Sikshana and again the question of Public-Private Partnerships

Kadrenahalli Govt. school

Visit made on 4 April 2006 by Prasanna (98455-18382) and Aradhana (98455-37269)

Contact info: Mr.Srinivasamurthy, Principal

The visit was made in connection with Sikshana (www.sikshana.org), which is supporting a number of government schools in this area as well as Kanakapura. This school boasts a board that says it is adopted by Sivasri trust (Sikshana’s trust). The school closes for summer on April 10th, but because exams were over, the kids had stopped coming, so we could not attend any class. However we talked to 2 teachers Ms. Vidhyadhare (maths teacher) and Ms. Rukamma (incharge of 1st standard kids), in the absence of the principal Mr.Srinivasamurthy.

The school is housed in a two-storey building and has 426 kids and 11 teachers. School timings are 9:30-3:30pm with a mid-day meal provided under the akshara daasoha scheme. The school has classes from 1st – 7th grade and is kannada medium.

Typically all govt schools in Bangalore receive free textbooks (but not notebooks), a set of uniform and food (under the mid-day meal scheme), and teachers’ salaries from the government. For any other purpose, the school fends for itself through donors. This school got some land donated from a donor, and is constructing a building there to house the increasing number of kids, especially the small ones in 1st and 2nd grade. While the Sarva Siksha Abhiyaan (SSA) will help with the construction cost, the building (and land) has to be registered under the govt’s name when complete. The SSA has also provided some teacher training and some resource material from time to time (although this school sported a SSA poster that gives timelines of SSA’s goals). The toilet in the present building was constructed with donors’ help and water is from School Development and Monitoring Committee (SDMC). There is no playground and the kids use the playground nearby once a week. The school has only indoor games. There is supposedly a cupboard full of books that the kids check out; we didn’t get to see it, we just took their word for it. ISKCON had recently sent in a boxful of books which hadn’t been put in circulation when we visited due to the exams. 6th and 7th grade students pay a fee of Rs. 25/year, while it’s free for everybody else. SC/ST families receive Rs. 150/year/kid to send them to school. The school has depended on donors’ support for any field trips, annual/sports day functions.

Sikshana has helped provide notebooks, printed exam question papers, exam answer sheets, 2 computers and some computer training as well as contributed to the library.

The only contact of the school authorities with the government is through the Block education officer (BEO) who inspects the school and its results. All govt schools have to pass the kids at least up to the 7th grade and some till the 10th. We didn’t get to see the school results despite requests, but were told that it was one of the best in the area.

Aradhana’s viewpoint: I have been volunteering with AID Bay area since 1997 and the past 2 years in Bangalore. Volunteering at a couple of tuition centers in the Bangalore slums has been an eye-opener about the state of education in India. While lack of proper infrastructure (we’re talking blackboards, chalks, textbooks here) on the one hand can really affect the education being provided, on the other there is the lack of teacher’s interest, totally meaningless textbooks and methods of teaching that make schooling such a shore for kids. We’re talking about 7th, 8th grade kids who can’t do simple addition and subtraction, history books with totally uninteresting information, and of course boring English lessons taught to kids who grew up in a kannada medium environment (thus ensuring that they will never generate the enthusiasm to learn English!).

In the absence of govt. intervention, these govt. schools have a need to approach other donors for providing quality education to the kids all of whom are from economically backward backgrounds. We can very well say that these schools need to make the govt. accountable, but we all know that’s a long process and we cannot expect the schools to not do anything in the meantime. Sikshana’s role is that of a donor presently, providing the infrastructure that these schools lack, but that is also a need of the hour. Teacher training is needed, especially for interested teachers who are keen on providing quality and meaningful education. Prasanna and I would like to visit the schools (probably with other Bangalore vols as well) once they reopen on May 29th to get a better feel about the needs of these schools and how AID can help.

Prasanna’s viewpoint:

The first thing that put me off was the board put up at the entrance as mentioned by Aradhana. The School is put up by the government and some trust which gets its donation from some people claims to “adopt” the same.

