Here are some simple steps that would turn around and restore vibrancy to government hospitals
Devi Shetty
The Gorakhpur tragedy has exposed the weakness of the public health system. Instead of finding a scapegoat, let us look at how India’s broken public health system can be mended. There are three main problems with Indian public health, and none of them have to do with lack of money. The problems are (i) acute shortage of medical specialists; (ii) lack of career progression for nurses; and (iii) accountability.Shortage of medical specialists is evident even in a state like Karnataka which has the largest number of medical colleges. Yet there are over 1,200 vacancies for specialists in government hospitals. Unlike in the past, an MBBS doctor with adequate training but without a post graduate degree is legally barred today from performing a caesarean section, an anaesthetic procedure, an ultrasound or interpreting a chest X-ray.
The top 10 causes of death in India cannot be treated by an MBBS doctor. In simple terms, even a brilliant MBBS doctor cannot do anything more legally than what a housewife is permitted to do. These rigid regulations were created by the Medical Council and upheld by the Supreme Court for patient safety.Unfortunately, we also have an acute shortage of post graduate seats needed to convert existing two lakh MBBS doctors into specialists. Because of the shortage of specialists, Indian maternal and infant mortality rates are worse than some sub-Saharan African countries.The Lancet Commission on Global Surgery recommends preparedness for “bellwether procedures”, ie emergency caesarean section, laparotomy and surgery for open fractures at community health centres – of which there are 5,500 in India – as an indicator of an efficient public health system. Today, 60% of deaths are due to non-infectious diseases. According to the commission, while only 3.83 million people die globally due to malaria, HIV and TB, 16.9 million people die due to lack of access to safe surgery every year.
India needs 65 million surgeries annually, but only 26 million are performed and the rest suffer and die. Legally, only specialists can perform surgeries and treat non-communicable diseases. This is the reason a hospital without adequate number of specialists is of no use for the patient and the community.Ten years ago, maternal mortality rate (MMR) of Maharashtra was as bad as in the rest of the prosperous south Indian states. In 2009, Maharashtra’s health ministry recognised diplomas from the then 96-year-old College of Physicians and Surgeons (CPS) to convert MBBS doctors into specialists. Today, nearly a thousand specialist medical officers working for Maharashtra health service are not MD or MS but diploma holders from CPS. By 2013, these diploma holders had produced a Maharashtra miracle: they dramatically reduced its MMR from 144 to 68, half of Karnataka’s MMR. Very soon, Maharashtra will be challenging Kerala for the number one spot.
Fortunately, the Union health ministry is considering recognising CPS diplomas across India. National Board of Examinations is also converting large government hospitals as teaching institutes to train medical specialists. With trained and certified gynaecologists, paediatricians, anaesthetists and radiologists, community health centres and taluka and district hospitals will become the most vibrant hospitals.Second, the nursing profession is in crisis in India. In the US, 67% of anaesthesia procedures are administered by nurse anaesthetists. In India, a nurse who worked in an ICU for 20 years is legally not allowed to prescribe even a painkiller. The younger generation will never take up a profession where there is no career progression. Recently, the health ministry and Indian Nursing Council launched the nurse practitioner course, which will be a turning point in Indian nursing profession. Nurse practitioners can reduce doctors’ workload in government and private hospitals, improving clinical outcomes.
Third, the accountability question. People need hospitals only for the procedures. Health ministry should monitor hospitals on just four parameters for every government hospital – outpatient numbers, number of diagnostic tests, number and outcomes of surgeries and number and outcomes in critical care service. This data should be uploaded real time to a cloud-based app. Based on this data the ministry can grade every government hospital, plan budgetary allocation, increments and promotions of staff. Real time data in public domain will hold the mirror for policy makers to reflect on. We believe in god, but the rest is data.When i was growing up, government hospitals were the most vibrant institutions and government doctors were our heroes. My brother, a doctor himself, insisted on my getting a tonsillectomy in a government hospital. If there were 20 full-time paediatricians working at Gorakhpur’s BRD hospital, tragedy would have been averted.
