The ‘public’ in public health

The discourse must move beyond a top-down approach to listen to the people and formulate best insurance practices

Much ink has been spilled in documenting the inadequacy of budgetary allocations for public health insurance, specifically for the Rashtriya Swasthya Bima Yojana (RSBY), the world’s largest publicly-funded health insurance (PFHI) scheme. Though the 2017-18 budget allocation has marginally increased from last year’s revised estimates, it has declined relative to last year’s budgeted amount by about ₹500 crore. However, higher budgetary allocation can only constitute a small part of the solution to the scheme’s mixed, if not lacklustre, performance.

Under the scheme, a Below Poverty Line (BPL) family of five is entitled to more than 700 treatments and procedures at government-set prices, for an annual enrolment fee of ₹30. However, even nine years after its implementation, it has failed to cover a large number of targeted families — almost three-fifths of them. Their exclusion has been due to factors like the prevalent discrimination against disadvantaged groups; a lack of mandate on insurance companies to achieve higher enrolment rates; and an absence of oversight by government agencies.

Increase in hospitalisation

True, there has been a substantial increase in hospitalisation rates. However, it is unclear if it has enabled people to access the genuinely needed, and hitherto unaffordable, inpatient care. Often, doctors and hospitals have colluded in performing unnecessary surgical procedures on patients to claim insurance money. For instance, hospitals have claimed reimbursements worth millions of rupees for conducting hysterectomies on thousands of unsuspecting, poor women. Indeed, in the absence of regulations and standards, perverse incentives are created for empanelled hospitals to conduct surgeries. It is thus not surprising that there is no robust evidence of an improvement in health outcomes.

Evidence on the financial protection front is conflicting as well. One study revealed that poorer households in districts exposed to the RSBY and other PFHIs recorded an increase in out-of-pocket (OOP) expenditures for hospital care, and a corresponding rise in incidence of catastrophic expenditure. There is near-consensus that the RSBY has resulted in higher OOP expenditures. Though it is a cashless scheme, many users are exploited by unscrupulous hospital staff.

So, what is the solution? There is a need to bring the ‘public’ back into the discourse on public health to highlight its present culture. The conversation needs to move beyond a top-down approach specifying budget allocation and administrative and technical efficiency. It needs to involve listening to the real public to deliberate on various health practices and policies.

My ethnographic study of the RSBY in Kalaburagi and Mysuru districts between 2014 and 2016 brought to light that a top-down approach on allocation and coverage was important but, by itself, did not translate to expected outcomes. What mattered more was the existing culture of health insurance — how it was perceived, practised and experienced in the everyday, local worlds of the enrolled households. Though they valued aspects like the money available and the number of illnesses covered, they were more deeply affected by how other actors — doctors, local officials, neighbours and even relatives — related to health insurance.

Card not accepted

The disillusionment of Savitri, one of the beneficiaries, after obtaining the plastic card said it all: “If public officials only give us the card without telling us how to use it, the card is just plastic material. Sometimes information is also not correct, making us feel that the card is of no real value if we do not know how to use it.” Further, many hospitals refused to acknowledge the card’s value. Shivakumar’s observation summed it well: “We went to the hospital with the card. Not only could it not be used but also the doctors did not even acknowledge us as patients... We just brought the card home and tossed it to the shelf.” Many bemoaned the absence of public debate on health issues and the RSBY card. Deva’s pithy response was illustrative: “If it is not talked about and debated, we can only think that there is no big value that we should pay attention to.”

Households clearly separated the economic value from social ones. A section saw health insurance as a bad omen, one that announced arrival of illness. Ramesh Kumar, among those in his neighbourhood who refused to enrol, explained: “This card is not a solution for illness, it is a cause of it. You see, when you people knock on our doors to give us the card, it feels like an illness is knocking on our doors. The farther away we are from the card, the further we are from health problems.”

Overall, while the discourse on a greater allocation to RSBY and enhancement of cost-effectiveness are important, a shift of emphasis is needed, bringing the ‘public’ back into the sphere of public health.

Vani S. Kulkarni teaches Sociology at University of Pennsylvania, Philadelphia

Source: The Hindu, 16-05-2017

Women need respect and rights, not just protection

In a semi feudal and genderised society like ours, sexuality remains central everywhere; and rape looks like an indigenous, not an exceptional phenomena.

