Blog Post Year: 2019

Scaling the Mountain of Grand Corruption in the Healthcare Sector

This blog is part of a series. The first blog can be found here.

In this, my final blog on tackling corruption in the health sector, I focus on the menace of grand corruption, which is corruption at the highest level. From a generic point of view, two strategies are nearly universally required to tackle grand corruption in any professional sector.

First, there must be an involvement of the professional regulatory bodies concerned in the effort to eliminate corruption. All professional bodies should be educated to realise that corruption is killing them as professionals and that their trade may ultimately cease to be recognised as a profession. A sense of professional self-regulation should be instituted among the various professional bodies, particularly the Medical Council of India (MCI) and the various doctor’s associations.

Second, it is important to target high profile but corrupt individuals and bodies and prosecute them. This can have a deterrent effect by sending ripples of fear down the line, that no longer will business as usual be tolerated. An example is the expose of the corruption that exists in the MCI, a few years back.

It makes sense to introduce the ‘integrity pact’ concept into all forms of procurement for the medical profession, whether in the public or private sector. An integrity pact will commit all players that they will not adopt corrupt practices whenever procuring, or bidding for procurement contracts. Such an approach could bind pharmaceutical companies also, and could reduce the kickbacks in procurement of (or showing a particular preference for) medicines, lab services etc.

More stringent laws to curb some of the grey area practices may be required. In the US, the ‘Stark’ law describes medical-related offences, declaring them as criminal acts. There is no such law in India, which defines and criminalises many acts that are considered prima facie unethical and even criminal, but which continue as they pertain to the grey area that separates corruption from sharp business practice.

One cannot reduce grand corruption in the health care sector without coming down heavily on corruption in the pharmaceutical profession. There is a lack of oversight over unethical marketing practices adopted by pharmaceutical companies. A strict watch should be kept on these and companies should be named and shamed for offering gifts and other temptations to doctors, which even include foreign trips.

It may be necessary to bring more drugs under a price control mechanism, through an essential drugs list, with restrictions to ensure controls on the cost of patents, R&D and royalties.

Given that there are many branded versions of generic drugs available in the market, there ought to be guidelines that mandate doctors to prescribe at least 3 options whenever prescribing medicines, so that the consumer has a wider choice to purchase different brands of the same generic medicine. 

Purchase committees will need to be created in hospitals with full transparency. Every hospital will need the presence of private individuals with high reputation on every purchase committee.

The purchase committee will need to work under the framework of a hospital drug purchase policy, which will also be made transparent. Some of the ingredients of a hospital drug purchase policy could include:

  • Removing the individual incentive to receive kickbacks by mandating that any discount given by pharma companies, goes to the patient and not to the doctor concerned.
  • Restrict the discretion available to make purchases;
  • Direct that doctors only prescribe generic medicines, never brands and that the pharmacy purchase committee selects the cheapest medicine brand.

Kickbacks in the pharma industry can also be revealed through treatment audit.

Finally, there is a need to open up discussions on these sensitive aspects of corruption. One must encourage introspection, confession and whistleblowing by those who are seeking a change of heart. It is important to encourage those who suffer from remorse to not do so in silence, but to come out into the public space and come clean. The most important step in the long journey to cure corruption is to recognise it exists and speak openly about it.

When large numbers of the medical community  recognise that there is widespread corruption amongst doctors, when they comes out and discuss these matters with the intention of self-regulation, then it can restore faith of the people in the medical profession.

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References:

 

  1. Corruption in the Health Sector: U4 Issue 2008:10; U4 Anti-Corruption Resource Centre
  2. Mapping accountability in the health sector and developing a sectoral assessment framework for Mongolia, UNDP Regional Centre in Bangkok 
  3. Corruption in the Health Sector by M. J. Mwaffisi, Permanent Secretary, Ministry Of Health, Dar Es Salaam presented at the 9th International Anti-Corruption Conference
  4. Website of Transparency International, Bangladesh (http://www.ti-bangladesh.org/)
  5. Website of the Indian Journal of Medical Ethics (http://ijme.in/)
  6. Comments sent by Taryn Vian, PhD, Associate Professor, Department of International Health, Boston University School of Public Health in a correspondence conducted in 2011
  7. Discussion with various doctors and healthcare providers on these matters

 

A Practical Approach on Teaching about Governance

In recent months, the Learning and Development (L and D) team at the Accountability Initiative got the opportunity to run two editions of our flagship programme – Hum aur Humaari Sarkaar  – for grassroots development professionals. To conduct back-to-back sessions with such diverse audiences was a first for the team. Among our challenges was how we would deliver the course to two extremely varied groups of people, sectorally and geographically, making sure that both take home valuable and relevant insights from their participation?

The L and D team at AI believes that participants learn best when classroom teaching and discussion ties in with their field insights. With this in mind, the first of the two editions kicked off in Delhi on 19th June with state teams from the Pratham Education Foundation. Pratham works extensively across the country to improve learning levels of children, and we wanted to make sure that the course was interactive from the get-go, with content that was especially relevant to the education sector. Thus, we made sure to focus on aspects such as the complex public administration structure that inhibits effective service delivery of quality education to a child; how and why money to schools gets delayed, and how this impacts teaching and learning.

We tapped into reports and studies from AI’s rich experience of working in the education sphere. Conducting the course focused on administration of education, with an audience well-versed with the everyday ground realities of the topic, meant they could grasp and use insights from our education work. This work has included time-use studies on the education bureaucracy, PAISA surveys (our flagship methodology) which tracks education expenditure across states, and analysis from our annual Budget Brief series. Thus, we could provide useful and hard-hitting evidence for them to engage with the bureaucracy in a more effective and systematic way.

The AI team’s attempt was also to enable the participants to reflect critically on their experiences from the lens of the sarkaar, and be able to nuance how the government provides public services such as education. The idea was to enable the juxtaposition of the three modules of the course with their own experiences, namely:

  • ‘Who is the government?’
  • ‘How does the government function?’
  • ‘What is the role between citizens and government’

This helped our audience to better understand where the bottlenecks lie, and how citizens and governments could work together to overcome them.

As a result, the participants went ahead and held sessions with their peers in states, making the knowledge our course imparted, valuable to many more grassroots staff who interact with the education bureaucracy regularly.

