood test could not be done in time, the victim comes from a vulnerable section of the society and no one really bothered to file a FIR. Traffic fatalities increased by about 5 percent per year from 1980 to 2000, and since then have increased by about 8 percent per year. Things will probably get worse before they get better.

The Superstar's acquittal in the case will be welcomed by his fans, his sentence would be lamented by them. Would it affect the cause of Road Safety in India? We have all visualised a lot of wannabe Salman Khans, who take pride in emulating the super star and can be seen driving recklessly on urban roads. People will argue that perhaps it is not correct to blame Salman Khan for a certain behavior exhibited by these wannabes. A counter logic may belie such an argument. What remains indisputable is the tremendous star power of the super star. His fan base is large. Ironically, it is more among the vulnerable sections of the society. 

Michael Bloomberg, former mayor of New York City, announced a package of assistance on road safety through Bloomberg Philanthropies’ Global Safety Initiative. The overall goal of the Bloomberg Philanthropies Global Road Safety Programme in India is to support the Government of India to implement good practices in road safety in line with the national road safety strategy. The focus of the project is on promoting motorcycle helmets and reducing drink–driving.

A World Bank report mentions that  road accidents are easily preventable. Five strictly enforced interventions can make an initial impact:

1. Enforcing the compulsory use of seat belts and helmets.
2. Taking strong action against drunk driving and speeding.
3. Installing road signs, markings and crash barriers; segregating pedestrians and non-motorised traffic from the main vehicular stream; and ensuring that sidewalks and road shoulders are usable.
4. Tightening the driver-licensing and vehicle-registration systems; installing speed cameras and other automated devices at high-risk locations; and imposing credible fines for violations.
5. Establishing a string of trauma care centers so that victims can reach quality medical care within the golden hour.

Most of these interventions call for a change in law or an improvement of infrastructure. 

One intervention is more about public awareness, social marketing, community action and behavioral change. Drunk Driving and Speeding.  

A drunk driver in many cases would not be driving alone. He might not go unobserved if he is reckless in his driving. A reckless driver is surrounded by people who know that he is one. Can't we as a society stop him? How many of us have sat beside a family member who is drunk heavily and is driving, and have habitually prayed to God for a safe journey? How many of us have ever prevented a family member or friend to not consume too much alcohol, if he/she is required to drive after that? How many mothers have bothered about a son who drives a truck on the road, often in a drunken state, but have had no courage to prevent it? How many of us have the courage to socially boycott a person, for his irresponsible behavior regarding the consumption of alcohol, much before he actually goes on the road and commits an accident?

A major social intervention is required to prevent road accidents and promote road safety, apart from legal action, and development of infrastructure. 

We hear that Salman Khan is a conscientious human being. He donates a large part of his income for his charity 'Being Human'. His charitable foundation has plans to expand its work in the area of healthcare and education. They have already done some notable work. Road injuries is one of the prominent health scare in India, Can a Superstar's Star Power not be used to promote safe driving in India? WHO produces evidence-based mass media campaigns after extensive research and testing conducted with target audiences. Social marketing campaigns to prevent drink–driving have been developed, aired and evaluated in India. Should a superstar, who is almost worshiped by his fans not be made a part of these campaigns? 

Whatever is the verdict in Salman Khan's case, I would like to imagine that Salman Khan turns into a teetotaler post his verdict, and a role model for his fans. If I have his number, I would make a call to him and request him to make Dabang 3 based on a story of a heroic truck driver who gives up drinking in order to influence others, promote safe driving and save lives. I would request him to promote the cause of Road Safety in India. 

Road Safety has been ignored for long. Its time that we sit up and prepare ourselves to take action, at our level in the society. An impending judgement in a superstar's case is not an important thing for a nation. Our safety is.

Maggi on the Indian dining table.

