Walk The Talk with Brajesh Mishra

Random Musings: Indian Healthcare

Apropos to the piece by Dr. Devi Shetty titled, Healthcare's grand reformation (Indian Express, June 16th), the eminent author has done well to highlight some of the issues that need the urgent attention of reformers and policymakers. However, Dr. Shetty has tended to focus on the financing aspect of the healthcare quandary and has referred to the US system, which sadly is not only the world's most expensive and inefficient, it is also the least equitable. The US has more than 44 million uninsured or underinsured people and spends over a trillion dollars to take care of its people. The litany of problems of that system are legendary and we would be better off not going down the American way.

It would be better if our policymakers look at the Bismarckian model of healthcare in practice in Europe. The social insurance network that the government has mandated allows both public and private hospitals to exist as providers, while allowing people in networks to buy insurance to pay for it. Dr. Shetty makes a reference to it through his successful Yeshawini scheme. Since health is a state subject, this social insurance can allow states to define what network people get into, be it at the district level or at a block or panchayat level. This scheme allows for multiple payers while at the same time allowing private competition both in insurance and in hospitals.

Secondly, Dr. Shetty has not pointed out the dismal spending on health by the Government of India. India spends a paltry 1% of its GDP, when more developed countries spend anywhere between 7-9% of their GDP. The World Health Organization recommends as 6% to be spent on health, clearly we have a long way to go before we achieve those levels.

Thirdly, there is a genuine need for the insurance network/market to gain ground for it can then allow the government to remove itself from the more capital intensive tertiary level hospitals and look at an extensive network of primary and secondary health care which provides preventative and accident and emergency care amongst other things. Today, the government is in a pointless competition with private players for the tertiary care "market" often at the cost of primary health care. The WHO had called for a strengthening of the primary health network in its 2008 annual report and it needs to be the focus of the current government.

Lastly, the explosion of the "mom and pop" clinics and nursing homes needs to be curbed. These are often manned by under-trained personnel with profiteering as their sole motive. A strong lobby ensures their continuity at all levels of the health care pyramid. A strong primary and secondary care network can help alleviate some of the problems that have manifested themselves as a result of this booming 'sector'.

Private healthcare needs encouragement but so does affordable healthcare. The mythical 'ideal' health system which has the triad of - affordability, quality and access does not exist anywhere in the world. All three of those attributes cannot exist at the same time. But the current malaise in the health sector needs to be addressed urgently and Dr. Shetty's prescription is a welcome step in the right direction.

Annals of Medicine: The Cost Conundrum: newyorker.com

Dt. Atul Gawande's experience from McAllen, Texas on why the cost of healthcare is soaring in the US. Makes for grim reading.

Annals of Medicine: The Cost Conundrum: newyorker.com

Shared via AddThis

: KAL's cartoon | The Economist

The American Healthcare mess in one brilliant cartoon:

: KAL's cartoon | The Economist

Shared via AddThis

Brown and Out

"If an injury has to be done to a man, it should be done so severe that his vengeance need not be feared" - Niccolo Machiavelli

British Prime Minister Gordon Brown must be ruing over the words of the great political mind that was Machiavelli as he battles to save his two year old premiership. The tumultuous rise and fall of Brown will surely be taught to students of political science and history in years to come. Here is a supremely talented man, who many felt was kept unfairly sidelined by the more charismatic rival Tony Blair, only to assume office and look like a complete novice in the job. Britain had many expectations out of Brown, but they find the New Labour government under him battered, bruised and hemorrhaging ministers.

The litany of problems under Brown are endless. Starting the 10p tax row to the more seedy muck raking by aides against his political rivals, Brown's premiership has witnessed much and them some. The proverbial last straw came with the Daily Telegraph's expose/investigation into the expenses of MP's and Cabinet Ministers that shamed the political class. Though, we in India are used to acts of omission and commission from our elected representatives, the British consider their politicians useless, if anything, but not money raking machines as the Telegraph so proved. Ministers have been shown to charge the official coffers for items such has property rents to more inane items like curtains, prams, nappies and even pornographic magazines. While in the normal course of a country and its polity, these revelations would not have caused the outrage they did, but given the downturn in the economy and rising unemployment, knowing that your MP is charging the tax payer for the upkeep of their lifestyles rather than ensuring the tax payers interest have led to this current national mood. Indeed, a Telegraph cartoon captured the mood well, with two much maligned bankers talking to one another and comforting in the fact that "at least we are not MP's"!