The second edition of the course (held in Patna, Bihar) was different. Unlike the previous edition, where participants were all homogeneous in terms of the kind of work they did (which was education), this was an ‘open’ course with attendees having submitted candidature from diverse sectors such as health, education and livelihoods from across the state. Our effort shifted from focusing on a sector (education) to more on examples from the state of Bihar itself. To prepare for this, the team spent time interacting with our Bihar field research team who are seasoned experts on what goes on in the state, both in government offices and also the diverse kinds of work being undertaken by NGOs. This enabled us to bring in concrete, real life, and engaging examples from the participants’ own milieu during the sessions.

The Patna course was held with our largest batch size until now, and here too, we focused on facilitating our sessions in a way that encouraged maximum peer learning, interspersing lessons with discussions, activities and group work.

But our efforts did not end with the completion of the course edition.

A vital part of our teaching process is the sincerely followed practice of a debrief conversation at the end of every day of the sessions. This is the time when thoughts are shared by team members on how the day progressed, what worked and what didn’t. It is here that snippets of fascinating conversations with the participants, held during tea or lunch break, are also shared. We noticed that course lessons can bring out a gamut of emotions from participants, ranging from cheery optimism to sometimes a more measured assessment. This is in itself a great starting point for us to assess how the course is moving people to act.

We will be coming out with more course editions in the near future with the hope that the constantly evolving and intuitive nature of our programme will help us reach diverse groups of grassroots leaders, and play a meaningful part in their journey towards responsive governance.

Aamna is a Learning and Development Associate at Accountability Initiative.

Policy Buzz: Budget Session Special

Keep up-to-date with all that is happening in welfare policy with this curated selection of news, published every fortnight. This edition focuses on the Budget session of the Parliament. 

Policy News 

General 

  • The current session of the Parliament is likely to be extended a second time as per media reports. The session was originally scheduled to end on 26 July, but was extended till 7 August.  
  • 33 central schemes for beneficiaries living below the poverty line are to be mobilised by the government as part of a strategy to eradicate poverty by 2022, the year India celebrates 75 years of independence. The schemes range from nutrition to skill development. 
  • New Corporate Social Responsibility norms mooted by the government (amendment to Section 135 of the Companies Act) require mandatory spending on social activities. Failure to do so will attract jail time of up to 3 years and fines. 

Education

  • The deadline to submit feedback on the draft National Education Policy was revised by the Ministry of Human Resource Development to 15 August. This is the second such extension. The draft NEP, prepared by a committee under the aegis of Dr. K. Kasturirangan, has received over 70,000 responses.  

Food Security 

  • The ‘One Nation, One Ration Card’ (ONROC) scheme was launched on a pilot basis in four states – Telangana, Andhra Pradesh, Maharashtra and Gujarat – from 1 August 2019.  This will allow families who have food security cards to buy subsidised rice and wheat from any registered ration shop in these states. The scheme is envisioned to be scaled up to all states by next August, and intends to provide pan-India portability to beneficiaries provided their cards are linked to Aadhar. 

Labour

 

Bills passed 

The Budget Session saw the tabling and passing of a record number of Bills in the last 15 years. Till date, 39 Bills have been introduced in this session, out of which 17 have been passed by both houses. Details of some are given below:  

  • The Right to Information (Amendment) Bill 2019 was passed in the Lok Sabha on 22 July 2019. It was passed in the Rajya Sabha on 25 July 2019. The proposed amendments (to Sections 13 and 16) give the Union government power over tenure, salaries and terms and conditions of service of information commissioners at the Union and state levels. 

In this opinion piece, Yamini Aiyar (Founder, Accountability Initiative) stresses that the RTI Amendment undermines information commissions. She writes, “as institutional mediators between citizens, their right to information and the State, it is information commissions who shape norms and limits of transparency”. The amendments “are dangerous and must be resisted”.

  • The Banning of Unregulated Deposit Schemes Bill 2019 seeks to enforce a mechanism to tackle unregulated deposit schemes. In order to protect investors from ponzi schemes, the Bill saw a voice vote in its favour in the Rajya Sabha. 
  • The Motor Vehicles (Amendment) Bill 2019 seeks to amend the provisions of the Motor Vehicles Act of 1988. Aiming towards more vigilant road safety, the Bill is enforcing stricter penalties for road traffic violations. In addition, the government will be allowed to increase fines by 10% every year for traffic violations. The process for getting a driver’s license will be computerised and every applicant will be required to pass online tests. Aadhar card will be required as a mandatory identity proof for driver licenses. 
  • The National Medical Commision Bill seeks to overhaul the medical education system through the setting up of a National Medical Commission which will replace the Medical Council of India. The said commission will have responsibilities such as approving and assessing medical colleges, conducting common MBBS entrance and exit examinations, and regulating medical course fees. The aim of this Bill is to ensure affordable and accessible medical education for all. 
  • The Insolvency and Bankruptcy Code (Amendment) Bill, 2019, passed in the Lok Sabha on 1 August, 2019 seeks a timely process for resolution of insolvency of companies and individuals. The process has to be completed in 330 days.
  • The Protection of Children from Sexual Offences (Amendment) Bill 2019 was passed unanimously in the Lok Sabha on 1 August, 2019. An amendment to the Protection of Children from Sexual Offences Act 2012, the Bill seeks for stricter punishment for sexual offences against children – increasing the minimum punishment from 7 to 10 years. Penalties related to child pornography have also been made harsher with 5 years of imprisonment plus a fine. 
  • The Protection of Human Rights (Amendment) Bill 2019, an amendment to Protection of Human Rights Act 1993, proposes that only a person who has been Chief Justice of India (CJI)  can be made Chairperson of the National Human Rights Commission. At the state level, the Bill states that any person who has been a judge of a High Court can be made Chairperson of State Human Rights Commission. 

Bills Passed in the Lok Sabha: 

 

Recommendations on the Draft National Education Policy

About Accountability Initiative’s work on public school education 

Accountability Initiative is a research group which has worked on school education extensively. We have studied budgeting and planning for elementary and secondary education, education financing,  teacher motivation, student-teacher interaction, school culture, and school relation with the education bureaucracy.

Recommendations on the draft National Education Policy (NEP) given below are informed by our research.