This is a typical case of the so-called “Public Private Partnerships” (PPPs). With it comes the Classic Dialectic of the PPPs that confront us. On the one hand we have the so called “Right to Education” which makes Education a fundamental right of every citizen of the nation and this should make the government accountable and take the complete ownership of the schools run by it. But as Aradhana points out that it is a long process and till that time we cant expect the school to not to do anything and hence we are forced to promote such initiatives like Shikshana with the tag line “At least so many kids get blackboards, notebooks, textbooks etc., etc.,” Similar dilemmas are arising in the health sector as well with some people actively promoting the “take-over” (in other words “adopt”) of the Government run Primary Health Centers with the tag line that “at least so many people are getting the services at these centers”. I would be drawing a lot of parallels with the health sector to explain some of the points

While I don’t totally reject the above tag lines there are some fundamental problems associated with it

a) There is no question of empowerment and exercising of Rights in the private sphere. Here I bracket anything other than Government (public) as private. So it would include charitable organizations, NGOs, missionary institutions and of course purely private. So in a private either it is “collect user fees and deliver” (since they work on the concept of return of investment or at least break even) or it would be “collect donations and charitably deliver”(non-profit sector, read Shikshana). So either it is the paying capability in the former case or the benevolent nature of the organization that will to some extent ensure the service delivery (not assured always though) and hence no scope for the concept of “Right to Education” as Rights have no place in the private sphere. One more hypothetical question is that if the non-profits like Shikshanas were to not receive donations then they would also have to fall into the “User fees” option. This has happened to many of the missionary institutions. So what happens finally is that “Education is only for those who can pay” and hence whither “Right to Education”
b) One of the fundamental reasons for poor service delivery of public systems is the increasing disconnect between the Public and the Public Systems. There is no public left in the Public systems. It is a vicious circle. First the govt. systems don’t deliver and the public are totally indifferent and turn to private for service. This makes the Government think that anyway the public are not using so why should it run the systems and actively privatizes it (again I will use the broadest term of private) and hence the disconnect increases. Finally nobody is held accountable for anything. The government is very happy to palm its hands off in the name of PPP and the general public cant question the private as it is either money driven or charity driven, if it delivers it is good and lucky, if it doesn’t deliver then bad luck u cant question them. So what this means is that organizations like Shikshana increase the disconnect between the Government and public by insulating and isolating the Government from the public. So the Government doesn’t feel the heat and pressure of the public’s anger over the lack of the facilities that it provides for fundamental rights like Education and Health.

So one hypercritical question that needs to be asked is what is AID doing with supporting organizations like Shikshana which would insulate the Government from public accountability?

Is it a feel-good factor driven by the tag lines that at least so many children have got so many facilities as I mentioned before? But I thought we as AID have outgrown the “charitable” behaviour ( partly because of the middle class and upper middle class baggage that we carry)
Or is it because it fits into the “tangible” Black Box model of Inputs and “tangible” outputs? Our chapter has given so much money (input) and so many black boards, notebooks have been supplied (“tangible”, “measurable” outputs). Organizations with such initiatives can always get support as this fits into the category of the “Charitable” people and corporates which are looking for specific “Black box” type of initiatives. If this is the case then how has AID been different from the Rotaries and the corporate donors? If we are again catering to the same spectrum that these can do then what is the value-addition that is happening because of AID’s involvement [we, who understand the bigger people’s struggles which fight for more government accountability (a la Vimukthi, Narmada or a PHM)]. Of course, we didn’t get a chance to talk to Shikshana directly and we are not privy beforehand to the interaction that has happened between Shikshana and AID but from the inputs we have collected I cant see any value-addition. The school is so insulated from all the stuff that they didn’t even know that AID was involved somewhere. If there is no value addition then why is AID diluting its energies when there are enough and more people to do such things?
Or is it because it is easier to project to our donors? I think we as AID have earned enough credibility to be driven by such factors. If it is really so, then we should now learn to say “No” to such donors