Just days after Jyoti Singh’s killers were sentenced to death by the Supreme Court, on May 11, a similar case of gang rape and murder was reported from Rohtak in Haryana. Within the same week, another 10-year-old from the same area was found repeatedly raped by her stepfather and is now five months pregnant. On May 14 (ironically on Mothers’ Day), a young girl from Sikkim living in a hostel in Delhi, was forced late night into a car and gang raped by several men and on the very same day another young girl who was kidnapped while going to her school to collect her certificates,was rescued from a farm house in Meerut where she was being held forcibly and gang raped repeatedly.

What is happening here, you ask. To what do we owe this spate in sexual crimes against women and even little girls some as young as two months old ? Why, despite the strengthening of our archaic rape laws , did it take the Supreme Court of India almost five years to confirm the death sentence for the rapists and killers of Jyoti Singh, of whom one being a minor then, is still in a remand home?

One needs to understand here how fundamental sexuality is to the basic concept of gender in Indian society. And in a semi feudal and genderised society like ours, sexuality remains central everywhere (from homes, schools and cinema screens to Parliament) to define males and females. Under this rubric, submissiveness and non assertion are female qualities while domineering and forceful behaviour is deemed proof of male power. Add to this the fact that nearly three quarters of our population is below 40 years of age, and even to a dimwit, rape begins to look like an indigenous, not an exceptional phenomena.

The relative silence over the Rohtak gang rape and murder of a young Dalit girl allegedly by a rejected suitor, surprises one after the dramatic scenes and nationwide protests that followed the Jyoti Singh case and finally led to amendments in our rape laws. The news of this equally horrific gang rape is already relegated to inside pages as the media agitates over the debacle of the AAP and the disappearance of a sofa set brought in for the UP Chief Minister.

This is proof, if any is needed, that Indians are fast developing callouses on the subject of rampant sexual violence against women. Predictably the Haryana police having constituted a special investigative team is ‘looking into the matter’, the NCW has sent a two member team to meet the victim’s family and the Haryana government has announced a fat compensation for the victim’s family, but it is obvious that despite all the publicity over stringent new anti rape laws and “kadi se kadi saza” pronouncements from the System, not much has changed on the ground for women . The power pack in civil society, the legislature, the judiciary and the executive (mostly men), still represents to women a system squarely based on gendered definitions of rape from a pre-democratic India where women’s consent and silent support for every thing from personal laws to bigamy to marital rape was routinely obtained through threats of sexual terror and physical and social abasement. So our legislators and religious heads (often one and the same) still counsel women to touch their rapists’ feet and ask them to look upon her as a sister, or opine that if the society took to farming, and /or women did not go out after dark, or use mobiles or wore short dresses or have boy friends, rapes would stop.

“Women continue to be raped daily”, writes Justice Leila Seth, one of India’s finest judicial minds and member of the celebrated Verma commission that rewrote India’s rape laws, but adds that the normal approach, remains protectionist. Protectionism says women need protection as matter of right as a citizen, but because they are weaker and more subordinate than men. Despite the major legal amendments the Verma committee report helped usher in, even today this protectionist mindset among most members of the executive, the judiciary and the public continues to reinforce and validate a sexualised hierarchy in which eroticised dominance (as in Bahubali) defines masculinity and submission eroticised (as in Baji Rao Mastani) defines feminity. The State created largely from the male point of view combines coercion with authority. It counsels and supports moral policing women and khap panchayats that say whenever they step out of their homes, girls must be accompanied by a male chaperone. True, the law does not give men the right to kidnap and rape women or throw acid on their faces if they say ‘no’, but the Rohtak case shows this does not deter male predators seriously.

Some other details reveal the kind of world Indian men and women really inhabit socially and politically. Despite the recommendation of the Verma committee, the legislature chose to leave marital rape out of the list as a punishable crime. And more recently when the courts took up the triple talaq matter,the related issues of halala and polygamy had been neatly excised. It is obvious to women that at this point the State will not contradict the socially constructed and legally validated terms of men’s entitlement and access to women, never mind how they affect the lives of millions of Indian women.

Real equality of sexes under the law can only be realised first by accepting that gender inequality is a shrewd socio-political construct of a society which determines that most victims of sexual crimes will be women and men the perpetrators . By first defining and then stigmatising the woman victim as an inferior (often loathsome) weakling, it pre-determines that female victims’ distress instead of appealing to his conscience, will arouse the perps even more . Most recently this mindset has begun to surface in the shape of graphic molestation threats from trolls . Many women victims of these feel they are set on them by political parties they have been criticising because they seem directed particularly against women journalists and liberal feminists. Be that as it may, one thing is certain. The trolls deem sexual assault as just punishment for females who according to them are acting above their station.