 

NEP Chapter 5: Teachers

 

 

“Objective: Ensure that all students at all levels of school education are taught by passionate, motivated, highly qualified, professionally trained, and well equipped teachers.”

 

Recommendations on Sub-Sections 5.1, 5.2, 5.3 (related to Teacher Training): 

  • Teacher pre-service education and in-service trainings should include workshops to prepare teachers to tackle common issues encountered at the school level. These trainings should be conducted regularly. Topics should include:
    • Sensitisation on local caste dynamics and creating a prejudice-free environment in schools; 
    • Giving guidance to parents and students on health, security and career options; 
    • Efficiently managing critical school records such as maintaining attendance, enrolment, exam related records, and issuing school leaving certificates; 
    • Teachers’ service matters, such as how to draft letters for applying for leave, receiving no-objection certificates using official language and protocol, and grievance redress mechanisms, and knowledge of essential legal rules and provisions to help Heads of Schools and teachers take the right decisions at the school level.

 

  • Training on new-age modes of communication: All teachers and Heads of Schools must receive on-site training to effectively use technology such as computers, tablets and smartphones. They should be trained on how to analyse student information related to exams, attendance and other relevant indicators to identify management and academic areas that require further attention. These trainings could be carried by IT/computer teachers or staff posted in schools or CRCs/BRPs who should be given appropriate training beforehand. In the initial months, teachers and Heads of Schools should be given enough opportunities to practice using technological devices in CRC/BRC meetings with their peers. Only with such concerted training and follow up can schools move towards fully digitising, processing and using this information to aid effective school planning and decision making, and aiding students in their academic progress.

 

  • Non-teaching tasks:
    •  Clearly define what constitutes non-teaching tasks teachers may or may not engage in, beyond census, election and disaster management duties, which is currently exempt under the RTE.
    •  Lay down norms around the time spent on pre-specified non-teaching tasks that teachers could engage in, and strictly enforce the same, so that time spent on teaching is minimally affected.

 

  • Outsourcing auxiliary tasks: Students and guardians often struggle to fill out and provide essential documentation needed at the school-level and teachers end up filling forms for them, including opening bank accounts, creating an Aadhaar ID and its seeding. Time further goes in verifying, correcting, submitting and sometimes resubmitting this information. This affects the time and quality of inputs provided by the teachers inside classrooms. Such routine tasks could be outsourced to certified agents identified by the education department.

 

NEP Chapter 7: Efficient Resourcing and Effective Governance through School Complexes

 

 

“Objective: Schools are grouped into school complexes to facilitate the sharing of resources and render school governance more local, effective, and efficient.”

 

Recommendations: 

  • Separation of teaching-administrative duties: Schools should have at least one clerk to manage administrative records to reduce time spent by Heads of Schools and teachers on such activities. Ideally schools should have clerical staff posted in proportion to the school strength.

 

  • Streamlining school data collection, collation and usage by:
      • Streamlining state and district level data demands and removing formats that duplicate information.
      • Digitisation of school level data that allows for easy collation right up to national level.
      • Ensuring adequate HR in the form of data analysts at block and district level to process and analyse data.
      • Training all data generators and users on Microsoft Office software such as MS Excel and MS Word, good data management practices and how to use the data generated for evidence-based decision making.

 

NEP Chapter 8: Regulation and Accreditation of School Education

 

“Objective: India’s school education system is invigorated through effective regulation and accreditation mechanisms that ensure integrity and transparency and foster quality and innovation for continually improving educational outcomes.” 

 

Recommendations on Section P8. 1.7: Reinvigoration of CRCs, BRCs and DIETs 

  • Competency framework: Competency frameworks should be prepared for CRCCs and BRPs which would specify the core skills required to discharge their respective duties. This framework should be used to guide recruitments, feedback on performance and provide targeted trainings to build capacities.

 

  • Human resource rules: CRCCs, BRPs should undergo a probationary period before being finally posted in their respective schools, clusters or blocks. This would help assess the level of their core and soft skills, motivations, and whether they are the right fit for the job.  

 

  • Skill building: For CRCCs and BRPs, the following workshops must be conducted in a regular manner to develop their mentoring and resource building skills:
      • On facilitation; 
      • Conducting classroom observations and communicating feedback to teachers in a non-confrontational manner;
      • Effective time-management and multitasking; 
      • Analysing results to track student progress and provide appropriate guidance;
      • Creating subject-specific resource banks.

 

NEP Chapter A1.3.2: Efficient disbursal and use of public funds by addressing operational issues

 

Recommendations:

  • Untied Grant Funding: States should be provided with flexible financing aligned to the achievement of clearly articulated learning goals. Specifically, the government should create a new funding window for foundational learning that gives states two untied grants:
      • The first untied grant would be for states to meet school infrastructure and teacher requirements. The Right to Education Act (RTE) mandates that all states meet a set of infrastructure and teacher norms. States should estimate their infrastructure and teacher requirements [as per RTE Act’s Schedule of Norms and Standards for a school (a) Number of teachers for Class 1-5 and Class 6-8, and (b) building], over a three-year period. The first untied grant can be linked directly to these human and physical infrastructure deficits.
      • The second grant should be a formula-based, untied learning grant financed over a period of three to five years. Funding through this window should be based on a long-term learning strategy articulated by state governments and linked to clearly articulated annual learning goals. Since this is an untied grant, the Centre will no longer need to be involved in line item wise study of AWP&Bs but can focus on providing technical support and guidance to states. Over time, a third window could be created which links some proportion of funding to the performance of states or districts on learning outcomes.

 

  • Planning cycle: The planning cycle should move away from an annual cycle to a three-year cycle (with annual financial approvals) so states, districts and schools can plan better and ensure continuity in implementation. In the current annual government financial and administrative cycle, it takes a minimum of six months for money to move and new programmes to be implemented due to long administrative processes of planning,approval, procurement and financing. As a consequence, money often reaches schools and districts midway (and often at the end) of the annual financial year, resulting in late implementation and low utilisation of programmes. 

 

  • Transparent Portal of allocation, release and utilisation of funds till the last mile: The U-DISE portal is an excellent source of school -wise information. However, currently a similar portal on finances is not available. There are thus no mechanism to know the timing of fund disbursal and extent of utilisation at different levels. As per Section 4 of the Right to Information Act, such information should be provided in a timely manner in the Ministry of scheme-wise portal. Relatedly, states must declare their per-student costs in keeping with Section 12(1)(c) of the RTE Act. 

