Karnataka’s health care system: The english version of the article that appeared in Prajavani, dtd 21 Nov 16
Karnataka state recently celebrated the 61st Rajyotsava day on November 1st. While the state has made great strides in different areas of human endeavor, one needs to use this occasion to learn from the past and think through and strategize for the next 40 years. One of the critical elements for the progress of any state or country is the status of health of its citizens. It is here that we need to understand that the state of Karnataka could have done better keeping in mind what we as a people and a state are capable of. The human capital of the state is extremely critical for overall progress and we need to ensure that public expenditures from the current levels of less than 1% today is substantially increased. The State needs a health policy that is evolved from a systems thinking and an approach that takes into account all elements of the health care eco-system in order to ensure health care of its citizens decades from now.
De-medicalizing the health care system: Medical care is only a sub-set of health care and the perspective and practice that medical professionals should be at the helm of all health programs must be changed. Health is an area which has ample scope and in dire need for non-medical professionals with different skills and knowledge to participate in. For instance, a campaign on safe drinking water could be better managed and led by officers with skills in mass communication and in handling logistical challenges than physicians. ‘De-medicalization’ of health care by introducing people from disciplines and backgrounds in the ambit of public health must be a priority. This move can solve the problem of shortage of doctors while at the same time bring down the cost of providing health care too. The state should also consider bringing in an alternate model of training Physician Assistants who can be an intermediary service provider and reduce the dependency on a clinician.
Promotion of Integrative medicine: There are more than 70,000 traditional healers in Karnataka and the State’s health care delivery system must be based on knowledge that is inherently embedded in communities. We must look at traditional medicine systems and practices of AYUSH at par with other systems of medicine like Allopathy. Mutual respect for different streams of medicine with a view to genuinely understand the strengths and limitations must be promoted at all levels. Instead of having separate hospitals and health centers for Allopathy and Ayurveda, the state should start having Centers that promote and practice Integrative Medicine.
Streamlining Insurance Schemes: Schemes and programs towards making health care accessible to poorer sections of our population through insurance coverage have been introduced over the past years. However studies indicate that the poor families still have to bear out-of-pocket expenses and not all ailments are fully covered. There are evidences of gaps in pro-poor targeting mechanisms of programs such as Rashtriya Swasthya Bima Yojana and Yashasvini Scheme. This indicates that health coverage is implemented primarily from an insurance provider perspective and not the user’s perspective. Health coverage schemes must be designed with ‘eliminating the possibility of any individual being denied medical treatment for want of funds’ as their core objective and multiple insurance schemes of the state must be integrated into one master scheme.
Addressing regional disparities: Despite the efforts of the Govt., we still lack equitable distribution of health care services and regional disparities exist at all levels. Planning mechanisms must take into account disease burdens and other health characteristics of the districts or regions so that the resultant plans reflect the disaggregated focus that allows lagging or vulnerable districts to improve. A change in the funding pattern to the districts is needed, especially in terms of moving away from ‘facility-based’ funding to ‘need-based’ funding. As a result of facility-based funding, districts with greater needs and lesser facilities end up getting lesser funds than districts with lesser needs but higher number of facilities. The southern districts of the state have more than the required number of PHCs while the northern ones have significantly lesser numbers. Rationalizing the location of the PHCs based on the population and usage criteria will help reduce the inequity in infrastructure and also bring down the total number of PHCs from 2200 today to the required number of 1750.
Limiting the ‘verticalization’ of health department: We must put an end to the process and practice of creating disease-focused verticals in the health department and adopt an integrated approach to disease control. While there is no denying that prevention and control of diseases such as HIV/AIDS, TB, Malaria, etc. are huge challenges on their own and special emphasis is needed on them, disease-focused programs also create functional and administrative stress on a system. Disease control mechanisms can be effective only when convergence is established at the macro level and implemented through the existing primary care delivery system.
Strengthening community monitoring: The National Health Mission places a great emphasis on community participation in health, but the efforts to support it on the ground is a mixed affair. There is evidence to suggest that a sustained effort in strengthening community monitoring results in greater transparency and accountability at the grassroots level and generates local, cost-effective solutions to issues. Community monitoring and social accountability processes must go beyond the customary lip-service and should be integrated into the health care system itself.