So then as Aradhana points out should we remain silent till the government responds and let these children suffer since the government systems are not delivering or encourage a PPP like Shikshana, which would isolate the government from the public pressure ( I am also aware that it is easier for “haves” like us to take a strict ideological position) . One possible midway answer to this dilemma is that no doubt shikshana’s work is important (This is similar to a patient coming to the PHC adopted by an NGO with a snake bite to alleviate his immediate pain but at the same time the NGO should also mobilize the people against the government if the medicines to be given by the government is not supplied by it and not go back to its donor for buying of medicines) but AID should be able to bring in the value addition of impressing upon Shikshanas to also fight for the people’s rights in education in parallel with the service delivery that they are doing to alleviate the immediate pain of the people. In fact this should be made a condition for further support to them or a specific time frame (say 3 months) to be given to them so that this sort of value addition happens and if the NGO does not have enough time for doing the value addition then we need to take some hard decisions. Otherwise Shikshanas can continuously be on the artificial respiration provided by organizations and donors like AID and then the government on its side not feeling the public pressure goes on systematically undermining the public systems.

Some further reading on the PPPs:

Sainath’s articles:
http://www.counterpunch.org/sainath04122006.html

http://www.hinduonnet.com/2006/01/04/stories/2006010406091000.htm

PHM statement of PPP
http://lists.kabissa.org/lists/archives/public/pha-exchange/msg02582.html

My writing on Yashaswini, the "Health" Insurance Scheme

The whole issue of Health Insurance

Some clarification:

1. In the first place let us get this clear. What has to be brought into focus is the clarity that we are not talking of “Health” Insurance but of “Health care” insurance or Medical insurance. So let us all bear this in mind before we get carried away by this whole concept. I also hope that this group is in a position to understand and appreciate that Health is much bigger and Health care is not Health and comprises only a very small portion of the overall struggle for health. With this basic intro I would now be intermixing “health” and “health care” words.
2. Also this runs as an anti-thesis to the whole struggle of “Health as a Human Right”. This also runs contrary to the concepts of mainstreaming public health, that health is a public good and not a private property and that governments should take increasing responsibility for public health. This is not an empty rhetoric anymore. Increasingly research evidence is showing that countries which are having bigger health budgets and taking responsibility for the same (Sri Lanka, Scandinavian countries like Denmark, Norway, Sweden etc.,) have much better health indicators (Infant Mortality rate IMR, Maternal Mortality Rate MMR etc., which are listed in the Millenium Development goals (MDGs) as targets) than in countries where health care is privately financed like India, USA etc., Read also Kalpana Sharma’s article about the same http://www.hindu.com/mag/2005/09/18/stories/2005091800080300.htm
I was till yesterday in Mumbai attending a Global Researchers conference called as “Global Forum for Health Research” (www.globalforumhealth.org) an offshoot of WHO, which was formed again as the counter current in which the main objective is to overcome the “10/90 gap” as they call it in which they want to reverse the whole phenomena of 90% of the research money being spent on 10% of the problems and vice-versa. During this forum presentation after presentation presented this fact about public spending
3. As rightly pointed out by Dr. Sujit, there is a sort of “Fait Accompli” about the whole issue of public spending in health. There is an element of fatality about this whole issue. That the government has failed to deliver (Government’s health system delivery has got cold) and hence let us at least get an insurance which is privatisation by other means. Since the governments these days as well are very happy to grab hold of such “innovative” schemes which can deviate the public from its own failure. Most of these private insurance schemes anyways cover the privatised hospitals and none of them even talk about public health system, this suits the “Payment for health” dominant paradigm of the globalised health care providers. This again denigrates the whole argument of “Health for All” to “Health for those who can pay”.
4. The Globalised Governments is also giving into these arguments in the name of Public-private partnerships (PPP). The globalised medical fraternity (not the health fraternity) of India which promotes the whole concept of “Medical tourism” and tele-medicine in which India can become the sweat-shop for the world’s outsourced medical care so that a patient from the US can come to Narayana Hrudayalaya (whose director, Devi Shetty is incidentally responsible for bringing in the Yeshaswini scheme) for a cardiac operation for very little cost and Narayana Hrudyalaya can claim to have 100% bed ocupancy where beds of heart patients are arranged like a conveyor belt production (not joking, this has been one of the PR press conferences in which Devi Shetty has claimed to bring in this concept of conveyor belt heart operations). It really does not matter that 3000 children die of preventable diarrhea in India and UNDP says India is having the worst IMR and MMR indicators and that Bangladesh has fared better in its recently released Human Development Report of 2005. The Medical fraternity says the government health system has failed to deliver, so let us have a public private partnership in which the delivery systems would be taken care of by the private. The governments gleefully fall for this bait. So what does the government do? I will give you 2 examples of PPPs in India in which it is like “Kaam mera, naam tumhara”. The Government builds a multi crore hospital in Chattisgarh spends public money to build the same and then hands it over to a private fellow “Escorts” asking it to “maintain” the same. It is also entitled to collect maintenance costs from the patients. So it runs away with the profits at no extra sweat on its part. One more classical example of PPP is the privatisation of water in Delhi. In the name of PPP the Delhi government (the “performing” government of Shiela Dikshit) spent and built up all the distribution channels for the private French water company, Suisse, to “maintain” the same by charging user fees and run away with profits.
5. I know there is already a question arising in some of your minds. Some of you might have this question of “what is wrong with Privatisation and user fees if it can deliver?” The whole question is “Do they deliver?” I have mentioned many times that Private by its very nature is profit oriented (I am not telling profit is wrong). But because it is profit oriented its services would also be only where profits are there. So if you listen to Suisse story further you would come to know that the company stopped the distribution of water to some of the lower income places (for those who could not pay) and hence “Whither water and in the larger context Health as a Human Right”! So just like an Airtel does not serve the public beyond 10 kms from the city, Jet Airways does not fly from Manali to Delhi, Suisse will not deliver water to the public who need it most or an Escorts will not give medical care to those who fall ill the most, as it does not “pay” to deliver to such population and do not have a “return of Investment” and a problem further aggravated with PPP is that the private fellow has not even put in his Investment to begin with for it to think of an ROI! So profit orientation for Jet Airways or for an Airtel is still justified as we have still not come to a stage of asking for “Telecommunication is a Human Right or Air transport is a Human Right”. We can still categorise them as luxuries but can the same be said about air, water, food and the same yardstick applied to the same?
6. Some more problems with the privatisation and in this case insurance are the accountability mechanisms. Who is the private mechanism accountable to? Is there any entitlement concept in this? The only mechanism is the payment mechanism and historically and research wise (again some of the presentations in the Research Forum showed that, it might be good for you people to look at some of the abstracts of the Forum 9 which throws some light on these issues) is that the poor will not seek health care till the time it becomes catastrophal as the poor apply the same logic of buying the grains in which case buying is inversely proportional to the cost of the grain and hence poor tend to buy less and less of grain ( Sainath in one article quotes that since globalisation and privatisation of India, India’s per capita grain consumption has fallen from 161 kgs to 147 kgs per year) and by the same logic since the poor have to “buy” medical care, they would do so lesser and lesser till it becomes very critical or catastrophal
7. Health insurance not only justifies privatisation of health care, it does not create enough pressure mechanisms on the public sector to deliver. So the public system can be more and more undermined and finally abandoned leaving the health care of the poor to the sharks of the globalised medical fraternity who would be the products of the privatised medical colleges (logical conclusion of the recent SC ruling on private professional education). So the government would be made to wriggle away from one Human Right after another.
8. Of course, since most of you are in the US, you are also exposed to the over medicalisation or the lack of rational medicalisation that happens as a result of insurance. Today in India we are getting into a concept of financing the Sex selective Abortions where loans are given to doctors by medical devices companies to have an untrasound machine and recover costs and sine there is no Moral pressure or ethics involved in making profit, at some point of time insurance could be used to cover these! As Dr. Sujit says there is the issue of “Moral Hazard”.

Having said all these let us look at the situation of the poor and those who do not have access to health care at all

1. I have said these many times and reiterated by Dr. Sujit. The dreaded 80:20 ratio. 80% private and 20% public
2. More and more people driven to BPL because of Catastrophal Health care Expenditure(CHE). Second most cause of rural indebtedness.

But look at these other facts.

a) The doctors per capita ( both private and public included) is the highest in India
b) The bed capacity is also according to the WHO mentioned norms

So what needs to be done?

