What dreams bring

Yesterday was revelatory. About:

You. A personal word.

Animates. Embraces knowledge and belonging

Admits presence. Affirms existence. Perhaps; respects it.

You. A state of being worthy of an interaction.

Yesterday was revelatory. About:

Person. Impersonal dead-wood.

A state of nothing; disregarded by life.

 

I dreamt yesterday of a Person.

Trampling giant strides of scorched earth

In my carefully terraced garden.

An apology for humanity; marking time

With the rattling of the branches overhead.

Loathe to share her synchrony with a non-being,

My friend, the wind, crashed her protest through my reverie

Swept the scene clean. Brooked no opposition

Reclaimed for me my own place. Spread a fresh Sun’s

Swaying puddles of light on my earmarked space.

Nudged me to remember: Today, I must lop trees.

Crossing

It is a thin glaze of film on flimsy white paper

It must be easy to rip it apart. To climb

Within and into the selfsame space frame.

There was a Hanuman who tore apart his chest in divine ardor

In Chitth-ambaram too, they draw aside curtains; A different kind;

To reveal the same Rahasyam of the great Truth.

But that is sublime devotion and I have mere desire.

Desire needs a breaking out; a tearing through

A release into an Out. Away and Beyond.

‘Shivohambhava’

An imagined life

Much that she’s lived, she doesn’t recall with longing

It is not a touch she misses so much

Not a word. Not a deed. Not even a memory.

What she missed, she said, was the experience

Of that which was consigned to the imagination.

It was the connection from without. As, in a room of strangers

The search of a gaze; that seeking, sweeps across spaces

Stops, engages and locks. Eyes partnered in a dance none else sees.

It was the connection of the unspoken language of knowing;

The fleeting assurance of being a somebody’s someone.

 

Unlike the remembered clasp of joined hands

She experiences the cloaking embrace of a gaze

As an observed memory – a couple across a room it was.

Imagines it would have packaged her too in a wrap of belonging

If only; he instead had turned a few degrees her way

She too might then have been marked for divine purpose;

For the gift of intended union in an otherwise purposeless universe.

Fancy

I want to find the words

. I have to .

dig them up from within

from the pages of a dictionary

from remembrances of

learning and of experience

from  somewhere; any where.

And then, I must make

incantation necklaces

string up word beads;

make them fast and furious

or the moment will pass;

wind them around your insouciance

splutter sentiment out of steel.

Flat shriveled balloons of  words

that will jump to life under your gaze.

Your scorn, like flying fingers on rosaries;

only your scorn; will give them breath.

Waiting

Brother-in-law brought an animated cartoon

It is better watched than told, I know; still..

The joke was on me and to my ill-concealed delight..

Of a fraggle-like child-character calling your name incessantly 

Until a yell hollers in threatening response and it flees,

In relief overwhelmed by humiliated annoyance.

 

Countless are the times since; I have called

In empty cartoon clouds laden with unheard sound

Not daring to give them voice until I hearken

The affirmation of an echoing shout.

If silent it must be; we will be silent together.

 

Ah! Now, here come the walls. Swift sliding woosh-es past the silence.

Building compartments in practised haste

I survive because of these walls.

Some don’t have them that strong it seems

A fashion designer. A singer’s husband too.

Were theirs filigreed frames? Perhaps they had none.

Mine are fortressed over years; Brick by brick.

My sturdy stockades bolt down like granite

I can do nothing but wait inside them.

The unsung merits of Doordarshan in a consumerist age

Doordarshan Bharati is India’s PBS. Only, a more fusty version that continues to have a dedicated viewership due to the nonpareil content of its archives. It is a veritable Geniza of everything Indian – culture, language, music, arts and literature. The words, India and Indian, mean many things to each of us and the diverse experience and interpretation of Indian-ness seems to grow exponentially each year. Much has changed in the past decade; enough to feel a generational divide with those a mere ten years younger than us. Their experience and obsession with consumerism is one that my generation did not have and in any case, could not afford.