बिहार में पिछड़े वर्ग की आंगनवाड़ी दुविधा

बिहार में महादलित टोलों को कैसे मिले आंगनवाड़ी योजना का लाभ? में यह सवाल इसलिए पूछ रही हूँ क्योंकि आंगनवाड़ी बाल विकास परियोजना (ICDS) के तहत बच्चों का पोषण स्वास्थ्य और स्कूल से पहले की शिक्षा के लिए प्रथम सामुदायिक कार्यक्रम है| लेकिन महादलित पिछड़े वर्ग को सेवाएं प्राप्त करने में अधिक समस्या होती है, जो मैंने खुद देखा है|

ताज्जुब की बात यह है कि इस टोले के लिए एक ज़िले में अलग से प्राथमिक विद्यालय शुरू किया गया लेकिन आंगनवाड़ी केंद्र नहीं चल रहा था| यह एक समस्यापूर्ण स्तिथि दर्शाता है| नियमित रूप से पोषाहार की प्राप्ति, टीकाकरण, ज़रुरी दवाइयाँ और पोषण दिवस के दिन जो भी सुविधाएँ मिलनी चाहिए के संसाधन के अभाव में बच्चे कैसे शिक्षा ले पाएंगे? क्योंकि स्वस्थ और पोषण पूर्ण बच्चा ही तो ठीक से पढ़ाई कर पायेगा|

मैंने यह भी देखा है की जहाँ आंगनवाड़ी है भी, वहाँ ज़रूरी नहीं है की बच्चे आ पा रहे हों|  उदाहरण के तौर पर एक महादलित टोला गाँव के 1.5 k.m पर था जिसकी वजह से बच्चों को सड़क पार कर आंगनवाड़ी जाना पड़ता था| इस कारण ५ से कम आयु के बच्चे नहीं जा पाते थे, और सहायिका (जिनका इन बच्चों को इकट्ठा करने का काम है) वह भी बच्चों को लेने नहीं आती थी| सबसे दुःख की बात यह है कि आंगनवाड़ी केंद्र चलाने वाली सेविका और सहायिका किसी दुसरे गाँव या शहर की नहीं होती बल्कि उसी गाँव से होती हैं और वे ही योजना का क्रियान्वयन सही लाभार्थियों तक पहुचाने में असमर्थ होती है!  

इस सब के बीच लाभार्थी सरकार को कोसते रहते हैं कि सरकार कुछ नहीं करती| मगर ज़मीनी स्तर पर कार्यकर्ता क्रियान्वन के लिए ज़िम्मेवार हैं और सरकार के नुमाइंदे हैं|    

ऐसा मैं इस लिए भी कहना चाहती हूँ क्योंकि अभिभावक को जानकारी नहीं है की उनके बच्चों को कितनी राशि मिलनी चाहिए और यह भी की आंगनवाड़ी केंद्रों पर अनुश्रवन होता है लेकिन वह भी ना के बराबर है|

योजना का क्रियान्वयन सही तरीके से न होने का एक कारण है पदाधिकारी की अपनी मजबूरी| संस्थागत के तहत ज्यादातर सभी स्तर पर पदाधिकारी महिलाएं होती हैं और उनको सामाजिक कुरीतियों की वजह से अपने सुरक्षा का डर रहता है| इसी डर के कारण योजना के लाभ लाभार्थी तक नहीं पहुँच पता है, लाभार्थी  को उसके हक़ का पैसा या अन्य सुविधा नहीं मिलता है|

मेरा मानना है कि कड़ी अनुश्रवन अब ज़रूरी है| यह शर्म की बात है जिस टोलों के लिए यह योजना चलती है उनको अपना हक़ मिलता नहीं और कार्रवाई करने या देखने के लिए सभी स्तर पर पदाधिकारी कई कारणों से असमर्थ पाए जाते हैं| तो बिहार में महादलित टोलों को कैसे मिलेगा आंगनवाड़ी योजना का लाभ?

6 Things You Should know about India’s Quarterly Slowdown

India is considered a regional superpower in South Asia with its considerable natural resources and an enormous domestic consumer market. India’s GDP growth rate has been impressive throughout the 2000s but has suffered a decline since the early 2010s. Nevertheless, it maintained an impressive rate of growth among developing countries. Since then, the rates of growth of 8-10 per cent have remained elusive. Now, the government is eyeing to reach a USD 5 trillion economy. What will they keep in mind?

 

  1. Explaining the basics

The gross domestic product (GDP) is the metric by which a country’s volume of finished products, in terms of its monetary value, within a specific period of time (usually one year) is measured. It serves as a broad measure of how a country is doing economically. Recent research has shown that India’s GDP numbers along with other macro-indicators may have run the risk of being overestimated. Even though this claim has been largely discredited, recent estimates as published by the National Statistics Office, show a considerable slowdown in the recent quarterly estimates of GDP.

The quarterly estimate of the GDP indicates the monetary value of production within a three month period. The benefit of studying quarterly trends is that it directly measures consequences of policy decisions on the macro-economy. A comparison of quarter-on-quarter GDP (estimates of GDP in the same quarter in two successive years) provides a benchmark for productivity in the current year as compared to the previous. A lower growth rate in successive quarters could signal an overall slowdown for the country.

Source: NSO

 

  1. Factors behind the slowdown: Demand side

There are three basics of note here. There are demand side and supply side factors that affect the production of goods in an economy. The aggregate demand is often measured by components such as investment by industry in capital goods, government spending in public goods and services, domestic consumption and international trade.

Gross fixed capital formation (GFCF) refers to the rate at which the country is producing new capital goods and replacing capital goods that have deteriorated to ensure that productivity keeps increasing. Capital goods may refer to machinery, equipment, tools, electricity and other factors.

Private final consumption expenditure (PFCF) refers to the purchases by households on consumption items such as food, rent, clothing, health, leisure and other goods and services. In developing countries, PFCF is a crucial engine for growth as it accounts for a high proportion of the GDP.

Supply side factors include  the size and quality of labour, technological innovations, construction, and agricultural productivity.