Source: Hindustan Times, 16-05-2017

Simplifying The Pursuit Of Happiness

Anil K Rajvanshi





Everybody has their own definition of happiness depending on their outlook. Happiness is a state of mind and when we feel comfortable in our existence, happiness results.When the whole mind concentrates on a single object for a considerable amount of time, we get a sense of well-being. This is called Samadhi according to Patanjali Yoga. Often, we experience episodes of happiness when we get completely engrossed in our work with deep concentration. We even lose the concept of time.
Why does this happen? Part of the reason could be that with huge processing power the mind can resolve all conflicts so that we are at peace with ourselves. Another reason could be that it is a mind-expanding exercise where our minds connect to the Universal Consciousness. Thus, all of us, when concentrating on a positive thought or an idea have knowingly or unknowingly connected to the Universal Mind resulting in happiness.
Similar experiences have been related by people who consumed LSD or other mind-expanding drugs. Such episodes gave great happiness to the users and a sense of connectedness to the Universe. This is similar to the state of Sanyam where contemplation, meditation and Samadhi work together on an object.
The true feeling of happiness also comes when we are not attached to anything including a person or idea.Detachment helps in reducing the formation of psychological knots in the brain. These knots are produced when the brain is t not able to resolve properly the mismatch between expectations spe and reality so that permanent tr neural pathways or memories are formed. Memories use up neural pathways. The concept of detachment leading to happiness is also described in the Gita and Patanjali Yoga.
Most attachments happen because of the desire to possess either an object or idea. Possession gives us a sense of security. A powerful brain is able to resolve every issue and thus reduces the desire for possession. Desire for possession also comes from fear.
The brain is a continuously active machine and based upon signals from senses and internal churning; there are constant makings and breakings of neural pathways.
The number of neural path ways available for processing information increase drasti cally if we have less strong he memories stored in the brain.aking Strong memories are based on emotional events. Generally ee such events take place during childhood, or are due to traumatic happenings. According to Patanjali these memories can be dissolved through the science of Yoga and by practising Sanyam.
Some believe that money provides happiness. That may be true since money allows us to take care of mundane things so that the mind is not distracted and is able to focus fully on higher goals in life. But money should be looked at as means to an end and not an end itself. There should not be any attachment to money .
Absence of pain also leads to happiness. Recent researches done at Oxford University have shown that in the brain, the centres for pain, both emotional and physical, are located in dorsal posterior insula (front position of brain) and at the same place where the seat of ego exists.Thus, pain management is directed by the ego so that the whole brain is focussed for its alleviation.
Since happiness is perceived by the brain, by making our brain powerful through Yoga and meditation, we could resolve conflicts and live a happy and emotionally satisfying life.

Indian science needs hard work: duplication isn’t synergy

SPARK (Sustainable Progress through Application of Research and Knowledge) is a proposed initiative to synergise science activity in India. A new, more efficient way of managing science is surely welcome, but one needs to put in a lot of thought before taking any action.

The existing systems of science governance in this country are robust with departments reporting to ministers who in turn report to the Union Cabinet. There is no lack of sound advisory bodies and committees within these departments. As for overarching bodies, we already have the Scientific Advisory Committee to the Prime Minister and the Principal Scientific Adviser to the Government of India. Why are there two such similar bodies? Have any of their recommendations resulted in concrete actions? In the end, they have remained toothless. Do we need a third such body?

The science departments are too different from one another to come under the purview of one “overarching” body like SPARK. The Department of Science and Technology and Department of Biotechnology are purely funding and outreach organisations. The Council of Scientific & Industrial Research (CSIR) has a special and tricky mandate which involves interaction with industry.

The Department of Atomic Energy, Defence Research and Development Organisation, Department of Space and others are into mission-mode projects. There is hardly a government department or ministry that science does not touch.

Reality of Indian science

The goals of SPARK seem to be most closely attuned with NITI Aayog, and it might well be effective only within this parent organisation, taking inputs from various quarters such as industries, the ministries themselves and NGOs to make proposals, some of which could move forward to become major initiatives. What one needs is a management technique that effectively identifies scientific challenges and links the resulting breakthroughs with national problems.

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Indian science needs a revamp, says report

 

However, the issue is not that we need a new system of science management. The bald fact is that we do not have so much to manage. The report of top science administrators that recommended the setting up of this independent authority is correct in that “the stature of Indian science is a shadow of what it used to be” but this is not because of “misguided interventions”.

It is because there is a lack of scientific expertise across all levels. We have failed in our educational system to harness the enormous latent talent in our country and build a solid foundation of science.