Preparing for the ageing population: Currently, India can boast of its demographic dividend, but the increase of ageing population resulting in higher dependency ratios are a prospect Karnataka will face in the not-so-distant future. The burden of non-communicable diseases is also increasing and this coupled with the problems of aging needs special focus and attention.
Emphasis on Palliative Care: Palliative care is also a huge public health challenge and the recently announced Palliative care policy is a welcome move. One must recognize that palliative care is not just cancer care, but includes all chronic, incurable and progressive neurological, cardiac, respiratory, AIDS and other diseases. With the rise in ageing population, patients needing palliative care will only increase and the public health care delivery system must be prepared for this.
Integrating mental health into mainstream public health: WHO has predicted that 20% of the state’s population will suffer from some form of mental illness by 2020. There is a great need for pooling together resources to address mental health issues, awareness creation, and capacity building both in terms of curative and preventive aspects as well as breaking taboos and stigma.
Reforms and regulation of private sector participation in health: With less than 20% of infrastructure in their hands, private medical establishments are catering to more than 60% of people in need of medical care. This poses a huge quality challenge and appropriate regulation of the private sector accompanied by strengthening of public health care institutions is needed. At the same time, private sector contribution to health care must not be undermined and efforts must be made to include private sector players in dialogues on the nation’s health priorities and enhance their role in addressing the same.
A good policy with a long term strategic focus will be meaningless if the existing system is not geared up to deliver on the same. The capacities of the people in the public health system needs to be built and people should be held accountable for not delivering on key milestones that will have to be fixed for the short, medium and long terms. The need of the hour is to have an Ombudsman who can oversee and monitor this and ensure that the future of the people is both healthy and in safe hands.
“There were many good things in the ancient times, but there were bad things too. The good things are to be retained, but the India that is to be, the future India, must be much greater than ancient India.” – Swami Vivekananda
India is now going through a momentous phase of transition. While we race to catch up with a world being connected seamlessly through digital technology, we can find new ideas and new ideologies bombarding us from all sides. It is at times like this that we need to pause and ask ourselves whether we are going in the right direction and at the right pace. We need to explore as a nation whether we are building our future based on the lessons of our past or are getting caught up in the mindless pursuit of mere economic growth. This is also the time for us to revalidate the relevance of the message of Swami Vivekananda and his vision for India. Vivekananda dreamed of seeing Mother India in all her glory on the resplendent throne where she rightfully belonged. If we are to go beyond the romance of this statement, we first need to understand where we are today and what the challenges are ahead of us. We also need to understand where we were in the past and what lessons we can learn from the rich history of our culture and civilisation.
India of Today: The whole country is agog with the excitement of change. Everyone seems obsessed with our growing visibility around the world and is increasingly focusing on economic growth and the trappings of visible development. We seem to be overlooking the fact that despite this constant progress and growth, 50 per cent of children under five years of age suffer from undernutrition1. While on the one hand we are making rapid strides in space and defence technology, on the other hand a large part of our rural population still lacks basic amenities, including clean drinking water and sanitation facilities. 37% of our young people drop out of school by the time they reach the tenth grade. Gender and caste inequities are very real and distressing. Despite all our scientific attainments, close to 75% of our graduating youth lack employable skills. What we are building today in our children and youth is mere cognitive growth and not the overall social, emotional, and spiritual evolution of a balanced person. As a society, we are seeing a rapid erosion of our social capital, with visible manifestations of trust deficit, lowered interdependence, and vanishing reciprocity. Monetisation has become the metric of human success and attainment, while other dimensions of human achievement are getting marginalised. While one can argue that the benefits of our growth will trickle down and most of our citizens can indeed aspire to a better life, we need to recognise the challenges ahead of us.