Demand side factors

  • Gross fixed capital formation (GFCF) declined significantly to 3.6 per cent in the fourth quarter of FY 2018-19 after posting double digit growth numbers in the previous quarters.
  • Private final consumption expenditure (PFCE) has been sluggish. The quarter-on-quarter growth slowed down from 9.8 per cent in Q3 to 7.2 per cent in Q4 for FY 2018-19 as compared to FY 2017-18.
  • Exports of good and services too languished in the fourth quarter of FY 2018-19 from ₹ 7,61,502 crore in quarter 3 (16.7 per cent increase from FY 2017-18 Q3) to ₹ 7,45,430 crore in quarter 4 (10.6 increase from FY 2017-18 Q4).

 

Source: NSO

 

  1. Factors behind the slowdown: Supply side

  • The agricultural sector declined in the fourth quarter of FY 2018-19 as compared to the quantum produced in Q4 of FY 2017-18 by -0.1 per cent mainly due to a decline in the production of rabi crop.
  • Manufacturing declined to 3.1 per cent in Q4 as compared to a 12.1 per cent in Q1 in the beginning of the year.
  • Construction too registered a slowdown from 9.7 per cent in Q3 to 7.1 per cent in Q4 as compared to Q3 and Q4 in FY 2017-18.
  • However, the services sector registered an increase in quarter-on-quarter numbers for all four quarters in FY 2018-19 as compared to FY 2017-18.

Source: NSO

 

  1. Revenue and Expenditure Trends

Revenue receipts declined as a share of the GDP but the deficit was curtailed by declining expenditure as well:

  • Total revenue receipts increased from ₹ 13,74,203 crore in FY 2016-17 to ₹   14,35,233 crore in FY 2017-18. However, the share of total revenue receipts as a proportion of the GDP declined from 8.9 per cent to 8.4 per cent.
  • Total expenditure increased from ₹ 19,75,194 crore to ₹ 21,41,975 crore but declined as a share of GDP from 12.86 per cent to 12.53 per cent over the same period.

 

 

  1. Major Deficit Indicators

The government usually is the authority that is responsible for spending on essential public goods and services such as defence, internal security, roads, bridges, health care facilities, educational facilities and other goods and services. In order to pay for these, the government taxes income, corporations and traded goods apart from other transactions within the economy. A budget deficit occurs when the expenditure of the government on these goods and services exceeds the revenue that the government collects through taxation and other means. There are several ways of calculating deficits:

  1. Revenue deficit: the difference in the revenue expenditure over and above the revenue receipts is known as the revenue deficit. This deficit is the gap between current income and current expenses. A high revenue deficit indicates the inability of the government to cover its current expenses such as salaries, pensions, interest payments and other operating costs. The Fiscal Responsibility and Budget Management Act (FRBM) stipulates the government to maintain a 2 per cent revenue deficit as a proportion of the GDP.
  2. Fiscal Deficit: the difference in the total expenditure of the government over and above the total receipts is known as the fiscal deficit. Total expenditure of the government includes not only the revenue expenditure but also expenditure on capital goods. The difference between the fiscal and revenue deficit usually indicates the extent of borrowing by the government that is used for investing in capital goods. Even though running a high fiscal deficit potentially risks a high inflation rate in the economy and/or exchange rate fluctuations, it indicates the government is spending on assets in the short run that have a return on investment in the form of generating income in the future. Investing in manufacturing equipment, infrastructure and human capital (in certain cases) are examples of investing in capital goods. The FRBM stipulates a 3 per cent fiscal deficit target for the government to maintain public debt sustainability and fiscal prudence.

There was an improvement in both the fiscal and revenue deficit numbers since FY 2014-15 when the RD was 2.9 per cent of the GDP and the FD was at 4.1 per cent of the GDP.

  • The revenue deficit however plummeted to nearly 2.6 per cent of the GDP in FY 2017-18 due to a sharp decline in revenue receipts from 15 per cent in FY 2016-17 to 4.44 per cent in FY 2017-18 (Y-o-Y).
  • The fiscal deficit was limited to 3.5 per cent of the GDP because of a decline in total expenditure. Share of capital expenditure declined from 1.9 per cent of the GDP to 1.5 per cent of the GDP over the same period.
  • The GFCF too has declined as a share of GDP from 30.1 per cent in FY 2014-15 to 28.6 per cent indicating a decline in investments.
  • Fiscal prudence at the cost of spending on capital assets is cited as a worrying trend by economists.

 

  1. Off-budget financing

Over the years, concerns have been raised at the Government of India (GoI) for increasingly resorting to off-budget financing. The government uses off-budget methods of financing for both revenue and capital spending. The quantum of these borrowings, outside of Parliament control, have been rising but the system lacks transparent disclosures and a comprehensive management strategy to deal with them.

A report by the Comptroller and Auditor General of India (CAG) underlined three instances of off-budget borrowing that covered the deferring of imminent payments:

i) fertiliser subsidies by the Ministry of Chemicals and Fertilisers through special banking arrangements in which loans from PSU banks are arranged; ii) food subsidy bills of the Food Corporation of India through financial instruments and guaranteed Cash Credit Facility (CCF) extended by the GoI; iii) funding irrigation projects under AIBP through Long Term Irrigation Fund (LTIF) through NABARD (National Bank for Agriculture and Rural Development).

The financial loans extended under these off-budget channels are considerable. For example, the carryover liability (subsidies that remain unpaid in the current fiscal year) for the Ministry of Chemicals and Fertilisers in 2015-16 and 2016-17 were ₹ 43,356 and ₹ 39,057 crore respectively. In order to overcome the liquidity shortage, the department also applies for loans though PSUs, the interest for which accumulates over years. In 2014-15, the department paid an interest of ₹ 80.9 crore on these loans.

The FCI is even more in debt. The carryover liability in 2015-16 and 2016-17 was ₹ 50,037 crore and ₹ 81,303 crore respectively. Financial instruments such as bonds (₹ 13,000 crore), unsecured short-term loan (₹ 40,000 crore), loans through National Small Savings Fund (NSSF loans of about ₹   70,000 crore) and Cash Credit Facility through 68 other public sector banks (₹ 54,495 crore) cover liquidity shortages for the FCI.

The National Bank for Agriculture and Rural Development (NABARD) has a Long Term Irrigation Fund (LTIF) dedicated to providing loans for irrigation projects under the AIBP. This is for both the State and Central share of financing irrigation projects.