1. I met Deva in Mumbai and was having a discussion on the same. He says a well meaning public health person like him have to think in terms of health insurance, as sitting in the grass-roots he cant wait endlessly for the public system to deliver. He wants that to happen but till that time he would want to evolve a community based health financing scheme. This is again a “Fait Accompli” system. This also comes from an NGO sort of thinking But as explained above, the community with a community based health insurance (CBHIS) would not come anywhere near the public facilities to put pressure on the health care systems and hence the public systems would be further undermined. What about the community without any NGO to take the initiative. What about the communities which do not have any PPPs? Should they wait for an NGO to come by to get them health care? Even if this was to be mainstreamed what is the guarantee that the government-run CBHIS would deliver like the famed Yashaswini scheme?
2. The other problems with the CBHIS as of now is that they are dependent on the conditionalities of the market placed medical insurance people (like the Cholamandalam or the Sundaram etc.,) like Dr. Sujit mentions, the line between the lines. So again it needs an NGO, like ACCORD, to negotiate which understands the nuances and the fine print of the insurance people to get the maximum leverage
3. One more problem with CBHIS is that most of them cannot be organic or endemic. What I mean is that it can’t be run like SHGs in which there is an inherent homogenous risk sharing. People can’t just save some money per month or per year and then share the risk of the costs of health care by running their own insurance schemes (like the SHG cooperatives or federations which can run a diary). There is a minimum threshold level of risk pooling and cross subsidy that needs to happen if an insurance has to work and this makes them dependent on the market placed insurance companies which cross subsidize from the risk pooling of the so called “rich”. This makes the communities exposed to the market driven insurance companies.
4. There is also talk that once a sufficient critical mass of people begin accessing the services they begin to ask for better services (does it sound similar to the percolation theory of the globalisation which resulted in the crisis of Argentina, South Korea and even Singapore?), but what we all forget when it comes to medical services, is that the consumer-product relationship does not work in this case
5. Most of the private people offering the insurance schemes are offering the justification of the low bed occupancy in the private sector for giving insurance! Hence there is no concept of utilisation of the public services and building pressure on this to get better services.

Now Yashaswini scheme:

1. The great Ankaleshwar aiyer praised it as “Miracles at Rs. 7.50”. He must have been talking about the miracle PR that Devi Shetty (Director of Narayana Hrudayalaya) did with the help of having this scheme launched at Rs. 7.50 per month with everyone talking about this scheme and how this was the best thing under the sun!
2. First let me explain the scheme and then will comment further on this. Please give particular attention to the words within quotes
3. The scheme was started with the help of the then Krishna government. The broad contours of the scheme are as follows:
· This scheme is for farmers.
· Enrolment through the cooperative sector. All the people who are part of the cooperative will become beneficiaries
· The beneficiaries have to contribute Rs.60 per year and the government would contribute a further Rs. 30 towards the same
· Cooperative department would be in charge of operationalising the same.
· List of accredited private hospitals
· The scheme is valid for surgeries
· No reimbursement for diagnostic costs or instrument costs etc.,
4. It is true that this scheme costs the “farmer” only Rs. 7.50 per month!
5. Aiyer has been truthful in telling that “heart operations” cost lakhs. Aiyer has also been partly true in telling that “heart operations” can be costing only Rs. 7.50 per month.
6. He is also true in telling about the government also paying Rs. 2.50 per month (sadly true that a government has gullibly been made part of this).
7. I hope people are observing the quoted words. Actually what this scheme does is only to cover the surgeries and for that they take a premium of Rs. 60 per year from the farmer and then a further Rs. 30 from the government making it Rs. 90 per year. How was this done? How many of us still are observing the word surgeries or operations? If you have been observant, you can see the fallacy behind this. For most of the people, the PR bulldozing of Devi Shetty and his agents (like Aiyer) does not tell that most of the people who are paying up do not epidemiologically seek medical services for surgeries? Most of them spend money on non-surgical visits to the medical facilities. So what they need is not surgery but coverage of general medical conditions. Most of them poverty related (like TB, Malaria, HIV/AIDS etc., ) which anyways is surely excluded but heart operation, definitely yes! Most of the insurance schemes have delivery and pregnancy related costs also excluded (I don’t know for sure about Yashaswini) which in fact are the most common health care costs incurred by these people.
8. The brochure of the Yashaswini scheme reveals a very interesting statistic. In the list of objectives mentioned for the scheme, it quotes a study which says that the existing private bed occupancy in Karnataka is not fully utilised to its full potential and this scheme aims to improve upon the same! Hence to increase the private bed occupancy of the private sector (which includes his own conveyor belt heart operating hospital) this scheme was introduced. He also did not have to use too much of his great convincing capacity with the previous chief minister, who incidentally was thrown out by popular vote in the elections, because he was wanting to make Bangalore, the Singapore of India and sold to the globalised “medical tourism” concept.
9. If you people are still in the “so what? “mode, then let us talk about the other quoted words. I have put in quotes the word “Farmer”. If you look at Aiyer’s article he says “The numbers must be large (preferably lakhs), spreading risks”. So how was this achieved? The scheme simply, by getting the government in its bag, could convince it to help the scheme with the farmer’s cooperative that was 12 lakhs strong at that time. It was a different matter that neither the farmer was educated nor was he asked whether he needed it. In the Focus Group Discussions that my friend during the study did, she observed that most of them did not know what the card that was given to them meant, or why was Rs. 60 collected from them by the cooperative society at the time of their membership renewal. So there was no endemic or organic relationship here.
10. Further the concept of “Farmer” itself needs to be looked at. Who can be members of the cooperative? According to the rules of the cooperative, those who own certain acreage of land are eligible to become members of the cooperative! So is anyone able to understand the implications of this? So in one shot this was made “property-centric” or middle level and rich farmer – centric and hence reaching the same population which anyways had some access to health care. But who needs health care services more? Do we fight often that we need to reach health services to the poor, marginalised landless labourers, carpenters, gardeners, taxi drivers (not owning the taxi), garment workers etc.,?
11. Even accepting that farmers also need health care and there are poor people even among them, let us examine whether this has reached them. Let us come to the hospitals selected for the scheme. They are all again city-centric, again defeating the same purpose for which this scheme is supposed to reach. One of the main reasons for lack of access to the health facility or access to TB drugs is the perceived loss of opportunity costs to the people (loss of the wage for the day, the transport costs, the travel time etc.,) and if the clinics selected are all city-centric then who is this scheme reaching? There is some problem with the non-transparent selection of such clinics / nursing homes. Some clinics have come out openly with grievance that their clinic is not selected. There are cases where they had been selected but then removed from the list without giving any reason.
12. Let us examine why Clinics are crying hoarse on getting into the list of accredited hospitals. There is an incentive for the clinics to be enrolled in this! Actually what has happened is that there is a standard list of surgeries and their costs listed out for the patients and the rates allotted for these surgeries are quoted at Narayana Hrudayala prices which in turn would be much higher than the normal nursing homes. So they have everything to gain! So there is a coterie of people who make the decisions for the scheme in the most intransparent manner. Also this is a government scheme, so in this age of “Right to Information” and all that, the whole scheme is shrouded in mystery with nobody knowing how many people used this. What has been the expenditure on this etc., Efforts by many people and even ILO to get some basic information on this scheme has been met with little success. Nobody has as yet been able to get an appointment with the Secretary of the Cooperative department. So all the information that we get is only through the PR channels.

13. So then, is this scheme not at all reaching the people? Yes, it reaches some. In Insurance parlance there is a term called as “Adverse Selection”. What this means is that people pay the premium when they get a feeling that they are going to have health care costs (like for example pregnancy etc., or if you are detected to have a bigger operation). As I said before none of them know that such a scheme exists and the ones who know are the ones who always have the access to information (the literate, village heads, the big farmers etc.,). In the study conducted it was again revealed that these people were the ones who were making the adverse selection. Actually if you look at it from the health care point of view, the adverse selection is actually the normal selection but then we are talking about market-driven health care here and not the “Health for All”.
14. Of course, this scheme also has its usual exclusions. Medical / clinical tests done before the surgery are not covered! The instruments and devices needed like stents needed for heart surgeries (angioplasty) are all extra cost and such other exclusions for an apparently “poor” population and all this at Rs. 7.50 only!
15. The last point is purely commercial. We made a rough calculation of the money involved. If you were to take a rough estimate of 20 lakhs farmers included (I wouldn’t say enrolled) in the beneficiaries list and each of them paying Rs. 90 (including government contribution) then the money collected is Rs. 18 crores (Rs. 180 Million) and when we calculated this money against the number of operations conducted with an average cost of each operation is around Rs. 45000 (from Rs. 65000 being the upper limit for Heart operation) it was found out that the Yashaswini trust would be still left with lots of money per year Sorry, I have forgotten the exact number of surgeries. But by their very nature of being secretive how much they have actually spent on what operations is not known for any outsider to check out the viability or replicability of such an option. But even after this Devi Shetty is unhappy with the whole thing and then he is devising ways to part with the Government by starting his own pilot project with Rs. 120 as the premium and with ICICI as his partner in a Taluk called Anekal near Bangalore. We have not heard the last word yet.