The Challenges Ahead: India’s progress is going to be determined by how well we can manage three major challenges facing us. The first is the increasing intolerance that we are seeing and the growing reality of religious fundamentalism. Religion has now become a political tool. Not a day passes without evidence of this threat in some part of the world or the other – whether it is India, Pakistan, Syria, Iraq, Russia, Afghanistan, Egypt, or the United States. The second major challenge that is becoming more evident is growing economic inequity. The gap between the rich and the poor is the widest in our recent history. The top 10% of Indians generate and control more than 75% of India’s wealth, while the bottom 20% are generating and controlling less than 1%. The increasing economic tensions are having social ramifications, and outbursts of violence are no longer the exception. The third major issue is the manner in which technology is rapidly disrupting everyday life, manufacturing, and services. This makes demands on our youth to acquire skills that are not easily available and that are out of the reach of most of our rural population. Our ability to resolve these vexatious issues will eventually determine whether we are able to place India on the world stage and give our people the life that they deserve. What can we do to confront this reality and find realistic and pragmatic solutions? It is here that the message of Swami Vivekananda and his plan for building India’s future give us a solution. Swamiji strongly believed in learning from our past in order to build our future. While he was a romantic lover of everything Indian, he was also pragmatic enough to identify the ills that we had accumulated over the years and that had to be mercilessly discarded.
Our Rich and Hoary Past: An objective assessment of the India of the past in multiple dimensions demonstrates how advanced we were as a society. The work of the English economic historian Angus Madison conclusively proves the wealth of our nation from the beginning of the Christian era up till 1600 CE. He mentions how the Indian civilisation, with its enormous intellectual, trading, and manufacturing capacity produced 35% of global GDP and was possibly the richest country in the world during those 16 continuous centuries. It was also during this time that India contributed the binary system and the concepts of algebra, trigonometry, and calculus. Metallurgy and the chemical sciences were far advanced, and knowledge of astronomy, physics, democracy, and political science was at its peak. Apart from the sciences of the ‘external’, Indian scriptures were rich in their understanding of the ‘internal’. From psychology to spirituality, our thinkers made contributions that the rest of the world had yet to discover. One can safely say that this was the glorious era of Indian civilisation. The focus was on increasing the human and social capital of India. This obviously resulted in enormous economic benefits.
The Way Forward: Swami Vivekananda strongly believed in the control of man’s inner nature in order to ensure the optimal utilisation of resources and efective functioning in the external world. He could see how a colonised and conquered India had lost her moorings, and he felt the urgency to rebuild her human and social capital. Swamiji understood that a full expression of human potential would happen only when man constantly expanded his physical, intellectual, emotional, and spiritual capabilities. Only then could he have the capacity to lead and sustain his life. He understood that ‘education’ had to go beyond mere schooling and result in the expression of the inner perfection already inherent in man. He could also relate physical growth to mental and emotional growth. He asked young Indians to make their biceps stronger before embarking on the study of the Gita. For him, interpersonal and intrapersonal intelligence were as critical as social intelligence for man to progress and grow. He gave a new meaning and dimension to the pursuit of spirituality by making it practical and socially pragmatic. His call to serve the God in man as a means of spiritual evolution is possibly the most practical means of connecting man’s inner nature with the outer world. Swamiji’s message of working for the poor and the marginalised and the call for inner evolution and not an outer revolution further strengthens this argument. His thoughts on organising people and building institutions reflect the emphasis he placed on social capital. He knew that a country could not be built on sand and that democratic institutions can be created and sustained only by people of mettle.
And what India needs today is to revisit this concept of building a complete man, who can in turn create and manage institutions and thus build a great country. We need people with the qualities of compassion, humanism, a spirit of enquiry, humour, mindful existence, positive thinking and the intent to be good and do good. Imagine a nation that is led by a type of humankind that is responsible in its consumption, respectful of all of nature’s creation, constantly striving for both internal and external peace, harmony, and good will. Such a country would be wonderful indeed, where sharing and caring would be second nature to humankind and the mad rush to acquire everything for just oneself would be a thing of the past. Imagine such a nation where these self-evolved humans are interconnected and live with the awareness of mutual trust, interdependence and reciprocity! That is the social capital that India badly needs if it wants to stop hurtling towards self-destruction. India now needs a new narrative that talks about creating and expanding this human and social capital based on Swamiji’s vision. Sustainable development will then not be a mere slogan or a fashionable statement that is talked about, but a practical and realistic attempt to build this New India. In that new vision for India, development will be seen in terms of increased security and liberty for communities and individuals. This means that people will have the political space to voice their problems and choose the solutions that best represent them. Dominant players in development – whether they are the government, or civil society, or the corporate world—will then take the time to listen to people with respect and provide them with the platform to articulate their just and legitimate aspirations.