This incident happened a few years ago. A little neighbor of mine had come to keep me company, on a Sunday morning when I was apparently alone in the house. It was morning time and I had barely finished my breakfast on a sandwich. She declared that she was hungry because she had decided to visit me almost as soon as she woke up and she had not had her breakfast. I offered to make a sandwich for her. She said No. I offered her a variety of things, fruits, poha, biscuits, khakra, cake, milk shake etc. she said no to everything. Finally she said, 'If you have Maggi, please make Maggi, I have not had anything since morning.' Although reluctant to give her Maggi for breakfast and the fact that there was no Maggi in my kitchen shelf, I still walked up to a nearby shop to buy Maggi and cook it for her. A hungry child's dismal face can make you do that.

Later I found that there was a ration on Maggi in her house, and the consumption was limited to once in a week rule laid out by her wise grandmother. She had already consumed her quota of Maggi in the week and there was no way she could get more. And thus, this intelligent child had thought of a plan and had executed it most effectively, interlining some drama and emotional black-mail into it. With a glint in her eye, she said, after she had finished her Maggi, 'Grandmom says that if I eat more Maggi, than it is once in a week, the noodles will get entangled in my stomach and it will ache badly, but I have chewed them so well that they will not get entangled.'

There were times when Maggi was not a part of our lives. This entanglement with Maggi happened rather quickly making it a 2000 crore brand in India. To think of 2000 crore worth of money spent in creating a health hazard is horrific. The value of a food item becoming a 2000 crore brand comes from the fact that it has become an essential part of the Indian Dining Table. There are not too many 2000 crore brands in India among food items. It is also a fact that there have been many people around us, like my little neighbour's wise grandmother who have been cautioning against the possible health hazard caused by Maggi. Greater Common Wisdom receded in the case of Maggi, and gradually gave way to irrational, emulous, consumerism of modern living.

Maggi lead scare has forced many packaged food manufacturers to conduct food tests. Packaged food market is around Rs. 8000 crore in India. According to an analysis done by Tata Strategic Management Group (TSMG) in 2006 the ready-to-eat (RTE) market in India, was expected to expand to reach Rs. 2,900 crore by 2015. AC Nielsen estimates the Indian RTE market growth slowed from 44.9% in 2010 to 28.1% in 2011, reaching INR 506 crore. According to Raju Bhinge, CEO, Tata Strategic Management Group, “There is a huge untapped market opportunity arising due to rapid demographic shifts in income, urbanisation, and proportion of urban working women in India. The industry needs to concentrate on broadening the market and increasing penetration amongst Indian consumers.”

The reasons given for the rise in packaged food and RTE markets are lifestyles getting busier, rising disposable incomes and increasing number of women becoming a part of the workforce. Propensity for frequent substitution of traditional meals with ready to eat meals was estimated by A C Nielson for various countries, the results showed that Asians are fast changing their eating and cooking habits. 

India does not feature in this list of Asian countries, yet. Indians traditionally abhor ready to eat or packaged food. An idea of fine dining in India is about a freshly cooked food served hot. Greater Common wisdom has put checks in India over a picking trend of ready to eat foods. A disbelief in the ability of the authority to keep a vigil on quality has been another reason why Indians remain apprehensive about consuming ready to eat or packaged foods. Indian consumers are reluctant to believe in the safety of a ready to eat food supplied to them by a temperature controlled supply chain, so far.

However, it is a fact that lifestyle is becoming fast in Indian cities and more and more women are spending more time out of the house. 

School Education's contribution to Indian Economy

Alvin Toffler says that the present school system should be replaced by a school system that could make available customized education. A school that would open 24 hours a day, could let a student in any time, has a diverse curriculum and teachers teach while doing other jobs as well. Students could get the liberty to begin their formalised schooling at different ages. Such a school would cater to the needs of new economy, the knowledge economy.

India's school system was designed by Macaulay, reportedly, to produce clerks. It I use Toffler's words, it is a system that produces an educated individual by forcing him to go through a 'rote repetitive' stuff. An individual who is educated in this manner is no doubt a wonderful clerk material. Government sector was and still is the biggest provider of white collar jobs in India and thus Macaulay model seems to be extremely successful in the supply of an educated individual in India, may be for the last 100 years.