Medical specialists are always at the highest level of the government pecking order. Young and qualified medical specialists will insist on improvement of infrastructure to practice their newly acquired skill and build their reputation. As always happens in India, one of the 20 paediatricians would be taking care of a senior minister’s or politician’s grandchild, thus having access to the state’s power centre.Maharashtra’s experience has convinced us to believe that recognition of CPS diploma courses across the country will be a turning point in the history of vibrancy of government hospitals, along with empowering nurses and digital accountability tools. I am convinced, after spending my entire professional life in managing hospitals, that private enterprise cannot replace government hospitals for rural healthcare. If you think government is not capable of managing hospitals look at Jayadeva Institute of Cardiac Sciences Bangalore, UN Mehta Heart Institute Ahmedabad and ILBS Delhi which make India proud.
Date:22-08-17
Use Aadhaar for financial transactions
ET Editorials
Sebi’s reported plan to make Aadhaar, a person’s unique identification number, compulsory for stock trading is welcome. It will create audit trails, curb money laundering and tax evasion through the stock markets.Already, large financial transactions are tagged to the tax department’s Permanent Account Number (PAN). Quoting of PAN is mandatory for, say, opening a demat account, investment in mutual funds and even trading in unlisted shares beyond prescribed limits. However, PAN is not foolproof. To weed out duplicate PANs, the government has mandated linking PAN with Aadhaar.
Eventually, PAN will become redundant at least for individuals and should be phased out. Already, over a billion people have secured their Aadhaar, compared to about 30 crore people who have PAN cards. Instead of multiple identifiers, Aadhaar should become the single identifier that should be tagged to all financial transactions.The tax deduction and collection number, or TAN, is mandatory for legal entities responsible for deducting or collecting tax. The RBI has also done well now to introduce the legal entity identifier, a global reference number that uniquely identifies every legal entity or structure that is party to a financial transaction in any jurisdiction.It will be implemented for all participants in the over-the-counter markets for derivatives in a phased way. The objective, to improve the quality and accuracy of financial data systems for better risk management, makes eminent sense.
What extensive use of Aadhaar makes imperative is a rigorous data protection law. Aadhaar does have the potential to be abused, for instance, by using this tag to collate information on a person’s financial history. Citizens must be empowered to complain and get redressal if their data is misused.
Date:22-08-17
केरल लव जेहाद : प्यार पर सुप्रीम कोर्ट की नज़र
शेखर गुप्ता