The CAG audit report states that NABARD bonds worth ₹ 9,086 crore were issued in 2016-17 for LTIF porjects. It further extended ₹ 3,336.88 crore to LTIF projects and ₹ 2,414 crore to the Polavaram Project under Central share in National Water Development Agency (NWDA). It also extended ₹ 3,335 crore towards State share for LTIF projects.

There is also some concern on the final report that the Jalan committee on economic and capital framework is expected to release soon. If the committee gives the green signal for the government to identify surplus capital with the central bank (the Reserve Bank of India) and utilise the same for reviving debt-ridden PSUs, it may provide the government with adequate fiscal space to undertake reforms. However, whether it is at the cost of the autonomy of the RBI, transparency in the budgetary process of the government or the credibility of macroeconomic data in the public domain remains to be seen.

Strategies for Eliminating Corruption in the Healthcare Sector

This blog is part of a series. The first blog can be found here.

There are both generic and specific solutions to the problem of corruption in the health sector. Even though it is important to punish people who solicit and give bribes, we should also concentrate on addressing the environments that provide incentives for corruption. In this direction, many tried and tested generic solutions are useful in reducing petty corruption to a large extent. However, more specific solutions are required to tackle grand corruption, or the corruption that occurs due to the breakdown of moral ethics in the medical profession, wherever it occurs. Some of the ways in which corruption can be tackled in the health sector are below.

One could ensure vigilance over the quality of health services provided, through proper evaluation. Some of the ways in which this evaluation of the quality of health services can be done:

  • Internal assessment of health facilities through self-assessment and assessment by higher levels.
  • External assessment can be undertaken through regular client surveys. There are many models that one could use for this purpose. One way is to give a format to people who are waiting or who have received services, to assess the quality of the service provided. In the case of illiterate or semi-literate patients, it may be necessary to do this through assistance. The counselling centre could take up such regular surveys.
  • Ranking of facilities and giving high publicity could be undertaken. The media has a huge role to play in partnering with the government to reduce corruption. Regular publicity given to information on corruption, including a ranking system for hospitals could be a way to introduce a system of healthy competition. Rewards could also be offered to celebrate instances of systemic clean-up in health facilities, with a jury of individuals who are known for their impeccable integrity, and who are role models for society, judging the best facility.
  • Government hospitals need to be categorised according to the nature of specialisation and the referral system within the government structure ought to be made functional. This will ensure that general hospitals would not be empowered to force patients to unnecessarily undergo tests that are beyond their reach. However to hone the skills of general doctors from these hospitals, all staff must be rotated to higher specialised centres on a regular basis.

Some simple steps would go a long way in rapidly reducing petty corruption in hospitals.

Providing complete information to the public

Providing proper information to citizens on their rights and of the procedures they have to follow can substantially reduce petty corruption.

  • Proper signage in hospitals, stating out clearly what services are provided, by whom, where, the price, where to pay etc.
  • Standardisation of some of the charges, such as doctors and lab test fees.
  • A citizens’ charter listing out the obligations of health staff in provision of services.
  • An integrity pledge or integrity pact[1] can be signed, which lays out a pledge of integrity, broken up into specific ‘do’s and don’ts, which should be prominently displayed in the facilities. This can have the effect of being a permanent reminder to all the staff of the high ideals to which they are committed.
  • A help-desk cum counselling centre, handled by experienced, friendly and well trained counsellors, who are able to hand hold patients and help them through the procedures. The counsellors might need to be changed regularly, so that vested interests are not developed. Counsellors could also be empowered to register complaints against corruption. This will enable the public to feel safe and secure to report and see that action is taken against the culprit.

Also, there is a special need to inform the public, so that they can form opinions against the prevalence of unethical practices.

Essentially, one must ensure that patients know about these practices. When then there is information transparency, patients will then have to decide whether this is right or wrong. This can be done by starting discussions, promoting greater awareness and exposing the problem.  If people think that a particular practice is not illegal, then let it be made fully legal, but with an obligation to be fully transparent. If people think that something is not a right practice, then we must have stricter laws to curb it. That will create a deterrent effect.

 

Also Read: How the Lack of Information Can Affect Health Insurance Schemes

 

Streamlining procedures and increasing efficiency is another.

Improved technology and management procedures should be adopted to enhance efficiency and reduce long queues in health facilities. Some systems are quite simple, and include:

  • Having more counters for visitors at every level and enlarging the number of outpatient examination rooms based upon pre-defined doctor-nurse-patient ratios.
  • Introducing a token system to eliminate queuing up;
  • Introducing self-queuing, through online booking of health appointments,
  • Close circuit cameras to ensure that bribes are not taken at access control centres; Either doors are closed or open, but when they are closed, nobody is allowed; A connected reform would be to re-examine unnecessarily harsh timing restrictions on visitors to patients.

In my next blog, I will focus on the steps for tackling syndicated or grand corruption in the health care sector. 

 

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[1] Integrity pacts have been devised by Transparency International for reducing corruption in procurements. For knowing more, please go to: http://www.transparency.org/global_priorities/public_contracting/integrity_pacts.

The same approach could be adapted for a more general objective of improving consumer services in health facilities.

Tackling Corruption in the Health Sector

This blog is part of a series. The first blog can be found here.

In my previous blog, I explored petty and grand corruption in the health sector. In this blog, I look at the main causes of corruption in the sector which arise from the following:

First, there is a lack of useful information available to users of the health protection system. In many health institutions, there is lack of information on what services are provided, where and when they are provided, who provides them and the procedures to be followed. This creates an environment for soliciting and paying bribes and also tempts many lower and middle level staff to turn into middlemen and accept a cut for making such services available.

Second, there is excessive red tape, understaffing and therefore, long queues. Some processes and procedures, even if they are necessary, can result in long queues if there are shortages and inefficiency. This again leads to speed money bribes for jumping queues. This again arises due to  unrestricted influx of patients to government hospitals and a weakly functioning referral system (even if it exists on paper) within the government health care hierarchy of institutions.

Third, shortage of medicines and other medical supplies results in long waiting lists, including for elective services like surgical operations. Bribes are collected for jumping the queue. Sometimes, shortages can force hospitals to only perform emergency operations, leading to a higher premia for queue jumping.  