Science does not end with the Indian Institutes of Technology, Indian Institutes of Science Education and Research and other elite institutions. I disagree with the report’s contention that “there is a huge support system”, and “global goodwill” which is “positive”. We have none of these.

Anyway, India does not need global goodwill to succeed in science. It needs hard work, honest management and a critically large base of experts.

Soothing yet baffling expedients to solve the problems of Indian science might make for good copy in the short run but they are not going to yield real results. For example, SPARK is not even required to “closely work with industry and evolve public private partnerships”. That is the mandate of CSIR.

Decisions on new initiatives like SPARK should not be taken within government departments in Delhi following a proposal from one closed administrative group to another. A broad-based consultation with stakeholders is a must.

Even if SPARK is constituted, it needs financial independence; given the relationship between the Ministry of Finance and its Department of Expenditure on the one hand and the science departments on the other, this remains a moot point.

Large systems that work even moderately satisfactorily should not be tinkered with too much, for we may then have to face unintended consequences. Indian science is certainly not in a good state of health today. But what is wrong is not the structure of the system. The wrongs emanate from the many sins of omission and commission over the years by the individuals who have led the system.

Gautam R. Desiraju is a professor at Indian Institute of Science, Bengaluru, and former president of the International Union of Crystallography

Source: The Hindu, 11-05-2017

Remake the marriage contract

Nikahnamas that bar triple talaq could work much better than making the practice illegal.

A man issued a matrimonial advertisement seeking an extremely beautiful bride who should be tall, highly educated and from a reputed family. North Indians will be preferred, girls from the North-East and South India need not respond, it said. Hundreds of profiles were received, but he married someone who had not even responded and was an illiterate, ugly-looking, short and poor girl, whose father was from the North-East and mother from Madras. A PIL is filed in the apex court, challenging the constitutionality of this marriage with prayers for the annulment of a marriage which was based on the arbitrary and instant decision of this man. The PIL seeks the declaration of such marriages as a punishable crime.

The triple divorce case challenging its constitutionality is somewhat similar to the above situation, particularly in terms of the remedy being sought. The concept of constitutionality is intimately related to state action. The constitutionality of a law can be tested only on two grounds. First, on the issue of the competence of the legislature. Secondly, the law in question should not be in contravention of fundamental rights. It is difficult to say to what extent we can strike down private, personal decisions between husband and wife as unconstitutional.

Article 15 permits discrimination on the basis of religion, race and caste when it comes to the use of private wells, tanks and bathing ghats, which are not maintained out of state funds or are not dedicated to the general public. Thus, a Brahmin may exclude Dalits from his private well and we cannot challenge the constitutionality of his discriminatory private action.

What is the effect of something being declared unconstitutional? What can one say of private citizens, even governments do not care about things being held unconstitutional by the courts. Re-promulgation of ordinances has been held by the apex court to be not only unconstitutional but a fraud on the Constitution, yet theNarendra Modi government has re-promulgated land and enemy property ordinances. Men will continue to give triple divorce and women willing to continue in such bad relationships will be able to get a verdict of non-dissolution of marriage only after years of costly and time-consuming legal battles.

A husband and wife cannot be and should not be forced to love each other. Holding a husband liable for maintenance is one thing but compelling him to continue in marriage against his will is another. In most cases, what to say of husbands, even wives who have been given triple divorce would not be willing to live with such husbands; yet, the courts will force them too to suffer a failed marriage. Polygamy is a serious crime for Hindus, yet many Hindus do practice bigamy. Thus, outlawing polygamy too is not a pragmatic solution.

Muslim marriage is, after all, a civil contract, though a sacrosanct one. On Tuesday, the Allahabad High Court made a few unnecessary observations when the apex court is seized of the matter. In any case, the court is wrong in saying that marriage being a contract cannot be unilaterally terminated. All contracts can be terminated unilaterally; of course, one has to pay damages as per the contractual terms.

The marriage contract or nikahnama (prenuptial contracts) is the easy solution to the problems at hand — polygamy, triple divorce and halala. The historian Shireen Moosvi has collected several marriage contracts of the Mughal period which demonstrate a uniform pattern of the conditions of nikahnama. These bar domestic violence, prohibit the husband from marrying another woman and bar him from leaving the wife for long periods. Any violation of any of these conditions entitled the wife to divorce the husband or get the marriage annulled. Most marriage contracts also included the stringent condition that prohibited a husband from keeping a slave girl. But, if the husband did keep a slave girl, the wife had the right to take her away, or sell her and keep the proceeds.