India needs to become a pioneer in translating this vision of development into concrete reality, where the rule of law is the norm rather than the exception, where no Indian will go hungry, where human rights are not a mere slogan but a way of life, where democratic participation is not a fanciful aspiration but an everyday expression of citizenship, and where food, nutrition, livelihood, infrastructure, education, health care, and religious freedoms are not mere political promises but entitlements of an empowered citizenry. This is the India that Swami Vivekananda spoke of—and the India that we need to create.
The Complete Works of Swami Vivekananda, Advaita Ashrama, Kolkata, Mayavati Memorial Edition, Vol.6, p, 318
https://dhsprogram.com/pubs/pdf/OD56/OD56.pdf https://en.wikipedia.org/wiki/Water_supply_and_sanitation_in_India https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662127/ http://monitor.icef.com/2015/10/indias-employability-challenge/ http://www.thehindu.com/data/indias-staggering-wealth-gap-in-five-charts/article6672115.ece
With the skies opening up for a few days and the noise over the Cauvery water sharing coming down, life will go on as usual for most people. And our politicians, legal luminaries and policy makers will start their complex negotiations on how best to share the available water when the situation arises again, possibly next year itself. A uni-dimensional and technical approach to solving this serious and adaptive challenge will only be a temporary Band-aid while the larger issue of scientific and comprehensive water management will be given the go by.
What should the Government then do if it has to solve the problem keeping the larger picture in mind? Will the solution work if only the govt is involved in framing it? What about the actual user and his share of doing what needs to be done? We also need to keep in mind the fact that we have reached the current state not just by increasing the total land under irrigation or by building dams across the river but by impacting negatively the entire hydrological cycle itself. A recent media report citing a study mentioned how the city of Bangalore alone has lost 79% of its water bodies and had a 925% increase in concretization. 75% of the city is land paved and 98% of the lakes are encroached upon. 90% of the existing lakes are sewage fed and we still want to ensure that all the citizens of the city get safe piped drinking water sourced from the Cauvery river. This may not be peculiar to the city of Bangalore alone and most major metropolises in India suffer from a similar malady. Another report of the forest department of the Government mentions how the deforestation in the Western Ghats area is severely impacting the rainfall and water inflow into the Cauvery river and its tributaries.
Instead of merely focusing on the supply side, people and planners have to also consider the demand side issues and how to resolve them effectively. The state needs to have a comprehensive water resource management policy that plans for afforestation, lake management, rain water harvesting structures in private and public buildings. It needs to have clear blueprint for demand side management and ensure that better irrigation practices including drip irrigation is encouraged amongst our farmers. Famers also need to be encouraged to move away from water intensive crops like paddy and sugarcane to cultivation of millets. The state also needs to have a millet policy that not only encourages the growing of millets but also advocates it as a better and healthier calorie option for the consumer. Apart from changing behaviors of both the farmers and the ordinary citizen, the state also needs to embark on modernizing and desilting our dams if we need to make water storage efficient again. Though this may be expensive, experts mention that it can lead to an increase in the irrigation efficiency by 20%. At a personal level, each of us need to remember not to keep the tap water running when we are brushing our teeth or shaving. Having our leaky taps fixed and not using the shower for bathing are other simple but effective means to conserve water at a personal level. We also need innovative solutions on re-using gray water, especially for toilet flushing and watering the plants etc. The demand for water is ever increasing not only because of the increase in the population but also due to the increase in the per capita consumption. Scenes of people washing their cars, watering the streets and flooding the paved areas of apartment complexes to clean them are an everyday occurrence. Civic laws to control and reduce such wastage needs to be put in place and enforced strictly.
Mitigation and treatment strategies of the watershed and catchment areas of our rivers including the Cauvery needs to be kept in mind while addressing the larger dimensions incorporated in the hydrological cycle. Forests are natural sponges and they help store water too. No forests mean less rain but when we have rains it also means floods if there are no trees. We also have to let the Forest department manage our forests, mangroves and swamps without any political interference. The recent experience of flooding in our major cities should be a wake-up call to our politicians, urban planners and civic officials and they should ensure that both the inflow and outflow of our water systems and structures in the catchment area are open and free flowing.