अधिकतर भारतीय जूडी शाइंडलिन के नाम पर गौर ही नहीं करेंगे। मैनहटन पारिवारिक अदालत की न्यायाधीश रह चुकीं जूडी शाइंडलिन का शो पिछले 21 साल से चल रहा है। इसमें प्रतिद्वंद्वी पक्ष लाइव टीवी पर उनके सामने छोटे-मोटे विवाद लाते हैं। उन्हें पहले करार करना पड़ता है कि वे शाइंडलिन का फैसला मानेंगे।
लेकिन, हम यहां अमेरिका की बात क्यों कर रहे हैं? क्योंकि उनके एक शो की ऐसी क्लिप वेबसाइट पर आई है, जिसमें जज जूडी के सामने बैठे महिला-पुरुष एक कुत्ते पर हक के लिए झगड़ रहे हैं। महिला सबूत के तौर पर जानवरों के डॉक्टर के पर्चे दिखाती है, लेकिन जज जूडी उसे खारिज कर देती हैं। कुत्ते को लेकर खड़े शख्स से वे सख्ती के साथ कहती हैं, ‘कुत्ते को नीचे रखो।’ नीचे रखते ही कुत्ता दौड़कर पुरुष के पास चला जाता है। उसके चारों तरफ उछल-कूद करने लगता है। हर किसी की आंखें भीग जाती हैं और तालियां बजने लगती हैं। क्या यह सब पढ़कर आप को कुछ ऐसा महत्वपूर्ण मसला याद आता है, जिसने पिछले हफ्ते सुर्खियां बनाईं? मामला केरल का था और सर्वोच्च अदालत में इसलिए आया था, क्योंकि राज्य के उच्च न्यायालय ने मुस्लिम युवक के साथ उसकी शादी खारिज कर दी थी और उसके ‘पति’ ने फैसले के खिलाफ अपील की थी। हमारे माननीय सुप्रीम कोर्ट की पीठ ने महिला (अखिला) से नहीं पूछा कि वह कहां, किसके पास जाना चाहती है। इसकी बजाय उसने एनआईए को जांच का जिम्मा दे दिया। हमारी अदालत ‘कुत्ते को नीचे रखो’ जैसा सरल-सा सिद्धांत नहीं आजमातीं।
इस अदालती किस्से में उथलेपन की गुंजाइश नहीं है। सर्वोच्च न्यायालय की पीठ में दो सबसे सम्मानित और गंभीर न्यायाधीश चीफ जस्टिस जेएस खेहर और जस्टिस डीवाई चंद्रचूड़ हैं। जिरह कर रहे वकीलों में भी कपिल सिब्बल और इंदिरा जयसिंह के सामने अतिरिक्त सॉलिसिटर जनरल मनिंदर सिंह, श्याम और माधवी दीवान हैं। न्यायालय के प्रति निष्पक्षता बरतते हुए कुछ तथ्यों को रेखांकित करना जरूरी है। एक, न्यायाधीशों ने अभी तक मामले के कानूनी पहलुओं का परीक्षण नहीं किया है। एक पेज के आदेश में तथ्यों का पता लगाने को कहा गया है। दो, आदेश है कि एनआईए की जांच निष्पक्ष होने पर ही याचिकाकर्ता (युवती के पक्ष से) उसे स्वीकारेंगे। निष्पक्षता अदालत सुनिश्चित करेगी। तीन, तथ्य सामने आने के बाद न्यायाधीश अकेले में महिला की बात सुनेंगे। उसके बाद ही अंतिम फैसला होगा।
यह महिला ‘अखिला’ (जो अब हदिया कहलाना पसंद करती है) केरल में कोट्टायम से मेडिकल की पढ़ाई कर चुकी है। मुस्लिम कट्टरपंथी संगठनों के साथ उसकी निकटता से घबराकर उसके माता-पिता ने हाईकोर्ट से अनुरोध किया कि वह केवल उनके ‘संरक्षण’ में ही महफूज रहेगी। जनवरी, 2016 में खंडपीठ ने अनुरोध खारिज कर निर्णय लिया कि महिला खुद फैसला कर सकती है। अगस्त, 2016 में माता-पिता ने नई याचिका दायर की। इस बीच अखिला मुस्लिम संगठन सत्यसारणी के साथ रहने चली गई थी। उच्च न्यायालय की भिन्न खंडपीठ ने नई याचिका स्वीकार कर ली। मामले की सुनवाई चल ही रही थी कि एक दिन अखिला शेफी जहां के साथ अदालत पहुंची और कहा कि दोनों ने विवाह कर लिया है। अदालत ने कहा कि अभी वह इतनी बड़ी नहीं हुई है कि सही फैसला ले सके और यह भी कहा कि माता-पिता के संरक्षण में ही उसकी सबसे अच्छी देखभाल होगी। असल में अदालत ने पैरेंज़ पैट्री का सिद्धांत अपनाया, जिसके मुताबिक त्याग दिए गए बच्चों की जिम्मेदारी राज्य उठाता है। उन्होंने इस सिद्धांत को 24 साल की डॉक्टर पर आजमाया। गौरतलब है कि केरल उच्च न्यायालय की पहली खंडपीठ में एक हिंदू और एक मुसलमान न्यायाधीश थे। दूसरी खंडपीठ में दोनों ईसाई थे। अखिला (हदिया) और जिसे वह अपना पति बताती है उसने आदेश को सुप्रीम कोर्ट में चुनौती दी है। सुप्रीम कोर्ट के आदेश में सबसे अजीब बात उसकी फुर्ती है। हाईकोर्ट के फैसले के गुण-दोष पर तो उसने विचार ही नहीं किया है। यह जानना महत्वपूर्ण होगा कि वह आदेश जिन बिंदुओं पर आधारित है, उनके बारे में शीर्ष न्यायाधीश क्या सोचते हैं। कुछ उदाहरण:
अपने जीवन और भविष्य के बारे में उसका (अखिला का) कोई स्पष्ट रुख या विचार नहीं है… वह ऐसे लोगों के इशारों पर चल रही है, जो उसे उसके माता-पिता से छीन लेने पर आमादा हैं। याचिकाकर्ता के मुताबिक कट्टरपंथी उनकी बेटी को देश के बाहर भेजने की फिराक में हैं। उसके माता-पिता को डर है कि उनकी बेटी की शादी एक मुस्लिम शख्स से होने वाली है। वह (पति) कट्टरपंथी रुझान का है, जो फेसबुक टिप्पणियों से साफ है। हम संतुष्ट नहीं है कि अखिला को निर्णय लेने के लिए छोड़ देना सुरक्षित है। उसे अपने पालकों की देखरेख, संरक्षण और मार्गदर्शन की जरूरत है। वह केवल अपने माता-पिता के पास ही सुरक्षित रह सकती है क्योंकि वह अभी 24 साल की लड़की है। अदालत उसकी भलाई को ध्यान में रखते हुए पैरेंज़ पैट्री का उपयोग कर रही है। यह कर्तव्य यह सुनिश्चित करके निभाया जा सकता है कि लड़की सुरक्षित हाथों में है। सुप्रीम कोर्ट किसी भी मामले की जांच का आदेश दे सकता है और अपनी पसंद की एजेंसी को उसकी जिम्मेदारी सौंप सकता है। हालांकि उच्च न्यायालय के आदेश के परीक्षण को टालने से समाज पर पड़ने वाले असर की संभावना को देखते हुए सुप्रीम कोर्ट उस पर गौर कर सकता था। क्या 24 साल की युवती अपने बारे में फैसला करने के काबिल नहीं है? क्या न्यायाधीशों को बालिग होने की उम्र के बारे में प्रत्येक मामले के आधार पर फैसला लेना होगा? क्या नया न्यायिक सिद्धांत गढ़ा जा रहा है, जिसमें माता-पिता की सहमति विवाह की पूर्व-शर्त होगी? क्या 24 साल की युवती को ‘संरक्षण और मार्गदर्शन’ की जरूरत है और वह भी केवल पालकों की ओर से। क्या किसी को खतरनाक कट्टरपंथी घोषित करने के लिए फेसबुक पोस्ट काफी है?यहां हम फिर जज जूडी की ओर आते हैं, जिन्होंने चार पैरों वाले जानवर पर भरोसा किया यह तय करने में कि उसके लिए क्या अच्छा है। क्या हम 24 साल की युवती पर ‘अपने दो पैरों पर स्वतंत्रतापूर्वक खड़े होने’ का यकीन नहीं कर सकते हैं?
Date:21-08-17
Winner takes all
Election Commissioner Rawat’s brave and wise warning against the deforming of political culture must be heeded.
Editorial
At a conference on electoral and political reforms held in the capital last week, when Election Commissioner Om Prakash Rawat spoke of the “creeping new normal of political morality”, he sounded a cautionary note that must be heeded by all those with stakes in a polity more democratic. His intervention also marked a moment of institutional push-back that is as reassuring as it has become rare.Election Commissioner Rawat stood against the political current as he warned against the dominant narrative that places “maximum premium on winning at all costs — to the exclusion of ethical considerations”, in which “poaching of legislators is extolled as smart political management” and use of money and state machinery to bribe and to intimidate the political opponent is “commended as resourcefulness”, and “the winner can commit no sin”.