The trouble for Brown began much before this recent crisis, soon after taking over office, their were calls from all quarters - his aides, the media and political rivals, that Brown should call a general election so that his anointment after Blair's departure had a public mandate. Brown dithered, and lost public confidence who saw him less than astute in matters of politics. The cruel punch in the stomach, however, was the credit crisis and the recession. Having spent a decade in the Treasury, Brown was seen as the man with the requisite talent and skills set to steer Britain through the tough economic climate. Many world leaders praised his handling of the bank nationalisation and his attempts to build a global coalition to handle the crisis. But as sordid stories of executive pays packets, nepotism by the government and rising unemployment made its way to the headlines, people began to see Brown as the problem rather than solution. His star has faded ever since, with even minor setbacks - be it in local polls or in international diplomacy being magnified to show his overall inefficiency.

However, the biggest mistake, at least in hindsight seems to be Brown's move to install Blairites in his cabinet. This was seen a reconciliatory move to pacify and unite the party which was split down the middle. This act of unity has spectacularly backfired as not only have most Blairite ministers quit the Cabinet, thereby making Brown's position untenable, they have followed the "if I go, I will take you with me" approach. In resignation letter after resignation letter, ministers have seriously doubted Brown's leadership credentials and have suggested that he does the Labour party more harm than good by staying on as Prime Minister. Given this opposition from within and a virulent opposition benches with a younger shadow cabinet, Brown finds himself staring down the barrel. 

Brown may have some political steam left in him to see him through this crisis, he can claim that he cleaned up the Cabinet as soon as the Telegraph story became public. He can also argue that the country needs stability and reform in this hour of crisis. But the more he repeats this, the more he resembles the Emperor sans his clothes. The wind in the sails of New Labour has gone, as has the motivation of fellow companions in the party and government. Brown needs to be realistic and realize that his time is now over, the sooner he leaves, the faster the country can begin afresh and decide which direction it wants to take as we enter a new decade in the Twenty-First century. 

Arun Jaitley chosen the new leader in the Rajya Sabha

The BJP elects BJP General Secretary as the new leader of the opposition in the Upper House. Mr. Jaitley's take on the move. 

Between a rock and a hard(line) place

The election defeat has stunned the BJP into silence and much introspection. While leaders like Arun Jaitley and Venkiah Naidu have voiced some of the opinions in the party over the shock defeat, the party is yet to come out with a complete post-mortem of  the events that led to the poor show.  The big existential dilemma for the party is where it is heading after these unfortunate turn of events. The media and liberal voices have explained the verdict in simplistic terms, putting the blame on the NDA's prime ministerial candidate L.K. Advani, suggesting that his hardline image were unacceptable to the people of India while others like the RSS and the larger Sangh Parivar have argued that Advani was not vociferous enough to 'unite' the Hindu vote by raising issues like Article 370, Ram Mandir etc. 

The two arguments and reasoning seem to in direct contravention with each other. While it maybe that neither one is true, people may have rejected the Advani candidature as a result of the confused and mixed messages emanating out of the campaign (development one day, terror the other, soft PM and then Quattarochi and Swiss accounts), or because the threat of the dreaded unstable Third Front coming to power may have pushed people into opting for status quo. While this analysis is for political analysts and the party mandarins to ponder over, the larger issue that is now facing the party is over what direction to take given these conflicting reasons being spelt out for the defeat. Many noted writers suggest that it is time to drop Hindutuva from the mainstream agenda , while other argue that without ideology and Hindutuva the party will flounder. 

The resemblance of the BJP with the US Republican Party is not only uncanny but in fact eerily similar. After the defeat of their candidate, John McCain, who like Advani was riled by hardliners and the centrists within his party, the Republicans are struggling to find a sure footing. Vacillating between ideology, moderation, centrism and the role of the Christian Right in the party, various leaders have proclaimed themselves as the 'real' voice of the party. Right from Radio polemicist Rush Limbaugh to former vice president Dick Cheney everyone has a view on where to take the party after losing the White House and the Congress. This internal confusion and incoherence has ensured that President Barack Obama is facing virtually no coherent opposition with the principal opposition in disarray. While it has barely been a month since the loss in the general elections, it is much too early to expect a sudden resurgence from the BJP. However, what is also important is that the party should not let the defeat make the party become its own worst enemy. It has a job to do and that is of a responsible opposition. While ideology, future policy and leadership succession are all important, the primary role that the party must get back to is that of holding this government to account. It can ill afford to cede that space and in doing so give the UPA a free reign to oush a partisan agenda.