I am from the Southern part of India; a region distinctly different from the North, in both attitude and approach to life and living. In my time, those that could afford more than most were subdued and restrained with their wealth. Conspicuous consumption was frowned on. Severely. The appurtenance of wealth was seen, in maybe a big house (often with the same interiors as your own; only bigger spaces) or a car; but personal display was almost non-existent. All retired grandfathers wore veshtis and shirts. All mothers and grandmothers wore demure, mostly cotton, saris with red pottus and flower strands in their hair for adornment. All ate with their hands. There was a homogenizing sameness of lifestyle that transcended money. Not much distinguished a rich girl from a poor one in dress, food, habit or lifestyle. At the most, one had short hair and the other had a plait. And then she was called, ‘modern’, not rich. One wore maybe a city styled ‘fancy’ chappal; the other had Bata. When I was growing up, all kids, rich or poor, wore Bata chappals. That’s it. I only woke, with wide eyed astonishment, to the realization that there was something called ‘party shoes’ in my twenties. Indeed, it happened with the excruciating embarrassment of the universally experienced rite of passage; and yes, in an alien culture. ‘Children’ have party shoes today!! I am not a curmudgeon dinosaur (despite a sincere effort to have portrayed myself thus), but in my world, children do not need and, will never need party shoes!

Consumerism is not always a bad thing. It is a necessary driver of the economy; but, our children must be protected from its corrosive power. There is an age which indulges in it (and should); there is an age that retracts and detaches from it and there is an age that should not know it at all. It is hard to instill values of empathy, equality and sharing in children when materialism is competing for mind and heart space. This age is better served by intellectual consumption than by material consumerism. When these foundations are firmly in place; we build a citizenry of integrity who, while not shunning the consumerist experience, will be well schooled in not falling under its rapacious influence either. The ugly sights of a spurious entitlement, visible all around us today, might finally fade and die. And wealth might cease to be the sole arbiter of justice.

For those like me, whose days are filled with a perpetual nostalgia for a culture, past and with a shrinking horror of the new; Doordarshan is a reassuring balm. At the end of a working day in India when body returns home with a numbed mind; nerves on edge and crumpled souls sink into the pillowed comfort of its quiet monotone narration, its languid landscapes, sublime, identifiable music and richly illustrated documentaries of our history and traditions. In the rapidly alienating environment of modern India that questions the roots of our belonging; it is Doordarshan that reminds us each time that we are indeed, home.

I wrote this, in some agitation, after listening to a stirring poem by Gurudev, that was sung by Sasha Ghoshal as the title song of a documentary on Indian Nobels aired on Doordarshan. It left me with a profound sense of loss and a helplessness that is hard to explain in words. I dearly wish for you, my dear reader, to listen to it. The translation, from the Bengali, is copied below. This was the caliber of the people that made and shaped our identities. Remembering them, their lives, their words – how can we not mandate that as a daily exercise for ourselves and for our children? Do the young watch Doordarshan, anymore?

——————————————————————————————————– ——–     When my footprints no longer mark this road – Rabindranath Tagore When my footprints no longer mark this road, I’ll stop rowing my boat to this ghat, I’ll cease all transactions, I’ll settle my accounts and clear all dues, All business will stop in this mart – It won’t matter if you stop thinking of me then, Or cease calling me while looking at the stars.   When the strings of my tanpura gather dust, When prickly shrubs sprout in my doorsteps, When the garden flowers put on a mantle of weeds, When moss spreads all over the pond’s banks, It won’t matter if you stop thinking of me then, Or cease calling me while looking at the stars.    Then the flute will play on in this music hall, Then Time will flow on, Then days will pass just as they do now. Then ghats will fill with boats as they do now – Cattle will graze while cowboys play on that field. It won’t matter if you stop thinking of me then, Or cease calling me while looking at the stars.   Who can say I won’t be there that morning? I’ll be in all your fun and games then – this very me! You’ll name me anew, embracing me as never before, It won’t matter if you stop thinking of me then, Or cease calling me while looking at the stars. —————————————————————————————————————- Essential Tagore.  Translated by Fakrul Alam, Radha Chakravarthy

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Universal Health Coverage Part IV: A partnership for change

                                     

The gamut of services that shelter under the umbrella of Health and Medical Services are collected neatly into four broad verticals: Preventive, Promotive, Curative and Rehabilitative. Preventive and Promotive health services are in the ambit of Public Health and have come to be the responsibility of the government. They are structured as low incentive sectors whose outcomes also rely on the participation and behaviour of the targeted population. For decades, these two divisions (often clubbed as one), have suffered from lack-lustre funding and interest. Paradoxically, effective action implemented here, is what impacts health metrics and influences the success of health policy. At the other end of the spectrum, Curative and Rehabilitative services are high incentive and lucrative tertiaries where the private sector is the dominant provider. This end is technology intensive. It does not rely on market participation and does not share responsibility for outcomes. In practice, there is a wide grey zone where curative and preventive services are in intimate and interactive contact. Evidently, irrespective of lucid demarcations of purpose and goal, successful policy depends on an active and cooperative participation of both the public and the private sector.