Rawat’s comments come barely days after the Rajya Sabha election for one seat in Gujarat became prime-time theatre, riveting the nation’s attention with its mix of high-profile players and low tactics. Six Congress MLAs crossed over to the BJP ahead of the August 8 poll. The Congress subsequently herded 44 MLAs to a resort in Karnataka to ward off a predatory BJP, whose government at the Centre then presided over income tax raids on one of the Congress’s prominent crisis managers involved in minding the Gujarat MLAs in the state.
Fortunately, the high-voltage political drama did not have a murky ending: It climaxed in Nirvachan Sadan, with the EC using its constitutional powers under Article 324 to invalidate the votes by two rebel Congress MLAs, pointing to a breach of due process. Yet, till the EC stepped in, the Gujarat RS poll unfolded as an unscrupulous no-holds-barred fight, in which parties played to win — by any means, no penalties paid. Rawat is right to warn that the normalising, even extolling, of the poaching of MLAs and misuse of state machinery as the unexceptionable art of political management will only deepen the people’s cynicism and distrust of politics.
There is a larger backdrop in which Rawat’s intervention must be read. It is not just the Gujarat RS polls, the winner-takes-all approach to politics is mirrored in the wider polity as well, and it is threatening to undermine the careful mosaic of checks and balances of a constitutional framework. Today, a spectre is threatening to become real: A strong and domineering political executive, emboldened by electoral success, is imposing the logic of the numbers game to conquer all spaces and flatten out dissent.A majority of the vote in the electoral battlefield is threatening to mutate into a spreading majoritarianism in the life of a diverse nation. At a moment like this one, Rawat’s words are an important and valuable reminder of the need for institutions to speak up and speak back to the powers that be — to act as a corrective, to reassert and reclaim their role in a layered and intricate polity.
Date:21-08-17
Safeguarding the interests of farmers
Providing food to the poor or targeted groups at subsidised prices is fully WTO-compatible
Nirmala Sitharaman is Minister of State (Independent Charge) for Commerce and Industry, Government of India
Transformational changes are taking place in India currently, improving the way we live. These changes are impacting all our lives in small or significant ways. It is gratifying to know that the citizens at large are happy withthese changes. However, forsome who have fed themselves on the fodder that such changes are not for the near future, there is consternation. Even worse, these people find it difficult to comprehend that technology and policy are working together to remove discretion and opaqueness.
The ongoing discourse, particularly in Tamil Nadu, on thePublic Distribution System (PDS), the procurement of grains/pulses from farmers, public storage in Food Corporation ofIndia godowns, commitments made in the World Trade Organisation (WTO), Direct Benefit Transfer, etc. is interesting. However, there are strands in this discourse which are impressionistic and not based on data. They create a populist narrative and distract from the core issues. It is necessary, therefore, to infuse facts into the discourse.
Facts in Tamil Nadu
The PDS in Tamil Nadu is intact and continues to retain the feature of universal coverage even after implementation ofthe National Food Security Act, 2013 (NFSA). Although the guidelines under the NFSA prescribe identification of priority households, there is no denial of any benefit under the PDS. There is no reduction even in the total coverage from the earlier Targeted Public Distribution System, which was effective till Tamil Nadu joined the NFSA in November 2016. The average annual offtake or the annual allocation has remained 36.78 lakh tonnes. The major part of the subsidy for the distribution of foodgrains (90.81% for rice and 91.70% for wheat) is borne by the Government of India.