India is a young country, about 65% of population is under 35. A young educated guy comes out of the school roughly at about 17 years. But that is not enough to seek a basic white collar job. He has to go through at least three more years of education to seek a job. Two more to seek specialization, and a few more years to contribute to research and innovation. The fact remains that it is these students who excel in doing 'rote repetitive' stuff, in their formative years, usually reach the stage, where they learn the skills to do research and innovation.

First question is - Does present education system in India, suffocate these students in their formative years, who have the potential to do research and innovation later?  In order to find an answer to this question and reach a conclusion, an extensive research needs to be carried out. I tried to look for some such research but could not find anything. If I have to answer this question myself, I would say yes, I hated rote education wherever it was relevant, and failed miserably to do well in those areas. However, the family and society where I lived provided an amazing access to knowledge, in terms of books, library, newspapers, magazines etc. A large part of my learning in formative years came from 'outside classroom' activities like reading and participating in extra-curricular activities. I often wonder - In the absence of outside classroom learning opportunities, would I have been a case of a failed student, one who had major learning inefficiencies? My biology and chemistry school teachers should have definitely vouched for that.

Second question is - Does school education do anything to those who seek something like a basic government job? A research study conducted by P Duraisamy published in 2002, states that school education undergoes a diminishing rate of return, the returns up till secondary level rise and after that they decline. For women its the reverse, 'the returns to women's primary and middle levels of education declined while those to secondary and college levels increased during the decade 1983–94'. Investment in women's education back then, seemed to be a more profitable proposition. May be a new study in 2015-16 may bring diminishing returns for higher education for women as well. If a student does not attend school at all and studies all by himself at home for 8-10 years, will he be good enough to qualify a 10th class exam? Someone who starts his education at an age of 8-10 would be able to gather enough knowledge by the time he is 15 to qualify 10th or not?

A bigger question is - Did we go to school to gather knowledge? or Did we go to get friendship, companionship, which could foster our social and emotional development? or Did we go to school to get values? My personal answer to the second question would be yes, definitely. My answer to the first and third questions would be yes, in parts.

Coming back to the question of the challenge of educating a young country like India should lie in creating a model of Increasing returns to education. What if we provide each child with an I Pad and an internet connection? What if we construct public computer centers and public libraries instead of schools? A pilot could be done to find out if investment in laptop/ I Pad and library brings increasing returns to education. Let schools then be fun places to make friends, play, learn some language and maths, drawing, painting, music and other disciplines of performing and applied arts in the basic years of education, lets say 10 years. Let them learn yoga and meditation as part of formal education, for the first ten years. Let a student have a choice to continue formal education after that or to continue with an informal education and sit for his 10th and 12th exams.

Investment in this kind of education would be much lesser and thus the essential difference between cost and revenue would widen in school education and would reduce in college education to make it a proposition of increasing returns to scale. As it is, in a country like India, teachers are absent in government schools and colleges classrooms. Those who wish to educate themselves in that system resort to self learning. We don't need these educators anymore in the education system, who take away assured pay packages with them every month and make education a proposition of diminishing returns to scale. Instead, we can have artists, musicians, physical trainers, sports men, Yoga experts, etc. working as part time teachers in schools.

Let the budget for education be spent more on universities nurturing research and innovation, on labs and equipment and on developing IT enabled education material. Let school education be freed of shackles of Macaulay.

I remember, as a kid I once came back from school and declared that I wanted to change my school. A raised eyebrow asked for a reason. 'There is no discipline in school', I answered. 'Oh! you better keep yourself disciplined rather than change your school', the raised eyebrow said. That discipline seeking child doesn't remember clearly what was the real reason to demand for a change of school. What she does postulate is that schools need to get some discipline for a better economy.