The framework of our health system was developed and commissioned in the initial years after Independence. While it has expanded in scope; very little of the original thought or content has changed and Government continues to serve a dual role of provider and purchaser of services in competition with, but distinct and apart from, a vibrant private sector. This explicit separation cannot continue in any useful way anymore. Health is now complex and gargantuan. The failures of the public health system as also the serious lapses of the private sector on professional responsibility and ethics have forced a rethink. Experience has brought a new acceptance of effective capabilities: ‘Not for profit’ Government excels at stewardship and regulatory; whilst the profit-driven private sector is a more efficient provider of services. This, broad but true, understanding should inform the new collaboration.

At a fundamental level, health is simply a service that subscribes to the same ordinary equations of provider, payer, profit and cost. These four elements are at the centre of a grouping of healthcare models into four types: Bismarck, Beveridge, National Insurance and Out of Pocket. Table 1 details the salient features of each system. National healthcare models, fronted by Germany and the UK, preceded the push for UHC. The first three systems in both their nascent and current versions were developed for the local people with heed to culture, disease burden and economic context. To this day each model is still associated with its country of origin. Local culture and conditions are critical components of policy and make the design of each system unique. Countries that have followed in the wake of the early trendsetters have themselves developed unique systems borrowing elements from all these models. One size does not fit all and there is no one model that can be singled out for emulation; but the fundamental principles of these four models are recognizable in every system.

Some features of an ideal system would include: a single, not for profit payer with comprehensive coverage for all and with tight cost control. Most of the obstacles in the path towards these ideals are laid in stone by the structure of already existing systems that are hard to dismantle. Reform of existing but non-effective systems will need an exercise in understanding before an overhauling is undertaken. Here’s a very brief overview of India’s healthcare delivery and purchase patterns as they stand to date:

Provider:

Health service providers in India are divvied up  into: A) The public (government) health system owned and operated by the government – extends from tertiary hospitals to an extensive three tier network of secondary and primary healthcare that meanders through urban pockets, satellite townships, districts and interior villages. These facilities are ostensibly free and some charge a nominal amount. In reality; out of pocket expenses, borne by the poor at the public health system, are significant. The public health system is also one of the largest employers in the country. More than 2/3rds of the budget is expended on human resources. B) The private health system owned and operated by private individuals, companies and corporations – offers tertiary and secondary services restricted mostly to cities with a smattering presence at the town and district level. Privatized primary care is serviced through GPs, group practices and OP clinics at hospitals.

Purchase:

The critical details of purchase and spending were enumerated in UHC Part II. To briefly summarize; the bulk of healthcare spending is private; 86% of this is at point of care, direct and out of pocket. Public healthcare delivery and funding is decentralized to the State; which contributes 2/3rd of the outlay. The Union government absorbs the remaining 1/3 but bears primary responsibility of policy, stewardship, regulatory, establishment of standards and protocols and, audit. There are a plethora of, relatively new (2007 on), government sponsored health insurance schemes (GSHIS), distinct and apart from those for formal sector employees and civil servants. In 2009-2010, government sponsored insurance programs accounted for 8% of total health expenditure. The social-health insurance schemes are greatly fragmented, are funded by both the Centre and the State with considerable degree of overlap. government. According to WB 2010 figures; 25 per cent of the population have some sort of coverage; 19% is public insurance and 6% is private. Even if these figures seem low for a huge country; it is still a giant leap from a few years back and owes much to the expanded coverage of RSBY and some good state health plans. The pros and cons of the new GSHIS are detailed in Table 2 below.