The implication of this subsidy allocation to Tamil Nadu alone on the Government of India is approximately ₹843 crore per month and approximately ₹10,120 crore per year. Since the central issue price under the NFSA is much lower compared to the erstwhile Targeted Public Distribution System, the burden on the State government has come down. On implementing the NFSA, the savings for the State exchequer on account of this subsidy, thanks to the lower central issue price, is approximately ₹436.44 crore per year.
Union Consumer Affairs Minister Ram Vilas Paswan on August 1 stated in a series of tweets the data for Tamil Nadu and also highlighted the factthat Tamil Nadu gets the highest allocation in the country as ‘tide over’ allocation of 12.52 lakh metric tonnes of foodgrains. The narrative in Tamil Nadu cannot be devoid of these facts.
Ensuring trade transparency
Another disturbing strand in this narrative in Tamil Nadu is that the Indian government has callously sold away the interests of our farmers at the WTO by agreeing to the Trade Facilitation Agreement. Nothing can be further from the truth than this!
The Trade Facilitation Agreement was agreed on in 2013 in Bali and came into force from February 2017 after two-thirds of the WTO’s 164 members ratified it. Several trade-relatedissues such as transparency, predictability and efficiency at the ports, faster clearance procedures, and improved appeal rights for traders are to be addressed by countries. They shall notify various provisions to bring in the facilitation, over three years or more. Only the basic set of provisions will be implemented within one year. The Trade Facilitation Agreement allows for consultations before any new trade rules are notified. A WTO study indicated that when the Trade Facilitation Agreement is fully implemented, trade costs for member countries will decrease by an average of 14.3%. It is also estimated that the time taken to export and import will come down drastically. Finance Minister Arun Jaitley has made budgetary allocations for bringing in single-window clearance and improving customs clearance at the ports. A high-level committee chaired by the Cabinet Secretary will monitor logistics and efficiency at ports and related issues.
Thus, it can be seen that the Trade Facilitation Agreement is not about market access but inter alia about facilitating and bringing trade transparency. By ratifying the Trade Facilitation Agreement, India has not forgotten the developmental agenda lying unfulfilled at the WTO.
Protecting the farmer
The Public Stock Holding issue remains unresolved at the WTO. Although agreed on in Bali in 2013 and reiterated in Nairobi in 2015, that a permanent solution for Public Stock Holding be found by 2017, it is still a ‘work-in-progress’. The existing WTO rules would have allowed a legal challenge to our Public Stock Holding and minimum support price-based procurement programme in case we breached ‘the limit’ on procurement. ‘The limit’ is defined as 10% of the value of production of the particular grain being procured.
WTO rules classify procurement and holding of public stocks for food security purposes as ‘Green Box’ or non trade-distorting. However, if foodgrains for the public stocks are procured through an administered price/minimum support price and if this minimum support price is higher than the archaic fixed reference price (calculated on base period 1986-88), then it is considered as trade-distorting agriculture support. Such trade-distorting support should be within ‘the limit’, which is 10% of the value of production of the particular grain being procured.
One of the first things that this government did in 2014 was to intensely engage with the WTO to obtain a ‘peace clause’ so that even if we did breach ‘the limit’, no one shall challenge our programme till such a time a permanent solution is found, agreed on, and adopted by the WTO membership. Prime Minister Narendra Modi, on this matter, personally engaged with global leaders, and by November 2014 we obtained an open-ended peace clause from the General Council of the WTO, which waslater reaffirmed at the Nairobi Ministerial. So Prime Minister Modi has safeguarded the interests of the farmer and ensured that India’s sovereign right to protect them is not diluted.
Providing food to the poor or targeted groups at subsidised prices is fully WTO-compatible. This does not figure at all in the WTO calculations. We have not undertaken any commitment in the WTO for any kind of limit on the food supplied under the NFSA .
An informed discourse based on facts is welcome and I believe such a discourse shall strengthen public policy.
Date:22-08-17
Date:22-08-17
Date:22-08-17
Date:21-08-17
Date:21-08-17