The larger issue of Global warming and the melting of the glaciers all sound and seem distant but we need to understand how macro events are affecting our micro existence on an everyday basis. The dictum of the National water policy of providing safe water for drinking and sanitation as pre-emptive needs after which other needs including agriculture should follow is usually forgotten in the discourse of sharing the river water.
While the demand is ever increasing, the supply is either constant or depleting. In such a scenario, water resource management cannot be done only by technical experts alone. One also needs to remember that it is not just quantity but also the quality of water that we use. Human behavior and lifestyle have a deep impact on this issue and we need inter disciplinary teams of sociologists, behavioral scientists, engineers, political economists, anthropologists, irrigation & water experts to sit together and look at the complexity, the interconnectedness and the multiple layers of the problem. With this background the state needs to come with a comprehensive and visionary policy that will lay the ground work for managing our water resources. Finally, we need to bear in mind that water is indeed a limited resource and we need to use it wisely. Or we will have only ourselves to blame.
Ms. Anita Kaul
With communication being what it is nowadays, my day began with a piece of bad news arriving on Whatsapp. A friend had sent me a message that Ms Anita Kaul, one of Karnataka’s finest IAS (Indian Administrative Service) officers had passed away after a brief illness last night. This news was hard to believe (as with many Whatsapp messages nowadays) and I called up another good friend and erstwhile colleague of hers to verify. He had just reached Delhi to be with her family and told me the inevitable. She leaves behind her husband Sanjay Kaul and son Rohan.
Anita Kaul had retired from the IAS just more than a year ago after a long and distinguished service in the Karnataka Cadre. She was the Secretary to the Ministry of Law, Government of India at her time of her retirement, and post retirement had associated with a social sciences research organization. I had first met her a few decades ago and was impressed with her efficiency and insightful thinking right from this first interaction. She was with the HRD ministry of the Govt of India and had come visiting to Karnataka to launch one of her favorite women empowerment programs – Mahila Samakhya. What left me changed was the manner in which she accepted the prevailing realities of gender imbalance and was making suggestions that were practical, embedded in the context and implementable on a large scale. Her fiery passion for improving the lot of women was only matched with her sense of pragmatism.
Her visit to our tribal school at Hosahalli when she was the head of the DPEP program in Karnataka is still fresh in my memory. Her desire to know about all our educational experiments, her eye for detail and her constant questioning about the idea of the school’s architecture influencing the learning process was a learning exercise for all present. My closest interaction with her was when she was the Director General of Administrative Training Institute (ATI) at Mysore. It was during her time that this Institute along with the State Institute of Rural Development (SIRD) reached its peak. The innovative programs and the impactful training sessions that she personally designed needed to be seen to be believed. One could scarcely believe that this was a Government Institution and the professionalism that every member of ATI and SIRD demonstrated was a tribute to her leadership. The next location where she left her deep imprint was in the Ministry of Planning in the Govt of Karnataka. She tried hard to bring in evidence based policy making and rigorous program evaluations into the system but with limited success.
Every person who came in contact with her will remember her not just for her administrative brilliance but also for her humaneness, her constant concern for the common man, her instinctive ‘people-centric’ thinking and her stubbornness. Yes, she was stubbornly honest and unwilling to deviate even slightly from the path of the high standards of ethics and morality that she subscribed to. She was also known to take thoughtful decisions, but once she had made them, would stubbornly resist changing it. Another endearing quality of hers was the freedom that she gave everyone around her to argue and challenge her. One could feel very comfortable criticizing her, knowing fully well that soon she would be her caring motherly self again. Another dimension of her that people would hardly know was her concern for her aging in-law and mother. She was always trying to be by their side and care for them during their old age and infirmity.
People like Anita Kaul come along very rarely. Bureaucrats like her are rarer. She set high standards not just for the IAS but for the entire development community. She was a unique combination of passion, compassion, integrity, hard work, discipline and concern for the last man on the street. We will all miss you Madam, we pray to the Lord to give your family the strength to bear with the loss. Let your soul rest in peace.