GSHIS (Government Sponsored Health Insurance Scheme)
Advantages	Disadvantages
Covers 240 million as of 2010	Is not universal
Is restricted to BPL groups	BPL is not clearly defined or agreed upon
Packages are explicit. No surprises	They are not comprehensive. Cover largely catastrophic Inpatient. Primary care and OP care is largely excluded even though 70% of private spending happens here. Coverage limits vary. Low per capita cost directed at tertiary coverage reflects low utilization frequency. Exceptions are Yashasvini and RSBY
	Use TPA for administrative functions. Guaranteed to spiral costs in the long term. Government must invest in infrastructure and human resources to serve this role. Insurers under contract to these schemes have no incentives to control costs
	Inadequate vigilance measures
Networked to private hospitals and patient choice of provider.	Makes public health facilities at the tertiary and secondary level, duplicate and redundant.
Table 2: GSHIS

The crisis in public health is not one of funding alone; there are serious operational flaws too. That government fails at delivery of services is well established. The reasons are systemic and entrenched. At every level of governance,  the failure is more one of quality and credibility than of accessibility. Quality standards in government-run institutions are abysmal; these institutions are also underfunded, understaffed and absenteeism of employed staff is rampant. The poor react to this in two ways: 1) Avoid non-emergency care. They mistrust public health facilities and do not also have the money to pay for private service. 2) When delay makes the condition dire and/or in emergency situations, they opt to either pay out of pocket for private services or avail of tertiary public health services in large government hospitals. This utilization pattern is reflected, through the example of free meds, in the table below.

	Year	Free  meds	OOP spend (out of pocket)	Did not take treatment due to non-affordability
IP (in-patient)	Mid- 80s	30%	41%	13%
	2004	9%	72%	3%
OP (out-patient)	Mid-80s	18%	65%	12%
	2004	5%	65%	26%
Note: The number gap is filled by partially free drugs; those numbers haven’t showed significant movement to warrant detailing here. Also, OOP spending includes purchase for a fee at either private or government outlets. IP OOP can also reflect a shift to service utilization at private hospitals Source: HLEG
The reduction in free IP meds is matched by a corresponding increase in OOP spending. Despite this; people availed of the treatment as can be seen by the drop in non-treatment from 13%-3%. People availed of hospitalization even if they had to pay out of pocket. OP presents a different picture. Even here supply of free meds went down; from 18% to 5%. But OOP did not rise correspondingly. It stayed at 65%. People just stopped taking OP treatment (first line curative, preventive, protective) treatment. Their numbers climbed to 26% From this, it is possible to infer that the segment of the population that is unable to afford health, forgoes out-patient care and risks hospitalization (a more costly service). When their condition worsens forcing hospitalization; they then pay out of pocket as a desperate measure. Hospitalization is more expensive and consequently many are put through severe financial hardship; even bankruptcy. Behaviour can be reversed by increasing funding to OP services. IP are services of last resort and people will pay for them irrespective of funding. It is also important to note that, empirically, people in a crisis have more faith in and choose the private sector.
Table 1: Spending and behaviour

Coverage or Delivery? The shape and form of change:

Public healthcare in India is unique in that the government serves operates in both the demand side and the supply side as provider and purchaser. It does this in a market that is replete with multiple players on both sides. Coverage is meaningless unless linked to delivery. But, world over the scope of health and medical services has expanded to unwieldy levels and it is a Herculean task for governments to go it alone. When funding is already a problem; can the government realistically fund both and keep both, efficient and effective? Can government choose to fund one over the other and if so, how? Consensus is building on the possibilities of partnership with the private sector to tackle this conundrum. Some suggestions for how and a timeline for implementation are proposed below.

1. The scope and scale of government insurance coverage:

• The entrenched health system is rooted in delivery and coverage fragmentation. UHC, on the other hand, is a homogenizing concept. Transformation of a disparate system into a homogenized one can only be done incrementally
• Restrict the size of UHC by first making it available to all people under a pre-defined income bracket.  All existing state and central government insurance programs are merged into this one program now called GHC (government healthcare)
• Coverage under GHC to be comprehensive. All IP and OP, preventive and curative services will be covered along with a prescription plan.
• The holders of the GHC card can avail services at all government hospitals and the government health system network. This restriction on choice of provider is strictly time-bound. Upon the expiration of this period it is withdrawn in toto. The rationale behind restriction: Allowing GHC holders unrestrained access will bring with it a new set of problems. The public health delivery network becomes redundant and duplicated, since all holders will use the private hospital network. GSHIS is already providing us with valuable learning lessons on this front. On the other hand, giving people coverage to the existing, but crumbling, services at the public hospital will make GHC redundant and push people back into avoiding care.  Lastly, investment in the public hospital network alongside GHC brings up the bogey of funding both demand and supply side. Provision of service must thus be restricted to the public health network. How we prevent the GHC-covered from exercising a Hobson’s choice, is detailed in the following paragraph on delivery reform
• Institute a single model of purchase by mandating health insurance for all sections of society. Holders of private insurance use the private health network.
• Abolish direct payments 
• Impel stringent cost control price control and negotiated package rates instead of fee for service.
• Introduce ‘GHC plus’ for an intermediary group that has GHC as its primary insurance but that can afford to pay for it. Services in the government hospital network are scaled up to include hospitality for this group. Coverage of medical services is uniform for both but the addition of a separate paid-for category (even if only for additional hospitality) prods entitlement towards aspiration
• Standardize treatment protocols and quality measures.
• Ensure complete and full transparency and accountability. Subject UHC to a full third party and community audit