So is there an alternative?

1. One alternative is that the government starts a social insurance scheme (like earlier ESI) which also includes the health care expenditure tagged to the public health system and there are estimates that this can come about at a reasonable cost
2. Or we fight for “Health as a Human Right” without giving into the temptations of easier options of looking at the black box model of inputs and outputs. So much money given (input), so many people insured (output) types. Without getting into the fatalistic situation like “at least these many people have been saved from catastrophal situations”. These could be like the “cure is worse than the disease” or into a situation like if we don’t do it some other organisation can do a bad job.
3. Invest in people / bottom – up movements who can be change agents or counter currents to the dominant paradigm and hence bring about change in the society than simplistically an NGO
4. Work towards value addition in the Health Sector with people based movements in such a way that the work puts pressure on the public system to deliver a comprehensive primary health care ( like NAPM did with CEHAT in Maharashtra with support from an AID chapter by mainstreaming the whole concept of Community Health Worker in the tribal district of Maharashtra)
5. Have a proper media and communications strategy (cultivating the media) again as counter currents to the globalised media ( particularly Times of India type of newspapers) so that the general public are also not carried away by the media blitz.
6. Bring pressure on the governments to think about the 70% marginalised which vote for them and not the 30% globalised who run the system of parallel governance (the Devi Shetties) with no accountability mechanisms. This is as much needed in countries like USA which can suffer because of Katrina as for us in India. Read Articlehttp://www.hindu.com/mag/2005/09/18/stories/2005091800100300.htm Maybe if we started working there to identify and mitigate the causes of Katrina we could also be saved from these dominant paradigms and we could work towards Health as a Human Right and not a lesser Fait Accompli.

Coincidentally just as I finished writing this article yesterday night to send it to you people, today in the Hindu we have an informal interview between Devi Shetty and Sudershan http://www.hindu.com/mp/2005/09/20/stories/2005092000960100.htm which exactly reinforces what all I have tried to convey through this article.

The question now would be can we in AID work towards creation of these processes than being happy with the “Black Box” models?

The E-Mail Thread preceding my writing on Health Insurance

Dear All,

Most of you who have been connected with the Health issues in AID are getting increasingly interested in the Health Insurance schemes in general and community based health insurance for the under served. Particularly people are increasingly asking me the question after reading articles on one Insurance scheme, which is high on PR called Yeshaswini scheme in Karnataka. There have been many articles written on this scheme. One such article written by a globalised economist, Swaminathan Ankaleshwar Aiyar who wrote recently wrote in Times of India about “Miracles for Rs. 7.50” Read the news article http://timesofindia.indiatimes.com/articleshow/1080153.cms. and Devi Shetty himself writing about this scheme http://www.indianexpress.com/full_story.php?content_id=77940 ( forwarded by Shekhar last week asking my opinion on this). One more has been forwarded to us by Dr. Sujit Sinha as well. After some of these movements some of you have been off and on asking me the question about health insurance in general and Yeshaswini in particular. So I thought I will put some perspective to the whole issue of health insurance and then come to Yashaswini in particular. The reason is that Deva (Devadasan) of ACCORD ( listed by Dr. Sujit as one of the speakers at the West Bengal event) is a society member of CHC and one of my close friends did a small research on Yashaswini and since I was discussing this issue on a daily basis with her, I know some of the inside stories of the scheme than just the “PR” side of the scheme. I would like to endorse some of the observations of Dr. Sujit and also add some more comments to the same.

The email thread:

The article attached is less on rigour (not quoting references etc., ) and more on the perspective building side%2