Fourth, comparatively poor salaries might lead health workers (including doctors) to take bribes. One way to overcome this is to allow doctors to engage in private medical practice after their official hours of service, so that they can increase their income even when retained in Government Service. However, this move has had some negative consequences, as follows:

  • Doctors spending official hours in their private clinics, whilst absenting themselves from government hospitals, leaving patients unattended.
  • Doctors using government facilities and medical supplies to treat their private patients on priority basis.
  • Doctors using public facilities as a conduit to channel clients to their private facilities.
  • Doctors prescribing medicines that they know are not available in government facilities, and advising patients to procure them from their private facilities.
  • Theft and pilferage of medicines, equipment and consumables from public health facilities.

Fifth, poor management and supervision of health workers leaves them unchecked to do whatever they want to do. This leads to a breakdown of the management structure within a health institution. For example, the head of the institution may hesitate to take action against a junior staffer, who becomes more influential due to closeness to a powerful politician or bureaucrat (doctors who treat VIP patients are often treated leniently by their politically powerful patients). These become poor examples of good management for junior staff and more doctors attempting to build their influence through cultivating rich, famous and politically influential patients.

Sometimes, institutions that are designed for improving management, themselves become institutions of exploitation and corruption. For instance, local politicians and newly constituted local advisory bodies have the potential of improving the management of institutions. Instead, they often increase mismanagement by using their influence and power to seek individual favours. Sometimes, they build unholy alliances with corrupt interests and increase, rather than decrease the prevalence of unethical and corrupt practices at all levels. The media, through their potential for undertaking sting operations, can become institutions of exploitation and extortion too.

Unionisation of staff can lead to arm-twisting of hospital managers, unprofessional behaviour and mafia style running of corrupt syndicates that can powerfully resist reforms. They can also influence postings and transfers of senior managers.

Sixth, some kinds of corruption arise out of disregard of the law and/or its intentional breach. In many such cases, there is also collusion from the public and therefore, rarely do such instances come to light. Examples are as follows:

  • Pre natal sex determination tests;
  • Submission of false post-mortem reports, or doctors looking the other way, when the police falsify dying declarations in the case of victims of dowry related offences;
  • Trading in organs for transplantation;
  • Undertaking tests of medicines on patients, without authorisation or their consent. Sometimes, these battery of unnecessary tests are made expensive in the name of doctors giving themselves protection against accusations of negligent treatment later on.

In my next blog, I discuss various strategies for the reduction and hopefully, the elimination of corruption in the health sector.

Also Read: How the Lack of Information Can Affect Health Insurance Schemes

Policy Buzz: Budget Special

Keep up-to-date with all that is happening in welfare policy with this curated selection of news, published every fortnight. Our first edition is a Budget 2019 special, and focuses on the budget and social sector spending. 

Policy News

General

  • The Union government has shortlisted 167 big bang ideas that are to be implemented in the first 100 days of its tenure. These ideas will be selected after several rounds of presentations by all ministries. Additionally, they have also been asked to put out performance monitoring dashboards on all major schemes to enable public access to the progress made on these schemes.

Education

  • In a bid to improve teaching-learning outcomes and give a boost to the teaching profession, the Government of India is introducing a four year course – the Integrated Teacher Education Programme (ITEP) for pre-service training. The course will offer graduation in Primary and Secondary education.
  • The deadline for public feedback on the draft New Education Policy (NEP) has been extended by the government. The new deadline is 31 July 2019. NEP will be the lodestar for school education in the country. We have put out two blogs for you on why ‘non-teaching’ work in government schools and  grade-specific learning  warrant more attention in the new policy.

Health

  • The draft National Digital Health Blueprint (NDHB) has now been released for public comments. NDHB will focus on digital technologies to widen the provision of healthcare services. It has “specific details of the building blocks required to fulfill the vision of National Health Policy 2017”. 

Water

  • Finance Minister Nirmala Sitharaman has made the provision of piped water supply to every rural household a top priority by promising Har Ghar Jal by 2024 under the National Rural Drinking Water Mission in her Budget speech. Meanwhile, the Meghalaya Cabinet passed a draft water policy, making the state first among its peers to formulate such a policy. The need for coherent policy action on water is apparent given acute water shortages in parts of the country, including Chennai and Bengaluru.

Opinion 

Budget 2019 has been widely discussed, critiqued and appreciated. But what does the Budget hold for the social sector? A detailed analysis by the Accountability Initiative team on social sector schemes run by the Government of India can be found here, and features trends in allocations, expenditures and outcomes. This time, we have put together an interactive resource to provide you with a comprehensive overview of 10 major welfare schemes and their progress. Explore the new website for easy-to-understand facts from our latest Budget Briefs.

Calling Budget 2019 a ‘lost opportunity’, Yamini Aiyar (Founder, Accountability Initiative) writes, “with its resounding mandate, the government could have embarked on structural reforms, but instead has chosen an incrementalist approach, making clear- Modi 2.0 is going to steer the familiar course.”

Avani Kapur (Director, Accountability Initiative) opines that, on the one hand, allocations for welfare schemes in education, health and supplementary nutrition have increased from the 2018-19 Revised Estimates, there haven’t been many changes from the Interim Budget in February. In another piece, she and Ritwik Shukla (Research Associate, Accountability Initiative) discuss how the health budget seems to have prioritised Health System Strengthening under the National Health Mission, which will assist on public health facilities meeting Indian Public Health Standards (IPHS) and providing quality care. There is, however, a need to intensify public expenditure on health.

 

How the Lack of Information Can Affect Health Insurance Schemes

The roll-out of the Pradhan Mantri Jan Arogya Yojana (PMJAY) has been a frenetic affair (over 4 crore e-cards issued in less than 10 months). PMJAY is a massive health insurance scheme which aims to protect poor and deprived families from catastrophic expenditure arising out of health shocks by providing up to ₹5 lakh as cover. The apparatus for the scheme is complicated with several moving parts – private and public hospitals, insurance agencies, government-run trusts, a cadre of 1 lakh frontline workers, and over 50 crore insurees.

Running a health insurance scheme of this magnitude requires the availability of a vast amount of information – on who can provide quality health services, who is eligible to avail claims, which illnesses are covered, who requires what treatment, etc. However, access to information is limited as it is not a freely available public good, and usually one individual or group possesses more information than others.