2. Ownership of public health delivery:

• In order to ensure efficient delivery of services; it is proposed that Government plays the role of purchaser alone; disinvests, scales down and finally exits its role as provider. This also is instituted incrementally with the tertiary and secondary services commissioned first and primary care at a later stage
• Disinvesting in and divestment from delivery of services will provide a source of funding for GHC and the taxation burden on the middle class, who will subsidize some part of GHC, is reduced or not needed even anymore
• The entry of the private sector into traditionally owned government territory will guarantee growth, quality standards and equitable services on a scale similar to that in the private system.
• Privatized services in government hospital networks operate under the regulatory stewardship of government but with decentralized control and autonomy in decision making
• The scaling down of delivery should be matched by an investment in health monitoring and IT services, complete involvement of government in planning and monitoring of delivery, stringent regulatory, tough price control and government audit
• Data collection and record maintenance is stringently imposed, monitored and collated by investing in technology
• Empower community participation in regulatory activities at every level of healthcare delivery. Building a sense of rightful ownership will ensure the active involvement of the community in monitoring delivery and in ensuring responsible and ethical service from the provider

Government now ensures depth of coverage to all under GHC while the private sector guarantees the quality of that coverage under the government’s stewardship. Once the system has taken root, operational difficulties ironed out and services equalized across sectors restrictions on provider choice to GHC holders are removed. At this point, Insurance can transition to a National insurance model.

3. Human resources, education and the community:

At its core, health is a personal affair. Initiatives for health work well when there is active community involvement. The government has built an excellent infrastructure of community workers in health through the SHC and PHC network. Happily too, women form the bulk of the frontline of these health workers: ASHAs  (Accredited Social Health Activist), Anganawadi Worker (AWW), ANMs (Auxiliary Nurse Worker), etc. Despite the excellent infrastructure, actual benefits have not been realized; once again, due to the same operational and funding problems. The centres are understaffed, the Community Health Worker (CHW), a local person from the village who is expected to be the bridge to the PHC, is unable to handle the responsibility without support, is inadequately trained and is not integrated into the health system in a sustainable fashion.

This is an excellent opportunity for education to integrate with health. At long last, degree certification in Rural Medicine has been green-lighted. The private sector should be licensed to set up rural/semi-urban schools to offer different levels of training in translatable social and paramedical community health. The enrolment of these schools must be from the local communities. The institution of rewards along with clearly defined career growth will incentivize community participation. Education, until the roll-out of the first graduates, can locate in district centres. At these primary levels of health much can be accomplished with tele-communication aids. Once the first layer of a qualified professional group takes root from within the non-urban civil structure; a new generation of primary health care will truly take shape.

Core principles of the proposed delivery model 1. Government coverage for all under a certain economic bracket, patient choice initially restricted but regularised in a defined time period; private insurance mandated for all out of this bracket; tight cost control 2. Stringently regulated government partnership with private organisations in delivery with divestment targets to disentangle government from provider role 3. A new funding arm for UHC 4. Private running of government facilities to be monitored, audited, for quality and service checks by both government and community audit and 5. Primary care and rural medicine education privatised under strict regulation, standards monitoring and audit by the government.

At the centre of health reform is the goal of providing access to affordable health for all people in a population. The only thing standing in the way of that goal is a true political will. Change is easy to accept and implement if the larger purpose of an achievable goal is in focus. The private sector is not without its own set of serious flaws; but it trumps government in an analysis of service delivery and quality. Public perception, satisfaction and trust with government is at a nadir after a six decade experience with ever-failing competence. In this environment; the role of government as provider needs a re-think. By ridding itself of its debatable provider role and focusing instead on its imperative responsibility of ensuring access to affordable health for all its citizens; a true and outcome driven reform might finally take shape. 

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