These conditions were so common that there were nikahnamas which simply mention that marriage is subject to the four well-known conditions. The Supreme Court may make inclusion of the first three conditions mentioned above, mandatory in every nikahnama. Since slavery is no longer valid, the prohibition of instant triple divorce could be the fourth condition.

Such contracts were routinely enforced by British judges in India though under classical British law, pre-nupital agreements were considered against public policy. The Poonoo Bibi v. Puex Push case (1875) gives us a glimpse of progressive marriage contracts. In this case, at the time of marriage the husband had said: “I shall never give trouble in feeding and clothing you; I shall make over to you and nobody else whatever I shall draw from employment; I shall never exercise any violence on you; I shall not take you away from your home; I shall not marry or make nikah without your permission; I shall do nothing without your permission; If I do anything without your permission, you will be at liberty to divorce me and realise from me the amount of dower forthwith and this nikah will then be null and void.” But Poono was deserted. She got the contract enforced in spite of her husband’s assertion that the contract reduced him to the status of a slave despite the abolition of slavery, and so it was void.

Let the prohibition on polygamy and triple divorce be included in the nikahnama and once triple divorce goes, halala too will automatically go as in revocable divorces, parties can remarry without halala.

The writer is Vice-Chancellor, NALSAR University of Law, Hyderabad. Views are personal

Source:Indian Express, 11-05-2017

The Golden Incarnate

PARMARTHI RAINA





Chaitanya Mahaprabhu, a leading light of the Bhakti movement, is considered by many to be none other than Lord Krishna. He is known as Gauranga, the Golden avatara, because His body was the hue of molten gold. Shri Chaitanya disclosed that Krishna was so intrigued by the intensity of Radharani's unconditional love for Him, that to find out why Radharani found Him so attractive, He appeared on this earth as Chaitanya, a devotee of Krishna.He said whenever He wished to taste the sweetness (madhurya) of Krishna, He would assume the feelings and emotions Radha had for Krishna. But in His avatara as Krishna's devotee, His mission was to propagate sankirtana (congregational chanting of the names of the Lord) as the best way to counter kaliyuga and overcome material bondage.
Lord Chaitanya appeared on this planet in 1486 in Navadweep, Bengal. Not many people perceived Him as the Supreme Lord. But Krishna walked the earth over 5,000 years ago, during the Mahabharata days, without being recognised as God Almighty . The gopis of Vrindavana knew Him as the bewitching cowherd boy , Nandagopal.
Since Krishna is Absolute, explained Chaitanya Mahaprabhu, there is no difference between Krishna and anything associated with Him. For example, Krishna's name, qualities, form and pastimes (lilas) associated with Him are identical to Him. Thus, meditating on anything connected with Him, particularly His name, has the same potency as meditating on Krishna Himself.

Andhra must ensure children in drought-hit areas don’t fall prey to traffickers

Natural disasters exacerbate the root causes of human trafficking, including poverty and lack of viable livelihoods

A drought is not just water scarcity. It has several other implications: Migration, trafficking, malnutrition, livestock deaths and agricultural losses. Such trying times are also an occasion for the State’s safety net to kick in and help people tide over the crisis. But that is not happening in Andhra Pradesh, which is facing one of the worst droughts in recent years. According to a news website, a fact-finding team, which visited seven villages in the Anantapur district, saw “shortage of water for irrigation as well as consumption by humans and livestock, the lack of PDS outlets and ration cards, migration, banking and debt”. But the most “harrowing ordeals” described in the report are about the children in these villages: Many of them have been left alone or with their siblings in the village to fend for themselves while their parents have moved to the cities in search of work. At best some families had left behind the elderly too to look after the children.

The fact-finding team comprising of activists found another disturbing fact: Some children could not get rations from the public distribution system because either the shops are located at a distance or the families did not have ration cards. “Further, issues were reported with biometric verification as well, especially in cases where the person in whose name the ration card was had migrated, and the machine wouldn’t accept the fingerprint of the existing beneficiary. So sometimes, the children would walk kilometres only to be turned away at the PDS outlets,” they added.

In a paper (Trafficking and Natural Disasters: Exploiting Misery) in International Affairs Review of the George Washington University, Joshua Finn writes that natural disasters exacerbate the root causes of human trafficking, including poverty and lack of viable livelihoods. The added shock of a natural disaster to an already vulnerable population can lead to an environment where human trafficking is more likely to be profitable. Among other recommendations, the paper emphasises the need to secure “greater engagement of local stakeholders” and provide increased “access to safe spaces following a disaster”.

It is the Andhra Pradesh government’s duty to ensure that these children without families are safe and that they get enough provisions to tide over this difficult time.

Source: Hindustan Times, 10-05-2017