Information asymmetry can be defined as a situation wherein one party in a transaction possesses more information and knowledge than the other party. Information asymmetry is intrinsic to everyday life. It is practically impossible for both parties in a conversation, exchange, or transaction to possess the exact same level of information. One party possessing more information than the other can enable that party defrauding or taking advantage of the other party.

One of the fundamental problems in healthcare systems across the world is the vast information asymmetry that exists between doctors and patients. Doctors obviously know more about medical practices than their patients due to their extensive educational background and training. Hence, patients facing life threatening illnesses need to believe, and do believe, that the power of physicians is greater than it actually is.

The lack of medical knowledge among people, in some cases, puts them in vulnerable positions prone to abuse and exploitation by a profit-minded healthcare provider. In India, widespread illiteracy and the absence of basic medical knowledge makes matters even worse. The imbalance of information thus leads to a power imbalance.

 

It is crucial to pay attention to regulatory measures and awareness generation if we are to see the scheme achieve its full potential.

 

One such example is that of Caesarean Section Deliveries. In India, caesarean section rates are amongst the fastest rising in the world and are much higher in private institutions than in public institutions, with information asymmetry and profit seeking by private institutions being contributing factors. Over 40% of all deliveries in the private sector are C-section while the same is only 11.9% in the public sector (National Family Health Survey-4, 2015-16). The proportion of C-section deliveries in the private sector are much higher than the WHO recommended maximum limit of 15%.  In the states, the proportion of C-section deliveries are as high as 58% in Telangana, and in Andhra Pradesh they are more than 40%.

Most women are unaware of the health implications of a C-section.

Though C-sections are crucial under certain medical conditions, a rate as high as 40% is virtually impossible to attain if C-sections are conducted based solely on medical evidence. The disastrous consequences are listed in a 2018 report in The Lancet, which pointed out that unnecessary caesarean sections increase the prevalence of maternal and child mortality and morbidity.

A cautious note on health insurance 

Health insurance can complicate matters. When individuals have tight budget constraint or have less to spend, they are far more vigilant while spending. With health cover, that budget constraint is lifted, and people are willing to spend more. The Lancet study points out people with more money are likelier to spend on a procedure like a C-section, even when it may not be necessary. Therefore, the fact that people have more to spend on their healthcare is welcome, but the accompanying challenges within the context of an information imbalance (discussed above) must be acknowledged and addressed. 

Insurance coverage increases a person’s health budget, and they are tempted to go to an expensive, private hospital. As per the National Health Family Survey 2015, 55% of households prefer private hospitals over public hospitals. Apart from the poor infrastructure and poor quality of services provided by public hospitals, the perception of high cost treatment as quality treatment contributes to this trend. 

Package rates under PMJAY are fixed, so people may not exhaust their cover by going to a private hospital but are likely to incur higher out-of-pocket expenditure. This is because several health issues require multiple check-ups that typically occur 15 days after hospitalisation ends, the point after which outpatient care is no longer covered by PMJAY. Non-hospitalised treatment is far costlier in private hospitals, compared to government hospitals. While some outpatient care costs are covered, people may inadvertently spend more than they want to, if they aren’t provided adequate information about treatment options and the costs involved upfront. In some cases, this may lead to people having to borrow, or worse, stop treatment.

 

Also Read: India’s new tryst with government health insurance here

 

Furthermore, insurees are rarely aware of the services covered under the health insurance schemes. Both RSBY and PMJAY provide insurance coverage only for hospitalisation expenses and day care surgeries. Consultation fees, costs of diagnostic tests, expenses on medicine have to be paid by the patient if it doesn’t lead to hospitalisation. This is damaging especially if one is unclear about terms and conditions of insurance and has false expectations about what is covered. This situation breeds mistrust and resentment. There have been many instances reported of insurees feeling denied of insurance benefits they feel are due to them. People may be unwilling to use health insurance, even though they acknowledge the risks and rising costs of healthcare.

Thus, given that lives are at stake, information asymmetry in medicine and health needs to be addressed with greater incisiveness. There are some ways to bridge these information gaps.

Steps to address the issue 

Firstly, ‘trust’ has a role to play in managing the problem of information asymmetry. For the system to work, people need to trust that doctors will provide the right care and that the government will ensure that those eligible will receive cover, etc. Fraud and medical malpractices are a feature of health insurance schemes across the world. Therefore, to build trust, the government needs to act as a strong regulator.

Under PMJAY, an anti-fraud cell has been set up at the national level and officers under the cell are responsible for assessing fraud management capacity of states, liaising with anti-fraud cells of SHAs and developing state specific recommendations to strengthen anti-fraud measures. District Vigilance and Investigation officers under SHA undertake fraud investigations to ensure strict compliance to beneficiary identification, hospital empanelment and pre-authorisation guidelines. Additionally, a grievance cell and helpline has been set up. Their work will not be easy. While the government has put regulatory mechanisms in place, deep-rooted and systemic corruption is likely to pose a challenge to the implementation and enforcement of anti-fraud provisions exacerbated by weak capacity of the union and state governments.

Providing information directly to users is another option. People who reach empanelled hospitals can talk to Pradhan Mantri Arogya Mitras, the frontline cadre for PMJAY. However, if one wants to reach people, especially in the most deprived areas of the country, then the existing cadre of frontline health workers should be mobilised. Training frontline workers like Anganwadi Workers, ASHAs, and Auxiliary Nurse Midwives to disseminate information and interact closely with beneficiaries has been a step towards behaviour change in the domain of health, especially in rural India.

The functions and mandate of ASHAs, ANMs and Anganwadi workers can be expanded to include generating awareness about health insurance schemes. Visual aids and refresher training can be used to simplify complex information and improve retention, and providing frontline workers with pictorial job aids will assist them in conveying information effectively. However, frontline workers are often overworked and underpaid, and it is necessary to address these issues. Reaching out to several people at their homes is a mammoth task and expecting frontline workers to conduct this exercise on top of their other work might be unfair.

The stakes are high, and only time will tell whether health insurance in India can successfully deal with informational asymmetry. It is, however, crucial to pay attention to regulatory measures and awareness generation if we are to see the scheme achieve its full potential.

Ritwik is a Research Associate at Accountability Initiative and Shaivya is an intern.